For some time now, we’ve known that there’s a growing shortage of primary care doctors in America. In March 2015, the American Academy of Family Physicians released a report that indicated the United States would experience a shortage of between 46,000 and 90,000 physicians by 2025. That estimate included a shortfall of 12,500 to 31,000 primary care physicians with the balance of the deficit occurring in various specialty fields of medicine.
One of the specialties included in that estimate was rheumatology, and two new studies from the American College of Rheumatology provide further warning about the coming shortage of rheumatologists. A workforce study in the journal Arthritis Care & Research looked at supply and demand projections over the next decade and found that already, rheumatology has a shortfall of about 700 care providers. The gap is expected to widen significantly, expanding to more than 4,000 providers by 2030. The second study, appearing in the journal Arthritis & Rheumatology, examined the educational system and how its current arrangement won’t be able to graduate enough new rheumatologists to keep up with demand for this type of care.
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The American College of Rheumatology defines a rheumatologist as “an internist or pediatrician who received further training in the diagnosis (detection) and treatment of musculoskeletal disease and systematic autoimmune conditions commonly referred to as rheumatic disease. These diseases can affect the joints, muscles and bones causing pain, swelling, stiffness and deformity.” Some of the most common ailments that a rheumatologist treats are osteoarthritis (stiffness and pain in the joints), osteoporosis (a weakening of the bones that can lead to fractures), rheumatoid arthritis (an autoimmune disorder that causes inflammation in the joints and other tissues) and lupus (another autoimmune disease that causes chronic joint pain and inflammation).
Many of the diseases that rheumatologists treat are associated with aging, and this is contributing to the rising demand for rheumatological care in the United States. As our population ages, these ailments become more commonplace. “One thing that is guaranteed for everybody, if you live long enough, you will develop osteoarthritis,” says Dr. Wael Jarjour, professor of medicine and division director of immunology and rheumatology at The Ohio State University Wexner Medical Center in Columbus.
In addition, Jarjour says “there is a significant increase in demand for rheumatology care because many of the diseases we treat now have effective treatments. In the past when we lacked treatments, patients with these diseases were managed by primary care physicians. Now, however, we have seen a significant increase in patient referrals to our specialty” across the country and getting an appointment with a rheumatologist is getting more difficult for many people, especially those in rural or underserved parts of the country.
Couple that rising demand with the fact that many doctors currently practicing in the field of rheumatology are nearing retirement age themselves, and you start to see the scope of the predicament. “Up to 50 percent of our current rheumatology supply is planning to retire,” says Dr. Marcy B. Bolster, a rheumatologist at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School. Bolster was lead author on one of the studies and notes that, “when people retire, they often don’t just stop seeing patients the next day, they often taper off,” so they may not be seeing patients full-time for months or even years before they finally exit the workforce.
Other demographic trends in the workforce indicate there may be fewer doctors available to see patients full-time in the coming decade. These shifts include a rising number of female physicians, who often must shoulder family demands that can reduce their available working hours. “Our profession is predominantly outpatient care, and so that allows [women] to professionally come in and out of the workplace as needed and to balance this with their other responsibilities,” says Dr. Daniel F. Battafarano, division director, rheumatology service at the San Antonio Military Medical Center in Texas, formerly Brooke Army Medical Center, and lead author on one of the studies. Millennial-generation doctors have also been shown to have a different approach to work-life balance than their baby boomer predecessors, which may alter the availability of appointments for patients. “Every workforce phenomenon that’s happening in medicine is happening around the globe and in the corporate world. It’s just a workforce phenomenon, it’s not judgmental,” he says.
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To get a better handle on these trends in workforce availability, the researchers looked beyond the sheer number of providers and analyzed how many providers were seeing patients full-time or part-time. Battafarano says this study was the first to take into consideration the hours each rheumatologist is actually available to see patients. “What we tried to do in our model was to get an estimate of the total full-time rheumatologists in the U.S. or the full-time equivalents in the U.S. by including part-time rheumatologists as well.” By calculating the percentage of time rheumatologists are available to see patients, he says they arrived at a more accurate estimate of the actual need in the field.
This is important to do, Bolster says, because “it’s not just about numbers of people in practice but the amount of time being focused on practice. That makes a big difference, because if you said you have 10 rheumatologists, you would assume you have the workload of 10 individuals. If all of them were in private practice we might have the workload for 10 individuals. But if you had only two in private practice and eight were in academia, then 80 percent wouldn’t be at a full-time equivalent,” because rheumatologists in academia are spending a significant amount of time teaching or conducting research rather than seeing patients. By crunching all this data, Bolster says, “I think we got a more accurate prediction of what our supply might be.”
Another alarming aspect of these two studies was the indication that certain areas of the country are going to feel this shortage of rheumatologists more acutely. Currently, the highest concentration of rheumatologists can be found in the northeastern region of the U.S., while portions of the South and West have fewer doctors. This is because “a lot of people tend to train in an area and then stay pretty close — within 100 miles of that area. So you have this concentration of rheumatologists in the Northeast because there’s a lot of rheumatology training programs in the Northeast,” Battafarano says, and this problem is expected to get worse. “If we fast-forward 10 years, after you factor in [the anticipated] loss of 50 percent of rheumatologists with baby boomer retirements and all these other demographic shifts to a female, millennial workforce, suddenly we have a dramatic deficit. In 2025, the Northwest is going to have 0.5 rheumatologists for every 100,000 people, and the Northeast will have 1.6 rheumatologists per 100,000 adults. That means a lot of people aren’t going to have access to see a rheumatologist in 10 years,” Battafarano says.
So what can be done about this coming crisis? One potential solution is to expand the number of fellowship positions available to train more rheumatologists. “It makes intuitive sense to try to increase the number of people being trained and going into rheumatology,” Bolster says. But the issue there is financial. “Fellows are paid positions and we need salary support for these positions. There’s not an open bank account” to just endlessly hire new people, she says.
While adding more fellows and graduating more rheumatologists who go into private practice is certainly one aspect of the solution, Jarjour says there’s still a big need for rheumatologists in academia to train up-and-coming doctors. “In order to train more rheumatologists for the future, you need more faculty now in academic medicine to train them. The most difficult part, then, is for those of us who train rheumatologists to make a better case for these doctors to stay in academia and, thus, participate in training the next generation of rheumatologists. I think this is something that would help tremendously.”
But the question still stands: How do you make more rheumatology appointments available to patients who need them? One potential solution is to empower other care providers, such as nurse practitioners and physician assistants, to offer rheumatological care alongside physicians. In addition, Bolster says pharmacists, therapists and internists can also be better integrated into managing care for patients with rheumatic disease.
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To address the shortfall in areas of the country that are expected to have the biggest deficits in 2025, Battafarano says regions and hospitals that need rheumatologists may have to get creative in offering incentives to physicians to relocate. Increasing the number of training programs in underserved regions may also help address the uneven geographic distribution of rheumatologists.
In the end, there’s not going to be an easy answer to this growing problem. “Solving it is going to involve strategic direction from lots of different stakeholders,” Bolster says. “It’s going to involve the collaborative work of lots of very smart people to come up with innovative ways of looking at this problem.”
And it’s a problem that’s going to cause disruption in the delivery of health care for not just rheumatology patients, but virtually every field of medicine in the coming years. “I just think our study highlights that this is not a primary care story only — this is a national story, and our findings parallel the forecast for primary care. You may substitute rheumatology with any subspecialty of medicine, and you’re going to see the same national trend in the next 10 years,” Battafarano says
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What Can Be Done About the Growing Shortage of Rheumatologists? originally appeared on usnews.com
