At the recent EULAR congress in Barcelona, I sat down with a group of American rheumatologists for a late afternoon drink. We gathered in the lounge on the executive floor of the headquarters’ hotel. The hotel was a sleek high rise, Euro-modern in design, and the lounge adjoined a balcony overlooking the Mediterranean Sea. The day was warm and the water sparkled as a strong wind lifted white caps and propelled sail boards over the water like large fins.
The lounge was the perfect place for laughter and idle banter. Given the locale, the buoyant spirit of a beautiful city, and the sun that beamed down gloriously, our conversation should have bubbled and brimmed with optimism and excitement. Instead, the group seemed down. To a person, the Americans sitting in the lounge were reflective and sober as they expressed concern, even anxiety, about the landscape of rheumatology and the prospects for the future.
Before sitting with my friends, I went to the bar and poured a glass of water called Vichy Catalan. Somehow, I could not believe that a product called Vichy water still existed, but it fizzed nicely and was very refreshing. At the table, my American colleagues, instead of engaging in the usual gossip of academic comings and goings, were deep into a discussion of what many think of the crisis in rheumatology.
Rheumatology’s Paradox
Crisis is not my favorite word for a situation that seems chronic. The term, however, gives weight and seriousness to any discussion and certainly focuses attention. This crisis, which has been the subject of many important ACR initiatives and has been discussed in TR, reflects the collision of two ominous trends: the gap in the workforce as the supply of rheumatologists fails to meet the demand, and the increasingly troubled state of academic rheumatology. According to predictions, in the coming years more people will leave the field than will enter it and training programs can’t keep pace.
These trends are, of course, paradoxical because at present there is every reason for rheumatology to expand and prosper. With the increasing sophistication and complexity in patient care and the arrival of the baby boomers in droves at the doctors’ offices, the demand for rheumatology service will soar. Further, future improvements in care will likely involve more aggressive treatment approaches that will necessitate more visits and more intensive monitoring.
The past years have witnessed impressive treatment advances especially of inflammatory disease. Patient outcomes are continuously improving, with the development of new drugs and strategies making remission in RA, for example, a realistic goal. To explore fully the array of possibilities in RA alone afforded by existing agents, we would need a dramatic boost in investigators. To test the panoply of new agents in the pipeline, a veritable army would be needed. Similar issues pertain to the workforce needs to explore new treatments of osteoarthritis, osteoporosis, and the autoimmune diseases.
Nevertheless, despite the necessity to expand the field of rheumatology, many training programs can’t fund all of their approved positions and there is difficulty in recruiting new chiefs and leaders of once distinguished programs. In the setting of large academic medical centers, the training programs are often beleaguered as they are forced to downsize, hamstrung by financial models that are as harmful as they are baroque.
My thirst quenched with the Vichy water, I was about to switch to cava to get a jump on the festivities of the evening ahead. With my colleagues engrossed in a serious powwow, however, I wanted to stay sharp and participate with them to come up with ideas for lessening our crises. I poured another glass of Vichy water.
Our conversation ebbed and flowed as we sent up trial balloon after trial balloon for finding solutions. Many of the suggestions were expected: Lobby Congress to increase National Institutes of Health spending; convince the medical school deans of the importance of rheumatology services; develop new financial models to take account of the downstream revenues rheumatologists generate.
While the expected ideas all have value, somehow none seemed particularly compelling or likely to succeed. Indeed, as the sun shone brilliant silver-gold in the afternoon sky over the white buildings of Barcelona, the world seemed a bit darker.
Crisis Solved?
In situations like this one, the simplest thing to say is, “Think outside the box.” Along with crisis, this is another phrase that I resist. Frankly, I abhor the idea that I inhabit a box and the phrase “think outside the box” is one of the most trite and overused of all exhortations for a group. Nevertheless, original thought is good and I will relate an outside-the-box idea that our stalwart group in the executive lounge advanced just prior to our expedition to the Parc Guell for EULAR’s 60th birthday party.
The idea is a product of collective thought and has corporate ownership. I doubt, however, that any of us will put our name on this product despite its merit. If we did, the authorship would have some heavy hitters in the lineup.
Instead of giving the answer away now, though, I’m going to wait until next month to reveal our solution. Look for our chronic crisis solution in September’s “Rheuminations” column.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C. Contact him at [email protected].
