The regional distribution of rheumatologists: what can we do, what should we do?

Perceptions and Challenges Experienced by African Physicians When Prescribing Methotrexate for Rheumatic Disease: An Exploratory Study

OBJECTIVE

Guidelines for methotrexate (MTX) use in rheumatic disease may not be feasible for physicians practicing in the least developed countries. We aimed to understand the experiences of MTX prescribers relating to MTX use for rheumatic disease in African countries to inform the development of culturally and geographically appropriate recommendations.

METHODS

African physicians who self-identified as MTX prescribers from countries classified as having a low versus a medium or high Human Development Index (L-HDI versus MH-HDI) participated in semistructured interviews between August 2016 and September 2017. Interviews were transcribed verbatim, coded thematically, and stratified by HDI.

RESULTS

Physicians (23 rheumatologists; six internists) from 29 African countries were interviewed (15 L-HDI; 14 MH-HDI). Identified barriers to MTX use included inconsistent MTX supply (reported by 87% L-HDI versus 43% MH-HDI), compounded by financial restrictions (reported by 93% L-HDI versus 64% MH-HDI), patient hesitancy based partly on cultural beliefs and societal roles (reported by 71%), few prescribers (reported by 33%), prevalent infections (especially viral hepatitis, tuberculosis, and human immunodeficiency virus), and both availability and cost of monitoring tests. MTX pretreatment evaluation and starting and maximal doses were similar between L-HDI countries and MH-HDI countries.

CONCLUSION

The challenges of treating rheumatic disease in African countries include unreliable drug availability and cost, limited subspecialists, and patient beliefs. Adapting recommendations for MTX use in the context of prevalent endemic infections; ensuring safe but feasible MTX monitoring strategies, enhanced access to stable drug supply, and specialized rheumatology care; and improving patient education are key to reducing the burden of rheumatic diseases in L-HDI countries.

Impact of a Student-Led Rheumatology Interest Group on Medical Student Interest in Rheumatology

Objectives

This observational study was designed to evaluate the impact of a student-led Rheumatology Interest Group on medical student interest in rheumatology.

Methods

The mean numbers of student-rheumatology interactions per six months were assessed for elective enrollment, abstract submissions, and manuscripts, in the pre- and postinterest group period.

Results

Enrollment in the rheumatology elective increased from 2.0 ± 0.36 per six months in the preintervention period to 6.2 ± 1.24 per six months in the postintervention period (p=0.0064). Abstract submissions increased from 0.5 ± 0.34 to 5.86 ± 1.49 (p=0.0077), and manuscript submissions from 0.16 ± 0.16 to 1.57 ± 0.37 (p=0.074).

Conclusion

The Rheumatology Interest Group significantly increased medical student engagement in rheumatology.

Successes, challenges and developments in Australian rheumatology

Australia is a geographically vast but sparsely populated country with many unique factors affecting the practice of rheumatology. With a population comprising minority Indigenous peoples, a historically European-origin majority population, and recent large-scale migration from Asia, the effect of ethnic diversity on the phenotype of rheumatic diseases such as systemic lupus erythematosus (SLE) is a constant of Australian rheumatology practice. Australia has a strong system of universal healthcare and subsidized access to medications, and clinical and research rheumatology are well developed, but inequitable access to specialist care in urban and regional centres, and the complex disconnected structure of the Australian healthcare system, can hinder the management of chronic diseases.