Pediatric rheumatologists are calling a "Code (p)RED" — a pediatric rheumatology educational deficit.
There are too few pediatric rheumatologists to meet patient demand in the United States, and projections suggest that gap will continue to widen. Disappointing match trends also reflect issues with recruitment: Since 2019, only 50%-75% of pediatric rheumatology fellowship positions have been filled each year. For 2024, the subspecialty filled 32 of 52 positions.
Lack of exposure during medical school and residency, financial concerns, and a lengthy, research-focused fellowship are seen as major contributors to the workforce shortage, and novel solutions are needed to close the gap, experts argued in a recent presentation at the American College of Rheumatology (ACR) 2023 Annual Meeting.
"It's so important now to get ahead of this because what I'm afraid of is in 10-20 years, we're not going to have a field," Colleen Correll, MD, MPH, an associate professor in the division of pediatric rheumatology at the University of Minnesota Medical School in Minneapolis, told Medscape Medical News.
Growing Demand, Falling Supply
Because the subspecialty was officially recognized by the American Board of Pediatrics in 1991, "it's always been a small group of providers," Correll said. "It's honestly always been a recognized issue in our field."
But a 2022 report by the ACR on the pediatric workforce has brought more attention to the issue. Correll led the study and is the chair of ACR's Pediatric Rheumatology Committee. According to the report, an estimated 287 pediatric rheumatologists were working as full-time clinicians in 2015, while the estimated demand was 382 providers. By 2030, this projected supply of pediatric rheumatologists fell to 261, while demand rose to 461 full-time providers.
The distribution of pediatric rheumatologists is also an issue. It's generally thought that there should be at least one pediatric rheumatologist per 100,000 children, Correll explained. According to ACR estimates, the northeast region had approximately 0.83 pediatric rheumatologists per 100,000 in 2015, while the south central and southwest regions had 0.17 and 0.20 providers per 100,000 children, respectively. Projected estimates for 2030 dipped to 0.04 or lower for the south central, southwest, and southeast regions.
A separate study from the American Board of Pediatrics, also led by Correll, that is still under review offered more optimistic projections, suggesting that there would be a 75% increase in pediatric rheumatologists from 0.27 per 100,000 children in 2020 to 0.47 per 100,000 children in 2040.
"This does look better than the ACR study, though 0.47 is still a really small number and an inadequate number to treat our children in need," she said during her presentation at the ACR 2023 Annual Meeting.
Lack of Exposure During Medical Education
Few medical schools have pediatric rheumatology built into their curriculum, whether that is a whole course or a single lecture, said Jay Mehta, MD, who directs the pediatric rheumatology fellowship at the Children's Hospital of Philadelphia. Mehta, for example, did not know that pediatric rheumatology was a field before entering residency, he said. But residencies can also lack exposure: An estimated one third of residencies do not have a single pediatric rheumatologist on staff, he said.
"Those are places where people aren't necessarily getting exposure to pediatric rheumatology," he told Medscape, "and we know that if you're not exposed to a field, it's very, very unlikely that you will go into that field."
The ACR's Pediatric Rheumatology Residency Program is one way that the organization is working to address this issue. The program sends pediatric residents with an interest in rheumatology to the ACR annual meeting. The Rheumatology Research Foundation also runs a visiting professorship program, where a pediatric rheumatologist conducts a rheumatology education forum at an institution with no pediatric rheumatology program.
"I've done it a couple of times," Mehta said during his presentation at the annual meeting. "It's one of the most rewarding things I've done."
Financial Concerns
Additionally, although pediatric rheumatology requires more training, these subspecialists will likely make less than their general pediatric colleagues over their career. According to one study in Pediatrics, a pediatric resident pursuing rheumatology is projected to make $1.2 million dollars less over the course of their career compared with someone who started their career in general pediatrics immediately after residency. (Negative financial returns were also found for all pediatric subspecialities except for cardiology, critical care, and neonatology.)
This lower earning potential is likely a deterrent, especially for those with educational debt. In one analysis published in October, medical students with at least $200,000 in education debt were 43% more likely to go into higher-paying pediatric subspecialities than those with no debt. Nearly three out of four medical graduates have education debt, according to the American Association of Medical Colleges, with a median debt of $200,000.
While the Pediatric Specialty Loan Repayment Program was specifically designed to aid pediatric subspecialists with their educational debt, qualifying for the program is difficult for pediatric rheumatologists, explained Kristen N. Hayward, MD, of Seattle Children's in Washington. The program provides up to $100,000 in loan forgiveness in exchange for 3 years of practicing in an underserved area; however, the program stipulates that providers must provide full-time (40 hours per week) clinical care. At academic institutions, where most pediatric rheumatologists practice, there is usually a research component to their position, and even if a provider works the equivalent of 40 hours per week in a clinic in addition to their research, they don't qualify for the program, Hayward said.
"It's very difficult to find someone who's actually only doing clinical work," she said.
The ACR has worked to combat some of these economic constraints by demonstrating the direct and downstream value of rheumatologic care, Hayward said. In a recent white paper, it was estimated that including office visits, consultations, lab testing, and radiology services, one full-time equivalent rheumatologist generates $3.5 million in revenue every year and saves health systems more than $2700 per patient per year.
In addition to placing greater value on rheumatologic care, the healthcare system also needs to recognize the current nonbillable hours that pediatric rheumatologists spend taking care of patients, Hayward noted.
Especially with electronic medical records (EMRs) and online communication with patients, "there is increasingly a lot of patient care that happens outside of clinic and that takes a lot of time," Hayward said. For example, she spends between 1 and 2 hours every day in the EMR refilling medications and responding to patient concerns, and "that all is done in my spare time," she said. "That's not billed to the patient in anyway."
Length of Fellowship
The pediatric rheumatology fellowship is a 3-year program — like other pediatric subspecialities — with a research requirement. By comparison, adult rheumatology fellowships are 2 years, and fellows can pursue additional research training if they have a strong interest.
"It sounds like just 1 more year, but I think it's coming at a really pivotal point in people's lives, and that 1 year can make a huge difference," Hayward explained.
The 2 years of research might also be a deterrent for individuals who know they are only interested in clinical work, she added. About half of pediatric subspecialists only pursue clinical work after graduation, according to a recent report by the National Academies of Sciences, Engineering, and Medicine (NASEM) focused on the future pediatric physician workforce.
Additionally, only 17% of pediatric rheumatologists spend more than half of their time in research, said Fred Rivara, MD, MPH, chair of the NASEM report, in a statement included in Hayward's ACR presentation. The report, which recommended strategies to bolster the pediatric workforce, argued that the American Board of Pediatrics should develop alternative training pathways, including 2-year, clinically heavy fellowships.
The ACR workforce team is also exploring alternative training models like competency-based education, Hayward said. The Education in Pediatrics Across the Continuum project is already using this approach from medical school to pediatric residency. While this type of outcome-based program has not been tried at the fellowship level, "this has been done, it could be done, and I think we could learn from our colleagues about how they have done this successfully," she noted.
Ultimately, Hayward emphasized that there needs to be a "sea change" to close the workforce gap — with multiple interventions addressing these individual challenges.
"Unless we all pitch in and find one way that we can all move this issue forward, we are going to be drowning in a sea of Epic inbox messages," she said, "and never get to see the patients we want to see."
Hayward previously owned stock/stock options for AbbVie/Abbott, Cigna/Express Scripts, Merck, and Teva and has received an educational grant from Pfizer. Correll and Mehta had no relevant disclosures.
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