Rheumatology Workforce Shortage Demands Multipronged Approach

Jeff Evans

December 16, 2022

PHILADELPHIA – New rheumatology fellowships in underserved areas. Rheumatology training for nonspecialists. Telemedicine training, tools, and resources. These are a few of the remedies the American College of Rheumatology's new Workforce Solutions Committee has concocted to address a shrinking U.S. rheumatology workforce in the face of a rising population of patients with rheumatologic diseases.

In two sessions at the ACR's annual meeting, committee members provided insights on current workforce projections since the most recent ACR workforce study in 2015. They also outlined the 1-year-old committee's response to bridge the looming gap in patient care. Some projects are already underway, while others have yet to be implemented and require sustained monetary and project coordination commitments to make their impacts felt across the targeted regions.

Dr Daniel Battafarano

"At the current pace of physician departures from the workforce, even with fellows graduating from adult and pediatric rheumatology training programs, the subspecialty cannot be sustained," said Daniel Battafarano, DO, chair of the Workforce Solution Committee, professor of medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md., and adjunct professor at the University of Texas Health Science Center, San Antonio.

The Northwest is an example of the problem at hand. "For an adult, there's 1.65 rheumatologists per 100,000 in 2015. In 2025, there's going to be 0.5 [adult] rheumatologists per 100,000. That's a problem. If you look at every region in the United States, every single region is decrementing significantly," he said.

Even the Northeast, which boasted 3.07 adult rheumatologists per 100,000 in 2015, will drop to 1.61 in 2025. Other regions are much worse off. The Southwest will drop from 1.28 to 0.64, and North Central will drop from 1.64 to 0.69, projections show.

The situation for pediatrics "has been in a crisis since 2015," Battafarano said. It is much worse off than the situation for adult rheumatology, with 2015 figures going from 0.17 to 0.20 in the Southwest and from 0.03 to 0.04 in the South Central region by 2025, and in the Northwest from 0.67 to 0.13 and Northeast from 0.83 to 0.16.

"The ill effects of the pandemic are immeasurable to this point, but anecdotally we know we lost colleagues to part-time employment, we saw early retirements, and that happened across the full spectrum of the United States," he said. It's possible that up to 10% of full-time equivalents of physicians left practice in the United States since the pandemic began.

Rheumatologists largely practice in the 392 U.S. metropolitan statistical areas (MSAs), which are defined as a "core area containing a substantial population nucleus, together with adjacent communities having a high degree of economic and social integration with that core." The smallest MSA has nearly 59,000 people. This distribution leaves many people in the Northwest, Southwest, South Central, and North Central regions with few rheumatologists. Over 86% of locations where rheumatologists train and work are in MSAs.

"By definition, if you get into a region where there's 60,000 people or less, you can't support a rheumatologist," Battafarano said. He also noted that all pediatric hospitals tend to be in dense MSAs where rheumatologists might be.

South Central Region Serves as an Example

People in certain MSAs of the South Central region (Oklahoma, Texas, Arkansas) such as Laredo, Tex., population 281,805 – where there is no adult rheumatologist – have to drive nearly 2.5 hours to the nearest well-served MSA (San Antonio) where there is a rheumatology fellowship program and medical school.

"Texas may have rheumatologists, but it depends on where you live," Battafarano said. "The same applies to Waco, Texas; Texarkana, Arkansas; Lawton, Oklahoma; Pine Bluff, Arkansas; and Enid, Oklahoma, and you can see the range of traveling is between 45 minutes and 2.5 hours. That's adult rheumatology."

People in Laredo have an even longer drive to find a pediatric rheumatologist. In pediatrics, he said, "we don't even look at towns, we look at pediatrics by state. You can see there's a pediatric fellowship program in Dallas, and there's one in Houston. There's one or two [pediatric] rheumatologists in Austin. It just depends on how quickly they burn out and how long they stay. I'm in San Antonio. We don't have a pediatric rheumatologist in San Antonio, the seventh-largest city in the United States."

Pediatric rheumatologists are very often found where fellowship programs are located. "Ninety-five percent or greater of pediatric rheumatologists are housed in a pediatric hospital," Battafarano said. "There are very few adult rheumatologists who see children, for a variety of reasons."

Dr Beth Jonas

In a panel discussion and question-and-answer session that took place after Battafarano outlined concerns with the numbers and distribution of rheumatologists across the United States, committee member Beth Jonas, MD, professor of medicine and chief of the division of rheumatology, allergy, and immunology at the University of North Carolina at Chapel Hill, noted that the rheumatology specialty match is competitive and typically leaves close to 100 residents who had rheumatology as their first choice without a match because there are not enough fellowship positions for them to fill.

The Workforce Solutions Committee hopes to reduce this "bottleneck," she said, by identifying institutions that are ripe for opening new fellowship programs or have existing programs that can expand their number of positions, as well as expanding musculoskeletal training among nonrheumatologists, such as primary care physicians, advanced practice providers, and sports medicine physicians.

"I think that we're going to find ourselves needing to be more creative as we become overcome with events with shortages of physicians," Battafarano said. He gave an example of a recent pediatric rheumatology fellow in Seattle who wanted to go back home to Montana to practice. At the same time, the pediatric program wanted her to become a faculty member, so they said they would bridge their program to her, rotating fellows and covering her while on vacation.

"That's an example of a pediatric program spreading its wings," he said. "I think that we need to think that way, whether we talk about urban, suburban, rural. It's how can we stage rheumatologists in areas, how can we embrace our primary care providers, and have rheumatology health care teams so that we have rheumatology expertise located within arm's length but also within telemedicine length."

Interventions for 2023

As part of a report on the activities of the Workforce Solutions Committee, Jonas outlined a number of interventions that the ACR is set to launch in 2023. The committee created five intervention teams to support fellowship positions and training providers, recruitment opportunities, fostering patient-centered communities, virtual training programs, and grants for research and training. The ACR's initial pilot interventions are focused on, but not limited to, the Northwest, Southwest, and South Central regions.

The committee identified 10 potential partner institutions to develop new fellowship programs in the Northwest, Southwest, and South Central regions: University of Nevada, Las Vegas; Texas Tech University Permian Basin Program; Baylor Scott and White Medical Center Round Rock (Tex.) Program; Texas Tech University Health Science Center El Paso Program; University of Texas at Austin Dell Medical School Program; Abrazo Health Network Program in Arizona; University of Arizona Phoenix Program; University of Arkansas (pediatric program); Oklahoma State University; and University of Texas, San Antonio (pediatric program).

Jonas explained that opening new programs in these underserved areas should help establish new rheumatologists in these areas, because studies have shown that fellows tend to stay within 100-200 miles of where they trained.

In addition to starting new programs, "if you want to grow your program, if you want to add another fellow, we can support that," Jonas said.

To help convince institutions of the value of rheumatology care, a position paper will soon be released by the ACR that outlines the benefits of the specialty to a health care system. The paper will describe an annual preventive cost savings of $2,762 per patient who is in the care of a rheumatologist and an annual direct or downstream income of $3.5 million per rheumatologist in a community, committee members said.

To help with recruitment and retention efforts, the ACR will revise its CareerConnection website to make it more useful.

To help in developing patient-centered communities of care, there will be a discussion series with payers on topics such as access, care delivery, and financing, in which 12 payers (including Blue Cross Blue Shield, Aetna, UnitedHealthcare, and Kaiser) will discuss patient access, cost, and quality measures. An in-person payer summit is also scheduled for 2023.

Interventions to enhance rheumatology care will also keep an ongoing focus on virtual training programs for primary care physicians and advanced practice providers, including a Project ECHO (Extension for Community Healthcare Outcomes) virtual lecture and case-based training and mentoring series for nonrheumatologists, an online library of searchable topics targeted to nonrheumatologists, as well as a grand rounds podcast series on certain rheumatic diseases for residents in family medicine, internal medicine, and pediatric programs. For rheumatology educators in 2023, there also will be an online portal curated by the ACR and other sources to use as a resource for developing curriculum.

Dr Janet Poole

A newly revised Fundamentals of Rheumatology course started in June 2022, which can help many medical students, residents, primary care physicians, and students in rehabilitation professions to learn about rheumatologic diseases, said committee member Janet Poole, PhD, division chief, professor, and director of the occupational therapy graduate program at the University of New Mexico, Albuquerque. Grants from the Rheumatology Research Foundation are available to offset the costs of the course for attendees.

An "onboarding toolkit" for nurse practitioners and physician assistants is now available to provide advice to practices for hiring, mentoring, and conducting performance evaluations in rheumatology care teams, Poole said. And fact sheets about the roles of interprofessional team members are being revised to give nonspecialty providers a sense of what other disciplines are available to care for patients with rheumatic and musculoskeletal disorders. The Advanced Rheumatology course is also being revised and will be available in summer 2023.

Other planned interventions aim to optimize telemedicine for the rheumatology community with a telehealth curriculum for rheumatology fellows, tools to improve telehealth implementation and delivery, and educational materials for patients to optimize their participation in telehealth visits.

The committee created targeted outreach to promote all grants focused on workforce expansion. As a result, in the last year the committee noted a three- to fourfold rise in the number of grant applications, including people and programs in underserved areas that had not previously applied. The Rheumatology Research Foundation also created a baseline for measuring success of grant funding in underserved areas and earmarked funds to increase awareness of the grants and facilitate applications.

Dr Rosalind Ramsey-Goldman

Early signs of success are evident in the Rheumatology Access Expansion initiative in the ACR's Collaborative Initiatives (COIN) department, said committee member Rosalind Ramsey-Goldman, MD, DrPH, professor of medicine/rheumatology at Northwestern University, Chicago. A team of rheumatologists, a pharmacist, and Navajo cultural interpreters developed a 12-week rheumatoid arthritis training program for primary care physicians in the Navajo Nation American Indian reservation, where there's a high prevalence of RA and a shortage of local rheumatology providers. Results of the pilot study were presented in a plenary session at the meeting.

COIN also worked with the ACR's Diversity, Equity, and Inclusion task force to sponsor 2022 annual meeting attendance for 11 medical students who identify themselves as underrepresented in medicine to expose them to rheumatology early in their career, said Ramsey-Goldman. The ACR is starting a program for medical students at historically Black colleges and universities and minority-serving institutions to include mentoring, round tables, and attendance at next year's annual meeting.

None of the rheumatologists had relevant financial disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.


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