Current Supply
of Pediatric Rheumatologists: Numbers
In the United States, pediatric rheumatology
is among the smallest of the clinical
pediatric medical subspecialties (Table
1). The American Board of Pediatrics
(ABP) first offered a certifying exam
in pediatric rheumatology in 1992; as
of December 2002, the Board has certified
192 pediatric rheumatologists.
Table
1: Number of Board Certified Physicians
by Pediatric Subspecialty
Year
of First Certification Exam1 |
Number
of Certified Physicians2 |
2001 |
138 |
1992 |
192 |
1993 |
86 |
2002 |
299 |
1994 |
435 |
1974 |
582 |
1986 |
702 |
1990 |
781 |
1994 |
906 |
1978 |
966 |
1987 |
1,129 |
1992 |
1,165 |
1961 |
1,637 |
1974 |
1,675 |
1975 |
3,820 |
1 Source: American Board of Pediatrics
available at http://www.abp.org/STATS/WRKFRC/Menu1.htm
2 Source: 2003 American
Board of Pediatrics Diplomate File
Not all pediatric rheumatologists certify,
however. Data from the 2004 American
College of Rheumatology (ACR) Membership
Directory reveal that 185 non-trainee
physicians in the U.S. identified themselves
as pediatric rheumatologists (i.e., Board-certified
and non Board-certified) or reported being
Board-certified in pediatric rheumatology.
In addition, there were 25 pediatric rheumatology
trainee members of the ACR. ACR and ABP
data sources are described in Appendix
C.
[D]
Distribution
of Pediatric Rheumatologists
While access to pediatric rheumatology
care may be constrained for a variety
of reasons, the most conspicuous reason
for decreased access is the small number
of these providers and their uneven distribution.
4,
11
Past studies have shown that the overwhelming
majority of pediatric rheumatologists
practice in academic rheumatology settings;
6,
12
and nearly all pediatric rheumatologists
practice in metropolitan areas. 11
Based on 2004 ACR data, approximately
3 percent of counties in the United States
currently have one or more pediatric rheumatologists
involved in patient care (Figure 1) and
13 States have none at all: Alabama, Alaska,
Arizona, Idaho, Maine, Montana, Nevada,
New Hampshire, North Dakota, South Carolina,
South Dakota, West Virginia, and Wyoming.
6
Table
2: Percent of Pediatric Population Living
Within Selected Distances of Board Certified
Pediatric Subspecialists, American Board
of Pediatrics
Percent
of Population more than 50 miles
from a provider |
Percent
of Population more than 100 miles
from a provider |
27% |
10% |
16% |
4% |
29% |
12% |
7% |
2% |
42% |
21% |
16% |
6% |
13% |
3% |
23% |
8% |
18% |
4% |
19% |
6% |
14% |
4% |
19% |
5% |
23% |
9% |
19% |
6% |
35% |
18% |
47% |
25% |
The current distribution of pediatric
rheumatologists creates a situation in
which a substantial portion of the under-18
population in the United States lives
more than 50 miles from a provider (Table
2). Thirty-five percent of the pediatric
population in the United States lives
more than 50 miles from the nearest pediatric
rheumatologist; 11
approximately 18 percent live 100 or more
miles from such a provider. In contrast,
less than 10 percent of the pediatric
population lives 100 or more miles from
a provider for 11 of 16 pediatric subspecialties
studied. The average population-weighted
distance between a county in the United
States and a pediatric rheumatology provider
is 57.9 miles, making it one of the least
geographically accessible of the pediatric
subspecialties (Table 3).
Table
3: Average Population-Weighted Distance
to the Nearest Provider by Pediatric Specialty
In Figure 2, a Lorenz curve is used to
depict the equality of the distribution
of pediatric rheumatologists versus the
distribution of the under-18 population
in the United States. Over 70 percent
of the pediatric population lives within
a county that lacks a pediatric rheumatologist;
approximately 60 percent of rheumatologists
are located in counties where only 10
percent of the pediatric population lives.
Based on the area between the 45-degree
line and the Lorenz curve, the Gini coefficient
is used to quantify inequality and ranges
from 0 (in cases of perfectly even distribution)
to 1 (in cases of perfect inequality).
For pediatric rheumatologists in the United
States, the Gini coefficient equals .84,
suggesting a very inequitable distribution.
Figure
2: Cumulative Distribution of Pediatric
Rheumatologists in United States Counties
Weighted by the Population Under-18 Years
of Age
[D]
Population
It is important to consider the ratio
of pediatric rheumatologists to the under-18
population at a market level. Because
of the low incidence rates of pediatric
rheumatic diseases and the geographic
concentration of providers, the relevant
market for a pediatric subspecialist is
likely quite large. Using the Metropolitan
Statistical Areas (MSAs) as a proxy for
a market, the relative supply of pediatric
rheumatologists was compared to the relative
supply of other pediatric subspecialists.
These ratios use “head counts” of providers
rather than counts that adjust for percent
time involved in patient care because
individual level data on percent time
in patient care do not exist for all providers.
Furthermore, the percent of time an individual
spends in other professional activities
likely varies with supply. That is, providers
at institutions with more pediatric rheumatologists
may spend more time in research than those
in institutions with a single pediatric
rheumatologist. Thus, a single adjustment
(i.e., considering every rheumatologist
to be involved in patient care at 0.6
FTE) is inappropriate and will not change
the relative differences across MSAs.
Only 23 percent of MSAs in the United
States have a pediatric rheumatologist
available (Table 4). For all rural (i.e.,
non-metropolitan) areas, the number of
pediatric rheumatologists per 100,000
children under 18 years of age is 0.01.
For all MSAs there is one pediatric rheumatologist
per 100,000 children on average. In the
40 most-populated MSAs, there is one pediatric
rheumatologist per 233,000 children on
average. The ratio varies widely in these
most populated MSAs from 0.09 per 100,000
children under 18 in Riverside-San Bernardino,
California to 1.62 per 100,000 children
under 18 in Cincinnati, Ohio.
Table
4: Ratio of Board Certified Physicians
to Under-18 Population (in 100,000) by
Pediatric Subspecialty
Source: 2003 ABP Diplomate File
MSA: Metropolitan Statistical Area
Across all pediatric subspecialties,
pediatric rheumatology has the lowest
ratio in non-MSAs, the third lowest ratio
for all MSAs, and the second lowest ratio
in the 40 most populous MSAs. Some of
the differences in supply across specialists
reflect, in part, differences in the incidence
of diseases treated by these various providers.
The relevant market area may differ across
large and small pediatric specialties,
too.
Pediatric Rheumatologists’
Perceptions of the Pediatric Rheumatologist
Supply
The Arthritis Foundation (AF), in conjunction
with the American College of Rheumatology
(ACR), created and fielded a survey of
pediatric rheumatologists and internist
rheumatologists in the United States in
March 2004, hereafter referred to as the
AF/ACR Survey. Detailed information on
this survey, including descriptive statistics,
is provided in Appendix E. In this survey,
pediatric rheumatologists were asked to
assess the current supply of pediatric
rheumatology care locally and nationally.
Nearly two-thirds of responding pediatric
rheumatologists reported a local shortage
of pediatric rheumatology care and all
respondents reported a national shortage
of pediatric rheumatology providers (Table
5). Responding pediatric rheumatologists
were also asked to specify the average
wait time for an appointment in their
practice: less than 1 week, 1 to 2 weeks,
or 2 or more weeks. Sixty-five percent
of responding pediatric rheumatologists
reported that the wait time for an initial
patient appointment exceeded 2 weeks in
their practice.
Respondents were asked to select from
among a list of potential causes of the
shortage; the majority of providers indicated
that poor reimbursement contributed to
the current shortage. This finding is
not surprising given that Medicaid patients
comprise one-third of pediatric rheumatologists’
patients and a recent study showed that
the Medicaid-to-Medicare fee ratio was
0.69 (i.e., Medicaid pays 69 cents for
every dollar paid by Medicare) in 2003.
13
Other common factors cited as contributing
to the shortage included poor working
conditions and salary concerns. Among
those providers who wrote a specific concern
in the open-ended section (n=30), many
stated that lack of exposure to pediatric
rheumatology during training and lack
of mentors contributed to the current
shortage.
There was near universal agreement among
responding pediatric rheumatologists that
the current shortage had important consequences
for patients, including increased wait
times, delays in diagnosis and treatment,
misdiagnosis, and inappropriate treatment.
Among those who responded in the open-ended
section (n=11), most reported that the
involvement of other physician providers
(i.e., general pediatrician and internist
rheumatologists) in the care of children
and poor outcomes were adverse consequences
of the current supply and distribution
of pediatric rheumatologists.
Table
5: Pediatric Rheumatologists’ Perceptions
of Workforce Shortage, AF/ACR Survey (n=104)
The results of the AF/ACR survey also
provided useful insight into how retirement
and other activities influence pediatric
rheumatologists’ involvement in patient
care. Just over one-fourth of pediatric
rheumatologists have decreased their time
in clinical care in the 5 years preceding
retirement, with an average reduction
of 32.2 percent in their patient care
hours (Table 6). The primary reason reported
is having obtained salary support from
a research source (39.3 percent). Many
providers also reported decreasing their
patient care time because another pediatric
rheumatologist joined their practice (32.1
percent); they changed employers or career
(17.9 percent), or other reasons (25.0
percent). Of note, seven pediatric rheumatologists
reported decreasing time due to retirement
or semi-retirement and one responding
pediatric rheumatologist was excluded
from analyses because s/he had completely
retired.
Table
6: Changes in Patient Care Time, Pediatric
Rheumatologists AF/ACR Survey
About one-third of physicians plan to
decrease their time in clinical care in
the next 5 years with an average planned
decrease in clinical hours of 33.1 percent.
The primary reason for planning a decrease
in time is obtaining salary support from
a research source (45.5 percent); however,
many also report retirement (21.2 percent),
salary support from a business source
(18.2 percent), and other reasons (27.3
percent). About 15 percent (n=6) of responding
pediatric rheumatologists indicated that
they expected their clinical rheumatology
involvement to decrease due to funding
from another non-pediatric rheumatologist
clinical source. Those shifting to another
clinical area reported expected percent
reductions in rheumatology patient care
time ranging from 5 percent to 50 percent;
thus, they would still be involved in
pediatric rheumatology care part-time.
Pediatric Residency
Directors’ Perception of the Adequacy
of Pediatric Rheumatologist Supply
Pediatric residency directors oversee
the residency training of all pediatric
residents in the United States; as such,
they have a unique perspective on the
current and future supply of general pediatricians
and pediatric subspecialists. In a 2004
survey of pediatric residency directors,
described in detail in Appendix E, pediatric
residency directors were asked to describe
the adequacy of pediatric supply in their
catchment area. The majority of those
responding to this question felt that
either the supply was inadequate (41.7
percent) or the supply was adequate to
allow patient care but inadequate to allow
time for research and teaching responsibilities
(26.0 percent). Significantly more directors
in institutions that lacked a pediatric
rheumatologist felt supply was inadequate
(65.0 percent vs. 23.6 percent, p=0.001).
The majority of directors similarly felt
that the statewide supply of these providers
was inadequate (48.8 percent) or adequate
for patient care only (14.5 percent).
Programs without pediatric rheumatologists
were significantly more likely to describe
the statewide supply as inadequate (61.8
percent vs. 38.9 percent, p<0.01);
however, only 12.5 percent of programs
with a staff pediatric rheumatologist
described the statewide supply as adequate
for patient care as well as other responsibilities.
Many residency directors expressed concerns
about the shortage of pediatric rheumatologists
in their facilities. Some relevant quotes
from the open-ended “comments” section
of the survey are provided here.
- “Pediatric rheumatologists are
in short supply. We often have to rely
on adult rheumatologists to consult
on our inpatients, and always have to
send away [patients] for outpatient
referrals.”
- “Pediatric rheumatologists are
like gold.”
- “We desperately need a ped[iatric]
rheumatologist and have now for the
2nd yr [year] in a row secured a visiting
prof[essor] in same through the Amer[ican]
Coll[ege] of Rheumatology ... a finger
in the dike both for our pts [patients]
care and our housestaff education.”
- “There appears to be a tremendous
need for trained pediatric rheumatologists.”
- “There is clearly a shortage of
Pediatric Rheumatologists.”
- “We need a ped[iatric] rheum[atologist]
in the DC metro area.”
Clearly, pediatric residency directors
share pediatric rheumatologists’ sentiments
that the current supply of pediatric rheumatologists
is inadequate for patient care and medical
education.
Both from the perspectives of current
pediatric rheumatologists as well as pediatric
residency directors who oversee the training
of pediatricians, the current supply of
pediatric rheumatologists in the United
States is inadequate. Several factors
may contribute to inadequate supply, including
training capacity, salary concerns, and
competing professional demands. These
are discussed, in turn, in the rest of
this chapter.
Pediatric
Rheumatologist Training
To become a pediatric rheumatologist,
one must pursue 10 years of training after
completion of their undergraduate degree:
4 years of medical school, a 3-year pediatric
residency at an accredited institution
and a 3-year pediatric rheumatology fellowship
at an accredited program. After successful
completion of this training, a physician
is eligible to take the Pediatric Rheumatology
Board certification exam.
Pediatric
Training Program Requirements
As of July 2002, a pediatric rheumatology
program must meet multiple requirements
to gain accreditation. According to the
Accreditation Council for Graduate Medical
Education (ACGME) 14
, they include:
- The program must provide 3 years
of continuous training;
- There must be at least two Board-certified
pediatric rheumatologists on faculty;
- Physicians in related disciplines,
particularly pediatric orthopedics,
must be available at the institution
for consultation and collaboration;
- Registered physical and occupational
therapists must be available;
- The patient population must be sufficiently
large and varied to provide residents
exposure to both common and uncommon
rheumatic diseases; and
- Full support services must be present
at the facility, including nuclear medicine,
pediatric rehabilitation services, and
clinical immunology and electromyography
laboratory services.
These requirements are designed to ensure
that physicians completing this training
are proficient in the diagnosis and treatment
of children and adolescents with rheumatic
diseases. While some rheumatic diseases
exist in both pediatric and adult populations
others are unique to children. A pediatric
rheumatology fellowship provides trainees
with the knowledge and skills needed to
treat these diseases in the physical,
emotional, and developmental contexts
of childhood and adolescence. Exposure
to related physician disciplines and allied
health professions provides trainees with
opportunities to learn the roles of these
providers. Fellowship training also prepares
physicians to function as educators and
researchers.
Pediatric
Rheumatology Training Programs
According to the American College of
Rheumatology (ACR), there are currently
23 pediatric ACGME-accredited rheumatology
fellowship programs in 14 States. 16
According to the American Board of Pediatrics,
19 physicians entered their first year
of pediatric rheumatology fellowship training
in 2003 and 10 entered their third year
of fellowship training. Over the past
6 years the total number of pediatric
rheumatology trainees in the United States
has increased from 24 trainees in 1998
to 47 in 2003 (Table 7). This increasing
trend in the number of trainees has been
noted for all pediatric subspecialties
in recent years. 17
Table
7: Pediatric Rheumatology Fellowship
Trainees by Medical School and Gender,
American Board of Pediatrics
Source:
American Board of Pediatrics 15
In January 2004, program directors or
their administrative assistants were contacted
and asked to provide information about
the number of first year and total pediatric
rheumatology fellowship positions available
at their institution as well as the number
of positions currently filled (Table 8).
Three-quarters of available pediatric
rheumatology fellowship positions were
filled in 2003. The reasons for the failure
to completely fill available fellowship
slots is not clear; however, some programs
did report that insufficient funding constrained
the number of slots they could fill.
Because cognitive pediatric subspecialties
often do not generate sufficient revenue
to support fellows for their entire 3
years of fellowship, programs often depend
on grant funds to support their training
programs. Support for the clinical year
is variable from institution to institution
and may impact the ability to attract
and retain fellows. Because the availability
of funding in this field has been limited
for several years, the ability of programs
to offer pediatric rheumatology in the
future is often uncertain. 18
Given these factors it is not clear that
the goal of substantially increasing the
number of pediatric rheumatologists can
be achieved without dedicated funding
sources.
Table
8: Total Number of Pediatric Rheumatology
Fellowship Slots by Program
The Role of
International Medical Graduates
The role of international medical graduates
(IMGs) in pediatric rheumatology training
is unclear; in 2003, over one-quarter
of pediatric rheumatology fellows were
IMGs. A past report suggested that many
pediatric rheumatology fellowship programs
relied on IMGs to fill about half the
positions. 19
Over the past 6 years, IMGs represented
32-46 percent of all pediatric rheumatology
trainees (Table 7). Pediatric rheumatology
training programs are, consequently, relatively
reliant on IMGs.
Professor
Salary Concerns
As previously mentioned, salary concerns
were frequently cited as a cause of the
current shortage of pediatric rheumatologists.
In a recent report from the Medical Group
Management Association, the median salary
for a pediatric rheumatologist at the
assistant professor level was $115,022,
which was comparable to other cognitive
pediatric subspecialties (i.e., those
specialties that do not perform procedures);
however, it is far below salaries for
intensivist and procedural pediatric specialties,
such as neonatology ($155,202), pediatric
critical care ($144,933), pediatric cardiology
($149,159). 20
Furthermore, the average pediatric rheumatologist’s
salary is comparable to the salary of
a general pediatrician ($113,343) that
has not spent an additional 3 years in
training. Thus, the financial return
on the educational and time investment
to become a pediatric rheumatologist is
low. No estimates were available for
salaries at higher academic ranks due
to the small sample sizes; salaries for
more junior positions were also not available.
The Impact
of Competing Professional Demands
The supply of pediatric rheumatologists
is particularly sensitive to the effects
of competing professional demands. Pediatric
rheumatologists are significantly more
involved in research and teaching and
spend a smaller percentage of their time
in patient care than their internist peers.
This is due largely to differences in
the practice locations of pediatric and
internist rheumatologists: the majority
of internist rheumatologists are in private
practice, but the majority of pediatric
rheumatologists practice at academic medical
centers where they are generally expected
to see patients, perform research, and
educate trainees.
The 2004 ACR Membership File lists up
to three professional activities for each
provider. While 93 percent of practicing
(i.e., excluding trainees) pediatric rheumatologists
were involved in patient care, only 67
percent listed patient care as their primary
professional activity. Nearly three-fourths
of all pediatric rheumatologists listed
teaching as one of their professional
activities while one-quarter and one-half
listed basic and clinical research as
an activity, respectively. Past studies
have shown that pediatric rheumatologists
are significantly less likely than their
internist peers to list patient care as
a primary professional activity and significantly
more likely to be involved in teaching
and research. 11
Thus, the same pool of pediatric rheumatology
providers that diagnose and treat children
and adolescents with rheumatic diseases
is also responsible for medical education
and research.
The 2004 AF/ACR Survey, like previous
studies, found that responding pediatric
rheumatologists spent a substantial percentage
of their time in research and teaching
(Figure 3). Likewise, previous studies
have found that pediatric rheumatologists
spend significantly less time in patient
care 21,
22
and see significantly fewer patients per
week than internist rheumatologists. 22
Again, these discrepancies reflect differences
in the practice locations of these providers
as well as differences in the average
complexity of adult versus pediatric patients
with rheumatic diseases. Consequently,
even when a pediatric rheumatologist is
geographically accessible, their availability
for patient care may be constrained.
Figure
3: Average Distribution of Professional
Effort Among Pediatric Rheumatologists
(n=107) 2004 AF/ACR Survey
[D]
Summary
Less than 200 pediatric rheumatologists
practice in a limited number of areas
in the United States. On average, children
need to travel 57 miles to reach a pediatric
rheumatologist and 20 percent of the pediatric
population in the United States lives
more than 100 miles from a practicing
pediatric rheumatologist. Thirteen States,
including heavily populated states such
as South Carolina and Arizona, do not
have any pediatric rheumatology providers.
Pediatric rheumatologists unanimously
feel there is a National shortage and
that this shortage leads to delays in
diagnosis and treatment and suboptimal
care. Pediatric residency directors,
who oversee the education of pediatric
residents and are well-acquainted with
the current and future trends in the supply
of general and subspecialty pediatricians,
echo pediatric rheumatologists concerns
about the supply of pediatric rheumatologists.
While the number of pediatric rheumatology
trainees has increased over the last several
years, one-quarter of rheumatology fellowship
positions go unfilled. Finally, pediatric
rheumatologists practice primarily in
academic medical centers where the competing
professional demands of research and teaching
limit their availability for patient care.
Efforts to address the shortage of pediatric
rheumatologists must consider the effects
of the multiple professional roles that
they occupy.
|