PHILADELPHIA—Members of the ACR’s Workforce Solutions Committee presented a chilling picture of the approaching shortage of rheumatologists and discussed their efforts and ideas they hope will avert a gaping void in patient care.
The session was held at ACR Convergence 2022, where the looming workforce shortage was a topic of discussion across many sessions and posters.
The ideas being promoted by the committee, said chair Daniel F. Battafarano, DO, MACP, MACR, adjoint professor of medicine, University of Texas Health San Antonio, are “based on knowledge and data. That’s what’s driven us, not just pie-in-the-sky ideas about workforce solutions.”
Dr. Battafarano displayed two maps of the U.S. with boxes showing, by region, the number of adult rheumatologists per 100,000 people and, on the other map, the number of pediatric rheumatologists per 100,000 people, based on the ACR’s 2015 Workforce Study. Next to each of those boxes was another box, with the projected number of adult rheumatologists in 2025 and the projected number of pediatric rheumatologists in 2030.1,2
In the Northwest—a region that includes Washington, Oregon, Idaho, Montana and Wyoming—there were 1.65 rheumatologists per 100,000 people, projected to be 0.5 by 2025.
“That’s a problem,” Dr. Battafarano said. “If you look at every single region in the United States, every single region is decrementing significantly.”
In the same region, there were 0.67 pediatric rheumatologists per 100,000 and a projection of 0.13 pediatric rheumatologists per 100,000 by 2030.
“Pediatrics has been in a crisis since 2015, so if you look at the numbers there, they’ve been very, very small, and they’re getting worse,” he said.
In a study by the Association of American Medical Colleges in 2020, researchers estimated that there will be a shortage of between 54,000 and 139,000 physicians in the country as of 2033, and Dr. Battafarano pointed out that the data suggest the shortage will more likely skew toward the higher end of that range.3 COVID-19 has only made matters worse.
“We lost colleagues to part-time employment, we saw early retirements, and that happened across the United States,” he noted. Early estimates, he said, suggest a 10% reduction in the physician workforce just due to the pandemic, stacked on top of the shortages the field had already been experiencing.
A map showing the distribution of rheumatologists across the country shows barren areas all across the Northwest, upper Midwest, portions of the Southwest and elsewhere.
The shortage of rheumatologists in rural areas has been well established, but Dr. Battafarano drove home exactly how severe the problem is. In the Northwest, Southwest and South-Central regions of the U.S., more than 97% practice in a metropolitan statistical area or an urban area that has a relatively high population, at least about 60,000 people.
In the South-Central region of Arkansas, Oklahoma and north Texas, enrollment in Medicare Advantage—which can help get patients the care they need—is just 43%. Other challenges are that nurse practitioners are not common in the region and that most hospitals in the region are for-profit hospitals, which tend to provide less support for specialties like rheumatology, Dr. Battafarano said.
Fellowship programs and medical schools are almost exclusively located in urban areas in this region, he noted.
“So Texas may have rheumatologists, but it depends on where you live,” he said. If you live in Laredo, for example, you have a 2.5-hour drive to see a rheumatologist.
Pediatric rheumatologists are even more scarce.
“I’m in San Antonio—we don’t have a pediatric rheumatologist in San Antonio, the seventh-largest city in the United States,” he said, adding that very few adult rheumatologists see children, in part due to low volume and medication risks.
“As we look at our workforce, we’re trying to look at it coming down and drilling down to data in regions and states, and payers and hospitals and potential for GME (graduate medical education)—and, by the way, quality of life, burnout,” he said. “We need to build teams of people, not have anybody in solo practice who’s going to be vulnerable to burnout.”
The committee has created five intervention teams tackling distinct aspects of the workforce problem.
One team is covering the support of fellowship positions and training of providers, setting out to enhance fellowship training opportunities, promote early exposure to the field, and the consideration of a two-year pediatric rheumatology fellowship.
A second is covering recruitment, including establishing benchmarks for recruiting, along with incentives and loan repayment, creating end-of-career stepdowns to extend an aging workforce and providing financial support for telehealth and multistate licensing.
A third is dedicated to fostering patient-centered communities, facilitating an education summit with private or third-party payers and public payers, developing value-based payment arrangements and coordinating population health management strategies.
A fourth is devoted to virtual training programs for development and training for fellows, advanced practice providers and non-rheumatologists, and to help with training of primary care physicians and other providers on musculoskeletal and clinical rheumatology topics.
The last is dedicated to grant support, facilitating applications for grants for underserved areas and community practice, promoting existing ACR and Rheumatology Research Foundation grants, coordinating and tracking external grant activities, and establishing and managing new grants on workforce issues.
Beth Jonas, MD, chief of rheumatology, allergy and immunology, University of North Carolina, Chapel Hill, who has worked on workforce issues for several years, said progress has been made.
“The work that we have done, actually, over the last few years in increasing interest in rheumatology has been quite good,” she said. Over recent years, the number of rheumatology fellowship programs has increased from 108 to 123, but it hasn’t been enough.
“There’s a lot of interest in rheumatology now, but not enough training slots, so although we’ve increased programs and increased numbers of training slots, every year we leave about 100 people on the playing field who want to become a rheumatologist.”
The committee is working on places that are ripe for opening new fellowships and expanding their current programs. More training of primary care physicians and sports medicine physicians in musculoskeletal medicine is also an area of opportunity, she said.
Colleen Correll, MD, MPH, assistant professor in pediatric rheumatology, University of Minnesota, Minneapolis, and the lead author of the paper on the pediatric rheumatologist shortage, said the issue in pediatrics is different.
“We have a very small workforce—there are about 300 providers in the United States,” she noted. “But different from the adult rheumatology fellowships, pediatric rheumatology only fills about 70% of their slots, so about 30% go unfilled. We recognize this is an issue.”
The committee’s work involves “making sure all of those slots are filled,” she said.
“We’re really focusing on increased exposure, especially during medical school and pediatric residency, and really focusing on promoting the specialty.”
Thomas R. Collins is a freelance medical writer based in Florida.
- Battafarano DF, Ditmyer M, Bolster MB, et al. 2015 American College of Rheumatology workforce study: Supply and demand projections of adult rheumatology workforce, 2015–2030. Arthritis Care Res (Hoboken). 2018 Apr;70(4):617–626.
- Correll CK, Ditmyer MM, Mehta J, et al. 2015 American College of Rheumatology workforce study and demand projections of pediatric rheumatology workforce, 2015–2030. Arthritis Care Res (Hoboken). 2022 Mar;74(3):340–348.
- IHS Markit Ltd. The complexities of physician supply and demand: Projections from 2019 to 2034. Washington, D.C. Association of American Medical Colleges. 2021.