“Fifty percent of kids with rheumatic disease are taken care of by adult providers,” says Jay J. Mehta, MD, MS, attending physician and fellowship program director, Department of Rheumatology, Children’s Hospital of Philadelphia, and a co-author of the ACR’s recent pediatric workforce shortage study.1,2 “But adult rheumatologists may not have specific training in the rheumatic conditions that uniquely affect children or in the unique physical and psychosocial aspects of chronic disease in childhood. They may not have knowledge of medication dosing in children and could under- or overtreat as a consequence.
“Additionally, the wait times for some of these pediatric rheumatologists can be months. Arthritis can cause significant growth issues within months. Untreated lupus can cause kidney failure within months,” he continues.
In 2007, Sacks et al. estimated that nearly 300,000 children in the U.S. have significant pediatric arthritis and other rheumatic conditions. The researchers’ estimate of the annualized number of ambulatory healthcare visits was 827,000.4
An ACR U.S. rheumatology workforce study report on the supply and demand of rheumatologists from 2005–25 projected the demand for pediatric rheumatologists in 2025 would exceed the supply by 191 pediatric providers.5
The ACR’s report on the pediatric rheumatology workforce states that the pediatric rheumatology workforce in 2015 was estimated at 287 full-time equivalent (FTE) pediatric providers, while the estimated excess demand was 95 providers (33%). Correll et al. state: “The projected demand will continue to increase to almost 100% (n=230) by 2030 if no changes occur in succession planning, new graduate entrants into the profession and other factors associated with the workforce.”1
Colleen K. Correll, MD, MPH, assistant professor in the Division of Pediatric Rheumatology at the University of Minnesota Medical School, Minneapolis, and the corresponding author for the recent study, says the current shortage and future projections of a workforce shortage for pediatric rheumatologists come as no surprise to providers and patients alike.
Dr. Correll
“Most of us [pediatric rheumatologists] feel the impact of the workforce shortage on a daily basis when we practice clinical medicine,” she says, citing, for example, the long wait times to see new patients.
Long wait times to see a provider cause stress and anxiety for patients, particularly new ones, and can sometimes result in worsening disease, says Dr. Correll. For established patients, scheduling timely follow-up appointments can be challenging.
Because so many states have no pediatric rheumatologists and in others the only pediatric providers are in large urban areas, distance complicates scheduling and timely access to care. For example, all new and return English-speaking parents/guardians of patients visiting a single center in Minneapolis were surveyed over a period of six weeks to assess barriers to care. In this study, Bullock et al. found that 28% of the parents (45/159) reported traveling more than three hours to the pediatric rheumatology clinic. Forty-three percent (65/152) reported travel as inconvenient.6
Thus, patients and rheumatologists face a twofold and growing problem: there are too few pediatric rheumatology providers to care for the growing number of children with rheumatic conditions, and significant areas of the country have no pediatric rheumatologists at all.
Closing the Gap
Closing the gap between the number of providers and the number of children in need of care will take some creative solutions.
“The challenge is how many people are coming into the field every year,” says Dr. Mehta. “There are only about 20 matched fellows each year, meaning 20 people are entering the workforce. If there were no retirement, then we wouldn’t close the gap for over 11 years. The problem is that there is a significant number of retirees every year, so we are unlikely to close that gap.”
Although residents and fellows trained in adult rheumatology receive some training in pediatric rheumatologic diseases, the training and exposure is minimal and not nearly sufficient to understand the complexities of pediatric rheumatologic health.
“Many medical students don’t know that rheumatic disease in children is a specialty,” he says. “If you’re not exposed to the specialty, then you don’t have role models.”
Dr. Mehta
Given the particular and wide-ranging effects of rheumatologic diseases on children, Dr. Mehta says rheumatologists specifically trained in pediatric rheumatology are necessary to truly provide optimal care for these children. “There are lots of differences in not only how the disease themselves affect children vs. adults,” he says, “but also in complications over time.”
He notes that children are greatly affected physically, as well as socially, by arthritis and other rheumatic diseases. The conditions often limit a child’s ability to run and play, and interrupt school schedules and education. Their endocrine and reproductive systems may be affected. “All of a child’s developing organs could be affected by autoimmune disease,” he says.
By 2030, an estimated 142% increase in fellowship slots for pediatric rheumatologists will be needed to meet demand. However, unlike in adult rheumatology programs in which 100 residents go unmatched each year, the challenge in pediatric rheumatology is to increase the interest in, and demand for, available fellowship slots.
Solutions to help increase the supply of providers include increasing recruitment of physician and nonphysician providers, such as physician assistants and nurse practitioners to pediatric rheumatology; increasing the number of fellowships in underserved areas; using telemedicine; and working with healthcare partners in the community (e.g., primary care providers, occupational and physical therapists) to provide comprehensive patient care.
These solutions are all identified in an ACR workforce solutions initiative to help address ways to close the gap between supply and demand of rheumatologists. Described in detail in an article in The Rheumatologist, the initiative first focuses on targeting the above solutions to areas in geographical areas in the U.S. in most need, specifically the South and Southwest.1,7
“The specialty really has to focus on optimizing initiatives that have already begun, supporting those initiatives to help them grow and developing creative new solutions,” says Dr. Correll.
Keri Losavio is the editor of The Rheumatologist.
References
- 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.
- Mayer ML, Mellins ED, Sandborg CI. Access to pediatric rheumatology care in the United States. Arthritis Rheum. 2003 Dec 15;49(6):759–765.
- Althouse LA, Stockman JA. Pediatric workforce: A look at pediatric rheumatology data from the American Board of Pediatrics. J Pediatr. 2006 Dec;149(6):869–870.
- Sacks JJ, Helmick CG, Luo Y-H, et al. Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions in the United States in 2001–2004. Arthritis Rheum. 2007 Dec 15;57(8):1439–1445.
- Deal CL, Hooker R, Harrington T, et al. The United States rheumatology workforce: Supply and demand, 2005–2025. Arthritis Rheum. 2007 Mar;56(3):722–729.
- Bullock DR, Vehe RK, Zhang L, Correll CK. Telemedicine and other care models in pediatric rheumatology: an exploratory study of parents’ perceptions of barriers to care and care preferences. Pediatr Rheumatol Online J. 2017 Jul 11;15(1):55.
- Nierengarten MB. The ACR launches initiative to tackle workforce shortage. The Rheumatologist. 2022 May 12.
