Crisis as Opportunity: Rheumatology Prospects Boom Amid Shortage
In February 2018, a pair of analyses published in Arthritis Care & Research and Arthritis & Rheumatology issued a grim prediction for the rheumatology workforce: Given the baseline established in 2015, the demand for rheumatology services is expected to exceed the supply of providers by more than 100% in 2030.
In their analyses, the researchers detailed several issues integral to closing the rheumatology care gap, including the sheer number of full-time rheumatology providers, the uneven distribution of rheumatologists across the country and the need for additional rheumatology fellowship slots than currently allotted in the U.S.
These alarming reports have provided the clarion call for organizations such as the American College of Rheumatology and the Rheumatology Research Foundation to propel new initiatives to alleviate the projected workforce deficit, including recently proposed legislation for additional loan forgiveness programs, increased support and flexibility for foreign physicians to work in the U.S., and improved financial backing for rheumatology fellowships.
While the workforce shortage has exposed various structural flaws in the U.S. health care system, it has also unveiled a specialty rife with potential for new rheumatologists or those interested in entering the profession.
As demand for both rheumatologists and advanced practice clinicians is extremely high, new entrants to rheumatology will find the hiring market overly welcoming. Opportunities for advancement are also increasingly available. Many leadership roles are currently held by baby boomers who are reaching the age of retirement; as these professionals phase out of the medical field, younger rheumatologists will be given the opportunity to step in.
“In short, the workforce shortage offers unique job security,” Beth L. Jonas, MD, chief of the Division of Rheumatology, Allergy and Immunology at the University of North Carolina, Chapel Hill and chair of the ACR Committee on Training and Workforce Issues, told Healio Rheumatology. “Trained rheumatologists now entering the workforce have many opportunities at many different practices. This is a great time to become a rheumatologist because you know you are guaranteed a job and will most likely have your pick of a number of different jobs.”
“Even in the highly-clustered areas in the Northeast, there is tremendous demand for rheumatologist services,” she noted. “Although there will be many more opportunities in the rural areas, there are a great deal of opportunities in even the major metropolitan centers.”
One year after the shortfall in the rheumatology workforce first made headlines, Healio Rheumatology aims to tackle whether rheumatologists and other advanced practice clinicians entering the field should view the looming shortage as a warning sign or an open opportunity.
Rheumatology by Location
Among the three focal issues outlined in the ACR 2015 Workforce Study, the uneven distribution of rheumatologists across the country is expected to reach critical mass within the near future. As Battafarano and colleagues noted in their analysis in Arthritis Care & Research, while 21% of adult rheumatologists in 2015 practiced in the Northeast, just 3.9% practiced in the Southwest. The ratio of providers per 100,000 patients in the Northeast is expected to decrease from 3.07 in 2015 to 1.61 in 2030, while this ratio in the Southwest is projected to decrease from 1.28 to 0.5.
“The Northeast as well as Mid-Atlantic regions have a larger number of rheumatologists for the population of patients compared to other regions in the U.S.,” Anisha Dua, MD, MPH, fellowship program director at Northwestern University and member of the ACR Committee on Training and Workforce Issues, said in an interview. “Areas with a lower number of rheumatologists include the North Central and South Central regions as well as the Southeast and Southwest, with projected disparities worsening by 2025 — these same regions have more difficulty recruiting rheumatologists.”
However, even regional estimates often do not consider geographic variation of rheumatologist distribution within the state itself; clustering of rheumatologists around metropolitan areas often leaves other areas of the state with too few providers.
“Even in states where there appears to be an adequate number of rheumatologists for the population, they tend to be clustered in the metropolitan centers; for example, in my state of North Carolina, providers are gathered in the Raleigh/Durham/Chapel Hill area, and the Charlotte area,” Jonas said. “Otherwise, access to care in the rest of the state is relatively sparse, and people are traveling long distances to see the nearest rheumatologist.”
The outlook for access to pediatric rheumatologists is even worse, according to Guy Eakin, PhD, senior vice president of scientific strategy at the Arthritis Foundation. “For adult rheumatology, we have representation — even if it is inadequate — in every state. However, when we start discussing pediatric rheumatology, there are wide swaths of the nation where you could drive north to south across the U.S. without ever going through an area that had access to a pediatric rheumatologist within a 4- or 5-hour drive.”
Although the question of availability and accessibility of rheumatology services continues to haunt providers working in underserved areas, the silver lining may be that the workforce shortage has pushed the health care industry to seek out the basic economic solution: Increased compensation, benefits and opportunities to entice rheumatologists outside of their comfortable cluster.
Compensation: How Does Rheumatology Stack up?
A recent survey published in the Doximity 2018 Physician Compensation Report showed that rheumatology physicians received an average annual salary of $270,000. Rheumatology was also reported among the 20 lowest paid specialties, just above psychiatry with an average annual compensation of $268,000.
By comparison, specialties with the highest annual compensations included neurosurgery at $662,755, thoracic surgery at $602,745 and orthopedic surgery at $537,568, according to the report. Although rheumatologists are unlikely to see such lofty increases in the near future, the economic response to the workforce shortage has begun to turn the tide for rheumatology compensation.
“Right now the Northeast has the lowest compensation — the region has more physicians and more competition, which results in less compensation when it comes to salary, signing bonuses and other types of recruitment incentives,” Travis Singleton, executive vice president of clinical recruiter Merritt Hawkins, told Healio Rheumatology. “Compare that with the Southwest or the Heartland region in the middle of the country, where we have the fewest rheumatologists, you see the highest compensation. The difference between the two, give or take, is around 10% to 15%”
According to Singleton, another way to look at compensation is in terms of the recruitment market for rheumatologists. “Recruiters don’t have to concern ourselves with the rheumatologist who went to a training program, stayed where they trained and signed onto a group. No one had to recruit them, they wanted to be there, which is what you see in the Northeast. Right now, an average salary for a rheumatologist is right around $290,000; when you look at rheumatologists in the prime of their career, seeing a full patient load, we are seeing closer to $320,000.”
However, in areas outside of the densely populated Northeast, “you can’t get a rheumatologist to even look at you for less than $320,000,” noted Singleton. “This is either all straight salary, or salary plus signing bonus that is applicable the first year. We have clients guaranteeing $320,000 and more just to get a rheumatologist to work for them.”
According to the 2018 Medscape Physician Compensation Survey, rheumatologists in the U.S. saw compensation growths for the third consecutive year, with an above average 12% increase in 2016, 1% in 2017, and 9% in 2018. Although some surveyed rheumatologists attributed their increases to rising patient volume or productivity, others noted that promotions, raises and/or bonuses factored heavily into the increased compensation.
“In rheumatology, we have seen 2 years with a roughly 10% increase in compensation, which is crazy,” Singleton said. “Typically, you don’t see 10% over 3 or 4 years, which tells you that this is a highly competitive market. Clients are having to guarantee compensation higher than the American Medical Group Association or Medical Group Managers Association says rheumatologists should even make. The recruitment market is moving faster than the numbers, and one that is heavily weighted to the candidate side.”
However, Dua noted that while underserved areas can try and attract practitioners with higher salaries, retaining rheumatologists in these areas can be difficult as providers debate family and life planning.
“Being in a remote area does not change reimbursement, so while it may help to try and entice practitioners to come to a more remote or rural setting, lifestyle demands and the increasing opportunities nationally will make it hard to retain them and consistently outpace salaries nationally,” Dua told Healio Rheumatology. “At this point, even though the highest salaries for rheumatologists are in these areas — including the Southeast and South Central regions, where providers can make as much as double the salary of their counterparts in the Northwest — the higher concentration of practicing rheumatologists remains in urban areas, despite potentially lower salaries.”
Pipelines and Bottlenecks
Following the release of the earlier 2005 American College of Rheumatology Workforce Study, the ACR and the Rheumatology Research Foundation recognized that part of the problem was that medical students were not being sufficiently exposed to the specialty that is “usually buried in part of a musculoskeletal module,” noted Dua.
In an effort to grow interest in the field overall, the Rheumatology Research Foundation implemented various awards for medical students and residents curious about rheumatology research and developed the Preceptorship Program to foster greater awareness of rheumatology at earlier levels of medical training — efforts that are now coming to fruition.
“Although I won’t say that we have completely solved the problem, I will say we are well on our way,” Jonas said. “Rheumatology is actually a very popular specialty now among students and residents, but that interest has made it extremely competitive to get a rheumatology slot in a fellowship training program. In the most recent annual Specialty Match, only 65% of the applicants secured a slot for rheumatology training. However, there were an additional 119 applicants who did not match into the specialty.”
In a recent study published in International Journal of Rheumatology, researchers from George Washington University determined that student interest in rheumatology typically declined from the first to second year of medical school. However, the researchers also found that a student’s experience with a particular specialty in school as well as interactions with a mentoring faculty member heavily influenced their commitment to the specialty.
“Several studies show that exposure to a specialty during medical school is one of the major factors influencing ultimate career choice,” Victoria K. Shanmugam, MD, director of the division of rheumatology at The George Washington University, told Healio Rheumatology. “Interactions with mentors and specific enthusiastic teachers can be a major driver of future career. In view of this, early initiatives to highlight rheumatology as a career pathway before students narrow their focus to other specialties are important.”
Shanmugam and colleagues evaluated the impact of a student-led Rheumatology Interest Group — modelled on similar subspecialty interest groups in psychiatry and cardiology — on student uptake of the rheumatology specialty, and determined that such groups were pivotal in establishing student engagement with the specialty as evidenced by the increased generation of abstract and manuscript submissions, and growing enrollment in rheumatology.
“A student-led rheumatology interest group was shown to significantly increase student interest in rheumatology,” Shanmugam said. “Additionally, we demonstrated that, after development of the interest group, students had a significant increase in the number of faculty-student dyads working on abstracts and manuscript submission and there was a significant increase in enrollment in the rheumatology elective.”
Eakin noted that students can also take it upon themselves to attain exposure even if their program doesn’t guarantee it. “I would say that if medical students are interested at all, and their training program doesn’t include rheumatology, they should step out of their training program and get some exposure to this community,” he said. “Those students are going to find there is an abundance of unmet need and possibly find this specialty is something they can devote their life to with a very rewarding career.”
However, the growth of interest in rheumatology is only half of a small battle in an ongoing war against the workforce deficit. The lack of rheumatology fellowship slots for eager medical students represents a significant stumbling block to getting additional rheumatologists into the field, and training programs hinge on funding.
“We are faced with the challenge of having this tremendous interest in rheumatology training, but no way to accommodate all the interested physicians. On the other side, we have a great need for rheumatology services,” Jonas said. “How do we find available slots to train these applicants to be rheumatologists? There is a pressing medical need out there, but there is a bottleneck here. It costs money to train rheumatologists and with health care financing the way it is right now, has been and will continue to be in this country, the amount of money for rheumatology programs is limited. Many programs have the desire and ability to train more rheumatologists, but the challenge is how to support the education?”
A Field in Flux
To alleviate the shortage, numerous rheumatology organizations have repeatedly pushed for a variety of incentives to tempt young rheumatologists beyond the comfort zones of the states in which they received their training, and branch out to medically underserved areas. Incentive programs, such as loan repayment and loan forgiveness, are crucial in attracting medical students to new opportunities outside their home states.
“Medical students often enter practice with a significant amount of debt and there is no doubt that this plays a role in which field they choose to pursue,” Dua said. “A recent evaluation of rheumatology fellow debt showed that about 25% of U.S. graduates have more than $300,000 in student loan debt. While compensation structures have improved overall in rheumatology, this will continue to play a factor in which fields and subspecialties trainees go into.”
She added, “Incentives such as loan repayment programs and streamlined processes to help support international medical graduates to stay in the U.S. after fellowship and enter practice are two avenues that could be considered in attempting to support expansion of our workforce.”
In addition to petitioning for more fellowship slots, the ACR has publicly opposed the Trump administration’s proposed elimination of the Public Service Loan Forgiveness program, a move which could further constrict the supply of rheumatologists.
The ACR has also stood behind recent state legislation proposed in Georgia which would establish a loan forgiveness program for cognitive specialists who do not qualify for the federal Health Resources and Services Administration program. If enacted, the bill — H.B. 442 — could provide tax-free loan forgiveness in the amount of $25,000 annually to rheumatologists who practice in underserved areas of the state.
“Loan repayment programs are a huge lever that can be pulled,” Eakin said. “Providing that type of opportunity to someone entering into a career that is going to be one of service to an underserviced population — that is clearly a way that we can have a deep impact in offsetting the workforce shortage issues. The Arthritis Foundation has been working closely with other leaders, to institute loan repayment programs and legislation for pediatric rheumatology physicians by meeting with decision makers on Capitol Hill.”
Nevertheless, the outlook for the rheumatology job market appears strong, noted Singleton. “It’s hard to see rheumatologist compensation going anywhere but up based on basic supply and demand principles; more competition is going to continue to drive higher salaries.”
However, he cautioned, there is a financial ceiling. “When you have a limited amount of revenue that a physician can generate, you get to a point where you start losing money on them. Rheumatology is not there yet, but it is closer than people think. Even though rheumatologists generate revenue, and are critically important to the full continuum of care, you can’t just keep adding zeroes to the salary. We are close to that plateau in rheumatology and when it caps off, that doesn’t mean that we have solved a problem. It means that, sooner or later, a hospital will have to consider being more creative about where to spend that money.”
Beyond the compensation used to attract rheumatologists to underserved areas, Dua noted that incentives to retain them are just as important. “Investing in the physicians, supporting them through adequate nursing and support staff, not overburdening them with increasing time demands and administrative tasks, ensuring a supportive culture with opportunities for growth and advancement are all ways that individual practices or centers can try to retain their rheumatologists.”
She added, “Rheumatology, in my mind, is truly the best subspecialty with compelling diseases, continuity of care, amazing pathology, diverse patients, groundbreaking research and continuing advancements in treatment modalities for our patients. With the continuously growing need and the current shortage of supply, rheumatology holds a lot of promise for medical students, along with some potential challenges. As a field we will need to continue to be innovative to meet the needs of our patients and find ways to close the workforce gap.” – by Robert Stott
- Battafarano DF, et al. Arthritis Care Res. 2018;doi:10.1002/acr.23518.
- Bolster MB, et al. Arthritis Rheumatol. 2018;doi:10.1002/art.40432.
- Doximity 2018 Physician Compensation Report. Doximity blog. Posted March 27, 2018. https://blog.doximity.com/articles/doximity-2018-physician-compensation-report. Accessed March 11, 2019.
- Krupnikova SS, et al. Int J Rheumatol. 2019; doi: 10.1155/2019/4892707.
- Medscape. Medscape Physician Compensation Report 2018. www.medscape.com/slideshow/2018-compensation-overview-6009667#1. Accessed March 16, 2019.
- For more information:
- Anisha Dua, MD, MPH, can be reached at Northwestern University, 675 N. St. Clair St, 14th floor, Suite 100, Chicago IL 60611.; email: firstname.lastname@example.org.
- Guy Eakin, PhD, can be reached at 1355 Peachtree Street NE, Atlanta, GA 30309; email: email@example.com.
- Beth L. Jonas, MD, can be reached at UNC Rheumatology Clinic, 6013 Farrington Rd., Bldg 200, Suite 301, Chapel Hill, NC 27517.
- Victoria K. Shanmugam, MD, can be reached at The George Washington University, 2121 I St NW, Washington, DC 20052.
- Travis Singleton, can be reached at Merritt Hawkins, 8840 Cypress Waters Blvd. Suite 300, Dallas, TX 75019.
Disclosures: Dua, Eakin, Jonas, Shanmugam and Singleton report no relevant financial disclosures.