Because rheumatology is a complex cognitive specialty, rheumatologists and rheumatology professionals often see patients repeatedly for acute and chronic problems. Although that may lead to close relationships with patients, it may also make the specialty more prone to burnout, says Peter Y. Hahn, MD, MBA, CEO of University of Michigan Health-West, Wyoming, Mich.
“It can be hard when patients aren’t doing well or they don’t progress,” says Dr. Hahn, a pulmonologist who works with a variety of specialists in his executive role.
“Justifying treatment decisions to insurers, navigating unintuitive health records and [performing] other administrative [tasks] take time away from teaching and cultivating our patient relationships, which are the more fulfilling aspects of being a rheumatologist,” says Bethany A. Marston, MD, associate professor in the departments of pediatrics and medicine at the University of Rochester Medical Center, New York. Dr. Marston also chairs the ACR Committee on Rheumatology Training and Workforce Issues.
Insurer stall tactics, such as prior authorization and added paperwork, negatively affect patient care and satisfaction, says Norman B. Gaylis, MD, FACR, MACR, a rheumatologist in private practice in Miami and co-founder of the supplement firm NViroMune.
Electronic health records (EHRs) have caused headaches for anyone in medicine, as has the need to rapidly adapt to telemedicine, says Daniel F. Battafarano, DO, MACP, MACR, chair of the ACR Workforce Solutions Committee and professor of medicine at Uniformed Services University, Bethesda, Md., and adjoint professor of medicine, UT Health-San Antonio, Texas.
“Rheumatologists have become administrative assistants for healthcare systems instead of concentrating on medical solutions and treatment decisions, and listening to patients,” Dr. Battafarano says. The result for many has been exhaustion, anxiety, depression and potential medical errors, among other consequences.
All of these tasks lead rheumatologists to work more hours than ever, says Jennifer Moody, ECG Management Consultants, with locations around the U.S. Continuing medical education, academic and administrative responsibilities add to a growing to-do list for rheumatologists, she says.
Staffing changes and shortages have increased the burden of care for physicians across the board. Andrew Concoff, MD, FACR, CAQSM, rheumatologist and chief innovation officer, Exagen, Vista, Calif., says that when he was in private practice, his lead medical assistant retired, his second medical assistant took a job elsewhere, his scheduler moved and his physician assistant went on maternity leave. “I went from the dream team to a green team. I have never worked harder to deliver the highest quality care than I did during the ensuing period, when no one on my clinical team was familiar with their roles,” he says.
Staffing turnover and longer hours have led some rheumatologists, like Dr. Concoff, to shift career focus, such as venturing into industry. Others have retired or now use their knowledge in fields adjacent to medicine. Some have left medicine altogether. A study from Bain & Company found that 25% of U.S. clinicians are pondering a career switch, mostly due to burnout.1
A pre-pandemic survey of 128 attendees at a rheumatology symposium found that 50.8% expressed burnout in at least one Maslach Burnout Index domain.2 Dissatisfaction with EHRs was associated with a higher degree of burnout, along with lack of exercise and working more than 60 hours a week.
Workforce Shortage
Of course, clinicians’ leaving rheumatology contributes to workforce shortages—what Dr. Concoff now refers to as a workforce crisis.
An estimate of the 2015 adult rheumatology workforce—including physicians, nurse practitioners and physician assistants—posited that there were 6,013 providers and 5,415 clinical full-time equivalents (FTEs). However, the estimated demand exceeded the supply of clinical FTEs by 700 (12.9%).3 The same report predicted that by 2030, the number of clinicians would fall to 4,882 providers or 4,051 clinical FTEs, a 25.2% decrease from 2015 baseline levels. Demand in 2030 is projected to exceed supply by 4,133 clinical FTEs (102%).
Pediatric rheumatology is also expected to have a workforce gap, with demand reaching twice the supply, according to a 2022 report.4
These workforce shortages already severely affect the Northwest, Southwest and South Central regions of the U.S., says Dr. Battafarano. They’re only compounded by a baby boomer workforce looking to retire in the next few years.
The concern over workforce shortages along with related issues led the ACR to create a Workforce Solutions Committee in 2021.
It’s estimated that the pandemic may have caused an additional loss of 10% more full-time providers in the workforce, Dr. Battafarano says.
“It’s a tough time right now,” Dr. Hahn says. “And after three years of the pandemic, it could be the toughest time for healthcare because of staff shortages and everyone doing more with less.”
“Burnout, staffing issues and billing issues in the practice make it almost impossible for a private practice to survive,” says Dr. Gaylis.
Alleviate the Problem
The problem of burnout and workforce shortages in rheumatology, and medicine in general, likely won’t go away anytime soon. However, there are things leaders in private practices and academic organizations can do to try to address the issue:
1. Involve physicians more in leadership roles.
University of Michigan Health-West always aims to include physicians in different hospital projects, Dr. Hahn says. “This way they don’t feel they are just a cog in the wheel. When we implement a program, we want physicians actively involved and understanding the financials,” he says. One example is the creation and implementation of DAX, an app that uses artificial intelligence to take notes during patient visits. So far, the app is improving physician satisfaction, Dr. Hahn says.
2. Work with more advanced practice practitioners (APPs), such as nurse practitioners and physician assistants.
Attracting, training and retaining qualified APPs can help redistribute responsibility into a team-driven environment, Dr. Concoff says. Although this brings more clinical help to the specialty, APPs can also get saturated with too much work, Dr. Battafarano cautions.
3. Be clear about what the organization expects from rheumatologists.
Stu Schaff, founder of Contract Medicine, a service that helps physicians throughout the U.S. understand, evaluate and negotiate their employment contracts, often sees organizations hire physicians without communicating clear expectations from the beginning. This can leave a lot of room for misinterpretation about job responsibilities, work hours and other important matters. A better practice is to make it clear during recruitment, and regularly thereafter, what any expectations may be, so the physician can make informed decisions based on those expectations.
4. Ask what you can do to provide more support and resources…
…particularly to alleviate the daily burdens that pull rheumatologists away from patient care, Mr. Schaff advises. This could include the use of scribes, speech-to-text software and team-based care. “This is often more appreciated by clinicians than just cutting them a check,” he says.
Providing pharmacist resources to manage prior authorizations is another solution, Ms. Moody says.
Asking what rheumatologists find helpful can help systems de-emphasize what doesn’t work, Ms. Moody observes. She gives the example of patient–physician communication portals that are intended to make direct patient communication easier but have the unintended consequence of increasing after-hours workloads for providers.
5. Triage.
This likely happens already at many practices, but Dr. Concoff says triage may become a necessity to prioritize patients with inflammatory arthritis, vasculitis, or systemic lupus. Novel approaches, such as pre-consultation laboratory triage, also may become necessary, he adds.
The addition of rheumatology training fellowships in underserved areas could help sustain rheumatologists and rheumatology care in those regions since many graduating fellows stay within 100–200 miles of where they trained, Dr. Battafarano says.
6. Monitor for signs of burnout.
These signs include decreased satisfaction with daily activities, disconnecting from colleagues and feeling increased and overwhelming stress, Ms. Moody says.
At the University of Michigan Health-West, the Office of Professional Well-Being surveys clinicians annually for signs of burnout and offers voluntary coaching to help those who are struggling. While the office has been a success, it also takes an investment, Dr. Hahn says.
Self-Help
Although much of the responsibility to address burnout and workforce shortages may fall on the organizations that employ rheumatologists and on the greater healthcare system, clinicians can take steps to better manage today’s care responsibilities:
1. State your expectations upfront.
If you’re a new physician and facing a lot of student debt, you may feel pressure to simply accept whatever terms are given to you instead of objectively evaluating them, Mr. Schaff says. When negotiating for a new position, it’s important to make it clear what you want and what you need in terms of hours, number of days worked, care model, salary, and in other areas. “An honest dialogue will lead to better outcomes for you and your employer. The same is true if your circumstances change months or years into your employment; generally speaking, it’s better for everyone if you’ve shared the truth than if you’re quietly unhappy,” he advises.
2. Refer patients back to other physicians for care.
It’s common for specialists such as pulmonologists, nephrologists, and others to refer patients to rheumatologists for an emergent problem, Dr. Hahn says. This can be useful for the patient, but it could create a burden of care if the rheumatologist feels an obligation to continue to manage that patient over the long term. Refer patients back to their original specialist or their primary care physician if long-term rheumatology care isn’t truly needed.
3. Take steps back to recharge outside of work.
At this point, you’ve likely heard this advice numerous times. Still, it doesn’t hurt to state the basics of self-care again, like getting enough sleep, finding an enjoyable hobby, eating well and making time each day when you can unplug and not feel tethered to work messages or texts.
4. Inquire about a salary-based model.
The productivity-based compensation model based on the number of patients seen often puts rheumatologists at a disadvantage, Dr. Hahn says. Asking if a salary-based compensation model is possible could remove some of the burden of how many patients should be seen.
5. Invest in better hires and training.
As hard as it may be to find good people when you run a practice, it can make your job easier as a rheumatologist and help with consistency within the practice. It also can help with improved patient communication and workflow, Dr. Marston says.
6. Realize when you want or need more than what your current position offers.
If you can’t or don’t want to leave your current job, then consider ways to expand it. Dr. Gaylis did this by expanding his research into autoimmune disorders, long COVID and osteoporosis, and is currently co-founder of a supplement firm. His research has led to the first use of vagus nerve stimulation for rheumatoid arthritis (RA) in the U.S. He also continues to work at his multispecialty center in private practice. Rather than being buried in the “same old, same old,” creating new projects and activities, along with the “same old,” can actually be exciting and become the platform for new, refreshing activities, he advises.
To address some of the greatest sources of clinician dissatisfaction, Dr. Concoff decided to leave his practice and advance value-based care and precision medicine in rheumatology through his current work on RA. As chief innovation officer at Exagen, he leads the company’s RA initiatives. Dr. Battafarano stepped back from 36 consecutive years of leadership in the U.S. Army and as a rheumatology division director, research director and program director with succession planning. He transitioned to a part-time clinical rheumatology role with an underserved clinic and began to volunteer as a clinical professor at three medical schools. He also continues volunteer work with the ACR.
Despite challenges, Dr. Marston notes that fellowship applicant numbers within rheumatology continue to outpace the capacity to train fellows, showing that the strengths of the specialty remain clear.
“As a specialty, I think we need to continue to advocate for our patients, care team partners, and our trainees to overcome some of these factors leading to burnout. If we are able to maintain our strengths and our role in the health care system, I think the future for our specialty and our next generation of rheumatologists remains bright,” Dr. Marston says.
Vanessa Caceres is a medical writer in Bradenton, Fla.
References
- Ney E, Brookshire M, Weisbrod J. A Treatment for America’s Healthcare Worker Burnout. Bain & Co. 2022 Oct 11.
- Tiwari V, Kavanaugh A, Martin G, et al. High burden of burnout on rheumatology practitioners. J Rheumatol. 2020 Dec;47:1831–1834.
- 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 projects of pediatric rheumatology workforce, 2015-2030. Arthritis Care Res (Hoboken). 2022 Mar; 74:340–348.
