AT THE ACR ANNUAL MEETING
WASHINGTON (FRONTLINE MEDICAL NEWS) – The mass retirement of Baby Boomer workhorses, the changing face of a Millennial workforce, and the graying of America will deliver a triple-whammy to rheumatology over the next 15 years: By 2030, the United States will be short 4,700 full-time rheumatologists – just about as many as are currently in practice.
“This is drastic,” Marcy Bolster, MD, said at the annual meeting of the American College of Rheumatology. “We need to take action now or we will not be able to meet the expected increases in patient demand.”
Dr. Bolster, director of the rheumatology fellowship training program at Massachusetts General Hospital, Boston, was one of 10 clinicians who discussed the ACR’s massive new project, “The 2015 Workforce Study of Rheumatology Specialists in the United States,” a comprehensive assessment of the current supply of rheumatologists in this country, and a sobering prediction of how many will be needed in the future.
The overall picture is stark. There are now 4,997 full-time rheumatologists practicing in the United States, which is already far short of the current demand of 6,115. But those numbers will continue to diverge, Dr. Bolster said. By 2030, as Americans live longer, 8,184 rheumatologists will be needed to care for them. But by that time, as few as 3,455 may be working full-time – a 138% supply/demand discrepancy.
Released at the ACR meeting in Washington, the 2015 survey is the first that ACR has conducted since 2005. The project drew on a number of sources: questionnaires sent out to the entire ACR membership; published research, position papers, and government reports; the Institute of Medicine; and state licensure and National Resident Matching Program data. Four online questionnaires surveyed not only rheumatology clinicians and fellows, but other health professionals, adult and young patients with rheumatic diseases, and the parents of pediatric patients.
The survey response rate of 31% among practicing rheumatologists was not as high as the Committee on Rheumatology Training and Workforce Issues would have liked, said Daniel Battafarano, DO, a study cochair. But fellows had a 95% response rate, offering the study a very solid look at the near future of the specialty.
The 2015 results were a striking contrast to the 2005 report, which examined supply and demand up to 2025. It came to a brighter conclusion: that a relative balance would be maintained. Not so now.
The reasons for this projected imbalance are not overly complicated, and are actually recapitulated in other areas of medicine, said Dr. Battafarano, chief of rheumatology at San Antonio (Tex.) Military Medical Center. Baby Boomer senior physicians are tired of working 70 hours a week, and moving toward retirement in unprecedented numbers. In fact, according to the report, 50% of today’s full-time rheumatologists will retire within the next 15 years, and 80% of those plan to cut back their workload by about 25%.
“When I was a fellow, we assumed we’d be working into our 70s. But that’s not the case now,” he said in an interview. “We are tired and burnt out, and retiring earlier and in unprecedented numbers.”
It’s not that new blood isn’t coming into the profession. In fact, Dr. Bolster said during her presentation, the percentage of internal medicine residents moving into rheumatology will stay stable, at about 4%. But the number isn’t projected to increase as patient demand does, and these new doctors will look and practice very differently than the new doctors of 30 or 40 years ago.
“The majority of medical school graduates now – about 60% – are women,” Dr. Battafarano said. “And they are entering the workforce at a very challenging time of life, simultaneously building careers and families.”
Studies have also demonstrated that women have different practice patterns than men. They tend to spend more time with patients, so they sometimes see fewer in a day. In fact, in its supply assessment, the ACR study characterized women rheumatologists as 0.7 of a full-time equivalent position – an important factor in the projected supply gap.
But this story isn’t turning on women who want a cushy part-time job, Dr. Battafarano cautioned. Part of it is based on his own generation of work-a-holism. In general, young physicians now place more importance on a healthy work-life balance than did his generation, and this he sees as a healthy way to approach a new career.
“I’ll admit it: Baby Boomers are dysfunctionally working too hard, and they miss the importance of a health work/life balance. That’s changing, and that’s a good thing.”
His protégé, Katrina Lawrence-Wolff, DO, agrees. A second-year rheumatology fellow, Dr. Lawrence-Wolff is also expecting her first child. She presented the breakout results focusing on the adult rheumatologist supply/demand picture.
“None of us think working 8 hours a week is a good idea for us personally, or a good way to give good medical care to patients,” she said in an interview. “We would rather have more time with family, more time for volunteering in our community, or to do advocacy work. We want to be flexible, and we do understand that this attitude may change the level of our reimbursement. But we are willing to forgo some salary to become a happier, better-balanced person.”
International medical graduates also affect this snapshot of the future, Dr. Bolster said during her lecture. More than half of new medical graduates are international students, and 17% of those intend to leave the United States after their education is complete.
Shortages will affect all regions, but some more than others
All of these issues are now converging at a time when patient demand is expected to soar. In the United States, about 22.5 million adults and 300,000 children have a rheumatic disease. According to the study, that number will increase by 61% by 2030.
Dr. Lawrence-Wolff used population statistics to really put the numbers needed to care for these patients into perspective. Studies in the United States, Canada, and Europe generally agree that the ideal rheumatologist:patient ratio is somewhere around 2 per 100,000 adults. “In 2005, when we were felt to be balanced in this way, our ratio was 1.67/100,000 patients.”
This ratio will look very different by 2025, she said, and the regional imbalances already seen will be magnified. These regional differences aren’t a surprise, Dr. Lawrence-Wolff noted. They directly reflect the density of academic rheumatology training centers. “Most practicing rheumatologists tend to stay in the region where they received their training,” she said, “so we have more clinicians in areas with more academic centers.”
For example, the Northeast U.S. hosts a highly enriched rheumatologist population, with a rheumatologist:patient ratio of 3.7/100,000. By 2025, this will be reduced to 1.6/100,000 – still acceptable, but more than a 50% decrease.
That same decrease will be much more drastically felt in regions that already have a paucity of rheumatologists. In the Southwest, the current ratio is 1.2/100,000; in 10 years, this will be 0.64/100,000. Even areas that are moderately well supplied now will suffer. Both the Northwest and North Central regions have a ratio of about 1.6/100,000. Both those regions will sink into the range of 0.6-0.5/100,000.
“All regions are going to decline below the 1.67 threshold by 2030,” she said. “Every single one.”
Troubles for pediatric rheumatology workforce
If things are concerning in the world of adult rheumatology, they’re downright alarming in the world of pediatric rheumatology, said Dr. Battafarano, who broke out the pediatric subspecialty results.
These clinicians are already scarce, with only 287 currently practicing full-time in 2015. By 2030, 461 will be needed, but the supply is expected to drop to 231.
The pediatric supply problem starts much earlier in the academic process, he said. For years, about 50% of the slots of pediatric rheumatology fellows have gone unfilled. In this world, recruitment woes will drive supply problems more than retirement. “As a whole, pediatric rheumatologists are younger,” Dr. Battafarano said, with only 32% planning to retire by 2030.
“Recruitment into adult rheumatology isn’t a problem, but on the pediatric side, it’s been very hard to recruit. This isn’t unique to rheumatology; it’s being seen in other pediatric subspecialties as well.”
Reimbursement and work overload are at the root of it, he believes.
“It translates pretty well to income. Reimbursement for chronic diseases, like what we see, is predominately Medicaid. The reimbursement rate and income for subspecialty pediatrics is definitely lower than it is in other academic subspecialties. And I have to think that time spent observing an exhausted, overworked physician isn’t helpful either.”
The mandatory 3-year pediatric rheumatology fellowship may also be a deal killer for some potential recruits, Dr. Battafarano said. The prevailing thought has always been to include a year of academic research in the pediatric track, which extends it beyond the 2-year fellowship that adult rheumatologists experience.
“So you marry the 3-year fellowship with workload, quality of life, student debt, and income and you get a combination that’s just less appealing than some other areas.”
Adjusting that fellowship track is one way to potentially improve the pediatric supply picture, he said. “One of the things I recommended is adding a 2-year clinical track. There are ways to do research that can be folded into a clinical setting that wouldn’t require an entire year. The majority of adult fellowships are 2 years with concurrent research, so there is already a precedent.”
In fact, Dr. Lawrence-Wolff is doing just that, he said. “She will do clinical research that’s integrated into her practice, but her primary role is to learn to be a clinical rheumatologist.”
Ideas for stretching rheumatologic care
Dr. Battafarano had some other practical suggestions for improving recruitment into the field. “We have to offer some incentives. I’d like to see us exploring the potential of loan repayment and visa programs.”
Overall, expanding the musculoskeletal expertise of primary care providers should also be on the table, Dr. Lawrence-Wolff said. “It’s possible that we can help our primary care colleagues extend rheumatology care by treating things like osteoarthritis and gout.”
Rheumatologists also can’t afford to ignore the expanding-role of mid-level providers, she said. “We would like to recruit more nurse practitioners and physician assistants into the specialty. The numbers we hope will go up, even if the percentage remains the same as it is, about 2%-5%.”
Skillfully leveraging these clinicians’ strengths will be the key to successfully employing them.
“We see different ways to utilize them to stretch our care. One suggestion is having them in the clinic to see more patients per day, but also to use them to see lower-level patients so the rheumatologist can take care of the more complex cases.”
They could also serve patients who have multiple regularly scheduled checkups for chronic illness. “If you have a patient who needs to be seen four times a year, the NP or PA can see that person, check the labs and determine if the patent is stable, and doesn’t really need to see the rheumatologist.”
Technology will invariably come into play as well, Dr. Battafarano said.
“We envision this as a multipronged approach that includes telehealth and ‘E-consults,’ although we don’t precisely know what that will look like. But other specialties – and primary care as well – are going through very similar trends here. We are all talking about working with other providers to reach more patients, and telemedicine is a key area of investigation. We really are all in the same boat.”
Finally, Dr. Battafarano urges his fellow senior clinicians to consider severing professional ties gradually. “It’s not just a dearth of bodies we’re facing, but a sudden depletion of valuable experience and clinical wisdom. In my practice, for example, the three of us each have more than 30 years’ experience. That’s close to a century of experience, and two of them want to retire. It’s such a brain-drain on a terrific practice to lose our colleagues overnight.”
For some reason, he said, the locum tenens model has never really caught on in rheumatology, and he’d like to see that idea explored and embraced. It’s a perfect way to keep experienced hands in the mix, both seeing patients and mentoring young rheumatologists, he added.
“Even if we’re in our 60s and 70s, we’re not brain-dead yet. A lot of us want to keep contributing, just not full-time.”
None of the clinicians quoted in this article had any relevant financial disclosures.
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