Indian Journal of Rheumatology

EDITORIAL
Year
: 2019  |  Volume : 14  |  Issue : 3  |  Page : 174--176

Critical workforce challenges and the impact of rheumatic and musculoskeletal diseases: Urgent call for action


Sharad Lakhanpal1, Akshai Lakhanpal2,  
1 Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
2 Internist, Dallas, TX, USA

Correspondence Address:
Prof. Sharad Lakhanpal
8144 Walnut Hill Lane, Suite 800, Dallas, Tx 75231
USA




How to cite this article:
Lakhanpal S, Lakhanpal A. Critical workforce challenges and the impact of rheumatic and musculoskeletal diseases: Urgent call for action.Indian J Rheumatol 2019;14:174-176


How to cite this URL:
Lakhanpal S, Lakhanpal A. Critical workforce challenges and the impact of rheumatic and musculoskeletal diseases: Urgent call for action. Indian J Rheumatol [serial online] 2019 [cited 2019 Dec 8 ];14:174-176
Available from: http://www.indianjrheumatol.com/text.asp?2019/14/3/174/270058


Full Text



Rheumatic and musculoskeletal diseases (RMDs) are a diverse group of diseases that commonly affect the joints, but can affect any organ of the body. There are >200 different RMDs, affecting both children and adults. They are usually caused by problems of the immune system; inflammation; infections; or gradual deterioration of joints, muscles, and bones. Many of these diseases are long term and worsen over time. They are typically painful and limit function. In severe cases, RMDs can result in significant disability, having a major impact on both quality of life and life expectancy.[1]

In a 2018 survey of attendees at the national APICON meeting in India, 75% of physicians reported having had little or no exposure to rheumatology as undergraduates, only 20% perceived adequate rheumatology training during internal medicine residency, and 83% felt the need for further training or sensitization in rheumatology.[2] Although this may sound alarming, the lack of adequate RMD education in medical school curricula at both the undergraduate and postgraduate levels is a global issue.[3] The major quandary of our specialty is explaining to others the scope of what we do. One predicament for this is the fact that we do not “own” an organ such as the heart, lung, or kidney. The paradox is that RMDs can affect any and all body organs. The perception that rheumatologists treat joint pain tends to erroneously downplay the serious nature of diseases that we manage.[4] There is a lack of understanding and knowledge that RMDs can be serious, systemic, life-threatening diseases that, if untreated, can increase the risk for cardiovascular disease and malignancy; they can also reduce longevity and are a leading cause of disability in the world.[5] This message needs to be convincingly conveyed to the politicians, policymakers, medical school curricula developers, thought leaders, and the public. The effort will be critical to “move the needle” for understanding about RMDs and their impact on public health.

About one in four (54 million) US adults have doctor-diagnosed arthritis.[6] Of these, more than half of the adults with arthritis (32 million) are of working age group (18–64 years) and 24 million adults are limited in their activities from arthritis. The Centers for Disease Control and Prevention in the United States has described arthritis as a large and growing clinical and public health problem.[6] It is estimated that RMDs affect almost 2 billion people worldwide.[5] Despite being the most prevalent disease group, it is very disconcerting that the World Health Organization (WHO) does not mention RMDs in its global strategy for the treatment of noncommunicable diseases. Further, the RMDs are not even indexed as a topic on the WHO website.[7] This reflects the underappreciation of RMDs at the highest levels of health policy administration.

The population of the United States is increasing and people are living longer. There are more people living with RMDs, which has led to increasing demand for rheumatologists. Intriguingly, the same aging demographics that are increasing the prevalence of rheumatic diseases will also lead to a declining workforce because of the impending retirement of a significant portion of our workforce from the “baby-boomer” generation. The projected US rheumatologist shortage will be 2326 in 2020, 3845 by 2025, and 4729 by 2030.[8],[9] According to recent federal estimates, RMDs generate $140 billion in medical costs each year surpassing that of cancer care in the United States.[10] The rising prevalence of RMDs and inability of projected rheumatology workforce to provide adequate care is a universal phenomenon. There are 1308 registered members of the Indian Rheumatology Association. With a population of over 130 crores, the ratio of rheumatologists to patients in India is at a critical low. The current training programs in India produce only about two dozen new rheumatologists each year, a rate that is miniscule compared with the growth rate of the population and the trend will only deepen the crisis (personal communication from Professor Vikas Agarwal, member of Indian Rheumatology Association and Editor-in-Chief, Indian Journal of Rheumatology, on July 24, 2019).

The vexing question for the medical profession and policymakers in India and world over is how best to provide care for the burgeoning population with RMDs. There are no simple or easy answers. Several potential actions aimed at diverse inflection points will have to be considered and also require various stakeholders to work together for best outcomes. The proposals include increasing recruitment and training for rheumatology specialty, enhancing workforce diversity, retaining the rheumatologists to stay active in the workforce longer, tackling the maldistribution of rheumatology health professionals who tend to stay concentrated in larger metropolitan areas, promoting scientific discovery, and raising RMD awareness.[11]

The global shortage of rheumatologists and rheumatology health professionals means that patients with RMDs are more likely to get care from their primary care providers (PCPs). In fact, it is estimated that RMDs may account for 10%–30% of PCP visits.[3] With adequate education and training about RMDs during and after medical school, the PCPs should be equipped to provide satisfactory management for conditions such as mild/moderate osteoarthritis, nonspecific back pain, and regional pain syndromes. The early diagnosis and treatment of RMDs is important because the “window of opportunity” to control disease and prevent long-term complications may be limited. Despite best intentions and efforts, it may not be possible to train sufficient number of rheumatologists to deal with the rising global burden of RMDs. Therefore, the PCPs will need to be trained to screen patients with RMDs and expeditiously triage the more severe and urgent cases to rheumatologists such as those with inflammatory joint/muscle disease, vasculitis, and lupus/connective tissue diseases. The PCPs' access to rheumatologists may be improved via tele-medicine or video-conferencing, especially in rural areas. Regular regional and local RMD educational programs for PCPs will also be very beneficial in this regard.

To impact future health-care providers, the RMD education should be emphasized early on in medical schools. Rheumatology education and the management of RMDs is not a high priority in most medical schools' curricula at this time.[3] The basic teaching of proper joint and musculoskeletal physical examination is lacking at both the undergraduate and postgraduate levels. Collaborations between professional rheumatology associations and medical schools could help facilitate teaching of the core knowledge of RMDs to all practitioners at various stages of education. Medical education necessarily has to encompass the breadth of the field, but we must ensure that exposure to rheumatology happens in a meaningful way early and throughout the journey of training. All medical school graduates should attain a level of knowledge and skills about RMDs that can translate into good patient care. The clinical importance of rheumatology will only be appreciated by medical students if it gets commensurate weighting in examinations because “assessment drives learning.”[12] Therefore, it is very important that rheumatologists and rheumatology organizations should be advocating for the inclusion of RMDs in medical school examinations. Rheumatology should also be made an integral component of continuing medical education programs by national and regional medical associations to raise awareness about RMDs among all health-care providers. To achieve these goals, concerted efforts should be made to elevate rheumatologists to positions of prominence in the departments of medicine, hospitals, medical schools, and universities.[11] Rheumatologists should take leadership roles in medical education and also assume responsible positions in national medical associations and in health policy administration.

It is extremely important for our specialty to attract the best and brightest medical school graduates to rheumatology. There is a need for rheumatology mentoring for our medical students and residents. This entails rheumatologists to become good role models for our younger colleagues who are joining the medical profession. A Medscape poll of 292,000 physicians determined that rheumatologists are the happiest specialty.[13] Every rheumatologist, be in academia or in private practice, should find ways to inspire new trainees to our field. To increase the number of rheumatologists, we also need to collectively work to raise the number of rheumatology training positions. This will require commitment from governments, universities, medical schools, and professional rheumatology organizations.[11]

Not only is there a shortage of rheumatologists, the increasing world population has also led to a global shortage of physicians. In the United States, there has been development of “mid-level” health-care providers who are called physicians assistants (PAs) and nurse practitioners (NPs). They have a 2-year medical education and work semi-autonomously under the supervision of physicians. The American College of Rheumatology (ACR) has developed the PA/NP Rheumatology Curriculum Online. This helps the PAs and NPs who are interested in rheumatology to get specialized training. This has helped mitigate, to some extent, the rising rheumatology health-care provider shortage in the USA.

Many patients may accept the pain and stiffness associated with arthritis as part of life, not realizing the availability of newer, effective drugs and treatment modalities that have caused a paradigm shift in the management and outcome of RMDs. There is a need to educate and empower our patients so that they and their families can become spokespersons to raise RMD awareness. They will be the most passionate advocates as they speak for themselves. The success of ACR to attract celebrities from sports and show-business to become spokes-persons for RMD awareness is an effective strategy that merits replication elsewhere. Patient support groups and organizations such as the Arthritis Foundation in the USA help to raise awareness about RMDs in the public domain. The “Simple Tasks” campaign of the ACR has helped in raising public awareness about RMDs and educating the policymakers about their impact on patients, their families, and the society.[14] The willingness of rheumatologists to talk about RMDs at public forums such as health fairs/camps, rotary club/Lions club type meetings in the community and participating in media (including social media) discussions about health and disease will go a long way in raising RMD awareness. Each year, May is recognized as Arthritis Awareness Month, September as Rheumatic Disease Awareness Month, and October 12 as the World Arthritis Day.[4] These opportunities should be used by local, regional, national, and international rheumatology organizations for sustained advocacy to raise RMD awareness.

There is rising burden of RMDs in India and the world. The current and projected rheumatology workforce is woefully inadequate to cope with the demands and needs of our patients. A multipronged approach is needed to deal with the looming crisis. This will require dedication from each and every one of us. We all have unique stations and opportunities in our professional and personal lives to contribute to local, national, and global efforts to raise RMD awareness. We owe it to our profession, our patients, and future generations to individually and collectively do our share of the burgeoning responsibility and nothing less. If not us, who? If not now, when?

Let us heed this urgent call for action!

References

1van der Heijde D, Daikh DI, Betteridge N, Burmester GR, Hassett AL, Matteson EL, et al. Common language description of the term rheumatic and musculoskeletal diseases (RMDs) for use in communication with the lay public, healthcare providers and other stakeholders endorsed by the European league against rheumatism (EULAR) and the American College of Rheumatology (ACR). Ann Rheum Dis 2018;77:829-32.
2Misra DP, Ravindran V, Sharma A, Wakhlu A, Negi VS, Chaturvedi V, et al. Physicians perception of rheumatology practice and training in India. J Assoc Physicians India 2019;67:38-43.
3Al Maini M, Al Weshahi Y, Foster HE, Chehade MJ, Gabriel SE, Saleh JA, et al. A global perspective on the challenges and opportunities in learning about rheumatic and musculoskeletal diseases in undergraduate medical education: White paper by the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD). Clin Rheumatol 2019;6:6-10.
4Lakhanpal S. Vasudhaiva kutumbakam: The world is one family. Arthritis Rheumatol 2018;70:662-8.
5Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the global burden of disease study 2010. Lancet 2012;380:2163-96.
6Barbour KE, Helmick CG, Boring M, Brady TJ. Vital signs: Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation – United States, 2013-2015. MMWR Morb Mortal Wkly Rep 2017;66:246-53.
7Al Maini M, Adelowo F, Al Saleh J, Al Weshahi Y, Burmester GR, Cutolo M, et al. The global challenges and opportunities in the practice of rheumatology: White paper by the world forum on rheumatic and musculoskeletal diseases. Clin Rheumatol 2015;34:819-29.
8Bolster MB, Bass AR, Hausmann JS, Deal C, Ditmyer M, Greene KL, et al. 2015 American College of Rheumatology workforce study: The role of graduate medical education in adult rheumatology. Arthritis Rheumatol 2018;70:817-25.
9Battafarano DF, Ditmyer M, Bolster MB, Fitzgerald JD, Deal C, Bass AR, et al. 2015 American College of Rheumatology workforce study: Supply and demand projections of adult rheumatology workforce, 2015-2030. Arthritis Care Res (Hoboken) 2018;70:617-26.
10Murphy LB, Cisternas MG, Pasta DJ, Helmick CG, Yelin EH. Medical expenditures and earnings losses among US adults with arthritis in 2013. Arthritis Care Res (Hoboken) 2018;70:869-76.
11Harvey WF, Hassett AL, Lakhanpal S. Editorial: Ensuring the future of rheumatology: A Multi-dimensional challenge and call to action. Arthritis Rheumatol 2018;70:797-800.
12Newble DI, Jaeger K. The effect of assessments and examinations on the learning of medical students. Med Educ 1983;17:165-71.
13O'Dell JR: The happiest specialty: Rheumatology is # 1! Rheumatologist 2012. Available from: https://www.the-rheumatologist.org/article/the-happiest-specialty-rheumatology-is-1/. [Last accessed on 2019 Oct 10].
14ACR Simple Tasks Campaign Fact Sheet. Available from: http://simpletasks.org/wp-content/uploads/2013/12/Campaign-Fact_Sheet.pdf. [Last accessed on 2019 Aug 15].