Calling All Rheumatologists

By Debra Gordon and Donna Rae Siegfried

Jeri Stracner, 48, thinks nothing of driving an hour from her home in Carlisle, Kentucky, to see a rheumatologist in Lexington. Of course, that’s on a good day. On a bad day - say, if she gets stuck behind a tractor or someone hauling tobacco bales - the 45-mile trip to visit a rheumatology expert could take up to two hours.

Given the drive she’s willing to make to see this doctor, you might think he provides a level of service that can’t be found elsewhere. Turns out he’s simply the nearest rheumatologist. For those who don’t live near a major city, long drives to see rheumatologists are common. People in metropolitan areas may live close to a rheumatologist, but they, too, experience the effects of their doctor being overbooked, busy and in demand.

Since Stracner first began seeing her rheumatologist 13 years ago for rheumatoid arthritis (RA) and fibromyalgia, the rheumatology practice has gotten so busy it takes two or three days just to get a return call from a nurse. At least she’s not a new patient; average wait times for those appointments are three months or more. Stracner essentially competes for her doctor’s time.

Waiting to see a rheumatologist is more than just inconvenient. “For new patients, there’s a window of opportunity for starting treatments that can delay progression of the disease,” says Ramesh Pappu, MD, a rheumatologist at Albert Einstein Medical Center in Philadelphia. “If treatment is delayed for several months, permanent joint damage could occur. That’s something rheumatologists are concerned about.” And for established patients who can’t get in to see their rheumatologists, medication adjustments and critical laboratory tests could be delayed.

Currently, 46 million people have had a doctor tell them they have a form of arthritis, such as osteoarthritis (OA) or RA, or a related condition, such as lupus, gout or fibromyalgia. Within 25 years, as the over-60 population peaks, that number is expected to reach 67 million. And those figures don’t take into account the millions more who have joint symptoms and may need to see a doctor to find a diagnosis. They initially may see their family physician but then request to see a rheumatologist or be referred to one. This growing demand for rheumatologists could significantly affect care for millions of Americans.

What we know

The American College of Rheumatology (ACR) – the leading professional organization for rheumatologists, scientists and health-care workers who treat those with rheumatic diseases – began to study the situation two years ago. The results were released at its 2006 Annual Scientific Meeting.

The good news: The number of new rheumatologists has risen in recent years, from 122 in 2000 to 168 in 2006 – a 37 percent increase. The bad news: The healthy sounding growth will be outpaced by the rate of retirement. The ACR Workforce Study estimates that about half of practicing rheumatologists will retire within just eight years and that by 2025 there will be a shortage of 2,600 rheumatologists in the U.S.

The downside of demand

The nation’s more than 4,900 adult rheumatologists already struggle to keep up with an aging population and the resulting growth in patient load, even with primary care physicians and other health-care professionals sharing the load.

“Most people with OA are treated by a primary care physician, a physical therapist or perhaps eventually an orthopaedic surgeon,” says Chad Deal, MD, lead author of the ACR’s study and head of the Center for Osteoporosis and Metabolic Bone Disease at The Cleveland Clinic Foundation in Ohio. The same is true for some people with other forms of arthritis. On the other hand, primary care physicians send some patients to rheumatologists in an effort to diagnose and treat inflammatory forms of arthritis as soon as possible.

“Primary care physicians are now more likely to refer patients to rheumatologists because they realize they don’t have the expertise to provide the new biologic therapies,” says Walter G. Barr, MD, professor of rheumatology at Northwestern University in Chicago and head of the ACR Workforce Committee.

“Through bioengineering and a greater understanding of immunology, we’ve been able to develop extraordinarily powerful medicines that can make a quantum difference in people’s lives. The biologic drugs like abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), etanercept (Enbrel), infliximab (Remicade) and rituximab (Rituxan) provide the potential for disease modification now that we didn’t have 10 years ago,” says Stephen Paget, MD, physician-in-chief of the rheumatology division at the Hospital for Special Surgery, which is associated with Weill Medical College of Cornell University in New York City. But the best medications in the world won’t do much good if there aren’t enough doctors available to administer them.

Lack of manpower & funds

Today’s rheumatologists hope that research advances and new treatment options will draw newly minted doctors to specialize in rheumatology. “The field of rheumatology is on the cutting edge of science, and that makes it more attractive to medical students and residents,” says Dr. Paget. Still, getting future doctors to commit to rheumatology can hit a few snags, all of which boil down to money.

The path to becoming a rheumatologist requires three years as an internal medicine resident and then another two or three years completing a fellowship in the subspecialty of rheumatology. A pediatric rheumatologist will do three years as a resident in pediatrics and then take part in a pediatric rheumatology fellowship. Although the number of fellowship slots available is limited, in rheumatology some slots go unclaimed.

According to the 2005–2006 ACR study, 395 fellowships were available but only 366 were filled. The good news is that the completion rate for rheumatology fellowships is 100 percent - the doctors who take rheumatology fellowships stay with the field. Practicing rheumatologists often mention the ability to develop long-term relationships with their patients and the challenge of finding the correct diagnosis as top reasons they enjoy their chosen field.

Some slots remain empty, however, because funding isn’t available. Funding for fellowships helps a hospital pay for the doctor’s salary and benefits. Increasing the number of fellowship slots also requires increasing the number of full-time faculty to supervise them.

Another problem is that rheumatology remains among the lowest paid of all the internal medicine subspecialties, bringing in far less in reimbursements from insurance companies and Medicare. The American Medical Group Association’s Compensation and Financial Survey found the median compensation per rheumatologist in 2003 was about $180,000, compared with $305,000 for gastroenterology and $335,700 for general cardiology. This also plays a role in new doctors’ desire to go into rheumatology, especially when they finish medical school with $150,000 or more in debt.

Even if more doctors choose to specialize in rheumatology, there is no guarantee they will spend their career seeing patients. Among the 4,900 rheumatologists in the country, many incorporate teaching, research or administrative work in addition to seeing patients. Some do not see patients at all. The demand for medical doctors in business roles, from investment banking to management of health-care companies running hospitals, gives doctors other career options.

Group efforts

To address the shortage, the ACR has developed recruitment materials and raised money from pharmaceutical companies to attract people to rheumatology careers. And it has provided funds to give students exposure to rheumatologists they don’t receive early in their medical school training.

Still, more could be done. Redesigning medical practices to make them more efficient could help reduce costs, balance the supply and demand for rheumatologists and better serve patients. For instance, group appointments work well for educating patients, doing routine care and answering questions. And group appointments provide patients with an instant support group.

Group appointments are only one tactic for improving efficiency, says Timothy Harrington, MD, a rheumatologist in the department of medicine at the University of Wisconsin in Madison and a member of the ACR Workforce Committee. Dr. Harrington also recommends pre-appointment management for new patients. In 2001, he led a study reviewing the medical records of 279 patients referred to a rheumatologist and found only 59 percent of them needed to see one.

Such changes likely would take years. In the meantime, a lack of rheumatologists will not mean a lack of caregivers or access to care – for adults, anyway. (For children with arthritis, the situation is vastly different. See “Specialists for Children,” below.) The ACR plans to expand high-quality training programs for health-care professionals, such as nurse practitioners and physician assistants.

“Rheumatology relies heavily on teamwork to meet the needs of patients,” says Roderick Hooker, PhD, a physician’s assistant at the Department of Veterans Affairs Medical Center in Dallas and an author of the ACR study. “Physician’s assistants and nurse practitioners provide the continuity of care, which is needed to give the role of the rheumatologist room to expand,” he says.

Creating dependable care takes the understanding and support of all those affected – the patients, doctors and non-physician clinicians, says Dr. Harrington. “The financing and delivery of health care is broken in the U.S., and people need to advocate for fundamental change.” 

Specialists for children: few and far between

When it comes to pediatric rheumatology, a crisis isn’t coming; it’s here, says Patience White, MD, chief public health officer of the Arthritis Foundation and a pediatric rheumatologist. Although the 218 pediatric rheumatologists in the U.S. are younger, on average, than adult rheumatologists, most are women, who work fewer hours and see 35 percent fewer patients than their male counterparts. And within the next five years, 32 percent of pediatric rheumatologists plan to reduce the time they spend seeing patients, according to the American Academy of Pediatrics.

Although adults often face long waits for appointments with rheumatologists, the situation is far worse for the 300,000 children with rheumatic diseases, who may have to travel hundreds of miles for one appointment. And 10 states don’t have a single pediatric rheumatologist. Today’s shortage means that one-third of children younger than 18 who have arthritis will see an adult rheumatologist.

Legislation wending its way through Congress could improve the situation. When passed, the Arthritis Prevention Control and Cure Act (APCCA), supported by the Arthritis Foundation and the ACR, will help ensure an increase in pediatric rheumatologists by providing support for more pediatric rheumatology fellowships and partial loan forgiveness for medical school debt.

The Arthritis Foundation is stepping up not only through advocacy efforts to get the APCCA passed, says Dr. White, but also by trying to raise $5 million to pay for additional pediatric rheumatology fellowships. “We’ve been stepping up in research for years; now we’re stepping up in access to care and treatment,” says Dr. White.