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Editorial 
The Rewards of Taking a Hard Look at the Practice of Rheumatology
DR. JODY LEWTAS, MD, FRCP, It is alarmist to suggest that rheumatology is in danger of extinction. But it has to be admitted that our specialty is approaching a crisis. Medical manpower is a major issue in rheumatology throughout the world. The American College of Rheumatology predicts there will be more rheumatologists leaving practice (for retirement, etc.) in 2016 than entering practice1. In Canada, it has been predicted that there will be a 64% shortfall in rheumatologists by 20262. We are becoming an endangered species. At the same time, rheumatology has to be one of the most exciting specialties in medicine today. The science of immunology, cartilage repair, and bone metabolism is evolving rapidly. Every year there are new biochemical pathways to learn to keep current with potential future therapeutics. And rheumatology is uniquely rewarding in its practice. With the appropriate treatment we can see patients restored to near normal function who were completely disabled by inflammatory disease. We do not need studies of several thousand patients in order to prove we are making a difference. Rheumatology has gone from a specialty perceived as babysitting patients with an untreatable chronic illness, to one well aware of the impact proper therapy can have in modifying important patient outcomes. Then what is the problem? Why are we having difficulty recruiting trainees, caring for our patients, successfully lobbying for access to drugs and allied care? There are many reasons: The public, governments, and even many of our colleagues in other specialties continue to perceive that arthritis care is futile and uninteresting. We have a tradition in rheumatology of being undervalued. And it is very difficult to break with tradition. In an arena of competitive funding, we come into the contest as underdogs. How can we change matters? The first step is detailing the barriers to rheumatology care. The study by Shipton, et al3 describes the barriers that Ontario rheumatologists perceive in their practices. None should be a surprise to the readers of this journal. Our patients are barred from highly effective therapies on the grounds of cost. Physician remuneration is so poor for rheumatic diseases that, frighteningly, three-quarters of respondents were steering their practices away from patient care and toward independent medical services such as clinical trials or insurance company assessments. Patients have to wait far too long to see a rheumatologist both initially in consultation and for followup when problems arise. Rhematologists are increasingly busy, partly because the demand for our services cannot meet our manpower supply, but also because more of our time is consumed by the burgeoning administrative demands of insurance companies and new therapy applications. Our current situation is not, however, hopeless. Each of these problems has a solution. All the solutions involve a number of healthcare stakeholders (government, insurance, pharmaceutical, providers, hospital administrators and, importantly, patients). Traditionally, governments have excluded physician opinion for fear it is self-interested and biased. However, there is a growing recognition that physicians are well situated to recognize looming healthcare problems and propose appropriate solutions4. Most of us already do this within our own practices in response to the changing healthcare environment. Rheumatologists are particularly well suited to the work of healthcare reform5. We are involved in acute care and chronic care, hospital based care and office based care, primary care and tertiary care. We work in academic and community practices. And we have proven ourselves able to adapt professionally as medical practice has evolved these past decades. I suspect that most rheumatologists would consider themselves "reluctant politicians." However, whether we like it or not, advocating for our patients for access to therapies has become part of our daily business. The American College of Rheumatology and the Canadian Rheumatology Association, as examples of 2 representative societies, are respected and powerful organizations. Our profession is well placed to effect constructive improvements in providing care for patients with musculoskeletal disease. The barriers that have been defined by Shipton, et al in this issue can provide opportunities for renewing our specialty. With a lot of hard and organized work, it is not inconceivable that the best trainees will flock to rheumatology within the next 10 years. 1. Weinblatt ME. The best of times, the worst of times. Arthritis Rheum 2002,46:567-73. [MEDLINE] 2. Hanly JG. Manpower in Canadian academic rheumatology units: current status and future trends. J Rheumatol 2001;28:1944-55. [MEDLINE] 3. Shipton D, Badley EM, Bookman AA, Hawker GA. Barriers to providing adequate rheumatology care: implications from a survey of rheumatologists in Ontario, Canada. J Rheumatol 2002;29:2420-5. 4. Rockefeller J. Putting together the pieces. We need a comprehensive solution to a brewing crisis in healthcare. Mod Healthc 2002;32:24. [MEDLINE] 5. Reinhardt UE. Reforming American halthcare: An interim report. J Rheumatol 1999;Suppl 56:6-10. [MEDLINE] |