Precision Medicine on a Population Level

Over our 25 years as rheumatologists, care has advanced greatly. We each completed our rheumatology training in the late 1990s when both infliximab and etanercept first arrived on the U.S. market, ushering in the era of biologics in rheumatology. Since this time, our greater understanding of the immunologic basis of many rheumatic diseases has translated into a growing list of targeted therapies. It’s truly a fun time to be a rheumatologist and a time when we can offer many patients effective therapies. However, the current environment of rheumatologic care has crushing access issues.

Although the number of people in the rheumatology workforce slightly increased through 2020, many younger rheumatologists are not working full time, and projected retirement numbers will result in a reduced workforce in the near future.¹ The ACR projected a large and progressive shortage of rheumatologists by 2030, mostly due to rheumatology person-power shortages plus an increased demand for rheumatologic care.² This situation has been exacerbated by early retirements attributable to burnout, a process that accelerated during and after the pandemic. Concurrent with an increasingly limited supply of rheumatologists, shifting demographics, the prevalence of anti-nuclear antibody (ANA) positivity and gradual increases in autoimmune diagnoses have increased the demands placed on the U.S. rheumatology workforce.^3-5

We have not seen hard data, but colleagues from around the country describe wait times of six months or greater for a new patient, and 12-month wait times are not unusual at rural rheumatology practices;⁶ this situation is not sustainable.

There is a direct human cost to prolonged wait times in the rheumatic diseases—one that threatens our patients with a cascade of events leading to greater disability if traditional models of care fail to evolve to address the combined impacts of a smaller workforce and the greater demands it faces. Specifically, under the current paradigm, the supply-demand mismatch can be expected to increase wait times for initial consultation, resulting in longer time to diagnosis, and allowing greater progression of disease disability and accrual of permanent damage to joints and other organs.

Tackling the Shortage

The ACR has proposed ways to address this workforce shortage, including enhancing the number of trainees and increasing recruitment and training of advanced practice providers (APPs), such as nurse practitioners and physician assistants. Efforts to effectively address the epidemic of burnout may alleviate a cause of suffering among our colleagues, reducing early retirement from clinical practice. Yet these important steps to impact the supply side of the supply-demand mismatch in U.S. rheumatology are unlikely to add enough rheumatologists and interprofessional rheumatology providers quickly enough to solve the growing access problems. Are there other models of care that should be considered to improve the demand side of the equation?