Meanwhile, to help fellows headed toward a career in clinical practice, the Committee on Rheumatologic Care (CORC) and the ACR staff have prepared a book-length manual about how to start a career as a clinical rheumatologist. This comprehensive guide is in the final steps of development and editing, and will be available soon on the ACR Web site.
Room to Improve
More, however, needs to be done. The number of fellows in training is currently not greater than it was in 1981, but the population of patients with rheumatic diseases under our care is much larger, and growing rapidly. A workforce shortage already exists in rheumatology in the United States—due in part to the many unfilled training slots in the late 1990s—and will become more acute in the near future. The Lewin workforce study published in 2007 estimated that by 2025, an additional 2,500 rheumatologists would be required over the projected supply.2
Increases in the number of rheumatology nurse practitioners and physician assistants, the fastest growing segments of the ARHP, will be part of the answer. To better support the development of these key health professionals, the ARHP has created a new online series of curriculum modules which are being rolled out this fall. Improvements in the effectiveness of medications and other changes in practice patterns may help us practice more efficiently.
A strong case can be made, however, that we also need to train more rheumatology fellows, especially pediatric rheumatology fellows. Three hurdles need to be overcome to accomplish this: first, we need enough qualified applicants; second, we need to have additional approved slots; and third, training programs must have sufficient resources—enough funds to support these positions and enough faculty to do the teaching. Let’s examine each of these issues.
With 365 applicants (about 60% of whom are women) and about 190 positions, it would appear that enough applicants are available to fill more slots. Moreover, the majority of new fellows (but not a majority of the applicants) are U.S. medical graduates, unlike 10 years ago, when most were not. This implies that applicants are being turned down who would have obtained rheumatology fellowship positions 10 years ago. Are qualified applicants not matching to any position? Is visa status a significant obstacle for some applicants, since only permanent residents and U.S. citizens are eligible for some sources of fellowship funds, such as NIH training grants? Answering these questions is vital, because if there are no additional qualified applicants we need to redouble the efforts of the Research and Education Foundation (REF) to attract prefellowship trainees to a career in rheumatology.
Identifying Bottlenecks
How about the number of available fellowship slots? A recent survey of rheumatology training program directors, still being analyzed by ACR staff and volunteers, has revealed an important and, to me, surprising finding. Out of 72 programs that responded, the training program directors reported that, on average, one out of four ACGME-approved slots per program is currently unfilled. This means that many rheumatology fellowship slots are not placed into the match and most likely are not currently open in any way to applicants. Thus, we could substantially increment the number of rheumatology fellows by opening up the slots that already exist. (The situation for pediatric rheumatology is somewhat different, and the emphasis needs to be on attracting more applicants through, for example, the loan forgiveness provisions of the arthritis bill we have been strenuously pushing for during our trips to Capitol Hill.)
