rheumatologist shortage

Growing Shortage of Rheumatologists “Very Concerning”

New research predicts that the existing shortage of rheumatologists will worsen over the next decade, while the demand for arthritis specialists will continue to grow.

“In 10 years, we will have a significant challenge in America to take care of the demands of rheumatology care. Every region in the U.S. will be negatively affected by [having] far less rheumatologists than we think will be optimal,” says Daniel F. Battafarano, DO, division director, Rheumatology Service, San Antonio Military Medical Center in Texas.

Dr. Battafarano was the lead author of one article and senior author of a second article recently published online in Arthritis & Rheumatology and Arthritis Care & Research, respectively, about the future of the rheumatology workforce in the U.S.

In the first article, Dr. Battafarano and his colleagues estimated that in 2015 there were the equivalent of 5,415 full-time providers – including doctors, nurse practitioners (NPs) and physician assistants (PAs) – in the adult rheumatology workforce, and they projected that number would fall to 4,051 by 2030. During this same time period, the adult patient demand for arthritis care is expected to increase between 25 to 50 percent, mainly due to the growing and aging U.S. population. Essentially, the researchers calculate that by 2030 supply will be half of what is considered optimal. (Currently, it is about 13 percent below optimal levels.)

The analyses in the articles point to a number of factors that contribute to this shortage, including:

  • A numbers problem: 50 percent of rheumatologists say they plan to retire in the next 10 years.
  • A pipeline problem: There aren’t enough younger doctors to replace those who will are retiring.
  • A workforce interested in maintaining work-life balance: The current rheumatology workforce is 41 percent female, a number that is projected to climb to 67 percent by 2030. Prior studies have shown that women work 7 fewer hours per week and see 30 percent fewer patients per year than men. Millennials, born 1982-2004, make up 6 percent of the current workforce but their ranks will grow to 44 percent of the workforce by 2030. Millennials in 2015 saw fewer patients compared to their counterparts in 2005.
  • An ongoing distribution problem: Most rheumatologists work in urban and suburban areas, leaving much of the country under-served. For example, 21 percent of adult rheumatologists were located in the Northeast in 2015, with only 3.9 percent in the Southwest.

“The demographics of the rheumatology workforce are just shifting,” Dr. Battafarano explains. He says since these are projections, the numbers may not play out exactly over the next decade, but emphasizes there’s no question the trends are accurate.

“What is most important is this trend is very, very concerning,” Dr. Battafarano says, adding that it’s not limited to rheumatology. “This is happening across the board, in primary care and in subspecialty care, so all patients, moving forward, may encounter challenges with access to care to see a primary care physician or specialist.”

In the second article, a subgroup of the same researchers looked at graduate medical education, which is how a newly minted MD trains to become a specialist, such as a rheumatologist. After analyzing the different factors – including the number of fellowship (training) positions available, the number of international medical graduates who plan to return to their home country, and the shifting generational and gender trends – the authors conclude, “The current U.S. adult rheumatology workforce is in jeopardy of accelerated decline at a time when demands on the workforce face tremendous growth.”

Marcy B. Bolster, MD, associate professor of medicine at Harvard Medical School in Boston and lead author of the second paper reported a modest increase in the number of physicians pursuing training in rheumatology between 2005 and 2015 and a 35 percent increase in training positions during that decade. But that is far less than is needed.

“The importance of the study is to show there is a looming problem, and we should be proactive in developing new ways to improve access to care,” says Marcy B. Bolster, MD, associate professor of medicine at Harvard Medical School in Boston and lead author of the paper.

Both papers outline steps that can be taken to close the gap between supply and demand. They include increasing fellowship training positions; creating incentives, such as loan repayment programs, to attract more providers, including RNs and PAs, to rheumatology; removing barriers to using telemedicine; and loosening visa requirements and providing incentives so that international doctors will want to and be able to remain in the U.S.

“How we practice and manage rheumatology care in 2018 will likely morph into something different to maintain high quality care for our patients,” says Dr. Battafarano.

An accompanying editorial about these two studies, published online in Arthritis & Rheumatology, says the studies are a call to action for the worlds of medicine, policy and government, and echoes the call for improvements in recruitment, training, mentoring, retention, reimbursements and workforce diversity.

“We need trained rheumatologists to provide appropriate treatment to patients,” Sharad Lakhanpal, MD, immediate past president of the American College of Rheumatology (ACR) and one of the editorial’s coauthors.

“The biggest challenge is the ability to have more training programs for rheumatology, specifically in regions of the country that have a greater shortage. This requires increased funding from government and possibly private sources such as foundations,” Dr. Lakhanpal says.

Ann Palmer, president and CEO of the Arthritis Foundation, says the Foundation is “very concerned about the growing shortage of rheumatologists, and we applaud ACR for bringing attention to this issue.”

The Foundation has several initiatives in the works to address the issue, she says. “Our organizational priorities this year include a revitalized medical fellowship program and advocating for loan repayment for pediatric subspecialists to encourage more medical students and young physicians to choose rheumatology as their specialty.”

Retention of rheumatologists is important, too, Dr. Lakhanpal says. “Many of the young, trained rheumatologists have to go back to their native countries because of visa issues. Better reimbursement for rheumatologists will also help attract the best and brightest to the field.”

Telemedicine, which holds promise to improve access to care, particularly in underserved communities, will need to have legal and regulatory issues addressed to make it more accessible for doctors and patients alike.

“I think there will be different methods of providing telemedicine, whether it’s rheumatologists interviewing a patient or providing consultations to another physician who is seeing a patient,” says Dr. Bolster.

Anne Bass, MD, director of the Rheumatology Fellowship Program at Hospital for Special Surgery in New York City, who also serves as the chair for the ACR’s Committee on Rheumatology Training and Workforce Issues, says there is also likely to be a push to train other medical practitioners to assist rheumatologists with less complicated patients.

“More and more we are realizing we have to do more outreach into nursing schools and to physician assistants. We have focused a lot on medical schools and residents but done less on the health professional side, and that is an untapped resource,” Dr. Bass says.

That’s another area in which the Arthritis Foundation is focusing, Palmer adds. “We are actively exploring ways the Arthritis Foundation can support and enhance the role of nurse practitioners and physicians’ assistants in rheumatology care.

Access to quality medical care is essential for good arthritis disease management, and we will do all we can to help ensure this access,” she says.

Author: Jennifer Davis

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