2015 American College of Rheumatology Workforce Study: The Role of Graduate Medical Education in Adult Rheumatology

Feasibility of Physiotherapist-Led Rheumatology Triage: A Randomized Study

OBJECTIVE

Given global shortages in the rheumatology workforce, the demand for rheumatology assessment often exceeds the capacity to provide timely access to care. Accurate triage of patient referrals is important to ensure appropriate utilization of finite resources. We assessed the feasibility of physiotherapist (PT)-led triage using a standardized protocol in identifying cases of inflammatory arthritis (IA), as compared to usual rheumatologist triage of referrals for joint pain, in a tertiary care rheumatology clinic.

METHODS

We performed a single-center, prospective, nonblinded, randomized, parallel-group feasibility study with referrals randomized in a 1:1 ratio to either PT-led vs usual rheumatologist triage. Standardized information was collected at referral receipt, triage, and clinic visit. Rheumatologist diagnosis was considered the gold standard for diagnosis of IA.

RESULTS

One hundred two referrals were randomized to the PT-led triage arm and 101 to the rheumatologist arm. In the PT-led arm, 65% of referrals triaged as urgent were confirmed to have IA vs 60% in the rheumatologist arm (P = 0.57), suggesting similar accuracy in identifying IA. More referrals were declined in the PT-led triage arm (24 vs 8, P = 0.002), resulting in fewer referrals triaged as semiurgent (6 vs 23, P = 0.003). One case of IA (rheumatologist arm) was incorrectly triaged, resulting in significant delay in time to first assessment.

CONCLUSION

PT-led triage was feasible, appeared as reliable as rheumatologist triage of referrals for joint pain, and led to significantly fewer patients requiring in-clinic visits. This has implications for waitlist management and optimal rheumatology resource utilization.

Child Health Needs and the Pediatric Rheumatology Workforce: 2020-2040

The Pediatric Rheumatology (PRH) workforce supply in the United States does not meet the needs of children. Lack of timely access to PRH care is associated with poor outcomes for children with rheumatic diseases. This article is part of a Pediatrics supplement focused on anticipating the future pediatric subspecialty workforce supply. It draws on information in the literature, American Board of Pediatrics data, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, Strategic Modeling and Analysis Ltd., and the American Board of Pediatrics Foundation. PRH has a smaller workforce per capita of children than most other pediatric subspecialties. The model demonstrates that the clinical workforce equivalent of pediatric rheumatologists in 2020 was only 0.27 per 100 000 children, with a predicted increase to 0.47 by 2040. Although the model predicts a 72% increase in providers, this number remains inadequate to provide sufficient care given the number of children with rheumatic diseases, especially in the South and West regions. The likely reasons for the workforce shortage are multifactorial, including lack of awareness of the field, low salaries compared with most other medical specialties, concerns about working solo or in small group practices, and increasing provider retirement. Novel interventions are needed to increase the workforce size. The American College of Rheumatology has recognized the dire consequences of this shortage and has developed a workforce solutions initiative to tackle these problems.

Rheumatology Training in Latin America: A Collaborative Study by the Pan American League of Associations for Rheumatology

BACKGROUND/OBJECTIVE

Demand for rheumatology care has steadily increased in recent years. The number of specialists in this field, however, seems insufficient. No recent studies have diagnosed the attributes of rheumatology training in Latin America.

METHODS

This is a descriptive cross-sectional study. We obtained data on each country through local rheumatologists of the Pan-American League Against Rheumatism, who acted as principal investigators for participating countries. Our sample was analyzed and described through means and standard deviations or through frequencies and percentages, depending on the variable.

RESULTS

Countries with the most rheumatology-training programs were Brazil (n = 50), Argentina (n = 18), and Mexico (n = 15). Ecuador, Honduras, and Nicaragua do not have rheumatology-training programs. The countries with the most available slots for rheumatology residents were Brazil (n = 126) and Argentina (n = 36). To be admitted into rheumatology training, candidates were required to have completed graduate studies in internal medicine in 42.1% of the programs. In 8 countries (42.1%), residents are not required to pay tuition; the median cost of tuition in the remaining countries is US $528 (interquartile range, US $2153).

CONCLUSIONS

Conditions associated with rheumatology training in Latin America vary. Significant differences exist in income and tuition fees for residents, for example, and 4 countries in Latin America do not currently offer programs. Information collected in this study will be useful when comparing the status of rheumatology services offered in Latin America with those in other countries. Most countries require a wider offering of rheumatology-training programs, as well as more available slots.

The Association Between Physician Gender and Career Advancement Among Academic Rheumatologists in the United States

OBJECTIVE

To determine the potential association between physician gender and academic advancement among US rheumatologists.

METHODS

We performed a nationwide, cross-sectional study of all rheumatologists practicing in the US in 2014 using a comprehensive database of all licensed physicians. Among academic rheumatologists, we estimated gender differences in faculty rank, adjusting for differences in physician age, years since residency graduation, publications, National Institutes of Health (NIH) grants, registered clinical trials, and appointment at a top 20 medical school using a multivariate logistic regression model. We also estimated gender differences in leadership positions (i.e., division director and fellowship program director).

RESULTS

Among 6,125 total practicing rheumatologists, 941 (15%) had academic faculty appointments in 2014. Women academic rheumatologists (41.4%) were younger and had completed residency more recently than men. Women had fewer total publications, publications on which they were the first or last author, and NIH grants. In fully adjusted analyses, women were less likely to be full or associate professors than men, with an adjusted odds ratio (OR) of 0.78 (95% confidence interval [95% CI] 0.62-0.99]). Women in rheumatology had similar odds as men of being a fellowship program director or division director (adjusted OR 0.99 [95% CI 0.69-1.43] and adjusted OR 0.96 [95% CI 0.66-1.41], respectively).

CONCLUSION

Among academic rheumatologists, women are less likely than men to be full or associate professors but have similar odds of being fellowship program directors or division directors, when adjusting for several factors known to influence faculty promotion. These differences suggest barriers to academic promotion despite representation in leadership positions within rheumatology divisions.

Exploring Pediatric Tele-Rheumatology Practices During COVID-19: A Survey of the PRCOIN Network

Healthcare providers were rapidly forced to modify the way they practiced medicine during the coronavirus disease 2019 (COVID-19) pandemic. Many providers transitioned from seeing their patients in person to virtually using telemedicine platforms with limited training and experience using this medium. In pediatric rheumatology, this was further complicated as musculoskeletal exams typically require hands-on assessment of patients. The objective of this study was to examine the adoption of telemedicine into pediatric rheumatology practices, to assess its benefits and challenges, and to gather opinions on its continued use. A survey was sent to the lead representatives of each Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) site to collect data about their center's experience with telemedicine during the COVID-19 pandemic. Quantitative data were analyzed using descriptive statistics, and qualitative data were thematically analyzed. Responses were received from the majority [19/21 (90%)] of PR-COIN sites. All respondents reported transitioning from in-person to primarily virtual patient visits during the COVID-19 pandemic. All centers reported seeing both new consultations and follow-up patients over telemedicine. Most centers reported using both audio and video conferencing systems to conduct their telemedicine visits. The majority of respondents [13/19 (68%)] indicated that at least 50% of their site's providers consistently used pediatric Gait Arms Legs and Spine (pGALS) to perform active joint count assessments over telemedicine. Over half of the centers [11/19 (58%)] reported collecting patient-reported outcomes (PROs), but the rate of reliably documenting clinical components varied. A few sites [7/19 (37%)] reported performing research-related activity during telemedicine visits. All centers thought that telemedicine visits were able to meet providers' needs and support their continued use when the pandemic ends. Benefits reported with telemedicine visits included convenience and continuity of care for families. Conversely, challenges included limited ability to perform physical exams and varying access to technology. Pediatric rheumatology providers were able to transition to conducting virtual visits during the COVID-19 pandemic. Healthcare providers recognize how telemedicine can enhance their practice, but challenges need to be overcome in order to ensure equitable, sustainable delivery of quality and patient-centered care.

Designing an Intervention to Improve Management of High-Risk Lupus Patients Through Care Coordination

Health care disparities are a major cause for large discrepancies in health outcomes between different populations with systemic lupus erythematosus in the United States.A team-based model that incorporates a care coordination strategy in the management of high-risk lupus patients can provide an effective method to overcome the obstacles posed by health care disparities.Access, behavioral modification, community outreach programs, depression, and education are key aspects that need to be addressed when designing interventions to improve the quality of care for high-risk lupus patients.

Representation of Women as Authors of Rheumatology Research Articles

OBJECTIVE

In academic medicine, journal article authorship is central to career advancement and promotion. This study aimed to examine the contemporary representation of women as first and senior authors of rheumatology original research articles.

METHODS

The gender of the first and senior author, disease category, research design, and funding source were extracted from rheumatology original research articles published in high-impact rheumatology and general medical journals between 2015 and 2019.

RESULTS

The analysis included 7,651 original research articles. In total, 51.5% of the articles had women first authors (95% confidence interval [95% CI] 50.4-52.6%) and 35.3% had women senior authors (95% CI 34.2-36.4%). Women were significantly less likely to be first and senior authors of articles reporting randomized controlled trials compared with other clinical research designs (P < 0.001), and of articles reporting industry-funded/industry-initiated studies compared with studies not funded by industry (P ≤ 0.01). Of the articles reporting industry-funded/industry-initiated randomized controlled trials, women were first authors in 18.5% (95% CI 13.8-24.0%) and senior authors in 23.9% (95% CI 18.6-29.8%).

CONCLUSION

In rheumatology research articles, there is gender parity for first authorship, but women are underrepresented in senior authorship positions. Underrepresentation of women in authorship is particularly apparent in articles reporting randomized controlled trials, and especially those that are initiated by industry.

Addressing the rheumatology workforce shortage: A multifaceted approach

A significant challenge facing the field of rheumatology is the projected gap between the growing demand for rheumatologists and the available workforce. In order to improve access to care, augmenting the rheumatology workforce is required. Herein we discuss potential solutions to the anticipated workforce shortage, including 1) expanding the training of rheumatology physicians; 2) increasing nurse practitioner, physician assistant and pharmacist utilization in rheumatology practice; 3) growing the use of telemedicine; and 4) reducing burnout in order to retain practicing rheumatologists. Building on the existing literature in these areas, we propose a multifaceted approach to addressing the rheumatology workforce shortage.

Challenges in Optimizing Medical Education for Rheumatologists

The field of rheumatology has expanded rapidly in recent years, and innovations in immunology, epigenetics, and bone metabolism continue at an astonishing pace. In this fast changing field, optimizing medical education for rheumatologists is vital for maintaining a competent workforce to meet the needs of patients with rheumatic diseases. Several key challenges lie ahead and efforts to optimize medical education for rheumatologists are discussed in this article.

Workforce Trends in Rheumatology

The United States is facing a rheumatology provider shortage over the next decade, which will negatively affect care for patients with rheumatic disease across the nation if this deficit is not thoughtfully addressed. The increasing numbers of retiring rheumatology specialists, women entering the workforce, and rheumatology graduates seeking part-time employment were identified as the most significant factors driving the projected decline in supply of providers. The major factors driving the projected increase in demand include an aging and growing population and improved treatment options, both of which increase disease prevalence and the challenge of managing chronic rheumatologic diseases.

Encounters with Rheumatologists in a Publicly Funded Canadian Healthcare System: A Population-based Study

OBJECTIVE

To quantify population-level and practice-level encounters with rheumatologists over time.

METHODS

We conducted a population-based study from 2000 to 2015 in Ontario, Canada, where all residents are covered by a single-payer healthcare system. Annual total number of unique patients seen by rheumatologists, the number of new patients seen, and total number of encounters with rheumatologists were identified.

RESULTS

From 2000 to 2015, the percentage of the population seen by rheumatologists was constant over time (2.7%). During this time, Ontario had a stable supply of rheumatologists (0.8 full-time equivalents/75,000). From 2000 to 2015, the number of annual rheumatology encounters increased from 561,452 to 786,061, but the adjusted encounter rates remained stable over time (at 62 encounters per 1000 population). New patient assessment rates declined over time from 10 new outpatient assessments per 1000 in 2000 to 6 per 1000 in 2015. The crude volume of new patients seen annually decreased and an increasing proportion of rheumatology encounters were with established patients. We observed a shift in patient case mix over time, with more assessments for systemic inflammatory conditions. Rheumatologists' practice volumes, practice sizes, and the annual number of days providing clinical care decreased over time.

CONCLUSION

Over a 15-year period, the annual percentage of the population seen by a rheumatologist remained constant and the volume of new patients decreased, while followup patient encounters increased. Patient encounters per rheumatologist decreased over time. Our findings provide novel information for rheumatology workforce planning. Factors affecting clinical activity warrant further research.

Evaluating the Perception Among Rheumatologists of Maintenance of Board Certification in the US

OBJECTIVE

There continues to be a debate about the value and purpose of maintenance of certification (MOC) programs in the US. The goal of this study is to assess the impact, value, and purpose of MOC programs in rheumatology.

METHODS

A survey was sent to 3,107 rheumatologists in the US. The survey addressed how rheumatologists perceive the value and impact of MOC programs on rheumatology practice and patient care.

RESULTS

A total of 515 rheumatologists completed this survey. The majority (74.8%) believed there was no significant value in MOC, beyond what is already achieved from continuing medical education. Most rheumatologists did not believe MOC was valuable in improving patient care (63.5%), and the majority felt that the primary reason for creating MOC was either the financial well-being of board-certifying organizations (43.4%) or to satisfy administrative requirements in health systems (30%). Although 65.6% perceived that staying current with new medical knowledge was a positive impact of MOC programs, the MOC was perceived to result in time away from providing patient care (74.6%) and time away from family (74%). When asked about potential effects of requiring MOC, 77.7% reported physician burnout, 67.4% early physician retirement, and 63.9% anticipated an effect on reducing the overall number of practicing rheumatologists.

CONCLUSION

The majority of rheumatologists do not believe there is significant value for MOC programs. There is evidence for lack of trust in board-certifying organizations, and rheumatologists believe MOC programs contribute to physician burnout, early retirement, and loss in the rheumatology workforce.

Challenges of Practicing Rheumatology in a Government Setting: A County Hospital and Veterans Affairs Hospital Perspective

In this article, we review the challenges and opportunities afforded by working in a government setting by providing the perspective of the Veterans Affairs experience as well as the county/public hospital experience from Los Angeles County Department of Health Services. This article highlights processes and services that are unique to practicing rheumatology in a government setting, specifically, resource allocation with clinic space and staffing; protocols for access to conventional and biologic disease modifying antirheumatic drugs; and research opportunities for rheumatologists working in a government setting. Our aim is to expand the reader's understanding of this practice setting.