A previous ACR president once stated that “a major issue facing our subspecialty [is] an accurate prediction of clinical and academic manpower requirements during the next decade and beyond.” He commented on the ACR’s “responsibility to manpower planning and attention to the needs of younger clinical rheumatologists,” and put this in context of the fact that “between 160 and 190 fellowship positions are being filled each year.”1
These comments of Giles Bole, MD, seem as pertinent today as they were in 1981. In 2008, we confront the concurrent development of daunting challenges to both the clinical and academic environments in rheumatology. These circumstances have created new pressures and hurdles at each of the critical transition points in a career in rheumatology: recruitment into our specialty; launching of an academic or clinical career; and transition from the early career phase to long-term stability, productivity, and career satisfaction. In my final TR column as your ACR president, I’ll assess where we stand in developing rheumatology’s future workforce, describe what the ACR is doing to meet the challenges that confront us, and suggest additional steps that the ACR might consider.
Good News About Today’s Trainees
Compared with 10 years ago, important progress has been made. Almost all rheumatology fellowship positions that are offered are filled, versus one-third sitting empty. A rheumatology match has been successfully implemented, thanks to the efforts of Walter Barr, MD, Carlos Lozada, MD, and other current and former members of the ACR’s Committee on Training and Workforce Issues. For the 2009 match, 99 rheumatology fellowship programs participated, and fewer than 10 remained outside it. A total of 181 first-year positions were offered in the match, and 168, or 93%, were filled through the match, with an additional 10 filled soon thereafter. Including positions outside the match, the number of first year fellows in 2009 will be about 190. Currently, 2.9% of internal medicine residents go on to a rheumatology fellowship versus 1.9% at the beginning of this decade. For the past few years the applicant pool has numbered about 365, suggesting that if more positions were available, more could be filled. For 2009, 22 positions were offered in the pediatric rheumatology match; 17 (77%) were filled.
The ACR is playing a more active role in training rheumatology fellows through an updated curriculum, a standardized in-service exam, programs that offer every fellow the chance to attend at least one ACR meeting annually, new and expanded mechanisms for support of fellows’ salaries through the REF and, in 2008, the first ACR Rheumatology Research Workshop (RRW). The workshop, held in August, brought together one hundred rheumatology fellows, students, residents, and junior faculty, together with a smattering of experienced faculty, to present and discuss research, learn about the key steps in developing a career in research, and interact socially in a relaxed setting. Thanks to superb planning by the Committee on Research, led by Bill St.Clair, MD, and the meeting chairs Betty Diamond, MD, and Steve Goldring, MD, the RRW was a terrific success, and it will be held at least every two years going forward. The workshop is one way for the ACR to augment the mentoring of our fellows. Another approach worth considering would be establishment of a national Internet-based mentoring system that would link rheumatology faculty with specific areas of expertise and experience to trainees who can benefit from such interactions. The Fellows’ Subcommittee and the Committee on Training and Workforce Issues are already working on this concept.
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.)
So what is stopping us from offering more slots? Here, again, the survey of training program directors and a parallel recent survey of rheumatology division chiefs, provide some important clues. The biggest obstacle to training more fellows does not appear to be the available applicant pool, the number of approved slots, or the number of available faculty (although each of these issues is important for some programs)—the key missing ingredient is sufficient funds for training fellows. Indeed, there is widespread concern about the ability to maintain funding for fellows even current levels. Complicating the situation is the complex combination of sources of funding for rheumatology fellowships, which includes institutional clinical positions from Medicare GME dollars; other clinical revenues; National Institutes of Health (NIH) funds; the REF; other foundations, such as the Arthritis Foundation (AF); and industry. The ACR is actively working to maximize support for our training programs. The development of an REF endowment for its core programs, especially fellowship training, is on track to reach $25 million by 2010, as a first big step towards a $100-million REF endowment. It’s clear, however, that increasing the number of fellows will require further expansion of the role of the REF as well as better support from other sources, including the NIH.
The National Institute of Arthritis, Musculoskeletal and Skin Diseases (NIAMS) is concerned about career development issues in rheumatology and earlier this year convened a “Roundtable Discussion on Research Career Paths in Rheumatic Diseases” that included leaders of the ACR, REF, AF, NIAMS staff, and members of the Young Investigators Subcommittee of the ACR’s Committee on Research. The group agreed that support for a large number of trainees is required to produce a modest-sized cohort of researchers, and identified two post-fellowship bottlenecks to research career development: the first at the point of competition for an initial mentored faculty-level grant, such as a “K Award,” and the second at the transition from junior faculty to independent status, which typically involves successful application for NIH “R Series” grants. Strategies to address these bottlenecks are possible. By funding K-bridging awards this year, the REF and the AF have proven their ability to jointly devise and rapidly implement such a strategy. These awards will support young faculty whose K grants were ranked very highly by the NIH but not funded, allowing these new investigators to maintain research productivity while reapplying to the NIH. The REF is also working to devise a new grant program to assist rheumatology researchers in achieving the K to R transition using strategies that leverage a modest investment of REF funds to give our younger researchers a competitive edge in applying for an NIH grant.
Help on the Horizon and Beyond
The ACR needs to be just as imaginative in supporting the career development of our practicing clinicians. Our educational activities, clinical practice support staff, advocacy efforts, and an online book on how to start a rheumatology practice that is nearing completion are all part of meeting this challenge. A practice-management course to be offered during the April 2009 State-of-the-Art Symposium in Chicago will feature a full-day session that will expose fellows to practice management concepts and skills.
Much more, however, needs to be done. Big questions that we are hoping to tackle include: What will be the scope of practice in the field of rheumatology in the future? and What business models will be viable for the practice of rheumatology five or 10 years from now?
Also of fundamental importance to clinical rheumatologists, and to our ability to train the workforce of tomorrow, is the question, What business model(s) can allow our academic rheumatology units to survive and even flourish, so that we can retain faculty in academic positions where salaries may be lower, but where they are needed to continue to train new generations of future rheumatologists? These are large, complex questions, and answering them will not be easy or inexpensive. Thoughtful members of the ACR are asking it to tackle these issues, and the time is right—we are already scheduled to undergo a major strategic planning process in 2009.
Providing an optimal workforce for the future is not, therefore, an isolated educational endeavor. Success in this task will require us to confront all of the major challenges in our field. Over the next few months, ACR members should think carefully about whether the ACR is asking the right questions and taking the right initiatives. Members can then provide their views to ACR leadership and staff regarding what they hope to see accomplished through the ACR’s new strategic plan that will be created in 2009.
Acknowledgement: Thanks to Abby Abelson, David Daikh, Amy Miller, and Mark Andrejeski for helpful suggestions during the preparation of this column.
Dr. Fox is president of the ACR. Contact him via e-mail at [email protected].
References
- Bole GG. The American Rheumatism Association 1990. Presidential Address to the American Rheumatism Association, June 4, 1981. Arthritis Rheum. 1982;25(1):1-9.
- Deal CL, Hooker R, Harrington T, et al. The United States Rheumatology Workforce Study: Supply and demand, 2005–2025. Arthritis Rheum. 2007; 56:722-729.
