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The literature is replete with publications concerned with the future of pediatric rheumatology, particularly the sustainability of the subspecialty and increasing its ranks in the pediatric residency programs and medical schools (1–6). In this issue of Arthritis Care & Research, the article by Mayer et al addresses the insufficiency of pediatric rheumatologists in the pediatric residency programs as well as the inadequate educational components therein (7). In contemplating this editorial, I thought about 3 areas related to the current status of pediatric rheumatology; namely, what are the positives, the negatives, and the solutions or recommendations for improvement in this slow-growing subspecialty?

The field of pediatric rheumatology has greatly increased in scope and number of pediatric rheumatologists over the last 30 years. In his discussion of the history of pediatric rheumatologists (presented in 1977 at the first American Rheumatism Association Conference on the Rheumatic Diseases of Childhood), Bywaters cites the slow growth of pediatric rheumatology up until that time (8). Notably, the number of pediatric rheumatologists has significantly increased since that time, albeit not to a sufficient number. If one looks at the positives that have evolved to our current status in pediatric rheumatology, one can identify several areas. First, the number of pediatric rheumatologists has increased over the last 3 decades, reducing some of the supply needs. The American Board of Pediatrics has certified 215 pediatric rheumatologists from 1992 to 2004 (9). However, the demand is still unmet. Thirteen states still do not have a pediatric rheumatologist; however, this will soon be reduced to 11 or less with new graduate fellows filling in important vacancies.

Second, the number of pediatric rheumatology fellows has gradually increased. The accreditation of pediatric rheumatology subspecialty residency programs and the certification of pediatric rheumatologists by the American Board of Rheumatology in 1992 have increased the recognition of the subspecialty. The 2005 data from the American Board of Pediatrics list a total of 65 fellows in training: 28 at level 1, 20 at level 2, and 17 at level 3 (9). A negative twist on the pediatric rheumatology subspecialty residency numbers is that there is an approximately one-third reduction in the number of fellows who start their fellowship at year 1 and complete it at year 3. Additionally, more than one-quarter (18 of 47) of the pediatric rheumatology subspecialty fellows are international medical graduates, some of whom may not stay in the US for their clinical or research careers. Third, new breakthroughs in immunology, genetics, and pharmacotherapeutics may increase interest in pediatric rheumatology, making it more intellectually stimulating and clinically fulfilling (10).

With a less optimistic viewpoint, however, there are still numerous areas of deficiencies that need to be addressed. Mayer et al assess this carefully, as do several prior authors (1, 3–5, 6, 8). The supply of pediatric rheumatologists shows that approximately one-third of medical schools still do not have a pediatric rheumatology position. Mayer et al note that more than 40% of the pediatric residency programs, which include university-based, university-affiliated, and nonacademic centers, do not have a pediatric rheumatologist. Additionally, approximately 30% of medical school–based pediatric rheumatologists are solo and 22% are in groups of 2, which is an insufficient critical mass to do research and conduct consistent enthusiastic education (1). Pediatric rheumatology may need to consider training nurse practitioners and physician assistants to triage and to care for less complicated patients as well as to provide case management for complex patients in order to improve access and reduce the clinical burden.

An important area of attention should be directed to the reduced numbers of pediatric residents taking electives in rheumatology. Mayer et al and Spencer both cite this as an area of significant concern (7,11). Patients are not going to be properly identified, referred, and treated if our residents are inadequately trained to identify rheumatologic problems. Two articles in the literature cite inadequate exposure to topics in musculoskeletal disease in medical school or residency and poor knowledge on subsequent testing with a validated musculoskeletal basic competency examination (12, 13).

Funding for fellowships remains an obstacle to training more pediatric rheumatologists. Some institutions will pay for one clinical year but rely on the pediatric rheumatology program director to find extramural funding for the second and third years.

Pediatric rheumatologists are at the low end of the salary scale for academic physicians. Physicians in the cognitive specialties are typically at the low end of reimbursement and have only limited procedures to supplement their income. This is a deterrent to continue training for resident physicians who have large medical school loans to repay.

Pediatric rheumatology is becoming a predominantly female subspecialty, which has many positives; however, the reality is that women commonly have 2 jobs and find it difficult to juggle full-time positions versus family demands. Innovation in developing part-time positions and job-sharing opportunities is necessary (14). Additionally, attention to promotion, academic advancement, and mentoring as major issues for the female pediatric rheumatologist is mandatory.

Another pervasive issue in the academic community is the significant migration of pediatric rheumatologists throughout the country every year. There is a “musical chairs” phenomenon that detracts from the stability of the programs and reduces growth within each individual center.

There is an increased demand placed on the time of overcommitted physicians to do nonphysician work such as medication and procedure preauthorization, medication reconciliation, and laborious documentation for reimbursement and medicolegal protection as well as consultation purposes. The Accreditation Council for Graduate Medical Education has increased the rigor of evaluation for residents and subspecialty residents, which is time consuming albeit necessary in the new competency-based curriculum.

Many children with rheumatologic diseases are diagnosed and treated by adult rheumatologists (15–17). Notably, however, adult rheumatologists are often inadequately trained in pediatric rheumatology. A common appeal at the annual American College of Rheumatology Program Directors' meeting is for adult rheumatology fellows to receive more training in pediatric rheumatology.

The heightened attention to quality of care by the Institute of Medicine brings mandates for improved access of care and continuous quality improvement. Pay for performance and recertification requirements are now tied into the quality of care era. This will increase the time that pediatric rheumatologists spend in these areas, which will further reduce available time for teaching and research.

Recommendations are obvious but need to be strategically addressed. It sounds simple. We need to increase the number of pediatric rheumatologists to fulfill the promise that was made at the first American Rheumatism Association Conference on the Rheumatic Diseases of Childhood: 2 pediatric rheumatologists at every medical school. We have sorely fallen short of this goal. To do this, we need to increase awareness of musculoskeletal disease, particularly pediatric rheumatic diseases at the medical school level. We need increased teaching for pediatric residents through role modeling as diagnosticians, problem solving experts, and exemplary patient/family-centered care providers. Participation in morning report, teaching conferences, grand rounds, and curriculum-based teaching electives for the residents are mechanisms for increased visibility. We need innovative interdepartmental and intradepartmental collaborations; for example, a musculoskeletal elective with a combination of orthopedics, rheumatology, and perhaps sports medicine. Additional combined electives are possible with nephrology or with allergy/immunology. All of these initiatives require time for development and implementation. Unfortunately, insufficient time to think about and act on the improvements is deterring the progress. We need to improve our recruitment of PhDs and MD/PhDs into the research ranks of pediatric rheumatology to maximize our position in the academic world. Establishing strong research leaders will increase the financial stability of the divisions and make the departmental chairpersons more likely to support development of large pediatric rheumatology centers. Meanwhile, we need to direct attention to education gaps for the adult rheumatologists who provide care to a large percentage of the pediatric rheumatology patients. The same teaching modules can be adapted to the pediatric residency programs that lack input from a pediatric rheumatologist. Lastly, we cannot work harder; instead we need to work more efficiently through process improvement, patient registry development, electronic medical records, and sharing of educational materials. Addressing what is needed poses great needs to the pediatric and rheumatology community that will take another generation to fulfill.

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