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Manpower and fellowship education in rheumatology 1980.

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1168
MANPOWER
SERIES
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MANPOWER AND FELLOWSHIP EDUCATION IN
RHEUMATOLOGY, 1980
13. RALPH SCHUMACHER and MICHAEL LOCKSHIN
The American Rheumatism Association (ARA)
and the Arthritis Foundation (AF) convened a workshop on manpower and education goals September 2729, 1980. Participants* included rheumatologists involved in active investigation of manpower and education, as well as representatives of government and the
academic community at large with expertise in these
areas. The format for the workshop and this report was
based on questions identified during the previous year
by a series of mailings to ARA members.
The scope of the problem. Malcolm Peterson
outlined past difficulties in medical manpower planning. Since the Bane report in 1959, medical school
class sizes have increased, and large numbers of foreign
medical graduates have entered the United States.
Numbers of physicians have now reached 200 per
100,000 population from the prior 140 per 100,000. In
addition, physician assistants and nurse practitioners
have entered the health care field in increasing numbers.
What is the need for rheumatologists a s perceived by communities, patients, agencies, governments,
medical schools, rheumatologists, and other physicians?
~.
From the Philadelphia Veterans Administration Medical
Center. University of Pennsylvania School of Medicine, Philadelphia,
and Iiospital for Special Surgery, New York, NY.
H. Ralph Schumacher, MD: Chair of the ARA Education
Committee; Michael Lockshin, MD: Chair of the A F Professional
Education Committee.
Address reprint requests to H. Ralph Schumacher, MD, VA
Medical Center. University and Woodland Avenues, Philadelphia,
PA 19104.
Submitted for publication December 22, 1980; accepted in
revised form February 25, 1981.
Arthritis and Rheumatism, Vol. 24, No. 9 (September 1981)
Daniel J. McCarty reviewed data about geographic distribution of rheumatologists relative to population (1).
In 1975, there were only 2 states with 1 or more rheumatologists per 100,000 population. By 1979, there were
20 such states. ARA members designating their primary
activity as rheumatology more than doubled from 916
in 1975 to 1,884 in 1979. This rapid growth in numbers
still leaves considerable variation in distribution. Fifteen states, mostly in the South and Midwest, still have
fewer than 0.6 rheumatologists per 100,000. Dr.
McCarty suggested that the younger rheumatologists in
Wisconsin practice more rheumatology and less general
internal medicine than do older rheumatologists. The
Donald Balaban. MD. MPH, Philadelphia, PA; E. Lovell
Becker. MD, New York, NY; Bernard Bloom, PhD. Philadelphia, PA;
Giles Bole, Jr., MD, Ann Arbor, MI; Kenneth D. Brandt, MD. Indianapolis, IN; Wallace V. Epstein, MD, San Francisco, CA; Steven
Eyanson. MD. Indianapolis, IN; Mitchell Forman, DO, Brooklyn,
NY; James F. Fries, MD, Stanford. CA; Eric P. Gall. MD, Tucson,
AZ; Don L. Goldenberg, MD, Boston, MA; Robert Greer. MD. Hershey, PA; Virgil Hanson, MD, Los Angeles, CA; Edward D. Harris,
Jr., MD, Hanover, NtI; Louis A. Healey, MD, Seattle, WA; Curtis
tlenke. MA, San Francisco, CA; Evelyn V. Hess, MD, Cincinnati,
OH; James R. Klinenberg, MD. Los Angeles, CA; Matthew Liang.
MD, Boston, MA; Michael Lockshin. MD, New York, NY; Daniel J.
McCarty, MD, Milwaukee, WI; Frederic McDuffie, MD, Atlanta,
GA; Thomas A. Medsger, Jr.. MD, Pittsburgh, PA; Robert F. Meenan, MU, MPH, Boston, MA; Robert C. Mendenhall, MS, Los Angeles. CA; Gregorio Mintz, MD, Mexico City, Mexico; Malcolm Peterson, MD. Seattle, WA; Cecil 0. Samuelson, Jr., MD, Salt Lake City,
UT; H. Ralph Schumacher, MD, Philadelphia, PA; John F. Sherman,
PhD. Washington, DC; Lawrence I:. Shulman, MD, PhD, Bethesda,
MD; Hugh A. Smythe, MC, FRCP-C, Toronto, ON: Mary Betty Stevens. MD, Baltimore, MD; Joan I). Sutton, RN, MSN, Baltimore.
MD; Alvin Tarlov, MD, Chicago, IL; George Webster, MD, Philadelphia, PA; Verna Wright, MD, Yorkshire, England.
MANPOWER AND FELLOWSHIP EDUCATION
key role of academicians in teaching general physicians
and internists has not yet been adequately explored.
Wallace V. Epstein pointed out that utilization
and demand can be evaluated much more easily than
true need. We cannot really measure “need” until we
can determine with certainty the amount of benefit from
different types of services. In his 1975 study of resources
for care of arthritics in Redding, California (2), 75% of
the physicians in that town did not feel any need for a
rheumatologist in their community, but a random telephone-administered questionnaire in the community
suggested that 7.9% of the population had musculoskeletal disability.
Verna Wright described objectives prescribed by
the socialized system in Great Britain. One rheumatologist consultant per 250,000 population was believed optimal; teaching hospitals were allotted 3 per 250,000.
Thus, the important role of the rheumatologist as
educator of the general physician, researcher, and consultant is recognized. Primary care of rheumatic disease
is not provided by rheumatologists in Great Britain.
Gregorio Mintz reviewed data on manpower estimates made by the Mexican Social Security system. In
Mexico City and Michoacan respectively, 6.3 and 8.0%
of visits to general practitioners were for musculoskeletal symptoms. It was calculated that there were
2,600 referrals each year to a rheumatologist for 100,OOO
population. A full-time rheumatologist was thus believed to be optimal for each 100,000 adult population.
The average rheumatology consultant only infrequently
assumed full care of patients with chronic rheumatic
conditions. Twenty-five percent of all disability pensions were for rheumatic disease, with 13% for osteoarthritis and 5% for rheumatoid arthritis.
Alvin Tarlov, chairman of the Graduate Medical
Education National Advisory Committee (GMENAC),
reported that his organization advises on balancing physician supply with requirements for 1990 and beyond.
Whether surpluses might be counteracted by market
forces was not a mandate to GMENAC. According to
GMENAC projections, physician supply will greatly
exceed demand by 1990. To arrive at estimates of needs,
GMENAC used “Delphi panels” composed of nonphysicians, generalists, and specialists for each specialty
and subspecialty. For final calculations, it was estimated
that 11% of patients with arthritis will see rheumatologists. The intent is that specialists provide continuing
care for only the most difficult cases. The GMENACpredicted increase of rheumatologists to 3,000 by 1990
yields 1.23 per 100,000 population nationwide, but
1169
GMENAC suggests maintaining the current 0.7 per
100,000 ratio. Major reductions in fellowship training
from 180 new fellows each year to 70 would be required
t9 reduce rheumatologist supply to the lower level recommended by GMENAC.
John Sherman, from the American Association
of Medical Colleges, emphasized the continuing need
for academic rheumatologists. He pointed out that future needs for specialists will be influenced not only by
universities and specialty societies but also by national
decisions as to whether the patient or primary care physician (as in Great Britain and Mexico) determines if
specialty care is to be sought. In addition, methods of
reimbursement for services affect practice patterns.
Sherman also spoke in favor of the pending accreditation of individual subspecialty programs under the Liaison Committee for Continuing Medical Education.
Does rheumatology justify itself as measured economically or by patient outcome? Despite clinical impressions and physician beliefs, it has always been difficult to document the effects of different types of care.
Rheumatologists have directed recent efforts toward
techniques to do this.
Giles Bole reported on a study assessing the level
of care of rheumatoid arthritis (RA) patients by primary
care physicians in a community setting (3). Researchers
performing record audits for rheumatoid arthritis identified poor documentation of physical signs and historical features, overprescription of adrenocorticosteroids,
and underutilization of physical medicine modalities.
The limitations of chart audit to document level of care
are recognized. Mitchell Forman is studying the benefits of switching patients to the care of a rheumatologist
in an ambulatory clinic setting. The number of patients
entered is still small. Hugh Smythe has used trained independent assessors to evaluate care of patients with
RA. Interestingly, he found that nearly half of 174 patients referred for the RA study program from nonrheumatologists could not be confirmed to have RA.
Addition of a trained physical therapist to aid the referring general practitioners did not result in significant
improvement in the outcome.
Three hundred eighty-four patients with RA
who responded to an advertisement are the subjects of a
5-year study by James Fries. Now 2% years into the
study, he is surveying without intervention to compare
those treated by general physicians with those treated
by rheumatologists. Rheumatologists use more “remittive agents” than do nonrheumatologists. Initial costs
for the rheumatologists are more than for general prac-
1170
titioners. Two-thirds of patients in this study are receiving care from more than 1 physician.
Another group of presentations addressed the
methods for measuring patient outcome in arthritis.
Matthew Liang measures functional outcome (4) and
has developed a reliable and valid self-administered
functional status scale that can be used to evaluate effects of various interventions. Robert Meenan (5) has
used a 15-minute Health Status Questionnaire for over
650 arthritic patients. Donald Balaban has developed a
similar Health Status survey with greater emphasis on
the contributions of non-disease-specific variables to
functional outcome of a given disease. Functional outcome seems most important to patients. Needs identified by patients are not invariably the same as the goals
set by their physicians.
Bernard Bloom summarized the deliberations of
the manpower portion of the workshop. In light of a
consensus that a physician excess is possible, he urged
that we address the need for rheumatologists by identifying more precisely what rheumatologists do or should
do and whom they care for or think they should care
for. Two-thirds of patient encounters with rheumatologists are for rheumatic problems; this is a higher fraction than for many other subspecialties. We need to
study whether the practices of board certified and “selfdesignated,” younger and older rheumatologists differ.
He cautioned us against confusing our need for fellows
in our training programs with need for more rheumatologists.
What is the outcome of fellowship training in
rheumatology? What are the practices like? What are
sources of teachers and researchers? Lawrence Shulman described the future possibilities for more training
support and reported that National Institutes of Health
(NIH) recognized the need for support for research in
epidemiology and health services that will help guide
future manpower and education decisions. Curtis
Henke reviewed his survey of 650 ARA members to
compare characteristics of academic and community
practices of rheumatology (6).
Ralph Schumacher examined the short- and
long-term outcome of fellowship training at three academic centers. At these centers, most fellows with a
single year (32 of 38) or 2 purely clinical years of fellowship (47 of 54) went into practice. Of those who spent a
second year in laboratory research, 25 of 42 went into
full-time academic positions as their initial employment. After followup for up to 23 years, 26 of these 42
people are in academic medicine. Methods to estimate
SCHUMACHER AND LOCKSHIN
needs for researchers and teachers may be as difficult as
identifying needs for practitioners.
Robert Mendenhall reviewed his results of practice-pattern done for the Bureau of Health and Manpower (7-9). Fifty-two percent of patients seen by rheumatologists came to the rheumatologist for their
“principal care,” which often (40%) included more than
1 problem. Interestingly, rheumatologists see only 5% of
all patients with arthritis and rheumatism, while orthopedists see 16%, and general practitioners and general
internists see the remainder. Information was not available by individual diagnosis.
Louis A. Healey briefly reviewed his 2-month
survey of the patients of 4 practicing rheumatologists;
the survey showed that 96% of patients had rheumatic
disease symptoms.
What measures are useful in evaluation of fellowship training? George Webster of the American
Board of Internal Medicine reported on information obtained from the rheumatology subspecialty exams.
There is a current total of 1,137 board-certified rheumatologists. The board influences training by requiring a
2-year fellowship in an accredited department of medicine. E. Love11 Becker confirmed the interest of the
AMA in certification of training programs in medical
subspecialties. It is expected that certification of subspecialty fellowship programs will be required in the
near future.
Kenneth Brandt reported the effect of a rheumatology elective on house officers’ ability to manage gout
(10). Family physicians, also surveyed, believed that
they were now providing adequate diagnosis and treatment of gout, but their perceived adequacy did not correlate with their recognition of the importance of examining joint fluid. Eric Gall reported on the use of trained
patients as instructors in physical diagnosis and history
taking.
What is the most important period for training in
rheumatology? Don Goldenberg has completed a 1980
survey of undergraduate education in rheumatology.
Only 16 of 119 schools still have no full-time rheumatologist, and 25 have no fellows. Full-time medical
school faculty has increased from a total of 212 in 1974
to 451. Only 30% of schools present rheumatology in
basic science courses, only 60% teach performance of
the musculoskeletal examination in physical diagnosis,
and only 7% offer research electives in rheumatology or
inpatient teaching unit rotations. There has been no attempt to evaluate the quality of the teaching that is
done.
MANPOWER AND FELLOWSHIP EDUCATION
Mary Betty Stevens teaches medical students on
an elective basis in a 72-bed inpatient rheumatology
unit. She suggests that the undergraduate years are the
key time to generate interest in rheumatology. Cecil
Samuelson is beginning to examine critical periods for
rheumatology education in surveys of students and
rheumatologists in his area. Contacts with individual influential teachers during medical school and residency
appear to be most important in career choices.
Who should be involved in teaching rheumatology fellows? Wallace Epstein has surveyed rheumatologists to obtain a retrospective review of fellowship training experience (1 1). He urges teaching of research skills
in epidemiology, economics, and patient care that all
rheumatologists can use in their careers. Edward Harris
is evaluating the effect on his fellows of more organized
instruction by therapists. The ensuing discussion
brought out the need for studies on the effectiveness of
various physical modalities. The role of orthopedists
was addressed in a survey by Michael Lockshin and
Emmanuel Rudd, who found that 50% of their fellows,
despite a combined rheumatology-orthopedic clinic,
still felt the need for more training in aspects of orthopedics relating to rheumatology.
What are the current fellowship programs? Using prescheduled interviews in June-August 1980,
Thomas Medsger conducted a telephone survey of all
current university fellowship programs for the ARA
Education Committee. Estimates given suggest that fellows being accepted and trained will continue to be
about 160 per year through 1982. Occupational therapists actively involved in training were found in 73% of
programs, physical therapists in 87%, pediatricians in
71%, and psychiatrists in 33%. Almost all programs had
clinics, clinical conferences, and journal clubs, but only
70% had research conferences, and 56% had conferences
with rehabilitation medicine. Hospitals funded 49.3% of
fellows, only 15.3%were funded by local chapters or national AF, and only 14.8%were funded by NIH. Evelyn
Hess reported on successful state funding of fellowships
at 3 schools in Ohio.
DISCUSSION AND CONCLUSIONS
Rheumatology is still a young, small, very rapidly growing subspecialty. It may have different manpower and education problems than more established
subspecialties. Manpower projections based on an estimate of either 0.7 or 1.0 rheumatologists per 100,OOO
population suggest that, unless the activities of rheuma-
1171
tologists or the nature of rheumatic diseases change,
there may soon be a surplus of rheumatologists. Actual
needs are not really known. Current manpower estimates do not adequately consider the need for rheumatology teachers and researchers who are still in short
supply. Estimates for practicing rheumatologists have
been largely based on a “demand model” that may not
be ideal. Perhaps the laws of the marketplace will eventually dictate the size of the manpower pool; medical
students and residents are acutely aware of practice opportunities in each field. A small, broadly based AF ad
hoc committee will review the GMENAC assumptions
and process. This committee or another may also survey
rheumatologists to develop short-term policy guides for
manpower planning. This approach is necessary, since
needed long-term studies on patient outcome will not
provide guidance in the near future. Studies that examine functional outcome and health status of patients
treated in various ways will eventually be most valuable.
Although we must consider changes in the numbers and types of people trained in rheumatology, we
prefer not to propose any major alterations in training
programs without further study. Ways to improve undergraduate and postgraduate training of nonrheumatologists will remain critical, since no matter
what policies evolve, many arthritis patients will continue to be treated by generalists. When and how is
rheumatology ideally taught to the practitioner? How
can we best change physician behavior and patient outcome? What techniques really give sustained benefit?
Studies are beginning to look at these questions and at
the importance of continuing education for the patient
consumer.
A better understanding of what we actually do as
rheumatologists may require more detailed study. Do
rheumatologists make the most impact in more severe
diseases? Should we direct more manpower and education effort at these? Conversely, patients with less severe
diseases, often misdiagnosed, may respond more rapidly
and completely to the care of a rheumatologist; these
areas may need emphasis. A formal task analysis of
rheumatology and nonrheumatology practices may help
us define our special contributions. Costs of various
types of treatment with potentially different outcomes
remain difficult to evaluate but are being studied.
A commitment to define what is best for medicine, rheumatology, and society has been identified. It
should be pursued by members of our specialty and experts skilled in health systems technologies.
SCHUMACHER AND LOCKSHIN
1172
ACKNOWLEDGMENTS
The following companies generously supported this
workshop: Pfizer, Merck Sharp and Dohme, Burroughs Welcome, Eli Lilly, and McNeil Laboratories. Maureen Stephens
provided invaluable assistance organizing and supervising the
administrative aspects of this workshop. Drs. Frederic
McDuffie, Alan Cohen, Daniel McCarty, and Giles Bole provided sustained encouragement and suggestions.
REFERENCES
1. McCarty DJ: Geographical distribution of consultant
rheumatologists in the United States-1979. Arthritis
Rheum 23:344-346, 1980
2. Yelin E, Henke C, Epstein WV: Resources for the care of
arthritics in a non-metropolitan community. Arthritis
Rheum 20:45-57, 1977
3. Stross JK, Bole GG: Evaluation of a continuing education
program in rheumatoid arthritis. Arthritis Rheum 23:846849, 1980
4. Liang MH, Jette AM: Measuring functional ability in
chronic arthritis. Arthritis Rheum 24:8&86, 1981
5. Meenan RF, Gertman PM, Mason JH: Measuring health
status in arthritis. Arthritis Rheum 23: 146-152, 1980
6. Elpstein WV, Henke CJ: Variation in characteristics of academic and non-academic United States rheumatologic
practices: 1976- 1977 (abstract). Arthritis Rheum 22:607,
1979
7. Aiden LH, Lewis CE, Craig J, Mendenhall RC, Blendon
RJ. Rogers DE: The contribution of specialists to the delivery of primary care, N Engl J Med 300: 1363-1370, 1979
8. Girard RA, Mendenhall RC, Tarlov AR, Radecki SE,
Abrahamson S: A national study of internal medicine and
its specialties. I. An overview of the practice of internal
medicine. Ann Intern Med 90:965-975, 1979
9. Mendenhall RC, Tarlov AR, Girard RA, Michel JK, Radecki SE: A national study of internal medicine and its
specialties. 11. Primary care in internal medicine. Ann Intern Med 91:275-287, 1979
10. Eyanson S, Brandt KD: Some effects on house officers of
an elective rheumatology rotation. J Rheumatol 7:25 1-257, 1980
1 I . Henke CJ, Epstein WV: The training of United States
rheumatologists, 1927-1976: description and evaluation of
the training experience. Arthritis Rheum 22:287-296,
1979
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