This is the final part of a four-part series on the 2006 Rheumatology Workforce Study. (See Part 1 on page 1 of the January 2007 issue, Part 2 on page 1 of the April 2007 issue, and Part 3 on page 1 of the August 2007 issue.)
The small pediatric rheumatology subspecialty is growing, although demand is likely to increase faster than supply, according to the results of the Rheumatology Workforce Study commissioned by the ACR in 2006. However, a variety of efforts to support fellows interested in this field both during training and early in their careers offer rays of hope for the future. For example, the number of pediatric rheumatology fellowships is steadily increasing and both pediatric and adult rheumatologists are taking bold steps to change the practice model and become mentors for medical students.
“Exposure of the field is a major issue for pediatric rheumatology,” says Marisa Klein-Gitelman, MD, a pediatric rheumatologist in the division of pediatric immunology-rheumatology at Children’s Memorial Hospital and assistant professor at Northwestern University in Chicago. “We hope that by taking steps to let rising medical students know about this field and to lessen the clinical burden for those who do choose to become pediatric rheumatologists, we will recharge the workforce over the next few years,” she says. Dr. Klein-Gitelman served as a member of the ACR Workforce Study Advisory Group in 2005–2006. She adds that continuing efforts by the pediatric rheumatology executive committees at both the ACR and the American Academy of Pediatrics (AAP) are aimed at spreading this message.
One new idea to bolster the pediatric rheumatology workforce is a practice model in Arizona, which resulted in bringing a pediatric rheumatologist to the state for the first time. Other initiatives include a plan by a group of pediatric rheumatologists to do multicenter research in the United States and Canada, visiting professor programs, sponsoring residents to attend professional meetings, and increasing the number of fellowships and mentors for those who choose this specialty.
Survey Findings
The ACR’s analysis shows that the supply and demand for the subspecialty will run in parallel during the next 20 years. Projected increases in demand stem from increases in the overall population as well as in real personal income per capita that enables consumers to purchase a greater level of healthcare services. The overall population of the United States is expected to rise in the next two decades with definitive increases in the population under age 18. The study predicts that the baseline demand for pediatric rheumatologists will rise to 287 in 2025. Meanwhile, the supply will increase to only 254 in 2025, too little to meet the demand at that time.
The Lewin Group, which prepared the report for the ACR, says that, according to data from the American Medical Association (AMA) in 2005, the number of board-certified and/or fellowship-trained pediatric rheumatologists is 171. Supplementing the AMA list with ACR membership files, the total estimate rises to 256. This includes some physicians trained in both adult and pediatric rheumatology (46). The majority of pediatric rheumatologists are board certified (138) and 45 have both adult and pediatric board certification.
Because of the differential between supply of and demand for pediatric rheumatologists, many children are seen by adult rheumatologists. But this doesn’t mean that there is always an available provider willing to take on a new pediatric patient. The survey asked adult rheumatologists the youngest age of patients they are willing to treat. The highest percentage (27.7%) said they would treat a patient between 16 and 17 years old; another 22.4% said they would treat patients between 12 and 15 years old. But the percentage that would treat younger patients drops dramatically: 9% would treat 7–11-year-olds; 7.1%, 4–6-year-olds; and 10.9%, children 4 and under. Respondents also were less likely to take on 18-year-olds (only 17.3%).
Pediatric rheumatologists are a little younger than their adult counterparts. While the median age for the adult rheumatologist is 51, the median age for pediatric rheumatologists is 47. Just under half (49%) are female. The median age for rheumatologists on the whole is older than some other medical specialties due in part to the fact that the normal path to this profession is a residency in internal medicine or pediatrics followed by a two- or three-year fellowship.
Even more striking is the age spread within pediatric rheumatology. The percentage of women varies considerably by age, with a majority of pediatric rheumatologists over age 55 being male and, in contrast, 67% of pediatric rheumatologists under 40 being female. Females account for 69% of new pediatric rheumatology fellows. The survey analysis speculates that retirement will pose less of a factor in the future because females tend to stay in practice longer than their male counterparts. However, averaged over their careers, women tend to work fewer hours than men, which will affect the number of pediatric rheumatologists needed to meet annual demand.
Pediatric rheumatologists practice mostly in academia and in large urban settings. The highest concentration (28) is found in the New York–Northern New Jersey–Long Island, N.Y.–N.J.–Pa. metropolitan statistical area (MSA). The highest percentage per one million population is 2.7 in the Boston–Cam-bridge–Quincy, Mass.–N.H. metropolitan area. There are nine states that had no pediatric rheumatologist (Alaska, Idaho, Maine, North Dakota, Nevada, South Dakota, West Virginia, Wyoming, and Vermont). Only recently has Arizona come off this list, with a specialist for these children in the Phoenix–Mesa– Scotsdale, Ariz., area of 3.6 million.
Pediatric rheumatology fellowships have increased from 25 total positions in 1997–1998 to 58 in 2004–2005, although some are unfilled. The number of first-year positions available in 2004–2005 was 24; 12 (53%) were filled, and nine (39%) had completed their program at the time of the survey. The percentage of international medical graduates in these fellowships went from 33% in 1997–1998 to 20% in 2004–2005.
These numbers are on the rise despite the fact that salaries for pediatric rheumatologists are in the low range for specialists. Most physicians who chose pediatric rheumatology instead of adult rheumatology end up working in academic medical centers where they can do clinic research and see patients but make less in salary than those in private practice. The median total compensation for academic faculty in pediatric rheumatology in 1998 was $106,844. That rose 9.2% during a four-year period to $116,723 in 2002. As a comparison, physicians who go into internal medicine, endocrinology, allergy/immunology, and geriatrics tend to have higher salaries than pediatric rheumatologists.
Many Avenues to Meet Pediatric Need
“Choosing to go into pediatric rheumatology is daunting,” says Patience White, MD, chief public health officer for the Arthritis Foundation, professor of medicine/rheumatology at George Washington University in Washington, D.C., and a member of the Workforce Study Advisory Group. “The reasons for the shortage are complex and there are many factors that make the earning potential less attractive than in other subspecialties,” she says. “In the academic setting, there are limited numbers of good mentors and great teachers who motivate the students with exposure to exciting cases in pediatric rheumatology.”
The Arthritis Foundation is working with the ACR on getting a bill passed by the U.S. Congress to help students who are interested in this field pay for their medical education. The Arthritis Prevention, Control, and Cure Act has been introduced in both the U.S. Senate (S626) and the House (HR 1283). A hopeful sign for this authorizing bill (with no exact funding caps) is the lead taken by Senator Edward Kennedy (D-Mass.) who is a sponsor and chair of the Health Education Labor and Pensions (HELP) Committee.
Dr. Klein-Gitelman says that the ACR and the AAP have both had positive feedback for a visiting professor program that will fund a pediatric rheumatologist to work with residents and fellows and spend two days each week teaching pediatric rheumatology. The first of these visiting professorships was completed at the University of Alabama, Birmingham. Alabama has historically had a severe shortage of pediatric rheumatologists.
In 2002, the ACR established the Pediatric Residents Program to provide a travel grant, complimentary registration, and a networking breakfast to 25 Pediatric Residents to the ACR Annual Scientific Meeting. Since its inception the program has funded 100 pediatric residents to ACR Annual Scientific Meeting of the participants 29% have entered a pediatric rheumatology fellowship program.
A major need is for all medical school curricula to include pediatric rheumatology, say Drs. Klein-Gitelman and White. The ACR has taken a keen interest in pushing for this commitment from all medical schools in the U.S., she says. “We need to teach everyone who will listen about the benefits of this field of medicine,” says Dr. White. “We have been successful in increasing the number of fellowships and raising funds to support our fellows,” she says.
Drs. White and Klein-Gitelman know what it is like to be the lone specialist in a practice and say that a new generation of mentors to guide future pediatric rheumatologists is also critical to meeting long-term goals.
Sharing the Load: A New Model
One unique mentoring effort is taking place in Arizona. “It had become the accepted norm that children are seen by adult rheumatologists,” says Paul Caldron, DO, head of Arizona Arthritis and Rheumatology Associates, Paradise Valley, AZ. Until recently, Arizona had no pediatric rheumatologists. “Most adult rheumatologists have some training in pediatrics, but it is fragmented,” he says. “New physicians are afraid to go solo because it is tough to make a living, they have no training in business, and above all there are no mentors to help in the practice with patient load and on-call schedules.”
His practice is the largest for rheumatology in Arizona and the surrounding states. In the past he has seen as many as four to five pediatric patients each day. “It was 25% of my practice,” he says. But that is now down to approximately 5%.
Dr. Caldron spearheaded an effort that resulted in a formal collaboration between his practice and the Children’s Hospital of Phoenix. The two developed a single contract that pays for the salary of a pediatric rheumatologist who splits his time three ways—two afternoons a week at the community clinic (office space and support staff provided), three afternoons at the hospital’s pediatric rheumatology clinic, and mornings on rounds seeing patients in the hospital.
“We split call coverage so that our new pediatric partner has on-call duty one night a week and one weekend a month,” says Dr. Caldron. “We seek his input. We have to be open to listen and understand the problems that our new colleague will have.”
Michael Shishov, MD, is the pediatric rheumatologist who joined the Arizona group, and so far he has been pleased with the outcome. “When I came out of training in 2003, many people told me it wouldn’t be a good idea to look at taking this position in Arizona,” he says. “But some like Dr. Caldron were really encouraging me to go for it.” One of the main things that attracted him to the position was the network of practice support that would alleviate some of the burdens of private practice. “My fellow doctors like Dr. Caldron share on-call duty with me and I have medical assistants and infusion nurses to help in the practice. We borrow ideas and help each other.”
Dr. Shishov says he knows that there is room to grow this collaborative program and looks forward to working to achieve that. “When my schedule is full and we can no longer see children within a good time frame, then we might look at adding a nurse practitioner,” he explains. “The hospital has really allowed me to ramp up slowly. I am sure I could see as many as 50 kids a week in the clinic, but that would be too much to handle right now,” he says. “This program has allowed me to go at my own speed and do things I could not do if I had chosen to take a job at an academic medical center,” says Dr. Shishov. “There is no doubt that I had many reservations when I decided to come here. But I definitely have never regretted it. Now if we can just get the word out to others to create similar practice models and entice residents to take a chance, I think we may change the field of pediatric rheumatology for the future.”
Others interviewed for this article have a similar optimism for the future of pediatric rheumatology. “Working in a group practice as a pediatric rheumatologist is a good lifestyle and a rewarding profession,” says Dr. White.
Terry Hartnett wrote the Workforce Study series.