ARTHRITIS & RHEUMATISMVol. 56, No. 3, March 2007, pp 730–731DOI 10.1002/art.22436© 2007, American College of Rheumatology

American College of Rheumatology Response to the2006 Rheumatology Workforce Study

Neal Birnbaum

Rheumatology enters this millennium energizedwith an optimism that is fueled by potent new therapies,by dramatic advances that give us the courage to thinkabout cures, and by an increase in the quantity andquality of applicants for rheumatology fellowships.Never has there been such a rich period of opportunityfor rheumatologists to improve the lives of our patients.

Yet the American College of Rheumatology(ACR) knows that our members confront significantchallenges in a rapidly changing health care environ-ment: declining reimbursements, increasing paperwork,and complex, confusing, and at times inexplicable de-mands from insurance companies and government. Themean age of US ACR members is 56 years (AmericanCollege of Rheumatology: personal communication).Practitioners face increasing demand for services at atime when our aging rheumatology workforce mighttypically intend to reduce its workload. Academiciansconfront these same problems and also struggle tosustain research and training in an era of increasingcompetition for a limited pool of resources. In addition,an experienced academic workforce will need to bereplenished with new mentors to train a future genera-tion of researchers and educators. These pressures haveprofound implications for our members. The ACR isfirmly committed to helping both practitioners andacademicians meet these challenges.

In 2005 the ACR Board of Directors, under theleadership of our President, Dr. Betsy Tindall, voted toobtain the first comprehensive workforce study of rheu-matology in more than a decade. The Board recom-mended that The Lewin Group, one of the nation’s mostrespected independent contractors in this area, under-take the study. The Workforce Study Advisory Group ofthe ACR Committee on Training and Workforce Issues,led by Dr. Chad Deal, worked with The Lewin Group in

an advisory capacity. This study, a summary of which ispublished in this issue of Arthritis & Rheumatism (1),included a comprehensive survey of our members andprovides an important glimpse into rheumatology prac-tice in 2006.

Why do a workforce study? Other such studies,including our own in the past, have sometimes givenflawed projections. This new study includes a computermodeling tool that will allow periodic reassessment of itsprojections. Perhaps the real value to any workforcestudy is that it forces us to evaluate our profession andproject where it most likely will be in the future. For theAmerican College of Rheumatology, the study chal-lenges us to consider the impact on the practice of ourmembers and how to prepare our members to continueto offer the highest-quality rheumatology care.

Major conclusions from the study are as follows:1) Demand for rheumatology services will grow in thenext 20 years. 2) The number of practicing rheumatolo-gists will grow little or not at all during that same period.3) These factors will lead to a substantial and potentiallycritical shortage of rheumatologists.

At first glance, such news appears welcome. Atminimum, it suggests job security and some promise ofsustaining current levels of income, which, according tosurvey data, are satisfactory for a majority of rheuma-tologists (2). (Some of that satisfaction may be the resultof income from newer therapies and diagnostic instru-ments, which may continue to be subject to pressures fordecreased reimbursement.) However, the potential forshortcomings in service to patients is real as the gapbetween supply and demand grows. Even now there maybe a shortage, as indicated by prolonged wait times andthe number of our members seeking new associates nowor in the near future (2). It is not clear that the currenthigh levels of job satisfaction can be sustained if futurepatient care demands are overwhelming.

The projected shortage of rheumatologists occursin the context of an overall projected shortage of physi-cians that may reach 200,000 by 2025 (3). The American

Neal Birnbaum, MD: University of California San FranciscoSchool of Medicine and California Pacific Medical Center; President,American College of Rheumatology, 2006–2007.

Submitted for publication September 21, 2006; accepted inrevised form December 6, 2006.

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Association of Medical Colleges has recently recom-mended a 30% expansion of the positions in allopathicmedical schools, to be accompanied by a similar expan-sion of graduate medical education (GME) positions(4). Such a dramatic increase over the current cap onMedicare-funded GME positions will likely be impededby ongoing budgetary concerns in Washington and theuncertainty surrounding future funding of the entireMedicare budget. This is particularly true given the lackof public consensus on whether the number of physiciansin the US should be increased (5).

In addition, the expansion of current trainingcapacity in rheumatology would require not only anincrease in salary support for fellows, but also meaning-ful growth in training resources, including academicfaculty, dedicated space for educational endeavors, in-creased clinical opportunities, etc. The AccreditationCouncil for Graduate Medical Education has developedrigorous program requirements that help ensure thequality of training programs, but in doing so has createdgenuine hurdles that new programs must overcome atstartup. In the face of all of these substantial challengesit seems unlikely that we will see any significant growthin the number of rheumatologists entering the workforceany time soon.

How has the ACR responded to this workforcechallenge?

First, changes in the design of practices arenecessary in order to increase the number of patients forwhom any individual rheumatologist can provide care. Inrecent years Dr. Timothy Harrington’s workshop onpractice redesign for rheumatology has been one of thebest-attended workshops of our annual meeting. TheCollege will continue to support educational initiativesthat promote practice efficiency and help practitionersmeet the growing demand to demonstrate quality ofcare. Practice redesign will also need to preserve, andhopefully improve, the quality of professional life thatACR members seek.

In addition, in partnership with the Associationof Rheumatology Health Professionals (ARHP), theCollege has undertaken the development of a newphysician assistant/nurse practitioner education programto assist members to expand use of physician assistantsand advanced-practice nurses. The ACR and the ARHPtogether will, more than ever, need to create initiativesthat provide professional development for allied healthprofessionals and expand the capacity of individualrheumatologists to provide quality patient care.

The struggle for financial survival is great for ourcurrent rheumatology training programs, and may be-

come greater. The ACR Research and Education Foun-dation (REF), under the direction of Dr. Jim O’Dell, hasdeveloped a strategic plan that commits the REF toexpanding its support for training programs through itsFellowship Training Awards. In addition, the REF sup-ports recruitment initiatives aimed at medical studentsand residents, so the current pipeline of rheumatologyfellows is assured. Finally, the REF has decided to in-crease the number of awards for young investigators inorder to help preserve our current academic programs.Unless we assure the viability of these programs, we willnot be able to continue producing rheumatologists ateven the current number, however inadequate thatnumber may be.

Supporting efforts to redesign practices to be-come more efficient and productive, expanding the poolof allied health professionals, and supporting the aca-demic enterprise are just some of the ACR and REFefforts currently under way. The ACR will also continueits ongoing advocacy efforts to improve reimbursementfor the complex cognitive services provided by rheuma-tologists. Unless rheumatologists are fairly reimbursedfor the services we provide, we are unlikely to see realgrowth in the quality and quantity of care provided.

In the upcoming months, the ACR will considernew opportunities to assist our members as we transitionto a new health care environment. We face manychallenges, as parts of the workforce study indicate.However these challenges loom no larger than those wehave faced in the past. We have inherited from priorACR leaders a remarkable legacy of resolve, determina-tion, persistence, and success. Never before has rheuma-tology been a more exciting field or rheumatologistsnearly as effective in alleviating the suffering of ourpatients. I am fully confident that, by combining theefforts of the entire ACR membership, its staff, andvolunteer leadership, we will create, both for our pa-tients and for us, a future that is brighter than we cannow possibly imagine.

REFERENCES

1. Deal CL, Hooker R, Harrington T, Birnbaum N, Hogan P, Bouch-ery E, et al. The United States rheumatology workforce: supply anddemand, 2005–2025. Arthritis Rheum 2007;56:722–9.

2. American College of Rheumatology Web site. URL: www.rheumatology.org.

3. Wilson JF. U.S. needs more physicians soon, but how many more isdebatable. Ann Intern Med. 2005;143: 469–72.

4. American Association of Medical Colleges Web site. URL: www.aamc.org.

5. Goodman DC. Too many doctors in the house. New York Times.July 10, 2006.

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