Often overlooked and underfunded, as well as being underpaid compared to internal medicine, it is difficult to convince prospective medical students, many of whom already have substantial debt, to choose a career in pediatric rheumatology.
As future clinicians celebrate the annual Match Day, a dark cloud looms over the workforce in pediatric rheumatology: a diminishing workforce and waning interest from younger clinicians.
Results of the National Residents Matching Program (NRMP) indicated that most eligible applicants were able to be successfully matched to fellowship programs in 2022.1 The percentage of available adult programs filled 97.8% of available fellowship slots, however pediatric programs only filled 62.8% of available slots suggesting a direct need to increase interest in pediatric rheumatology. According to data published in 2020, there was only approximately 300 practicing pediatric rheumatologists in the United States.2 As a byproduct of this limited workforce, availability of pediatric rheumatologists is severely limited in some parts of the country.
In fact, 6 states only have 1 pediatric rheumatologist, and 9 states have none at all.3 Only 1 in 4 children with arthritis are able to be seen by a pediatric rheumatologist, with the average patient having to travel over 50 miles to be seen by a specialist, which is more than double the average distance for other pediatric subspecialties.4
Due to the lack of pediatric rheumatologists, providing care for children with rheumatic diseases is challenging because healthcare providers often lack specialized training in this area. Karen Onel, MD, Chief of Pediatric Rheumatology at the Hospital for Special Surgery, stated previous estimates indicate approximately half of pediatric patients were being treated by adult rheumatologists. Access to care for these children remains a significant problem.
Daniel Lovell, MD, MPH, Associate Director of Rheumatology at Cincinnati Children’s, said he feels fortunate to work in a large academic center with a strong pediatric rheumatology division. However, he recognizes his experience is not the norm for many practicing within the subspecialty in the US.
“Over the years, new fellows have simply replaced retiring ones, and this problem is expected to worsen as there are many pediatric rheumatologists who are near retirement age,” he explained.
This sentiment reflects the discrepancy between the number of fellows entering pediatric rheumatology and the number needed to meet the demands of the subspecialty. The need for pediatric rheumatologists is so great due in part to the large patient population and their complex medical needs. They require significant time and attention from physicians, as their diseases often involve multiple organs and may require multiple medications and coordination with other clinicians.
“The availability and affordability of new drugs can also be challenging, as insurance coverage and costs may vary widely,” Kabita Nanda, MD, Associate Professor of Pediatric Rheumatology, and the Program Director of the Pediatric Rheumatology Fellowship Program at Seattle Children's noted. “For instance, the recent introduction of adalimumab biosimilars presents new insurance challenges, with potential delays in care as insurance coverage transitions are made.”
The challenges faced by pediatric rheumatologists are not overtly unique, with similar struggles facing healthcare providers in other fields, which includes a growing physician shortage, staff turnover during the pandemic, and struggles with balancing patient load and staff support.
“Many pediatric rheumatologists, including myself, do outreach work in remote areas,” Nanda explained. “At Seattle Children's, we cover the ‘WWAMI’ region, which consists of Washington, Wyoming, Alaska, Montana, and Idaho. However, some states have only 1 or 2 pediatric rheumatologists serving the entire state, which poses a challenge for patients living in remote areas. The geographic area covered by providers can be large, and this may hinder patient access to care.”
Several factors contribute to why medical students and residents may be intimidated by a career in pediatric rheumatology, some of which involve a lack of exposure and the length of the fellowship program.
The 3-year training program required for pediatric subspecialties, including pediatric rheumatology, is seen as a major contributor to the shortage. In contrast, adult rheumatologists undergo a 2-year clinical training program and are only subjected to additional research training if they have a strong interest in research. While this allows for a more flexible approach to training and enables individuals to focus on what they are most interested in, it hampers the incentive for potential rheumatologists to enter the pediatric field.
"This could result in missing out on skilled professionals who may not want to commit to such a lengthy training period,” Anisha Dua, MD, MPH, Associate Professor of Medicine (Rheumatology) at Northwestern University, explained. “The current structure of training programs is limiting the number of individuals entering the field.”
While this discrepancy is also seen in academic rheumatology, the market for private and community practice in adult rheumatology is larger. Although students may choose to specialize in fields like rheumatology to contribute to the academic mission and be a part of moving the field forward, the opportunities in adult rheumatology are designed to provide faster training for those who want a more clinically focused practice and to help serve underserved parts of the country may be beneficial.
Further, pediatric subspecialties have traditionally been difficult to recruit for due to the financial burden of the fellowship requirement. Despite the extra years of training, most pediatric rheumatologists earn less than primary care pediatricians after their training.
“Trainees may be deterred from these fields because they pay $25,000 less than their adult rheumatology colleagues, and they may choose other fields that pay more, like intensive care unit or emergency room,” Onel explained. “Choosing to be a pediatric rheumatologist, as opposed to a general pediatrician, could result in a loss of $1 million in wages over the course of a career.”
Some argue the shortage of pediatric rheumatologists is a self-perpetuating issue to a certain extent. In most instances, medical students are not exposed to pediatric rheumatology, making it difficult to attract them to the field. Early exposure to specialty practice is crucial for those interested in pursuing a career in pediatric rheumatology as it helps them understand the day-to-day realities of the field.
Onel explained medical students only get a few lectures on rheumatology during their education, which may make it appear to be more complicated compared with other subspecialties. A third-year medical student who was interested in pediatrics recently expressed these concerns to Onel, highlighting the need for better education and exposure to the field of pediatric rheumatology.
Another challenge is that residency training is primarily focused on inpatient care, whereas pediatric rheumatology is an outpatient subspecialty. Therefore, residents may only experience the rare hospitalizations of patients with critical illness and, as a result, they are not afforded the opportunity to see the positive impact that pediatric rheumatologists have on patients' lives.
“I believe that there are 2 important areas in pediatric rheumatology: patient care and research,” Lovell explained. “However, not everyone has the same level of motivation for both. Therefore, we should tailor adult learning opportunities in pediatric rheumatology to match the interests of individual individuals.”
The American College of Rheumatology (ACR) has been proactive in addressing the issue of attracting more medical students and residents to pursue careers in rheumatology or increase exposure in
rheumatology by sponsoring them to attend rheumatology meetings and by having visiting professors give teaching conferences at institutions without a pediatric rheumatologist. Although these efforts by the ACR are important, most agree there is still more work to be done to bridge the gap between institutions with and without a pediatric rheumatologist and increase exposure to the field.
“Organizations like the ACR need to find creative solutions to tackle the shortage of pediatric rheumatologists,” Beth Martson, MD, Associate Professor of Pediatric Rheumatology at the University of Rochester Medical Center, suggested. “This can include advocating for early exposure programs and embedding pediatric rheumatology training into medical school curricula. However, if there is a lack of career opportunities for pediatric rheumatologists to practice how they want to, it’s not going to be a successful initiative.”
Cross-training programs can also provide opportunities for well-trained physicians to practice in areas without a full-time pediatric rheumatologist. Martson also proposed supporting other healthcare providers to provide non-specialized pediatric rheumatology care.
“By training primary care pediatricians or creating localized musculoskeletal centers that include trained physician assistants and orthopedics, patients can receive the initial evaluation they need without necessarily accessing a pediatric rheumatologist,” Martson proposed. “While that may not help to expand the ranks of pediatric rheumatologists, it may help better use the time that we have among the people who are already practicing who could then support that sort of practice through things like remote education and telehealth, among other creative care pathways.”
Martson stressed that unless changes in physician training and specialist reimbursement occur, the shortage is unlikely to change. Onel emphasized the ACR has been instrumental in lobbying the government to fund the pediatric subspecialty loan repayment program. These initiatives are crucial in making it possible for people to pursue a career in pediatric rheumatology.
“Pediatric rheumatology combined my love for pediatrics with the fascinating nature of the diseases,” Onel explained. “However, I understand that not everyone may have the same opportunities for exposure that I did. That's why programs like the visiting professor program are so important, as they send pediatric rheumatologists to areas where there are none. It's crucial that we continue to create opportunities for individuals to discover and pursue this field.”
As medical students need to make decisions about their residency choices early in their training, exposure to pediatric rheumatology may be helpful in influencing them to choose the subspeciality.
“To make a lasting impact in the field of pediatric rheumatology, we need support from various sources including medical schools, department chairs, and other organizations,” Onel explained. “Early inspiration and exposure to the specialty can make a big difference.”
At Onel’s institution, for example, third-year medical students who are interested in pediatrics are able to spend time with different pediatric subspecialties, including pediatric rheumatology. This gives them a chance to get hands-on experience and figure out if pediatric rheumatology specialty is the right career path for them. She expressed the desire to see more residents be offered the opportunity to understand the importance of pediatric rheumatology.
“We need to find ways to make this field more appealing and accessible to future pediatricians, especially those who may be apprehensive about an academic career,” Onel stated. “We must provide support and encouragement to young individuals who want to make a difference in the lives of children.
For those familiar with the field, it is obvious clinicians who choose to specialize in pediatric rheumatology find their work fulfilling. However, the field is still facing significant challenges. Often overlooked and underfunded, as well as being underpaid compared to internal medicine, it is difficult to convince prospective medical students, many of whom already have substantial debt, to choose this career path. While the recent loan repayment program was a marked advance for the field, the need for more support is apparent.
Those in the field pediatric rheumatology recognize the high potential for success moving forward. With the right changes in the academic and healthcare systems, it can provide better patient outcomes and increased access to care in underserved areas. A focus on cognitive care, interprofessional team-based care, multidisciplinary care, and more equitable compensation would contribute to making the field more appealing as a career opportunity for future providers.