Encouraging Medical Students to Choose Rheumatology

Facing a growing shortage, rheumatology is looking to attract the next generation of providers. 

Rheumatology Network spoke with Marcy Bolster, M.D., from Massachusetts General Hospital, about sparking interest among fellows, as well as other providers, including nurse practitioners and physician assistants. Dr. Bolster, director of the Rheumatology Fellowship Training Program at Massachusetts General Hospital, spoke on “The Role of Graduate Medical Education in Adult Rheumatology" at ACR 2016.  [[{"type":"media","view_mode":"media_crop","fid":"56845","attributes":{"alt":"Marcy B.Bolster, M.D.","class":"media-image media-image-right","id":"media_crop_9880483210512","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7156","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; float: right;","title":"Marcy B.Bolster, M.D.","typeof":"foaf:Image"}}]]

Rheumatology Network:  What constitutes accelerated attrition among rheumatologists?

Dr. Bolster:  About 50 percent of the workforce plans to retire by 2030 and meanwhile, the demand for rheumatologists will continue to rise. And as they prepare for retirement, these physicians predict they will see 25 percent fewer patients as they scale down. 

Rheumatology Network:  What does reduced productivity look like?

Dr. Bolster:  It’s multifactorial. It’s not only retiring physicians seeing fewer patients. When you examine our workforce from 2005, the field shifted from being male-dominated to approaching equality. By 2030, rheumatology will be 58 percent women, and they see fewer patients than men. The millennial generation will also account for more, and data shows they see fewer patients than their older counterparts. Rheumatology-fellow data revealed between 18-20 percent plan to work part-time, with 90 percent being women. So, we’re seeing workforce shifts of gender, age group and retirement rate. We’re also seeing large numbers of international medical graduates, between 15-20 percent, who predict they will leave the U.S. to practice in their home country. We must prepare for this huge shift. 

Rheumatology Network:  What incentives exist to prompt students to choose rheumatology?

Dr. Bolster:  We need more incentives. Rheumatology doesn’t have a big medical school presence. Students get more cardiology, gastroenterology, pulmonary and hematology/oncology exposure. Part of the goal is increasing exposure so they discover how much fun rheumatology is and realize they’d like to pursue it. 

We don’t have anything in place right now for fellows. The data shows fellows have student loan debt, so repayment programs would help. Incentives could encourage international medical graduates to stay here. Another option is looking at the nationwide rheumatologist maldistribution. Some states have no providers and no training programs, so we could benefit from incentives for rheumatologists to work in under-served areas.

Rheumatology Network:  What is being done to increase graduate medical education funding?

Dr. Bolster:  Graduate medical education funding and increasing fellowship slot numbers to meet demand is one of our biggest concerns. It’s important we figure this out, and it may come through focused funding efforts through the Centers for Medicare and Medicaid Services or through more innovative methods.

The Rheumatology Research Foundation is a wonderful resource. After the 2005 workforce study, the Foundation created a partial-salary grant system for fellows. It initially started at $25,000 annually, and in 2014, it increased to $50,000. To date, they have provided just under $11 million. That’s a tremendous resource. Still, we’ve only increased our fellows from 180 to 215 yearly. That’s not doubling the workforce. We need more planning. Addressing this issue won’t happen overnight.

Rheumatology Network:  How are nurse practitioner and physician assistant roles growing?

Dr. Bolster:  They’re growing tremendously. It’s a strong reserve for the workforce to recruit nurse practitioners and physician assistants. It gives us greater access to care. Nurse practitioners and physician assistants need exposure to see how fun rheumatology is and how rewarding caring for our patients is. If they’re exposed earlier, they may choose rheumatology. They get trained broadly, so they can move between specialties nimbly. They could start with cardiology and choose rheumatology after seeing what it is. We want to recruit more nurse practitioners and physician assistants for sustained positions in rheumatology, so we must develop curriculum for those entering rheumatology practice. Work is underway, and some resources are already available online on the Foundation’s website. We’re not at the starting line with this. It’s a work-in-progress, but we have more to do. 

Rheumatology Network:  What is being done to improve patient access to care?

Dr. Bolster:  We’re looking at rheumatologist distribution. Most fellows practice and stay within the geographic region where they train. So, if we don’t have training programs in the Northwest or Mid-Northwest states, it will be hard to get people to practice there. We need ideas. The Foundation has a program that invites medical students from under-served rheumatology-population states to attend the American College of Rheumatology’s annual meeting. We’re hoping it will expose them to rheumatology, letting them see the rewarding specialty we have and leading them to learn more about it. That’s just one small way we’re tackling access to care. 

Rheumatology Network:  If these changes don’t occur, what’s the future for adult rheumatology?

Dr. Bolster:  There’s going to be a tremendous deficit. Demand continues to increase, and supply continues to dwindle. The gap is widening. We’re going to be in a crisis because we won’t be able to offer access to care. There are things we can do with training and recruitment, but we can’t decrease demand in terms of patients having illness. We might have to develop different technology uses and practice patterns to provide appropriate access to care. I’m sure much will involve technology, but not all of it. We might partner with other physicians to the benefit of us all. We know we need a multifaceted approach in managing this increasing gap.  

References:

Marcy Bolster. "2015 ACR/ARHP Workforce Study in the U.S.:  “The Role of Graduate Medical Education (GME) in Adult Rheumatology,"

Abstract number 1960.

12:15 p.m., Nov. 14, 2016. ACR/ARHP 2016 Annual Meeting.  

2015 Workforce Study of Rheumatology Specialists in the United States

, presented November 2016