What Changes May the Next Decade Bring to Rheumatology?

Dr. Kumar

Is it 2024 already? It seems like yesterday that I stuffed all my earthly belongings into my black Volkswagen Jetta and headed from Lexington, Ky., to Iowa City, Iowa, to start my rheumatology fellowship.¹ That was 10 years ago. Now, in 2024, as I go online—particularly on social media—and see the various happy, smiling faces of those who are going to enter our rheumatology family in 2024, I’m struck by the wistfulness of time marching forward. What world will these newest rheumatologists inherit in the year 2034, as they pick up an antique version of the January 2024 edition of The Rheumatologist? Let’s rheuminate!

The Rheumatologist as a Tech Wiz

It’s safe to say that in 2034, the healthcare field will likely be unrecognizable. As much as 2014 seems alien to us in 2024, 2034 will be even more bizarre because technology is advancing at an accelerating pace. I firmly believe that artificial intelligence is here to stay and will do a lot of the heavy, repetitive work that we rheumatologists now have to do as part of our jobs. Although there are concerns that artificial intelligence will subsume our field and render the need for human rheumatologists moot, I am confident that rheumatologists will figure out ways to synergize our unique humanistic skills with technology.

While a large part of my fellowship was spent in memorizing details and applying them in clinical settings, the rheumatology fellows entering in 2024 are probably going to be better served by learning the technological tools that make such memorization unnecessary. That means not only understanding the basics of artificial intelligence  and large language models, but going beyond to appraise the utility of different tools in the clinical setting. I would counsel rheumatology fellows to practice their prompting skills and to continuously challenge their creativity in using tools, such as ChatGPT, to solve practical problems.

At the same time, I would strongly encourage fellows to remember the things that only they can offer to patients. I doubt that patients will ever be truly comfortable with a machine being their clinician, even if the clinician heavily uses those computer-based tools.

Although anything can happen, I don’t see more technology as a solution to our workforce crisis, especially in rural and other underserved areas. The emerging rheumatologists of 2034 will have to devise new methods of extending themselves without over-extension and over-reliance on technology.

I’m also very doubtful that any artificial intelligence can truly emulate empathy and compassion as only a human being can. Therefore, during fellowship, I would strongly advise the newest rheumatologists to reflect on, and engage in, deliberate practice on softer skills, those involving strengthening the patient-physician relationship, especially non-verbal communication and rapport building. Those were important in 2014, are important in 2024 and will be of even more paramount importance in 2034.

Every Rheumatologist Will Be a Policy Expert

On similar lines, I envision that every rheumatologist will go to Washington, D.C., at least once in their career, and a large percentage will go there annually to advocate for their patients. Because much of the clinician work will be supported by clinical decision support tools, including artificial intelligence, rheumatologists will need to have a greater say in policy development at all levels. This includes rheumatologist input in determining reimbursement, regulations and recognition.

For rheumatology fellows entering in 2024, it should be a priority to understand these larger systems that impact their practices. Such opportunities as the ACR’s Advocacy 101 can be invaluable in imparting skills that create such awareness and lead fellows toward becoming experts in advocacy. Other events, at the local and the state levels, may also be helpful and may, in fact, be even more impactful for practice. Beyond the ACR, advocacy events from other professional and specialty associations may supplement efforts to achieve these educational ends.

Of course, this particular future depends on the idea that our sociopolitical systems are going to be largely intact over the next 10 years. Nobody knows if that will happen. But here, rheumatologists in 2024 can play a vital role. The more that we advocate in our everyday capacities, the more we can shore up the democratic norms of citizenry and advocacy—and, in the process, lead us to that future that we seek. In this case, we have enormous agency to mold the future as we wish it to become.

Better Treatments & Cures

My biggest hope for 2034 is that we’ll look back at 2024 and see how crude our tools were to help treat patients with rheumatic disorders. By 2034, thanks to massive investments in basic, clinical and translational research, I anticipate that we’ll have treatments (and cures!) for many of the chronic immune disorders we manage.

Currently, we are undergoing a renaissance in basic science knowledge of immunology. In 2014, innate-like lymphoid cells (ILCs) were barely characterized, having been identified only in 2008.² Now, in 2024, we recognize the indispensable role they play in maintaining homeostasis of the immune system. Between now and 2034, there will undoubtedly be a proliferation of new science that helps uncover the hidden realms of the immune system. Instead of tenuously hypothesizing about links between cells, cytokines and end effects, I imagine there will be a larger, more tangible map outlining pathways that lead to immune regulation and immune dysfunction.

By 2034, new medications will finish their journey to the pipeline. They will have names that are utterly unpronounceable to human beings, but they will exist. And these medications will enable us to treat patients by uniquely targeting the steps in such pathways that we do not know today. In the ideal setup for the rheumatology clinic for tomorrow, we won’t need to guess whether a patient will respond to a medication or not, but rather can counsel patients how soon a given medication will work based on basic lab work and other investigations.

In the same way that we look at gold injections or thalidomide as ancient remedies, I feel that rheumatologists in 2034 will look at prednisone as an historical artifact. Even in 2024, prednisone seems to be on its way out, with urgent appeals to reduce prednisone to its lowest possible dose for as little time as possible. In 2034, my hope is that it will require a compounding pharmacy to synthesize a dose of prednisone to the patient because prednisone will be replaced by cheaper and more effective medications with less adverse effects.

More optimistically, I believe there will be cures—truly cures—to many of the chronic inflammatory conditions that we consider today to be stubbornly unresponsive. We’re at the infancy of CAR-T therapy for such conditions as systemic lupus erythematosus and systemic sclerosis. And although there have been setbacks and concerns about the risks of therapy, including malignancies, exist, I feel confident the technology will continue to advance so the benefits will unambiguously outweigh risks.³

Rheumatologists Will Unite with Other Specialists

With the proliferation of knowledge and skills, rheumatologists are going to study a very different field than our forebears. Rheumatologists of 2034 are going to be part hematologists, part clinical immunologists and part infectious disease specialists, among other hybrids. I anticipate there will be a lot more cross-training during fellowship and more interdisciplinary involvement so we can learn from our colleagues. This will include primary care, and I am eager to see the burgeoning field of preventive rheumatology grow into its own over the next 10 years.

To the newest members of the rheumatology community, fellowship will be the ideal point to have elective clinical experiences and research projects, so the academic rheumatologists in 2034 can have deep and meaningful relationships with our colleagues. The private practice rheumatologists of 2034 will obviously have a different sphere that they inhabit, but having knowledge that transcends what is traditionally rheumatology will be just as essential.

In turn, many of these other specialists will likely become part rheumatologists and we’ll have to negotiate new spaces to collaborate with them. Rheumatology fellows entering in 2024 will have to develop leadership skills to ensure these newfound spaces are both equitable and inclusive for everyone involved.

On a larger scale, our community will need to come up with innovative solutions to expand rheumatology training spots, so that more rheumatologists can enter these new spaces and be willing to lead them. Creative means of sharing costs and other administrative burdens will need to be embraced at institutional and national levels. In 2024, it is shocking that more than 70 applicants were unable to match, which represents about 20% of all applicants.⁴ My hope is that in 2034, we can marshal enough resources to ensure that more people can enter our rheumatology family.

The Rheumatology Community Will Be More Diverse, Inclusive & Equitable

The rheumatology workforce has become more diverse over the past few decades, and I anticipate that by 2034, it will become even more diverse.⁵ Our ranks will be drawn from a more diverse population that better reflects the populations we serve. Between 2014 and 2024, a much greater awareness has been instilled regarding the principles of diversity, equity and inclusion and how they strengthen the foundations of the work that we do. Over the next decade, that awareness will be translated into meaningful action. In 2034, we will be recruiting internal medicine and pediatric resident physicians who have been raised with even greater social conscience and zeal to remake the world so that it is more equitable and inclusive.

The rheumatology fellows who are entering in 2024 will be indispensable in achieving this aim. One thing that I do not envision changing is the central role that fellows have in inspiring their colleagues, both junior and senior, to become better people. Those entering this year are going to be exemplary role models because they will undoubtedly reflect on their place in the world and how they can grow to make the world a fundamentally better place.

So whether you are reading this in 2024, or 2034, or anywhere in between (or even beyond), I can’t help but feel a great sense of optimism for our specialty. Rheumatologists have consistently shown an incredible tenacity in adapting and overcoming challenges to ensure our patients receive the best possible care. It may not exactly be prophetic, but it is nevertheless true: 2024 will be an exceptional year for rheumatology and so will the coming decade.

Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X @BharatKumarMD.

References

1. Kumar B. 7 tips for new rheumatology fellows. The Rheumatologist. 2015 Aug;9(8).
2. Vivier E. The discovery of innate lymphoid cells. Nat Rev Immunol. 2021 Oct;21(10):616.
3. Kolata G. Innovative cancer treatment may sometimes cause cancer, F.D.A. says. The New York Times. 2023 Nov 28.
4. Hicks L. Rheumatology fills over 97% of fellowship programs for 2024. Medscape. 2023 Nov 29.
5. Case SM, Kerr GS, Chandler M, et al. Recognizing racial bias and promoting diversity in the rheumatology workforce. Arthritis Rheumatol. 2022 Sep;74(9):1459–1463.