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Pediatric rheumatologyStatus of the subspecialty in united states medical schools.

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Table 1. Number of pediatric rheumatologists in each US medical
Pediatric rheumatology: status of the subspecialty in
United States medical schools
* Values are the no. of medical schools.
As we approach the twenty-first century, major
changes are taking place in the manner by which medical care
is delivered in the US. In planning for the future care of
children with rheumatic diseases in this country, several types
of information are needed, such as the population distribution
of these children (urban versus rural), frequency of the various
rheumatic diseases, academic needs of training institutions,
and outcome of the different approaches to care. This report
deals with the current representation of pediatric rheumatology in academic medical centers in the US.
At the 1976 Conference on the Rheumatic Diseascs of
Childhood, sponsored by the Pediatric Section of the American College of Rheumatology (ACR), the participants envisioned that a pediatric rheumatology service would be established in each medical school in this country. Rationales for
this goal were to ensure adequate teaching of all medical
students and house officers in this vital area of chronic illness
in children, and to provide a role model and standards of care
in this subspecialty for graduates of US medical schools (I). A
number of trends related to reimbursement for patient care
and the financing of departments of pediatrics have thwarted
realization of this goal.
A list of 178 pediatric rheumatologists in the US has
been compiled from the records of the American Board of
Pediatrics (ABP), the Rheumatology Section of the American
Academy of Pediatrics (AAP), and the Pediatric Section of the
ACR. Of this number, 121 were certified in pediatric rheumatology by the ABP, and 135 of these physicians were associated
with a medical school. In an effort to examine whether there
has been an adequate increase in the supply of pediatric
rheumatologists during the last 20 years, the number of
pediatric rheumatologists in academic centers in 1976 and
1986, the years of the first and second Conference on the
Rheumatic Diseases of Childhood, was compared with data
from 1996. The number of academic centers with at least 1
pediatric rheumatologist in 1976, 1986, and 1996 was 17, 71,
and 80, respectively. The total number of pediatric rheumatologists was 27, 103, and 178, respectively.
In 1996,45 of the current 125 US medical schools had
no representation in this important area of chronic illness in
children (Table I). Although it is gratifying that 35 academic
centers in 1996 had between 2 and 6 pediatric rheumatologists
each, 45 had only a single physician in this subspeciality. These
solo rheumatologists seem especially vulnerable academically
within the current environment of severe financial constraints
and cost containment.
Additional comparisons were performed of the number of pediatric rheumatologists in the 15 research-oriented
medical schools that received the largest amount of National
Institutes of Health funding (Division of Research Grants,
No. of pediatric rheumatologists
1994), and of the 40 medical schools that graduated the highest
percentage of students entering primary care (range 28-44%)
(2). In the research schools, 1 had no pediatric rheumatologist
and the other 14 had 1-5 each. In the primary care schools, 17
had no pediatric rheumatologist and 14 had only 1. Thus, the
training of primary care physicians in this subspecialty has
especially been imperiled by the lack of teaching of, and role
models for, pediatric rheumatology in these schools.
According to data from the ABP, during the 6-year
period 1990-1995, 7-21 first-time takers of the general certification examination in pediatrics planned on entering a pediatric rheumatology fellowship. Although the average has been
12 fellowships per year, there were only 7 in 1992 and 1995.
The number of fellows in training who could be expected to
replace current pediatric rheumatologists is an unknown number. A work-force survey by the ACR and AAP is currently being
completed. In view of the new Residency Review Committee’s
requirements for fellowship training in pediatric rheumatology,
probably no more than 20 centers will qualify for certification (19
have applied in 1996). How many programs will choose to train
fellows in the future, or be able to do so, is uncertain, since
funds have been severely limited in this area for some years.
Based on the available data summarized above, 2
major conclusions can be reached: 1) Approximately one-third
of our medical schools do not have on their faculty any physician
experienced in the medical care of children with rheumatic
diseases, and 2) this deficit is particularly significant for medical
schools that provide training for primary care physicians.
Challenges will abound for the smaller pediatric subspecialties in this era of cost containment and emphasis on
primary care. Let us, as a profession, affirm that a subspecialty
such as pediatric rheumatology saves medical care dollars in
the long run, and that excellence in training in primary care
and pediatrics cannot be ensured without adequate representation of specialties such as pediatric rheumatology in our
medical schools.
James T. Cassidy, MD
University of Missouri School of Medicine
Columbia, MO
Balu Athreya, MD
Thomas Jefferson University
Philadelphia, PA
and Alfied I. DuPont Institute
Wilmington, DE
1. Cassidy JT: Pediatric rheumatology: fellowship training requirements and survey of specialty needs. Rheum Dis Clin North Am
13:169-173, 1987
2. Association of American Medical Colleges: Graduate Medical
Education Tracking Census (1988, 1989, and 1990)
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