How to Address the Rheumatology Workforce Gap

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The College’s principal journals have been telling the tale of workforce woe, exploring the reasons for our predicament and potential solutions for the long and short term.^1,2 Among the medium-term remedies is increased use of advanced practice clinicians (APCs), as we collectively refer to nurse practitioners and physician assistants in rheumatology practices.

Solutions

Estimates of the proportion of practices employing at least one APC are 25–55%. The 2015 ACR Workforce Study puts the ratio of APCs to rheumatologists in practice at roughly 1:10. Arizona Arthritis and Rheumatology Associates PC, where I practice, is a private entity that has employed APCs since its organization 25 years ago, and for several years has maintained a ratio of APCs to physicians close to 2:1. Utilization has been demand driven within a patient base predominately insured by managed care, Medicare and Medicaid. We share the same challenge that so many of our colleagues across the U.S. do with regard to recruiting new physicians in response to demand.

If the rheumatology community at large had pursued a similar strategy, our workforce projections might look very different—3,455 rheumatologists in 2030 accompanied by 6,910 (not 596) APCs. If APC productivity is the estimated 70–90% of a physician full-time equivalent, 9,674 providers would well serve the projected demand. It is certainly not too late to capitalize on the opportunity.

The integral role of APCs in rheumatology has been amply described.^3-6 The College has developed a strong modular curriculum for APCs, although it is best tackled after a year or more of exposure, and more recently has developed a core curriculum schedule for training APCs.⁷ In March 2018, the College announced grants for the training of individual APCs. Nonetheless, rheumatologists may still feel ill equipped to identify, attract and successfully develop the right APC, because best practices for these key steps remain underdeveloped.

Challenges

The challenges of recruiting and developing rheumatology APCs include our specialty’s obscurity and the relative paucity of exposure that APCs generally get in their didactic and clinical curricula before entering the workforce.

We are the greatest impediment to this path. For the private practice rheumatologist, the economic investment and the time necessary for training can seem daunting. Reflexive concerns of physicians about empowerment and delegation come into play, and liability enters the equation. Retention is paramount, because the loss of an experienced APC can be almost as disruptive to a practice as the loss of a physician.

The ideal operational construct—whether the APC works directly with the rheumatologist, sees a separate patient panel, provides something less than full direct patient care or maintains an independent practice as NPs are allowed to do in Arizona—remains to be evaluated.