Rheumatology workforce challenges are a global concern. Many challenges, especially the lack of trained rheumatology clinicians, are similar among countries and regions of the world, while others differ. The 2024 ACR Global Summit session on workforce featured a discussion by representatives of regional rheumatology organizations and the ACR addressing issues central to developing and retaining workforce in our field.
Dr. Ahmed
Panelists for the summit included Sakir Ahmed, MD, DM, Kalinga Institute of Medical Sciences, India (APLAR); Anja Strangfeld, MD, German Rheumatology Research Center and Charité University Medicine Berlin (EULAR); Farhanah Paruk, MBChB, PhD, University of KwaZulu-Natal, South Africa (AFLAR); Daniel Battafarano, DO, University of Texas Health-San Antonio, and Uniformed Services University (ACR); and Ana Maria Arredondo Gonzalez, MD, Hospital de San José Centro, Bogota, Colombia (PANLAR). Some of the key topics addressed by the panelists included workforce training, reimbursement, availability of affordable medications, salaries, national and international healthcare priorities that disadvantage rheumatology services, and use of technologies and artificial intelligence tools to improve patient and provider education and disease management.
Focus on Asia
Dr. Paruk
In India, there are fewer than one rheumatologist for every 1 million people, according to Dr. Ahmed. This severe shortage of rheumatologists poses major challenges especially for reaching underserved populations. Most of rheumatologists are geographically clustered in major metropolises.
“This is not just about India,” said Dr. Ahmed. “There are lots of diversities, cultural, socioeconomics across the APLAR region. Each country has its own unique challenges and advantages.”
Using technology, including artificial intelligence approaches, has great potential to help address these problems. Dr. Ahmed also commented that, as a comparatively newer discipline, rheumatology has not been well integrated into the undergraduate syllabus, affecting training but also awareness of the discipline as a career choice. As in many countries, reimbursement for non-proceduralist practices in which physicians spend time with patients is poor, and the patient workloads are high. Consequently, practitioners who go into rheumatology often do not have the ability to participate in teaching the next generation of rheumatologists.
Dr. Battafarano
Focus on Europe
The need for better data collection regarding rheumatology needs and workforce was emphasized by Dr. Strangfeld, who chairs the EULAR Subcommittee on Epidemiology and Public Health of the EULAR Research Committee. This group is collecting data across Europe to provide the key facts and figures to policymakers for workforce planning, finding a large difference among European universities in rheumatology education.
For example, Dr. Strangfeld noted that “Less than 50% of German universities have rheumatology programs in place to ensure that the required teaching obligations for rheumatology are met, whereas in Denmark, rheumatology is an important part of medical education, and all Danish universities teach rheumatology.” To enhance the workforce, she said, “The first step we must take is to reach students in medical school and motivate them with information on the rheumatology field, [letting them know] that it is very interesting, exciting [field] to be in.”
In the next few years, demographic change and the anticipated retirement of around a third of the rheumatologists currently working will force us to look for the next generation of rheumatologists.
Focus on Africa
The high burden of serious and often fatal infectious diseases in Africa, such as malaria, tuberculosis and HIV, and the impact of managing these diseases has had on healthcare resource allocation was commented upon by Dr. Paruk. She pointed out the extreme shortage of rheumatologists across much of Africa and cited the many other healthcare challenges faced by rheumatology patients in Africa, including socioeconomic factors, poor state infrastructure and lack of human resources.
Dr. Arredondo
Most of the approximately 3,000 rheumatology providers in Africa are in countries with higher incomes, such as North Africa; 12 of the 44 African counties surveyed have only between one and 10 rheumatologists, and 17 have none. At the same time, several countries in East and West Africa have expanded or created new training programs in recent years, including Kenya, Rwanda, Zambia and Ghana.
A very serious issue is loss of trained professionals due to low earning potential and lack of opportunities. “You can train people, but a lack of viable practice and research opportunities often leads to feeling of being unable to deliver adequate care resulting in looking for jobs out of Africa,” said Dr. Paruk. “The shortage of posts and a high demand for rheumatology training, combined with a lack of basic needs to deliver rheumatology care leads to frustration.”
In terms of improving basic care for rheumatology patients, Dr. Paruk noted, “We find that basic courses in rheumatology offered by EULAR, and a recent handbook written by two local experts, Professors Tikly and McGill, about rheumatology in Sub-Saharan Africa have contributed to increasing awareness of rheumatological diseases among primary care providers, who see the vast majority of patients.”
Online courses and skills that can be gained in telehealth programs are important education delivery methods in Africa.
Focus on the U.S.
The need for more rheumatologists and the impact of COVID-19 on the workforce in the U.S. were among the topics addressed by Dr. Battafarano. He quoted the 2015 ACR workforce study, which projects a need for about 1.6 rheumatologists per 100,000 adult patients although the needs for pediatric rheumatology are less certain.
“In order to meet the future demand, without any interventions, a 100% increase in the number of rheumatologists would be needed to meet the U.S. demand for rheumatology services by 2030,” said Dr. Battafarano.
There have been dramatic shifts in the rheumatology workforce since 2015 due to baby boomer retirements, a female predominance, millennials and an increase in part-time rheumatologists since COVID-19. “Steps to retain senior rheumatologists in the workforce in various capacities could help alleviate the effects of these losses,” said Dr. Battafarano.
Lifestyle and work expectations of millennial rheumatologists also affect the workforce needs, as do the aging population in the U.S. Even though new training programs have opened, the U.S. cannot train enough rheumatologists. Despite a 100% fill rate for adult rheumatology programs, over 100 applicants per year are turned away. In contrast, many training spots in pediatric rheumatology go unfilled, largely because of a three-year fellowship and poor remuneration.
Several initiatives have been developed and include opening new fellowship programs in underserved areas. Virtual lectures for adult and pediatric grand rounds are now available for primary care programs, as well as a website, to assist primary care providers assessing rheumatic symptoms, interpret laboratory tests and reference medications. Virtual training in telehealth and training grants for nurse practitioners and physician assistants in rheumatology are available. A pilot program to look at creating a rheumatology network with primary care providers is also underway.
Focus on Latin America
As in many regions of the world, there are major differences in the availability of rheumatology services in Latin America. Dr. Arredondo noted the majority of rheumatologists in Latin America are in the southern countries of Brazil, Uruguay, Argentina and Chile, with fewer providers in absolute numbers or per population in countries like Nicaragua, Honduras and El Salvador.
Among the barriers to workforce development are the costs of fellowship, which are often borne by trainees, and the lack of training positions in some countries. For example, in Nicaragua, El Salvador or Ecuador, where there are no rheumatology programs, the problem seems to be that residency positions are controlled by governments that do not see the need or importance of opening rheumatology programs in their countries to train physicians in their local universities, so all rheumatology specialists must study abroad.
Dr. Arredondo noted that workforce aging in Latin American may not be as big a problem as in some other parts of the world. On the other hand, Dr. Arredondo said, “There is a leak of trained rheumatologists that has affected the workforce. In Latin America, the most important example is Venezuela, which has had a large exodus of rheumatologists and other healthcare workers.”
Themes
Although not all factors affecting rheumatology workforce could be addressed in the hour-long session, a number of themes stood out as of particular concern, including:
- Lack of integration in medical education: Rheumatology is not well integrated into undergraduate medical curricula.
- Financial barriers: Costs of training are high and reimbursement rates are low for rheumatologic care.
- Geographic and socioeconomic barriers: Significant disparities in access to rheumatologic care exist across different regions.
- Demographic change: The retirement of a considerable proportion of rheumatologists currently working and the high proportion of women in rheumatology requires new concepts to improve the compatibility of family and career and address the growth of part-time work.
Strategies to Address Shortage
- Improve medical education: Rheumatology needs to be better integrated into medical school curricula and more training opportunities need to be provided.
- Leverage technology: AI and telemedicine can be used to reach underserved populations and improve efficiency.
- Advocate for policy change: Rheumatology organizations and individual clinicians need to engage with governments and international organizations to prioritize rheumatologic diseases.
- Support young rheumatologists: Networks and mentorship programs to support early career rheumatologists need to be created.
- Tap the non-rheumatology workforce: Primary care providers and advanced practice providers need to be trained to identify rheumatologic conditions and manage these, if necessary (in more complex diseases or patient cases) in collaboration with rheumatologists.
Challenges & Solutions
- Attrition: The reasons why rheumatologists leave the field, such as burnout and financial concerns, need to be addressed.
- AI and technology: The potential of AI to assist in diagnosis and patient management and the need for reliable internet access must be addressed.
- Government and policy support: The importance of advocacy to ensure rheumatologic diseases are recognized and prioritized by health agencies cannot be overstated.
In Sum
Many workforce problems are essentially the same from region to region, although some are unique to certain areas. A number of strategies were mentioned that can be helpful to support young people who are interested in going into rheumatology to be more effective and have greater career opportunities.
The need for better networking and better mentorship was highlighted. Numerous countries and regions have developed such programs, including the North American Young Rheumatology Investigator Forum, the EMEUNET network of young rheumatologists, ArLAR Young Rheumatologist Group, Young PANLAR group of study, and APLAR Young Rheumatologists (AYR), to name a few. To address students before they specialize, EULAR offers free registration and hospitality for annual, weeklong summer camps for medical students and junior doctors; reimbursement for online training courses; and free registrations to its annual congress.
AI will certainly have a role in enhancing training and practice, and practice efficiency, improving disease screening and diagnosis, assisting with documentation so more time can be spent with the patient and less on administrative functions, and improving patient education.
If used intelligently, the electronic medical record could improve clinicians’ practice and quality of life. Training primary care providers can improve the referral process, avoiding unnecessary specialist referrals while assisting them in managing a significant number of patients with rheumatic disease in follow-up. Participants acknowledged the double-edged sword of technology and equity and ethics in healthcare.
A strong point of consensus is that as rheumatologists, we have a responsibility to promote the interests of our patients, healthcare providers and learners to ensure they receive the care, support and resources they need to improve health, career satisfaction and the science of rheumatology. An important aspect of advancing rheumatology is advocacy at every level, whether local, institutional, national or global.
The panelists at the Global Summit emphasized the importance of collaboration, technology and policy advocacy in addressing the workforce shortages, and underscored the common challenges and the need for solutions that consider regional differences.
Eric L. Matteson, MD, MPH, is the chair of the ACR’s Global Engagement Committee. He is a professor of medicine (emeritus), Mayo Clinic College of Medicine and Science, Rochester, Minn.
Evelyn Hsieh, MD, PhD, is the past chair of, and advisor to, the ACR’s Global Engagement Committee. She is an associate professor of medicine and epidemiology, Yale School of Medicine/School of Public Health, New Haven, Conn.
