In December 2006, just before New Years, my primary care physician ordered up some blood tests for me. I seemed to be in pain all the time, all my joints hurt, and I was exhausted everyday. I'd get home from work at 6:00 PM and just sit in the car for another twenty minutes trying to summon up the energy to walk into the house. Right after New Years she called me with the results. The tests indicated the possibility of rheumatoid arthritis. Since the blood tests for RA are not definitive, I would need to see a rheumatologist for a history and physical exam. That's when I learned that the closest rheumatologist was a 1 hour drive away (the closest!!) and that no matter how far I was willing to drive it would take at least three months before I could get an appointment. In fact, it turned out to be four months. Whenever I talked to anyone about it, I would joke that there must be a shortage of rheumatologists, and that if they knew anyone in medical school they ought to pass on the word.
I finally got my appointment -- in April -- and was diagnosed as being in the early stages of rheumatoid arthritis, and began medication. This past week I had my second follow-up visit, and while I was waiting in the waiting room (so aptly named), I picked up a copy of Arthritis Today Magazine put out by the Arthritis Foundation. The issue was only a few months old, and the cover story was "The Rheumatologist Shortage". It was one of those "ah-ha!" moments when I find the data to support one of my gut feelings or pet theories.
The story of the rheumatologist shortage, places in bold relief some of the problems inherent in our patchwork private/public/profit/non-profit medical care system in the United States.
Rheumatology is a specialty whose number of practicianers are steadily declining, and whose number of patients are steadily increasing. According to the article: "Currently, 46 million people have had a doctor tell them they have a form of arthritis, such as osteoarthritis (OA) or RA, or a related condition, such as lupus, gout or fibromyalgia. Within 25 years, as the over-60 population peaks, that number is expected to reach 67 million." On the supply side, the article states: "The ACR [American College of Rheumatology] Workforce Study estimates about half of practicing rheumatologists will retire within just eight years, and that by 2025 there will be a shortage of 2,600 rheumatologists in the U.S."
There have been enormous strides in the development of new medicines for rheumatoid arthritis -- you've probably seen the ads on television for Humira or Enebrel or Remicade. The problem, there are not enough rheumatologists available to get these drugs to the people who need them. It doesn't matter how wonderful the treatments are, if there is no one available qualified to prescribe the treatment.
So why is there this shortage? You'd think with such high demand, there'd be people clamouring to go into the field. There are several interacting causes, discussed in "The Rheumatologist Shortage". After completing medical school, the physician aspiring to the field of rheumatology must spend three years as an internal medicine resident and then another two or three years completing a fellowship in the sub specialty of rheumatology. This is a some what longer period of training that some other specialties, although there are others that are more popular that take more years. The biggest catch is the fellowship requirement. First there has to be a full-time faculty member in that specialty to supervise the fellowship, and with declining numbers of rheumatologists these are harder to find. Second, there has to be funding for the fellowship, funding that pays for the salary and benefits of the fellow -- who after all has to have something to live on while he or she is working. There's a shortage of funding for rheumatology fellowships. Arthritis after all does not have the cachet of some other diseases, and has not attracted as much attention or fund raising.
"According to the 2005-2006 ACR study, 395 fellowships were available, but only 366 were filled." Some of the unfilled fellowship slots remained unfilled because there was no money to pay the fellows. Some remained unfilled for the lack of a qualified supervising faculty member. And some remained unfilled because rheumatology, despite its slightly longer training period, is lower paying that other internal medicine specialties. Annual salaries for rheumatologists are about 60 percent of the salaries of specialists in such fields as gastroenterology and general cardiology. When the average physician is burdened with more than $150,000 of debt for his/her education, significant salary differences can be influential in choosing specialties.
In our current medical care system long-term chronic conditions (which require careful monitoring by a physician, but no surgical procedures or other types of treatments other than medication) receive much lower reimbursements from private insurance companies and federal government programs. When the course of rheumatoid arthritis does require surgical intervention (as it often does) a surgeon (not the rheumatologist) reaps the reward of the higher insurance payout. The perversity of this system is that a good job by a rheumatologists in early diagnosis, careful monitoring and supervised drug therapy can make surgery (and its high cost to insurance companies and government) unnecessary.
The shortage of rheumatologists is merely an inconvenience today, it is likely to become a crisis within twenty years, unless something changes in the funding and availability of fellowships and the relative pay for rheumatology practitioners.