Issue: February 2021
Source: Battafarano DF, et al. Arthritis Care Res. 2018;doi:10.1002/acr.23518.
Disclosures: Jonas, Mehta and Patty-Resk report no relevant financial disclosures. Mixon reports consulting relationships with AbbVie, Amgen, Eli Lilly, Novartis and Sanofi. Smith reports being on the speaker's bureau and advisory board of and consulting for Abbvie and Sanofi Genzyme, and being on the advisory board of Pfizer.
February 18, 2021
12 min read
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Workforce shortage: Selling a specialty that should sell itself

Issue: February 2021
Source: Battafarano DF, et al. Arthritis Care Res. 2018;doi:10.1002/acr.23518.
Disclosures: Jonas, Mehta and Patty-Resk report no relevant financial disclosures. Mixon reports consulting relationships with AbbVie, Amgen, Eli Lilly, Novartis and Sanofi. Smith reports being on the speaker's bureau and advisory board of and consulting for Abbvie and Sanofi Genzyme, and being on the advisory board of Pfizer.
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The looming workforce shortage in rheumatology is not a new problem, and it is certainly not going away. But ongoing campaigns to draw talent to the specialty, novel paradigms of patient care and the unexpected twist of COVID-19 may be changing the game.

The 2018 data set from Battafarano and colleagues published in Arthritis Care & Research outlining the workforce shortage has appeared in peer-reviewed publications, at national meetings and in the pages of Healio Rheumatology. Their conclusions are disquieting: Due to imminent practitioner retirements and sluggish personnel replenishment, the rheumatology workforce is projected to be severely shorthanded by 2030. The implications for patient access to care could be profound.

Source: Adobe Stock.
Source: Adobe Stock.

Beth Jonas, MD, chair of the American College of Rheumatology’s Committee on Rheumatology Training and Workforce Issues, said that the shortage is a “huge priority” for the ACR and the Association of Rheumatology Professionals (ARP).

“We need to work on creative ways of building rheumatology practices and the availability of rheumatology training where it does not exist,” she told Healio Rheumatology. “These are not new challenges, but they are difficult ones.”

Jonas laid out some of the basic targets for expanding the workforce. “There are efforts to increase advanced practice provider (APP) programs,” she said. “Also, we are looking at ways to remedy the uneven geographic distribution of rheumatologists around the country.”

The early push to increase the number of APPs in the field has already borne fruit. Amanda Mixon, PA-C, a physician assistant with the Colorado Center for Arthritis and Osteoporosis, has been a rheumatology APP in a number of different settings, and she believes that the efforts of organizations like Rheumatology Advanced Practice Providers (RhAPP) are paying off. “At a meeting like ACR 10 years ago, I might run into one other APP who specialized in rheumatology exclusively,” she said. “But they are becoming more and more common.”

While headway is being made to showcase the clinical and lifestyle benefits of rheumatology to more medical students, Beth Jonas, MD, noted that advanced practice providers will be critical to ensuring that delivery of rheumatology care is not interrupted. “The rheumatology community, writ large, has to be able to recruit APPs to the specialty and then train them to provide appropriate care. They will fill an important niche.”
While headway is being made to showcase the clinical and lifestyle benefits of rheumatology to more medical students, Beth Jonas, MD, noted that advanced practice providers will be critical to ensuring that delivery of rheumatology care is not interrupted. “The rheumatology community, writ large, has to be able to recruit APPs to the specialty and then train them to provide appropriate care. They will fill an important niche.”

Source: UNC School of Medicine Chapel Hill.

However, the “geography problem,” as Jonas called it — with plenty of rheumatologists in and around major cities and at academic medical centers, but few or none in rural areas — continues to vex decision-makers, particularly in pediatric rheumatology.

Brett Smith, DO, of Blount Memorial Physicians Group and East Tennessee Children’s Hospital, has firsthand experience with this issue. Like many rheumatologists in non-urban places with no academic medical center, he is required to treat both adults and children. “We could be in serious trouble if more efforts are not made to fix the shortage,” Smith said. “It is only a matter of time before we see the impact on patient outcomes, particularly with kids.”

Despite these warning signs, there is evidence that the tide is turning. For example, findings from the most recent National Resident Matching Program (NRMP) — commonly called the Match — showed that for the 2021 appointment year, of 338 applicants interested in rheumatology, 246 matched to the specialty, a rate of 72.8%.

The interest is coupled with an increase in residency opportunities, according to Jonas. “We added 15 new programs and 36 slots for first-year trainees,” she said.

Whether these increases will be enough to fill every gap in the U.S. remains to be seen.

If there is an X factor in all of this, it is COVID-19. Due to the systemic inflammation that accompanies the most severe cases of the virus, a number of drugs and therapeutic approaches commonly used in rheumatology have been used to treat it. Consequently, rheumatology has gained considerable attention. But it is too early to tell whether that attention will translate into an increase in the number of trainees entering the field. Regardless, the leadership at ACR, ARP and other such organizations are aware that the spotlight is shining on rheumatology and are prepared to capitalize.

As the pandemic rages on and more and more rheumatology providers retire, experts must take all the information given, the negative and the positive, and work toward expanding rheumatology patient care however possible.

Popularity Contest

The prevailing wisdom is that, as a job and a medical specialty, rheumatology — with an attractive work-life balance profile and an endless stream of compelling clinical puzzles to solve — sells itself. The primary concern is that not enough medical trainees are exposed to the field early in their training.

As for the attractive features of rheumatology, one is that patients with rheumatic and autoimmune diseases rarely have true emergencies. What this means is that rheumatologists, by and large, rarely field 3 a.m. phone calls and are generally able to spend evenings as they wish.

Another benefit is that chronic conditions lead to satisfying, long-term provider-patient relationships. “I am growing older with my patients,” Mixon said. “I know their spouses and their families, I am seeing them have kids, and I am showing them pictures of my kids.”

Jay Mehta, MD, MS
Jay Mehta

This benefit can be even greater for pediatric rheumatologists, according to Jay Mehta, MD, MS, attending physician with the division of rheumatology and associate program director of the Pediatrics Residency Program at Children’s Hospital of Philadelphia. “My patients span a whole range from infancy to young adults aged 18 to 20 years,” he said. “In certain other fields, you end up treating people in one age range your whole career.”

This is not the only benefit to treating both younger and older patients, according to Smith. “Kids have a hard enough time with the normal aspects of growing up,” he said. “They should not have to worry about whether they can walk or run or whether they will be waking up at night in pain. We can help ease those worries.”

A rheumatic or autoimmune disease can “hit a kid like a sledgehammer,” Smith said. “When we treat these patients, we can give them their life back. The children and their parents are bonded to you, because you make them remember how life should be.”

A companion point to all of this is the myth that rheumatology exclusively entails treating older people with arthritis. “The immune system is by far the coolest system in the body,” Mehta said. “Dealing with the complex pathophysiology of many of these conditions and managing the consequences of abnormalities in the immune system can be incredibly rewarding.”

Amanda Mixon, PA-C
Amanda Mixon

Mixon wondered whether this message is being broadcast effectively in medical school. “Medical trainees may only get two lectures on rheumatology: one in RA and one in gout,” she said. “But that is it. People do not understand how interesting and variable the specialty can be.”

COVID-19 notwithstanding, Mehta added that the current moment is a particularly exciting time for rheumatology. “Twenty years ago, all we had were steroids and methotrexate,” he said. “Now, we have so many good drugs to treat these diseases and target various cellular pathways. We need to let trainees know that this is a good time to be a rheumatologist.”

What all of this translates to is job satisfaction, according to Mehta. “There is something about the field where people are surprised at how nice everyone is, and how much we love what we do,” he said.

Brett Smith, DO
Brett Smith

With so many appealing features, it should follow that medical trainees would be fighting for spots. Smith mused on why they are not. “We need to be having these conversations about the specialty earlier,” he said. “I usually see medical students in the fourth year, but, by that point, they have already made up their mind about what field they are going to enter.”

As Jonas noted, efforts are being made to expose more medical students to the clinical and lifestyle benefits of a career in rheumatology. In the meantime, APPs are filling a lot of gaps in care.

Sharing the Burden

Having worked as an APP in a variety of settings — from a practice with one rheumatologist and five APPs to a large practice where she is the only APP to 12 rheumatologists — Mixon is uniquely qualified to comment on how these professionals can be most effectively utilized. “It is important for any APP going into a practice to understand the dynamics and what is expected of them,” she said.

A key point is that new and experienced APPs have different needs, according to Mixon. A new APP may have had little formal training in rare or specific conditions like vasculitis or lupus nephritis, so they must be brought up to speed clinically. An experienced APP, on the other hand, may benefit from more nuanced information. RhAPP offers education tailored to all these needs.

In terms of work-life balance, the demands on new and experienced APPs alike can vary greatly from practice to practice.

“There are many private practices in out-of-the-way places where a young APP might find a job straight out of training,” Mixon said. “But there is little time to train them and no way to really prepare them for the responsibility of working with the only practitioner for hundreds of miles. Unfortunately, they often get overwhelmed and end up quitting.”

Organizations like RhAPP are attuned to these concerns. “We want to give new APPs practical information that they can use the next day,” Mixon said. “The last thing we want is to throw someone into the deep end.”

To this point, burnout has become a “hot topic” for the broader rheumatology community, Mixon said. “It is just as important for those entering the workforce to consider the mental health component as the clinical components.”

This underscores an important disparity seen within the rheumatology community. In more densely populated areas, a rheumatologist can have that aforementioned stable and predictable life, with evenings and weekends free. However, a practitioner in a rural area can be worked to the point of exhaustion. In such situations, collaboration between rheumatologist and all supporting staff is of critical importance to ensure that there is no drop-off in patient care, regardless of personnel.

Working Together

For Cathy Patty-Resk, MSN, president of the Rheumatology Nurses Society, and an APP with the same rheumatologist for a decade, a key component to effective deployment of APPs is education of the rheumatologist. Some rheumatologists are happy to have the help. Others, understandably, are loath to surrender control.

Cathy Patty-Resk, MSN
Cathy Patty-Resk

“My message to rheumatologists is this: Your APP is only going to be as good as you train them to be,” she said. “If the physician is willing to put the time in and establish trust with the APP, they will come out so much farther ahead in the long run.”

The onus on the APP, then, is to learn. “I came to rheumatology with no experience,” Patty-Resk said. “I had to rely on my rheumatologist to teach and guide me. For the first 2-plus years I worked in the practice, I had my nose in a book for many long nights.”

But the learning paid off, according to Patty-Resk. “We have a very unique relationship, where we are sharing calls fifty-fifty,” she said. “He trusts me and I trust him to make the right decisions in the clinic.”

For rheumatologists who are still hesitant to surrender trust, Mixon offered the reminder that APPs and doctors alike want to make sure patients receive the best possible care. “We all want to give the best possible care,” she said. “Rather than viewing this in a competitive way, we have to view this as a positive for our patients.”

“Regardless of how they feel about it, a lot of practices are using APPs now,” Jonas added. “The rheumatology community, writ large, has to be able to recruit APPs to the specialty and then train them to provide appropriate care. They will fill an important niche.”

As Mixon has shown, it is possible for any individual APP to adapt to the variables any given practice may offer. Maintaining such poise has never been more essential than under the shadow of COVID-19.

Spotlight in the Pandemic

Given the swiftness and frequency with which public health recommendations and therapeutic options evolved throughout the pandemic, many experts believe that it could take some time — months, or even years — before the true impact of COVID-19 on the rheumatology workforce becomes clear. Jonas described the situation as “tremendously in flux.”

However, Jonas is encouraged that despite many practices slowing or shutting down to ensure the safety of doctors, patients and support staff, the decline in patient care has not been substantial. “Also, I suspect that as we get our communities vaccinated, many of those practices will be up and running at full capacity again,” she said.

If there is one reason rheumatology practices survived during COVID, it is telehealth, according to Jonas. “If nothing else, the pandemic accelerated the acceptance of telehealth in rheumatology,” she said.

Jonas noted that the drive to build the technological infrastructure to support tele-rheumatology has been accompanied by an increased willingness among third-party payers to reimburse these visits.

This has played out across the country in the form of individual doctor-patient relationships. “I have been able to see new patients from Riverton, Wyoming via telemedicine, which is a 6-hour drive away,” Mixon said. “Many of them did not even realize that they should see a rheumatologist, or that that was even a thing. But we found each other through word-of-mouth. This has been a silver lining in COVID-19.”

Another piece of the puzzle is learning to stratify patients based on whether they are a good candidate for a tele-rheumatology visit. “Patients who are stable on their medications and able to get labs checked locally do not have to come into the office to see us as routinely,” Jonas said. “They can check in via a telemedicine visit.”

Patients with more severe disease or who require hands-on care are going into the office, according to Jonas.

The potential impact of this on patient outcomes is clear: Using a combination of telehealth and in-person visits, rheumatologists can maximize their time and deliver appropriate treatment to all types of patients. This model of care may not have evolved were it not for COVID-19 and the associated periods of quarantine.

Another positive aspect of the COVID-19 discussion pertains to the amount of attention that rheumatology drugs received as potential treatments for the virus. “As a rheumatology practitioner, it was exciting to hear that cytokines were at the forefront of the virus,” Patty-Resk said. “This is definitely going to raise the profile of rheumatology and provide greater understanding of what we do.”

Like many others in the field, Jonas has found that this attention, and this ability to contribute so greatly to general public health, has been “professionally rewarding.”

This, obviously, translates into greater visibility for rheumatology as a specialty. “But I am not sure whether it is attracting, or will attract, new residents and trainees,” Jonas said. “At the moment, it is just rewarding to be seen as thought leaders in this crisis.”

Looking to the future, Mixon suggested that the pandemic has changed not only how medicine is practiced, but how it is taught. “Online education has completely changed the way we can educate the next generation of the workforce in a number of positive ways,” she said.

Before the rise of Zoom and other online meeting platforms, trainees and young practitioners may have felt that the only way they were really going to build their knowledge base was to travel to conferences. “With RhAPP, we have done smaller online workshops where you have thought leaders giving lectures on really complicated and specific topics like vasculitis or scleroderma, and you have trainees thousands of miles away who are able to interact with them directly,” Mixon said. “This kind of thing does not happen as much at major medical meetings, and it definitely was not happening before COVID.”

That said, Mixon looks forward to a time when it will be possible to have in-person meetings again. “In terms of recruiting and getting people excited about the specialty, there is no substitute for going into schools to lecture or meeting people face to face,” she said.

While Patty-Resk suggested that it is far too early to speculate on whether all of the attention from COVID will translate into more interest in rheumatology, she made one key point about people who enter the field. “Rheumatology seems to attract people who are independent thinkers and who like to be challenged,” she said. “If more of those types of people can see what we do as a result of the focus on cytokines from COVID, we may see an increase in interest.”

Looking Ahead

Regardless of whether COVID-19 positively or negatively impacts the rheumatology workforce, the issues that were present before the pandemic are likely to be ongoing when it is finally in the rearview mirror, according to Smith. “So many of us who treat children and adults are split between two places,” he said. “It is difficult to fill both roles. I have to question the sustainability as the volume of patients increases without additional help.”

Smith is encouraged by the results of the Match and other parameters showing spikes in interest in rheumatology. “We are going to need as many people as possible,” he said.

It is critical that decision-makers at every level see rheumatology as a priority, according to Jonas. “Money alone is not going to solve this problem,” she said. “You need educators, you need discussion with local community clinics, with universities and academic medical centers, and you need advocates at the major medical societies,” she said.

Patty-Resk underscored this point. “The Rheumatology Nurses Society has been focused on drawing people into the workforce for many years now,” she said. “We are doing everything we can to show what rheumatology is, how fun and exciting and challenging it can be.”

For Mehta, beefing up the rheumatology workforce goes hand-in-hand with advances made on the research side. “We have done so well over the last 10 to 15 years with new medications in terms of preventing long-term damage in our patients,” he said. “If we do not have enough providers, we risk undoing a lot of that.”

It is for this reason that Mehta continues to beat the drum for the specialty. “If we can let medical trainees know how much of an impact they can have on their patients’ lives, we can attract many more people to the field,” he said.