Even before I started my rheumatology fellowship, I knew it would be a demanding career, diagnosing complex diseases with only a few management options in seriously ill patients. What I didn’t appreciate as much before is how badly we are needed across the country.
According to the 2018 outcomes report from the National Resident Matching Program, rheumatology is becoming one of the most competitive subspecialties, with 1.4 applicants per position, joining the ranks of cardiology, hematology and oncology.1 However, it would be amiss to ignore more ominous projections—a serious mismatch between supply and demand. According to the 2015 ACR/ARHP Workforce Study of Rheumatology Specialists, a 31% decline in clinical supply, from 4,997 to 3,455 rheumatologists, is predicted against the backdrop of a 138% increase in demand from 6,155 to 8,184, equating to an excess demand for 4,729 adult rheumatologists.2
Besides a quantitative gap, a persistent geographic gap persists, with the ACR Committee on Rheumatology Training & Workforce Issues reporting clustering of rheumatologists in largely metropolitan areas and in the Northeast.3 All of this is occurring in the midst of trying to fulfill demands for more frequent follow-ups to achieve treat-to-target goals.
Strategies proposed to combat these gaps have focused primarily on increasing the workforce, essentially training more fellows and scaling up ancillary care providers (e.g., nurse practitioners). Another side of the argument focuses on changing how care is delivered. Utilization of telemedicine as an alternative strategy has particularly garnered interest.
Broadly defined as “medical information that is exchanged from one site to another through electronic communication to improve a patient’s health,” telemedicine exists to connect remote patients without ready access to a rheumatologist.4 Arguably, its greatest strength lies in its potential to increase access, as well as to reduce costs related to time and transportation for the patient and, potentially, increase patient satisfaction in the process.
Currently, telerheumatology is being incorporated into practice across several medical centers, including the University of Pittsburgh Medical Center, Dartmouth-Hitchcock Medical Center, headquartered in Lebanon, N.H., and the Alaska Native Tribal Health Consortium, based in Anchorage. These institutions use video conferencing technology, in which a patient is remotely presented to the rheumatologist by a trained presenter. However, this approach has not been immune to criticisms and concerns, including excessive costs to set up appropriate broadband technology (often falling on the shoulders of the providers themselves), variable reimbursement policies for Medicaid and Medicare across states and the absence of clear regulations protecting both the physician and patient from medical malpractice (see “The Doctor Will See You Now,”).
However, a limited number of published studies suggest encouraging potential.
