New generation of rheumatologists needed to meet future demand

According to a 2005 American College of Rheumatology Workforce Study, a burgeoning elderly population combined with a lack of growth in new rheumatologists was projected to lead to a shortage of 2,500 rheumatologists in the United States by 2025. A 2013 study reported that some micropolitan areas of the United States have few or no practicing rheumatologists. In 2015, an updated workforce study replicated the findings of the 2005 study, substantiating the significant need for a new generation of trained rheumatologists. 

“There is clearly a shortage of rheumatologists right now, and given all the current conditions, a growing shortage in the future,” Calvin R. Brown Jr., MD, professor of medicine and director of the rheumatology training program at the Feinberg School of Medicine at Northwestern University told Healio Rheumatology. “The number of rheumatologists we need has continued to go up. We have a growing population, more older patients and more people with access to care from the Affordable Care Act. Even with a full current training pipeline, there are still not enough rheumatologists being produced.”

Cal
Calvin R. Brown Jr.

Brown spoke with Healio Rheumatology about the causes of the shortage, the history of rheumatology workforce growth and possible solutions to this imminent problem.

Question: How is the United States different from other countries in terms of the distribution of physicians?

Answer: Unlike most western nations, the United States does not manage or actively regulate the number, type or geographic distribution of its physician workforce, including its rheumatology workforce. England, for example, actively regulates it physician workforce. In the United States, medical trainees, including rheumatology fellows, choose what and where they train and, eventually, where they are going to work. To work for the health system in England, there needs to be an available position in a particular specialty in a particular location. England carefully regulates the number of rheumatologists they have, and tells them where they have positions that are open or filled.

Q: Why is there a shortage overall in new rheumatologists?

A: Rheumatology is a relatively new specialty, and did not become a specialty you could train for in the United States until around or after World War II. As the field developed, and as knowledge developed, so did the training of physicians. Initially, these training programs were in the large cities where there were more medical schools, and then began to eventually spread across the country. Up until the 1980s, rheumatology was an attractive specialty and virtually all the training positions were filled. An important point is that at that time, there was not a huge disparity among the income of physicians. Radiologists and orthopedic surgeons did make more than rheumatologists, but not several folds more. Trainees could therefore choose their specialty based on their intellectual interest, not based on income penalties for some specialties.

However, from the 1980s forward, three major trends occurred. The first is that the disparity between specialty pay grew significantly. The incomes of the higher paying specialties — surgery and surgical specialties, radiology, ophthalmology, dermatology and anesthesiology — grew at a much greater rate than primary care or lower paying “cognitive “specialties like rheumatology or infectious disease. Some specialties, like pediatrics, fell even further behind.

The second factor that occurred was educational debt. As medical school tuition grew, student indebtedness grew and student debt of more than $250,000 grew dramatically. This is a major debt to carry and became a major driver of specialty choice.

The third factor was that during the Clinton administration, a major goal was to reform American health care and drive more physicians into primary care and away from specialty care. There was talk at that time that rheumatologists were going to need to go back into primary care. When you combine those three trends together, it resulted in many rheumatology fellowships being unfilled between the late 1980s into the early 2000s. There was a big vacuum with no new, young rheumatologists going in. Then in the 2000s, things changed again.

Q: What occurred in the 2000s?

A: What changed was the concern about income disparity. Income disparity still exists, and has grown even more among high-paying specialties vs. low-paying specialties.  At the same time, medicine moved from a male-dominated profession as more women graduated from college and medical school, and began to choose their specialties. At the same time, more two-career medical families emerged. The result was a physician workforce motivated less by money and more by how controllable the specialty lifestyle was. If you are a general surgeon, for example, you are on call a lot, you will frequently need to go in at night, do emergency surgery, be away from your family.

Rheumatology is controllable. These are chronic illnesses. There are few emergencies. You can plan your day. Even more importantly, you can go in and out of the specialty when you have children. Thus, income disparity ceased to be a major factor because there were more people entering the field who were often part of two-career families. There is also a large crop of older rheumatologists who love the field and are wonderful mentors, so that has grown interest in rheumatology again. For the last several years, almost every fellowship spot has been filled. However, the pipeline, even though it is full, is not big enough to match the number of senior rheumatologists who retire every year.

Forced retirement is another issue. Factors like electronic medical records, more bureaucracy and paperwork, prior authorizations and many other factors are driving people out at the end of their rheumatology career. We are bringing as many new people as we possibly can, but it is not enough to fill that gap, with fewer mid-career rheumatologist than ever.

Q: Can you discuss the current and future demand for rheumatologists?  How does the demand affect the shortage?

A: The workforce study done in 2005 was memorable because as you walked into the American College of Rheumatology Annual Meeting, it was the first thing you saw in the main hallway. For the first time, we had actual data, numbers, charts and graphs that showed the demand was going to continue to increase. It was going to continue to increase because we have more people in the United States, we have more older people and we have better treatments available, so there are more things we can do. We looked at that study in 2005 and we said, “We have got a problem.”

Ten years later, in 2015, the ACR repeated the study using the same methodology, parameters and guidelines, and found that, lo and behold, the first study was correct. The trends predicted held forth, and the trend is expected to get worse. The number of rheumatologists we need has continued to go up and the total number go down

Q: How might this problem be remedied?

A: One obvious, intuitive solution is to make more rheumatologists. Since we are filling almost every rheumatology fellowship position that is available, there clearly is interest. Rheumatology is frequently cited as one of the most satisfying of all physician careers. Famously, in 2012, in a large study of physician satisfaction, rheumatology scored number one. It continues to be a satisfying and controllable career. It is a field that is working to become friendlier to women. We have more women as leaders. But we still have a way to go.

The problem is, we only have a bottleneck in generating new rheumatologists. Almost all physician training in the United States is sponsored by the federal government through Medicare.  Even though we have more medical schools now, we do not have more training positions. We do not have the funds or the resources to train more rheumatologists.

There have been some small, but important drivers to try to increase this.

The Rheumatology Research Foundation has added funds toward training. There has been some interest, although also some apprehension, about industry trying to help subsidize and train rheumatologists. But overall, because the vast majority of training is funded by the government and there are not more government dollars, making more rheumatologists does not seem like it is going to be an immediate answer.

Another way to deal with this is to find practitioners who can fill the gaps. That is clearly a possibility for the future — nurse practitioners (NPs) and physician assistants (PAs). Those programs are now growing, and we have a greater number of NPs and PAs coming into the field. The American College of Rheumatology Committee on Workforce and training is creating a model of formal rheumatology training for NPs and PAs. Attracting these people into rheumatology and having a clear and established pathway to become a rheumatology NP or PA is another way to fill the gap.

A third way is a sort of revolution that has been put forth by some organizationally forward-thinking rheumatologists. This approach is to stop being rheumatologists in the way that we all learned, which is one patient at a time, one visit at a time, scheduling regular appointments during regular days of the week. This new approach would involve changing the way we see patients. It might involve things like population management, where you have one rheumatologist who can manage many more people through group meetings and flexible appointments. Maybe patients who are doing well can put off their appointments and make space for those who are not doing well.

There are various innovative ideas that Timothy Harrington, MD, and Erin Arnold, MD, have been exploring. The idea is to take care of more patients in a more effective way in the same amount of time.

Obviously, we still need rheumatologists as the core of all this because they are the ones who know best how to use this knowledge, and more importantly, they are the ones who create new knowledge. We need new knowledge and information for the cures of the future. These interim strategies are great, but they are not long-term, sustaining strategies. They will be good additions to fill the gap and will likely play an increasing role in rheumatology care of the future. However, we still need to ensure the future of rheumatology by training rheumatologists who will take care of these patients, try these new methods of practice, and find new knowledge and strategies to improve patient care.

Q: Do you think the income disparity between higher- and lower-paying specialties will ever be eliminated?

A: This is an interesting question and one I am not insulated from because I am a salaried academic physician. I know private practice rheumatologists are always looking at it and trying to find ways to improve their business model. At the same time, the gap between the highest paying and the lower paying specialties continues to grow, and that continues to make our health care system inefficient. I do not know what the answers are for that under the current system.

Q: In your opinion, what are some of the strengths of rheumatology as a specialty?

A: We are a small field, but we are a unified field. There is not a whole lot of partisanship among rheumatologists, where one faction says X and the other says Y. We do not in-fight. Because there is a single, general unified community and a single leadership organization, we have been fortunate enough to look at these problems, acknowledge they exist and seek ways to deal with them. Hopefully, in the future, we will continue to use this knowledge to achieve these goals. That is the great thing about rheumatology. We face some serious problems, particularly in terms of our numbers in the future, but I am optimistic. If there is any group within medicine that can accept that there is a problem, ask the right questions and find answers to those questions, I think rheumatology is it. by Jennifer Byrne

References:

American College of Rheumatology. 2013. Available at www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/29/Shortage-of-RheumatologistsIn-Some-US-Regions-Closest-Doctor-May-Be-200-Miles-Away

FitzGerald JD. Arthritis & Rheumatology. 2013;doi:10.1002/art.38167.  

Medscape. 2012. Physician Lifestyle Report. Available at www.medscape.com/sites/public/lifestyle/20.

Smith BJ, et al. Abstract #2085. Presented at: American College of Rheumatology Annual Meeting; Nov. 11-16, 2016; Washington, DC.

For more information:

Calvin R. Brown Jr., MD, can be reached at 240 East Huron McGaw M300, Chicago, IL 60611; email: c-brownjr@northwestern.edu.

Disclosure: Brown reports no relevant financial disclosures.

According to a 2005 American College of Rheumatology Workforce Study, a burgeoning elderly population combined with a lack of growth in new rheumatologists was projected to lead to a shortage of 2,500 rheumatologists in the United States by 2025. A 2013 study reported that some micropolitan areas of the United States have few or no practicing rheumatologists. In 2015, an updated workforce study replicated the findings of the 2005 study, substantiating the significant need for a new generation of trained rheumatologists. 

“There is clearly a shortage of rheumatologists right now, and given all the current conditions, a growing shortage in the future,” Calvin R. Brown Jr., MD, professor of medicine and director of the rheumatology training program at the Feinberg School of Medicine at Northwestern University told Healio Rheumatology. “The number of rheumatologists we need has continued to go up. We have a growing population, more older patients and more people with access to care from the Affordable Care Act. Even with a full current training pipeline, there are still not enough rheumatologists being produced.”

Cal
Calvin R. Brown Jr.

Brown spoke with Healio Rheumatology about the causes of the shortage, the history of rheumatology workforce growth and possible solutions to this imminent problem.

Question: How is the United States different from other countries in terms of the distribution of physicians?

Answer: Unlike most western nations, the United States does not manage or actively regulate the number, type or geographic distribution of its physician workforce, including its rheumatology workforce. England, for example, actively regulates it physician workforce. In the United States, medical trainees, including rheumatology fellows, choose what and where they train and, eventually, where they are going to work. To work for the health system in England, there needs to be an available position in a particular specialty in a particular location. England carefully regulates the number of rheumatologists they have, and tells them where they have positions that are open or filled.

Q: Why is there a shortage overall in new rheumatologists?

A: Rheumatology is a relatively new specialty, and did not become a specialty you could train for in the United States until around or after World War II. As the field developed, and as knowledge developed, so did the training of physicians. Initially, these training programs were in the large cities where there were more medical schools, and then began to eventually spread across the country. Up until the 1980s, rheumatology was an attractive specialty and virtually all the training positions were filled. An important point is that at that time, there was not a huge disparity among the income of physicians. Radiologists and orthopedic surgeons did make more than rheumatologists, but not several folds more. Trainees could therefore choose their specialty based on their intellectual interest, not based on income penalties for some specialties.

However, from the 1980s forward, three major trends occurred. The first is that the disparity between specialty pay grew significantly. The incomes of the higher paying specialties — surgery and surgical specialties, radiology, ophthalmology, dermatology and anesthesiology — grew at a much greater rate than primary care or lower paying “cognitive “specialties like rheumatology or infectious disease. Some specialties, like pediatrics, fell even further behind.

The second factor that occurred was educational debt. As medical school tuition grew, student indebtedness grew and student debt of more than $250,000 grew dramatically. This is a major debt to carry and became a major driver of specialty choice.

The third factor was that during the Clinton administration, a major goal was to reform American health care and drive more physicians into primary care and away from specialty care. There was talk at that time that rheumatologists were going to need to go back into primary care. When you combine those three trends together, it resulted in many rheumatology fellowships being unfilled between the late 1980s into the early 2000s. There was a big vacuum with no new, young rheumatologists going in. Then in the 2000s, things changed again.

Q: What occurred in the 2000s?

A: What changed was the concern about income disparity. Income disparity still exists, and has grown even more among high-paying specialties vs. low-paying specialties.  At the same time, medicine moved from a male-dominated profession as more women graduated from college and medical school, and began to choose their specialties. At the same time, more two-career medical families emerged. The result was a physician workforce motivated less by money and more by how controllable the specialty lifestyle was. If you are a general surgeon, for example, you are on call a lot, you will frequently need to go in at night, do emergency surgery, be away from your family.

Rheumatology is controllable. These are chronic illnesses. There are few emergencies. You can plan your day. Even more importantly, you can go in and out of the specialty when you have children. Thus, income disparity ceased to be a major factor because there were more people entering the field who were often part of two-career families. There is also a large crop of older rheumatologists who love the field and are wonderful mentors, so that has grown interest in rheumatology again. For the last several years, almost every fellowship spot has been filled. However, the pipeline, even though it is full, is not big enough to match the number of senior rheumatologists who retire every year.

Forced retirement is another issue. Factors like electronic medical records, more bureaucracy and paperwork, prior authorizations and many other factors are driving people out at the end of their rheumatology career. We are bringing as many new people as we possibly can, but it is not enough to fill that gap, with fewer mid-career rheumatologist than ever.

Q: Can you discuss the current and future demand for rheumatologists?  How does the demand affect the shortage?

A: The workforce study done in 2005 was memorable because as you walked into the American College of Rheumatology Annual Meeting, it was the first thing you saw in the main hallway. For the first time, we had actual data, numbers, charts and graphs that showed the demand was going to continue to increase. It was going to continue to increase because we have more people in the United States, we have more older people and we have better treatments available, so there are more things we can do. We looked at that study in 2005 and we said, “We have got a problem.”

Ten years later, in 2015, the ACR repeated the study using the same methodology, parameters and guidelines, and found that, lo and behold, the first study was correct. The trends predicted held forth, and the trend is expected to get worse. The number of rheumatologists we need has continued to go up and the total number go down

Q: How might this problem be remedied?

A: One obvious, intuitive solution is to make more rheumatologists. Since we are filling almost every rheumatology fellowship position that is available, there clearly is interest. Rheumatology is frequently cited as one of the most satisfying of all physician careers. Famously, in 2012, in a large study of physician satisfaction, rheumatology scored number one. It continues to be a satisfying and controllable career. It is a field that is working to become friendlier to women. We have more women as leaders. But we still have a way to go.

The problem is, we only have a bottleneck in generating new rheumatologists. Almost all physician training in the United States is sponsored by the federal government through Medicare.  Even though we have more medical schools now, we do not have more training positions. We do not have the funds or the resources to train more rheumatologists.

There have been some small, but important drivers to try to increase this.

The Rheumatology Research Foundation has added funds toward training. There has been some interest, although also some apprehension, about industry trying to help subsidize and train rheumatologists. But overall, because the vast majority of training is funded by the government and there are not more government dollars, making more rheumatologists does not seem like it is going to be an immediate answer.

Another way to deal with this is to find practitioners who can fill the gaps. That is clearly a possibility for the future — nurse practitioners (NPs) and physician assistants (PAs). Those programs are now growing, and we have a greater number of NPs and PAs coming into the field. The American College of Rheumatology Committee on Workforce and training is creating a model of formal rheumatology training for NPs and PAs. Attracting these people into rheumatology and having a clear and established pathway to become a rheumatology NP or PA is another way to fill the gap.

A third way is a sort of revolution that has been put forth by some organizationally forward-thinking rheumatologists. This approach is to stop being rheumatologists in the way that we all learned, which is one patient at a time, one visit at a time, scheduling regular appointments during regular days of the week. This new approach would involve changing the way we see patients. It might involve things like population management, where you have one rheumatologist who can manage many more people through group meetings and flexible appointments. Maybe patients who are doing well can put off their appointments and make space for those who are not doing well.

There are various innovative ideas that Timothy Harrington, MD, and Erin Arnold, MD, have been exploring. The idea is to take care of more patients in a more effective way in the same amount of time.

Obviously, we still need rheumatologists as the core of all this because they are the ones who know best how to use this knowledge, and more importantly, they are the ones who create new knowledge. We need new knowledge and information for the cures of the future. These interim strategies are great, but they are not long-term, sustaining strategies. They will be good additions to fill the gap and will likely play an increasing role in rheumatology care of the future. However, we still need to ensure the future of rheumatology by training rheumatologists who will take care of these patients, try these new methods of practice, and find new knowledge and strategies to improve patient care.

Q: Do you think the income disparity between higher- and lower-paying specialties will ever be eliminated?

A: This is an interesting question and one I am not insulated from because I am a salaried academic physician. I know private practice rheumatologists are always looking at it and trying to find ways to improve their business model. At the same time, the gap between the highest paying and the lower paying specialties continues to grow, and that continues to make our health care system inefficient. I do not know what the answers are for that under the current system.

Q: In your opinion, what are some of the strengths of rheumatology as a specialty?

A: We are a small field, but we are a unified field. There is not a whole lot of partisanship among rheumatologists, where one faction says X and the other says Y. We do not in-fight. Because there is a single, general unified community and a single leadership organization, we have been fortunate enough to look at these problems, acknowledge they exist and seek ways to deal with them. Hopefully, in the future, we will continue to use this knowledge to achieve these goals. That is the great thing about rheumatology. We face some serious problems, particularly in terms of our numbers in the future, but I am optimistic. If there is any group within medicine that can accept that there is a problem, ask the right questions and find answers to those questions, I think rheumatology is it. by Jennifer Byrne

References:

American College of Rheumatology. 2013. Available at www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/29/Shortage-of-RheumatologistsIn-Some-US-Regions-Closest-Doctor-May-Be-200-Miles-Away

FitzGerald JD. Arthritis & Rheumatology. 2013;doi:10.1002/art.38167.  

Medscape. 2012. Physician Lifestyle Report. Available at www.medscape.com/sites/public/lifestyle/20.

Smith BJ, et al. Abstract #2085. Presented at: American College of Rheumatology Annual Meeting; Nov. 11-16, 2016; Washington, DC.

For more information:

Calvin R. Brown Jr., MD, can be reached at 240 East Huron McGaw M300, Chicago, IL 60611; email: c-brownjr@northwestern.edu.

Disclosure: Brown reports no relevant financial disclosures.