“Rheumatologic care doesn’t stop or end at a certain age. … The diseases we treat are chronic and continuous, and patients need care across ages,” says Cuoghi Edens, MD, FAAP, assistant professor of internal medicine and pediatrics at the University of Chicago. Dr. Edens is an internal medicine-pediatrics trained (Med-Peds) rheumatologist, a specialty type she hopes will become more desirable. She believes these specialists will better serve pediatric, young adult and adult rheumatology patients in light of the projected workforce shortage and increasing patient demand.
Workforce Demands
Between 2015 and 2030, the estimated demand for pediatric rheumatologists in the U.S. is projected to increase by 61%, and the demand already exceeds supply in many areas.1 It’s not uncommon for pediatric patients who are referred to a pediatric rheumatologist to wait three months or more to be seen. That statistic is only a small glimpse into the workforce needs, Dr. Edens notes.
Until recently, there wasn’t a pediatric rheumatologist in Dr. Edens’ home state of New Mexico. This shortage meant a pediatric rheumatology patient would either travel out of state for care, be cautiously treated by an adult rheumatologist or not treated at all, unfortunately. This scenario is common across the country due to the shortage of pediatric rheumatologists and is compounded by the shortage of adult rheumatologists. Dr. Edens says a rheumatologist with combined training would be well positioned to fill this void by seeing pediatric and adult patients and serving populations outside major metro areas.
Medical centers can also benefit from employing Med-Peds rheumatologists. Being able to see adults and children provides a unique and important niche for care continuity for pediatric patients transitioning to adult care. Dr. Edens has a transition clinic to help pediatric patients with rheumatic diseases safely adapt to adult rheumatology care. “When patients transition to adult care with those who are not trained in pediatric care, studies show diagnoses often get incorrectly changed from juvenile idiopathic arthritis (JIA) to lupus or Sjögren’s syndrome.”2
Often, pediatric-onset diseases have unique clinical courses, unique medication histories and risk factors that can get lost along the way. Studies also show adult rheumatologists are less aggressive in treating pediatric patients than their pediatric counterparts, and disease control may be compromised.3
Patient Needs
As treatment for all ages of rheumatology patients has dramatically changed over the past 15–20 years, many medications available to treat adult patients still lack approval for use in children. “Med-Peds-trained rheumatologists can encourage expansion of research into pediatrics and explore the clinical use of medications only approved for adults that may benefit pediatric patients based on our experiences with our older patients,” Dr. Edens says.
She also stresses the value of Med-Peds rheumatologists for diagnosing and treating certain medical problems sick pediatric rheumatology patients may face, such as venous thromboembolic events and heart attacks. “Often, these [conditions] aren’t at the top of the differential diagnosis in a pediatric patient who presents with shortness of breath, for example, but are common in adults with all diagnoses,” Dr. Edens says. “I’m very comfortable managing blood pressure medications and diuretics for my patients with renal complications from their lupus, for example, due to my internal medicine training.”
Dr. Edens says her combined training enables her to address such issues as school and work difficulties; mental health diagnoses; social concerns, such as drugs, tobacco use and vaping; and concerns surrounding reproductive health in patients of all ages. In particular, she hopes to broaden knowledge and resources for both pediatric rheumatologists and patients surrounding reproductive health issues. This topic is important to teens, young adults and parents affected by pediatric rheumatic diseases. Resources, such as those recently developed by the ACR, could also be beneficial for this population.4
Advancing the Role
In response to workforce demands and patient needs, current efforts are taking place across several fronts to increase the number of practicing Med-Peds rheumatologists.
1. Research
Dr. Edens is working with the ACR’s Committee on Rheumatology Training and Workforce Issues and Kimberly DeQuattro, MD, to explore various aspects of combined rheumatology fellowship training. Two questions Dr. Edens says need to be explored: Why do physicians in training choose a categorical or a Med-Peds fellowship? And how are Med-Peds trained rheumatologists using their training?
“It would be valuable to understand what happens to physicians who complete their combined rheumatology fellowship,” she says. “For example, are they dual-board certified? Are they taking care of more children [than] adults? And are they at an academic center or [in] private practice?”
These answers may help guide further efforts in addressing the workforce shortage.
2. Training
The course of medical education and training for a Med-Peds rheumatologist is substantially longer than both the categorical training for adult and pediatric rheumatology—which is a barrier to attracting residents to a combined fellowship, Dr. Edens explains. She says the rheumatology community is discussing incentives to attract more people to pediatric rheumatology in conjunction with legislation to help fund pediatric subspecialty training. Program leaders are also discussing ways to share costs for combined medical and pediatric rheumatology fellowship training to attract Med-Peds to their institutions.
3. Addressing Misconceptions
“There is a stereotype that if you pursue a combined fellowship, you will only end up seeing kids or adults and not use your combined training. I believe this is false,” Dr. Edens says. She notes more research to understand the career trajectory of Med-Peds rheumatologists will help address this assumption.
“Some people think Med-Peds physicians are indecisive. I just think we want it all,” she says.
Carina Stanton is a freelance science journalist based in Denver.
References
- American College of Rheumatology. 2015 workforce study of rheumatology specialists in the United States. 2016.
- Feger D, Longson N, Dodanwala H, et al. Comparison of adults with polyarticular juvenile idiopathic arthritis to adults with rheumatoid arthritis: A cross-sectional analysis of clinical features and medication use. J Clin Rheumatol. 2019 Jun;25(4):163–170.
- Van Mater H, Balevic SJ, Freed GL, et al. Prescribing for children with rheumatologic disease: Perceived treatment approaches between pediatric and adult rheumatologists. Arthritis Care Res. 2018 Feb;70(2):268–274.
- Sammaritano LR, Bermas BL, Chakravarty EE, et al. 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases. Arthritis Rheumatol. 2020 Apr;72(4):529–556. Epub 2020 Feb 23.
