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Given the potential for severe illness
and disability associated with pediatric
rheumatic diseases and the potential for
a markedly improved outcome with optimal
treatment, an adequate supply of pediatric
rheumatologists is essential to provide
access to expert care for children with
these diseases. An increase in the supply
of the pediatric rheumatology workforce
is appropriate at this time. Given the
analyses presented in this report, at
least a 75 percent increase in the number
of pediatric rheumatologists is needed.
To reach the goal of 400 pediatric rheumatologists
recommended by the American Academy of
Pediatrics Section on Pediatric Rheumatology,
the number of pediatric rheumatologists
in the United States needs to double.
Additional providers should be encouraged
to practice in those areas where they
are most needed, i.e., States with no
or a relatively low pediatric rheumatologist
supply. At a minimum the 45 medical schools
18
that currently lack a pediatric rheumatologist
on faculty would benefit from the presence
of a pediatric rheumatologist for resident
and fellowship training programs in pediatrics,
internal medicine rheumatology and orthopedics
in addition to providing subspecialty
care for affected patients. Increases
in the supply may be accomplished through
institutional support for fellowship training,
designated salary and research funding
for pediatric rheumatologists, and/or
improved reimbursement rates.
In addition to increasing the number
of pediatric rheumatologists, efforts
to increase the ability and willingness
of internist rheumatologists to manage
or co-manage the care of these children
could be pursued and evaluated. Efforts
to increase their involvement may provide
a short-term solution while pursuing “pipeline”
approaches as well as provide a long-term
solution in areas that lack sufficient
patient demand to support a pediatric
rheumatologist. Some possible approaches
already in use include continuing medical
education for internist rheumatologists
at the annual ACR meeting and for general
pediatricians at the AAP annual meeting.
The role of telemedicine in extending
the catchment area of pediatric rheumatologists,
as well as the ability of these providers
to co-manage care with distant physicians,
should be explored. The creation of pediatric
rheumatology care networks that formally
establish relationships between centers
without such providers and distant pediatric
rheumatologists may facilitate shared
management of patients using telemedicine
and other technologies. Long term approaches
to increasing the role of internist rheumatologists
and primary care providers include revising
ACGME program requirements to include
exposure to the care of adolescents and/or
younger children in internist rheumatology
fellowship training and to increase exposure
to pediatric rheumatology in general pediatrics
residencies. Efforts to study the relative
quality of care associated with different
management approaches should coincide
with efforts to enhance access to care
among children with rheumatic diseases.
More research is needed to determine the
relative quality of care of these various
providers and the implications for patient
outcomes.
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