The Pediatric Rheumatology (PRH) workforce supply in the United States does not meet the needs of children. Lack of timely access to PRH care is associated with poor outcomes for children with rheumatic diseases. This article is part of a Pediatrics supplement focused on anticipating the future pediatric subspecialty workforce supply. It draws on information in the literature, American Board of Pediatrics data, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, Strategic Modeling and Analysis Ltd., and the American Board of Pediatrics Foundation. PRH has a smaller workforce per capita of children than most other pediatric subspecialties. The model demonstrates that the clinical workforce equivalent of pediatric rheumatologists in 2020 was only 0.27 per 100 000 children, with a predicted increase to 0.47 by 2040. Although the model predicts a 72% increase in providers, this number remains inadequate to provide sufficient care given the number of children with rheumatic diseases, especially in the South and West regions. The likely reasons for the workforce shortage are multifactorial, including lack of awareness of the field, low salaries compared with most other medical specialties, concerns about working solo or in small group practices, and increasing provider retirement. Novel interventions are needed to increase the workforce size. The American College of Rheumatology has recognized the dire consequences of this shortage and has developed a workforce solutions initiative to tackle these problems.

Since the advent of pediatric rheumatology (PRH) as a subspecialty, there have been insufficient numbers of pediatric rheumatologists to treat the population of infants, children, adolescents, and young adults (hereafter, “children”) with rheumatic diseases.16  According to the most recent workforce model conducted by the American College of Rheumatology (ACR) in 2015, there were 311 clinical full-time equivalent (cFTE) PRH providers in the United States,7  of which 287 were pediatric rheumatologists, and 24 were nurse practitioners or physician assistants. The ACR model predicted that the supply of pediatric rheumatologists would decrease by 26% (231 cFTE) by 2030, whereas the number of cFTE needed to meet demand would increase to 461, equating to a shortfall of ∼50%.7  This increase in demand was based upon a projected increase in the child population (3% to 4% growth), rheumatologic disease prevalence, per capita income, and Medicaid expansion.

This article, part of an American Board of Pediatrics (ABP) Foundation-funded Pediatrics supplement focused on the pediatric subspecialty workforce,8  contributes to conversations about the PRH workforce by describing the patient populations cared for by pediatric rheumatologists, the current workforce, the projected number, distribution, and clinical effort of rheumatologists in 2040 using a novel microsimulation modeling approach.9  We discuss implications and suggest next steps to ensure a robust workforce.

The most common chronic rheumatic disease of childhood is juvenile idiopathic arthritis (JIA), affecting ∼300 000 children.10  Other chronic diseases pediatric rheumatologists treat include systemic lupus erythematosus, juvenile dermatomyositis, scleroderma, chronic noninfectious osteomyelitis, and systemic vasculitis. The incidence of these diseases has remained stable over time.11,12  Pediatric rheumatologists also treat a newly recognized family of chronic genetic autoinflammatory diseases, which are often complex, require complicated medical therapies, and are associated with significant morbidity.13  Although rare, these diseases require close monitoring and frequent medical visits. In addition, pediatric rheumatologists commonly evaluate and potentially treat children with chronic joint pain, chronic fatigue, fevers of unknown origin, chronic musculoskeletal pain syndromes, and chronic systemic inflammation of unclear etiology.

The number of available treatments for JIA, systemic lupus erythematosus, and other rheumatic diseases is expanding rapidly. Diseases need to be promptly treated by experts who understand the diseases and current therapies to avoid delays in care.14,15  New studies have demonstrated that shorter duration of disease before the start of biologic treatment is associated with improved outcomes in children with JIA.16,17 

Patients in rural areas, in particular, face barriers to care, including delays to care, long travel times, and missed school and work days.18  One study conducted in Minnesota demonstrated that 52% of patients traveled more than an hour, and 28% traveled more than 3 hours to the PRH clinic.19  Because of long travel distances, children with a suspected rheumatic disease are often referred to alternative specialists, such as infectious disease providers, adult rheumatologists, or orthopedists.20  Moreover, previous studies have shown that children who have delays in care and are referred to alternative specialists are subjected to unnecessary and invasive procedures (eg, joint injections) and are at increased risk of prolonged, active disease associated with worse outcomes.21 

Dr Jane Schaller, a pioneer in pediatric rheumatology,18  previously wrote a thorough and fascinating history of pediatric rheumatology, which we have summarized below.22  PRH is one of the newest pediatric subspecialties, as there was virtually no documentation of rheumatic diseases in children until after 1800. Although acute rheumatic fever, a disease well-described in adults, had been documented in some children previously, it was not until the mid 1800s to early 1900s that descriptions of children with chronic arthritis unrelated to rheumatic fever were seen in medical journals. One of the most recognized early descriptions was from Dr George Frederic Still, in London, who first described chronic arthritis, fevers, and systemic inflammation in 22 children. We now call this diagnosis systemic JIA, but many providers continue to refer to the illness as Still’s disease after his description. It was not until after World War II, in 1947, that a formal hospital unit was created to care for children with rheumatic diseases in Taplow, Buckinghamshire, England. This center trained many of the pioneers of pediatric rheumatology. The field grew significantly in the 1970s, when rheumatic diseases in children were formally recognized as distinct from those in adults, and new therapies were introduced.22  In the United States, certification in PRH was first offered by the ABP in 1992.

Based on ABP data through June 2023, a total of 626 pediatricians have ever been board-certified in PRH, 81% of whom were actively enrolled in Maintenance of Certification (MOC).23  These data include pediatricians who may be deceased, retired, or are no longer clinically active. To correct this, descriptions of the current workforce below limit the sample to the 508 currently board-certified pediatric rheumatologists ≤70 years. Over two-thirds (71%) identified as female and 29% as males; the ABP has only offered options to decline answering and nonbinary since 2021. The median age was 45 years; 13% were 61 to 70 years. Three-quarters (73%) were American medical graduates (AMG) with a Doctor of Medicine (MD) degree, 6% were AMGs with a Doctor of Osteopathy degree, 16% were international medical graduates (IMGs) with an MD degree, and 5% were IMGs with an international degree. Race and ethnicity estimates from 2018 to 2022 suggest that ∼12% self-identified as underrepresented in medicine, which includes Black or African American, Hispanic, Latino, or Spanish origin, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander backgrounds.

Data on the work characteristics of current board-certified PRH subspecialists are collected through the ABP’s MOC enrollment surveys. Surveys from 2018 to 2022 had a 56% response rate for PRH, reflecting responses from 227 eligible subspecialists ≤70 years. The majority reported being employed full-time (83%); 57% reported working ≥50 hours per week on average over the last 6 months, exclusive of time on-call but not working. Women (19%) were more likely to indicate part-time employment status compared with men (8%). Most (71%) spent ≥50% of their time in clinical care. In contrast, 15% reported spending ≥50% of their time in research, among the higher proportions of the pediatric subspecialties. Half (49%) endorsed that their primary work setting was within a medical school or parent university, with most (88%) having a faculty appointment. Three-quarters (76%) reported a primary work setting within an urban environment and 31% reported that ≥50% of their patients received public insurance. One-third (32%) planned to retire between 65 and 69 years. Prior data from the 2015 ACR workforce study predicted that 18% of new providers would practice part-time; the ACR’s part-time estimations are similar to ABP data.7 

When limited to the United States, ABP workforce data demonstrates an average of 9.3 (range 0–52) currently board-certified PRH subspecialists per US state in 2023; this translates to 0.7 (range 0–3.2) PRH subspecialists per 100 000 children 0 to 17 years across the United States (Fig 1).23  Several regions in the United States have far greater workforce deficits than others. The patterns are consistent with the ACR workforce study, where the highest distribution of pediatric rheumatologists per 100 000 children in the Northeast (0.83 per 100 000 children) and the lowest in the Southwest (0.17 per 100 000 children).7  Recent ABP data show that these deficits persist. There are models in which pediatric rheumatologists cover care for patients in some rural states. For example, providers in Washington travel to Alaska and Montana, and providers in North Dakota travel to South Dakota. However, fragile states with only 1 board-certified pediatric rheumatologist, such as Nebraska, are vulnerable to loss of rheumatology care because of shifting circumstances.

FIGURE 1

United States distribution of pediatric rheumatology subspecialists (≤70 years) per 100 000 children (0–17 years) in 2023 and fellowship program size and locations for academic year 2021 to 2022. Source: ABP Certification Management System and ACGME program data based on the 2021 to 2022 academic year snapshot. Sample: limited to pediatricians ≤70 years and maintaining their certification as of June 2023.

FIGURE 1

United States distribution of pediatric rheumatology subspecialists (≤70 years) per 100 000 children (0–17 years) in 2023 and fellowship program size and locations for academic year 2021 to 2022. Source: ABP Certification Management System and ACGME program data based on the 2021 to 2022 academic year snapshot. Sample: limited to pediatricians ≤70 years and maintaining their certification as of June 2023.

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When Turner et al examined the number and geographic distribution of ABP board-certified pediatric subspecialists in the United States in 2019, PRH fared worse compared with other pediatric subspecialties in both distance to care and the number of providers per capita.24  Although the distance to care improved from 2003 to 2019 (mean distance 60 miles to 42.8 miles, respectively), PRH had the longest distance for patient travel of all subspecialties, with 18% of patients traveling ≥80 miles to see a pediatric rheumatologist. This study also found that the ratio of pediatric rheumatologists to children per hospital referral region was the worst of any subspecialty (0.35 per 100 000 children 0–17 years). The study assumed a clinical effort of 1 for each subspecialty, which likely greatly overestimated the availability of clinical care since most pediatric rheumatologists work in academic settings and have many other nonclinical responsibilities such as teaching and research.

Yearly snapshot data from the Accreditation Council for Graduate Medical Education (ACGME) showed a 15% increase (33 to 38) in US-accredited programs from academic years 2012 to 2013 through 2021 to 2022. The fill rate for PRH fellowship slots was 69% (29 of 42) in 2020, 74% (25 of 34) in 2021, and 69% (27 of 39) in 2022.25  The ABP total count of first-year fellows, incorporating individuals who take positions before or after the Match, demonstrates that the number of first-year PRH fellows over the last decade increased from 23 in 2012 to 38 in 2022 (+65%), but there has been no change in the fellow trainee count over the last 5 years.

Among the 104 current PRH fellows in training levels 1 through 3 during academic year 2022 to 2023 and in standard, noncombined US fellowship programs, 77% identified as female, 22% as male, and 1% as gender nonbinary. The majority (73%) were AMGs with an MD degree; 6% were AMGs with a Doctor of Osteopathy degree; 1% were AMGs with an unknown degree; 14% were IMGs with an MD degree; and 6% were IMGs with an international degree. These distributions are comparable to those described above in the currently board-certified PRH subspecialists ≤70 years. The percentage of PRH fellows identified as underrepresented in medicine was 18.7% in 2022, a modest increase from 15.9% in 2018.26 

Fellows commonly take a first position post-training near their training location; Fig 1 shows the variability in PRH fellowship locations in academic year 2021 to 2022.27 

Catenaccio et al found that subspecialties with a lower lifetime earning potential had worse workforce shortages and lower fellowship fill rates,29  and PRH’s experience aligns with this observation. The same study recommended policy changes such as loan repayment plans and improved reimbursement rates for nonprocedural specialties.

The ABP Foundation partnered with the Carolina Health Workforce Research Center at the University Of North Carolina at Chapel Hill’s Sheps Center for Health Services Research and the Strategic Modeling and Analysis Planning Ltd. to develop a rigorous model that forecasts the future supply of 14 pediatric subspecialties at the national, census region, and census division levels from 2020 to 2040.8,9  The model contains baseline supply forecasts for 14 subspecialties and several alternative scenarios that display how the supply of subspecialists could change in the future under different assumptions (eg, if fewer fellows enter the workforce). Workforce projections presented in the model and Tables 1 and 2 below are in headcount (HC, absolute numbers) and clinical workforce equivalent (CWE, HC adjusted by the reported proportion of time spent in direct clinical or consultative care, including patient billing and charting with or without trainees) for subspecialists ≤70 years per 100 000 children 0 through 18 years. The model also accounts for changes in the child population at the national and subnational level based on the US Census Bureau28 ; differences by subspecialty for census regions are discussed in the summary article in this supplement.29  An interactive data visualization of the model is also publicly available online.30  Numbers reported below may differ from those in the previous section because of differences in years (2020 vs 2023), sample selection criteria, and inclusion of self-reported clinical time. Estimates of 95% confidence intervals are available in Tables 1 and 2 and on the online visualization tool.

TABLE 1

Estimated Headcount for Pediatric Rheumatology Subspecialists (≤70 Years) per 100 000 Children (0–18 Years) by US Census Division for Different Model Scenarios, 2020 to 2040

Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time, and Increased Early Exit by 5 Years From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 0.52 [0.51–0.53] 0.78 [0.63–0.94] 0.74 [0.61–0.88] 0.79 [0.64–0.93] 0.78 [0.63–0.94] 0.78 [0.62–0.94] 0.78 [0.65–0.91] 0.77 [0.64–0.91] 0.77 [0.64–0.89] 0.79 [0.64–0.93] 
(+51%) (+43%) (+51%) (+51%) (+51%) (+50%) (+48%) (+47%) (+51%) 
West North Central 0.61 [0.61–0.61] 1.04 [0.80–1.27] 1.00 [0.82–1.18] 1.07 [0.83–1.31] 1.04 [0.80–1.27] 1.04 [0.80–1.28] 1.02 [0.80–1.24] 1.05 [0.84–1.26] 0.99 [0.74–1.23] 1.07 [0.83–1.31] 
(+70%) (+63%) (+75%) (+70%) (+70%) (+67%) (+72%) (+61%) (+75%) 
South East South Central 0.41 [0.39–0.43] 1.46 [1.21–1.71] 1.39 [1.16–1.63] 1.54 [1.28–1.80] 1.46 [1.21–1.71] 1.46 [1.20–1.73] 1.46 [1.21–1.71] 1.46 [1.21–1.72] 1.37 [1.12–1.62] 1.54 [1.28–1.80] 
(+255%) (+239%) (+275%) (+255%) (+254%) (+255%) (+256%) (+233%) (+275%) 
South Atlantic 0.47 [0.46–0.47] 0.84 [0.74–0.95] 0.82 [0.72–0.93] 0.88 [0.75–1.00] 0.84 [0.74–0.95] 0.85 [0.74–0.95] 0.86 [0.75–0.96] 0.85 [0.75–0.95] 0.83 [0.72–0.94] 0.88 [0.75–1.00] 
(+80%) (+75%) (+87%) (+80%) (+81%) (+82%) (+81%) (+77%) (+87%) 
West South Central 0.21 [0.21–0.22] 0.39 [0.31–0.47] 0.37 [0.27–0.47] 0.41 [0.31–0.50] 0.39 [0.31–0.47] 0.39 [0.30–0.48] 0.39 [0.30–0.49] 0.39 [0.30–0.48] 0.39 [0.31–0.47] 0.41 [0.31–0.50] 
(+83%) (+74%) (+90%) (+83%) (+84%) (+84%) (+84%) (+80%) (+90%) 
Northeast Middle Atlantic 0.71 [0.70–0.72] 1.44 [1.26–1.62] 1.36 [1.17–1.56] 1.52 [1.32–1.71] 1.44 [1.26–1.62] 1.44 [1.25–1.62] 1.42 [1.24–1.60] 1.44 [1.25–1.63] 1.36 [1.18–1.54] 1.52 [1.32–1.71] 
(+104%) (+93%) (+114%) (+104%) (+103%) (+101%) (+103%) (+92%) (+114%) 
New England 0.96 [0.92–1.00] 1.99 [1.62–2.37] 1.97 [1.59–2.34] 2.10 [1.71–2.49] 1.99 [1.62–2.37] 1.98 [1.61–2.36] 2.01 [1.59–2.43] 2.00 [1.62–2.37] 1.97 [1.63–2.30] 2.10 [1.71–2.49] 
(+107%) (+104%) (+118%) (+107%) (+106%) (+109%) (+108%) (+104%) (+118%) 
West Mountain 0.29 [0.29–0.29] 0.60 [0.47–0.74] 0.57 [0.40–0.74] 0.62 [0.47–0.77] 0.60 [0.47–0.74] 0.60 [0.48–0.73] 0.57 [0.43–0.71] 0.56 [0.42–0.71] 0.56 [0.40–0.71] 0.62 [0.47–0.77] 
(+107%) (+94%) (+111%) (+107%) (+106%) (+96%) (+93%) (+90%) (+111%) 
Pacific 0.48 [0.47–0.49] 0.50 [0.42–0.59] 0.50 [0.40–0.60] 0.51 [0.42–0.60] 0.50 [0.42–0.59] 0.51 [0.43–0.58] 0.52 [0.44–0.60] 0.50 [0.41–0.60] 0.49 [0.40–0.58] 0.51 [0.42–0.60] 
(+5%) (+4%) (+6%) (+5%) (+5%) (+8%) (+5%) (+2%) (+6%) 
Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time, and Increased Early Exit by 5 Years From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 0.52 [0.51–0.53] 0.78 [0.63–0.94] 0.74 [0.61–0.88] 0.79 [0.64–0.93] 0.78 [0.63–0.94] 0.78 [0.62–0.94] 0.78 [0.65–0.91] 0.77 [0.64–0.91] 0.77 [0.64–0.89] 0.79 [0.64–0.93] 
(+51%) (+43%) (+51%) (+51%) (+51%) (+50%) (+48%) (+47%) (+51%) 
West North Central 0.61 [0.61–0.61] 1.04 [0.80–1.27] 1.00 [0.82–1.18] 1.07 [0.83–1.31] 1.04 [0.80–1.27] 1.04 [0.80–1.28] 1.02 [0.80–1.24] 1.05 [0.84–1.26] 0.99 [0.74–1.23] 1.07 [0.83–1.31] 
(+70%) (+63%) (+75%) (+70%) (+70%) (+67%) (+72%) (+61%) (+75%) 
South East South Central 0.41 [0.39–0.43] 1.46 [1.21–1.71] 1.39 [1.16–1.63] 1.54 [1.28–1.80] 1.46 [1.21–1.71] 1.46 [1.20–1.73] 1.46 [1.21–1.71] 1.46 [1.21–1.72] 1.37 [1.12–1.62] 1.54 [1.28–1.80] 
(+255%) (+239%) (+275%) (+255%) (+254%) (+255%) (+256%) (+233%) (+275%) 
South Atlantic 0.47 [0.46–0.47] 0.84 [0.74–0.95] 0.82 [0.72–0.93] 0.88 [0.75–1.00] 0.84 [0.74–0.95] 0.85 [0.74–0.95] 0.86 [0.75–0.96] 0.85 [0.75–0.95] 0.83 [0.72–0.94] 0.88 [0.75–1.00] 
(+80%) (+75%) (+87%) (+80%) (+81%) (+82%) (+81%) (+77%) (+87%) 
West South Central 0.21 [0.21–0.22] 0.39 [0.31–0.47] 0.37 [0.27–0.47] 0.41 [0.31–0.50] 0.39 [0.31–0.47] 0.39 [0.30–0.48] 0.39 [0.30–0.49] 0.39 [0.30–0.48] 0.39 [0.31–0.47] 0.41 [0.31–0.50] 
(+83%) (+74%) (+90%) (+83%) (+84%) (+84%) (+84%) (+80%) (+90%) 
Northeast Middle Atlantic 0.71 [0.70–0.72] 1.44 [1.26–1.62] 1.36 [1.17–1.56] 1.52 [1.32–1.71] 1.44 [1.26–1.62] 1.44 [1.25–1.62] 1.42 [1.24–1.60] 1.44 [1.25–1.63] 1.36 [1.18–1.54] 1.52 [1.32–1.71] 
(+104%) (+93%) (+114%) (+104%) (+103%) (+101%) (+103%) (+92%) (+114%) 
New England 0.96 [0.92–1.00] 1.99 [1.62–2.37] 1.97 [1.59–2.34] 2.10 [1.71–2.49] 1.99 [1.62–2.37] 1.98 [1.61–2.36] 2.01 [1.59–2.43] 2.00 [1.62–2.37] 1.97 [1.63–2.30] 2.10 [1.71–2.49] 
(+107%) (+104%) (+118%) (+107%) (+106%) (+109%) (+108%) (+104%) (+118%) 
West Mountain 0.29 [0.29–0.29] 0.60 [0.47–0.74] 0.57 [0.40–0.74] 0.62 [0.47–0.77] 0.60 [0.47–0.74] 0.60 [0.48–0.73] 0.57 [0.43–0.71] 0.56 [0.42–0.71] 0.56 [0.40–0.71] 0.62 [0.47–0.77] 
(+107%) (+94%) (+111%) (+107%) (+106%) (+96%) (+93%) (+90%) (+111%) 
Pacific 0.48 [0.47–0.49] 0.50 [0.42–0.59] 0.50 [0.40–0.60] 0.51 [0.42–0.60] 0.50 [0.42–0.59] 0.51 [0.43–0.58] 0.52 [0.44–0.60] 0.50 [0.41–0.60] 0.49 [0.40–0.58] 0.51 [0.42–0.60] 
(+5%) (+4%) (+6%) (+5%) (+5%) (+8%) (+5%) (+2%) (+6%) 

Numbers denote headcount per 100 000 children [95% confidence interval]. Percentages indicate change from baseline year 2020.

TABLE 2

Estimated Clinical Workforce Equivalent for Pediatric Rheumatology Subspecialists (≤70 Years) per 100 000 Children (0–18 Years) by US Census Division for Different Model Scenarios, 2020 to 2040

Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time, and Increased Early Exit by 5 Years From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 0.30 [0.29–0.30] 0.43 [0.35–0.52] 0.41 [0.33–0.49] 0.44 [0.36–0.52] 0.40 [0.32–0.49] 0.46 [0.37–0.56] 0.43 [0.36–0.50] 0.43 [0.35–0.50] 0.39 [0.33–0.46] 0.47 [0.38–0.55] 
(+47%) (+39%) (+48%) (+37%) (+57%) (+46%) (+45%) (+34%) (+58%) 
West North Central 0.36 [0.36–0.36] 0.58 [0.45–0.72] 0.56 [0.46–0.67] 0.60 [0.46–0.74] 0.54 [0.42–0.67] 0.63 [0.48–0.78] 0.57 [0.45–0.70] 0.59 [0.47–0.71] 0.52 [0.39–0.64] 0.64 [0.49–0.79] 
(+64%) (+58%) (+69%) (+53%) (+76%) (+61%) (+66%) (+45%) (+81%) 
South East South Central 0.22 [0.21–0.23] 0.80 [0.66–0.94] 0.76 [0.63–0.89] 0.85 [0.70–0.99] 0.74 [0.62–0.87] 0.86 [0.71–1.01] 0.80 [0.66–0.94] 0.80 [0.66–0.95] 0.69 [0.56–0.82] 0.90 [0.75–1.06] 
(+264%) (+246%) (+284%) (+238%) (+288%) (+264%) (+264%) (+215%) (+311%) 
South Atlantic 0.27 [0.26–0.27] 0.47 [0.41–0.52] 0.45 [0.39–0.51] 0.49 [0.42–0.55] 0.43 [0.38–0.49] 0.50 [0.44–0.56] 0.47 [0.41–0.53] 0.47 [0.41–0.52] 0.43 [0.37–0.48] 0.52 [0.44–0.59] 
(+74%) (+69%) (+81%) (+62%) (+88%) (+76%) (+75%) (+59%) (+94%) 
West South Central 0.12 [0.11–0.12] 0.22 [0.17–0.26] 0.21 [0.15–0.26] 0.23 [0.17–0.28] 0.20 [0.16–0.25] 0.23 [0.18–0.29] 0.22 [0.17–0.27] 0.22 [0.17–0.27] 0.20 [0.16–0.24] 0.24 [0.19–0.30] 
(+86%) (+76%) (+95%) (+73%) (+102%) (+88%) (+88%) (+70%) (+109%) 
Northeast Middle Atlantic 0.40 [0.39–0.40] 0.81 [0.71–0.91] 0.76 [0.65–0.87] 0.85 [0.74–0.96] 0.75 [0.66–0.85] 0.86 [0.75–0.97] 0.79 [0.69–0.90] 0.80 [0.70–0.91] 0.71 [0.61–0.80] 0.91 [0.79–1.02] 
(+104%) (+92%) (+114%) (+90%) (+117%) (+100%) (+103%) (+78%) (+129%) 
New England 0.54 [0.52–0.56] 1.12 [0.91–1.33] 1.10 [0.89–1.31] 1.18 [0.96–1.40] 1.04 [0.85–1.24] 1.19 [0.97–1.42] 1.13 [0.89–1.36] 1.12 [0.91–1.33] 1.03 [0.85–1.20] 1.26 [1.03–1.50] 
(+107%) (+103%) (+118%) (+92%) (+120%) (+108%) (+107%) (+89%) (+133%) 
West Mountain 0.16 [0.16–0.16] 0.34 [0.26–0.41] 0.32 [0.22–0.41] 0.34 [0.26–0.43] 0.31 [0.24–0.38] 0.36 [0.29–0.43] 0.32 [0.24–0.40] 0.31 [0.23–0.39] 0.29 [0.21–0.37] 0.37 [0.28–0.46] 
(+108%) (+96%) (+113%) (+93%) (+122%) (+97%) (+94%) (+77%) (+128%) 
Pacific 0.27 [0.26–0.27] 0.28 [0.23–0.32] 0.28 [0.22–0.33] 0.28 [0.23–0.33] 0.26 [0.22–0.30] 0.30 [0.26–0.34] 0.29 [0.24–0.33] 0.28 [0.23–0.33] 0.25 [0.21–0.30] 0.30 [0.25–0.35] 
(+4%) (+4%) (+5%) (−3%) (+12%) (+8%) (+5%) (−5%) (+13%) 
Census RegionCensus DivisionYear 2020Year 2040
Baseline ModelBaseline Model12.5% Decrease in Fellows12.5% Increase in Fellows7% Reduction in Clinical Time7% Increase in Clinical TimeIncreased Level of Exit at All AgesIncreased Level of Exit in MidcareerDecrease in Fellows, Reduction in Clinical Time, and Increased Early Exit by 5 Years From the WorkforceIncrease in Fellows and an Increase in Clinical Time
Midwest East North Central 0.30 [0.29–0.30] 0.43 [0.35–0.52] 0.41 [0.33–0.49] 0.44 [0.36–0.52] 0.40 [0.32–0.49] 0.46 [0.37–0.56] 0.43 [0.36–0.50] 0.43 [0.35–0.50] 0.39 [0.33–0.46] 0.47 [0.38–0.55] 
(+47%) (+39%) (+48%) (+37%) (+57%) (+46%) (+45%) (+34%) (+58%) 
West North Central 0.36 [0.36–0.36] 0.58 [0.45–0.72] 0.56 [0.46–0.67] 0.60 [0.46–0.74] 0.54 [0.42–0.67] 0.63 [0.48–0.78] 0.57 [0.45–0.70] 0.59 [0.47–0.71] 0.52 [0.39–0.64] 0.64 [0.49–0.79] 
(+64%) (+58%) (+69%) (+53%) (+76%) (+61%) (+66%) (+45%) (+81%) 
South East South Central 0.22 [0.21–0.23] 0.80 [0.66–0.94] 0.76 [0.63–0.89] 0.85 [0.70–0.99] 0.74 [0.62–0.87] 0.86 [0.71–1.01] 0.80 [0.66–0.94] 0.80 [0.66–0.95] 0.69 [0.56–0.82] 0.90 [0.75–1.06] 
(+264%) (+246%) (+284%) (+238%) (+288%) (+264%) (+264%) (+215%) (+311%) 
South Atlantic 0.27 [0.26–0.27] 0.47 [0.41–0.52] 0.45 [0.39–0.51] 0.49 [0.42–0.55] 0.43 [0.38–0.49] 0.50 [0.44–0.56] 0.47 [0.41–0.53] 0.47 [0.41–0.52] 0.43 [0.37–0.48] 0.52 [0.44–0.59] 
(+74%) (+69%) (+81%) (+62%) (+88%) (+76%) (+75%) (+59%) (+94%) 
West South Central 0.12 [0.11–0.12] 0.22 [0.17–0.26] 0.21 [0.15–0.26] 0.23 [0.17–0.28] 0.20 [0.16–0.25] 0.23 [0.18–0.29] 0.22 [0.17–0.27] 0.22 [0.17–0.27] 0.20 [0.16–0.24] 0.24 [0.19–0.30] 
(+86%) (+76%) (+95%) (+73%) (+102%) (+88%) (+88%) (+70%) (+109%) 
Northeast Middle Atlantic 0.40 [0.39–0.40] 0.81 [0.71–0.91] 0.76 [0.65–0.87] 0.85 [0.74–0.96] 0.75 [0.66–0.85] 0.86 [0.75–0.97] 0.79 [0.69–0.90] 0.80 [0.70–0.91] 0.71 [0.61–0.80] 0.91 [0.79–1.02] 
(+104%) (+92%) (+114%) (+90%) (+117%) (+100%) (+103%) (+78%) (+129%) 
New England 0.54 [0.52–0.56] 1.12 [0.91–1.33] 1.10 [0.89–1.31] 1.18 [0.96–1.40] 1.04 [0.85–1.24] 1.19 [0.97–1.42] 1.13 [0.89–1.36] 1.12 [0.91–1.33] 1.03 [0.85–1.20] 1.26 [1.03–1.50] 
(+107%) (+103%) (+118%) (+92%) (+120%) (+108%) (+107%) (+89%) (+133%) 
West Mountain 0.16 [0.16–0.16] 0.34 [0.26–0.41] 0.32 [0.22–0.41] 0.34 [0.26–0.43] 0.31 [0.24–0.38] 0.36 [0.29–0.43] 0.32 [0.24–0.40] 0.31 [0.23–0.39] 0.29 [0.21–0.37] 0.37 [0.28–0.46] 
(+108%) (+96%) (+113%) (+93%) (+122%) (+97%) (+94%) (+77%) (+128%) 
Pacific 0.27 [0.26–0.27] 0.28 [0.23–0.32] 0.28 [0.22–0.33] 0.28 [0.23–0.33] 0.26 [0.22–0.30] 0.30 [0.26–0.34] 0.29 [0.24–0.33] 0.28 [0.23–0.33] 0.25 [0.21–0.30] 0.30 [0.25–0.35] 
(+4%) (+4%) (+5%) (−3%) (+12%) (+8%) (+5%) (−5%) (+13%) 

Numbers denote clinical workforce equivalent per 100 000 children [95% confidence interval]. Percentages indicate change from baseline year 2020.

According to the baseline model, which used 2019 data to project incoming fellows, 393 board-certified pediatric rheumatologists were projected for 2020, which equated to 221 CWE. As of 2020, there were 0.27 CWE per 100 000 children nationwide. Apart from child abuse pediatrics (0.23 CWE per 100 000 children), PRH has the lowest number of providers per 100 000 children among pediatric subspecialties. In comparison, other similar and less-procedural pediatric subspecialties, such as hematology-oncology, endocrinology, infectious diseases, and nephrology, have larger workforces at 1.64, 1.11, 0.69, and 0.5 CWE per 100 000 children, respectively. In contrast, the workforce in more procedural subspecialties, such as neonatal-perinatal medicine and pediatric critical care medicine, is much higher at 4.36 and 1.84 CWE per 100 000 children, respectively. The model predicts that the total number of pediatric rheumatologists will increase to 773 providers (+97%) or 0.47 CWE per 100 000 children (+72%) by 2040.

The current geographic maldistribution of PRH providers in the United States is maintained in the model forecasts. Figure 1 shows that, of the 4 US census regions, the Northeast will experience the most growth (≥100%), whereas the West will experience very little growth (28%). However, the Northeast already has a higher density of pediatric rheumatologists and is projected to have the lowest level of population growth (2%) for children 0 to 18 years; regions projected to see the lowest pediatric rheumatologist growth, such as the South (0.21 to 0.42 CWE per 100 000 children) and the West (0.23 to 0.3 CWE per 100 000 children), are inversely projected to experience the highest amount of child population growth (19% and 23%, respectively).

Examining the 9 US census divisions (Table 2), New England has the highest CWE per 100 000 children (0.54), followed by the Middle Atlantic region (0.4 CWE per 100 000 children). The divisions with the lowest CWE are the West South Central region (0.11 CWE per 100 000 children) and the Mountain region (0.19 CWE per 100 000). The West South Central division is projected to experience the highest growth of its children population (28%) by 2040. Fortunately, that division’s projected growth is 86%. However, this only places the division at 0.22 CWE per 100 000 children.

The model also evaluates best- and worst-case scenarios. Best-case scenarios considered situations in which more fellows entered the field and existing providers had more clinical time. Worst-case scenarios considered situations in which fewer fellows were entering the field, existing providers decreased their clinical time, and all providers left the field earlier than expected (5 years earlier). When the model accounted for the best-case scenario, CWE increased to 476 (+116%) or 0.52 CWE per 100 000 children (+90%). The worst-case scenario model predicted an overall increase to 384 (+74%) by 2040, or 0.42 CWE per 100 000 children (+54%). All models predicted an ongoing geographic maldistribution, with New England as the only region with over 1.0 CWE per 100 000 children (Fig 2).

FIGURE 2

Estimated clinical workforce equivalent for pediatric rheumatology subspecialists (≤70 years) per 100 000 children (0–18 years) by US census region, 2020 to 2040. Clinical workforce equivalent indicates headcount adjusted by the reported proportion of time spent in direct clinical or consultative care.

FIGURE 2

Estimated clinical workforce equivalent for pediatric rheumatology subspecialists (≤70 years) per 100 000 children (0–18 years) by US census region, 2020 to 2040. Clinical workforce equivalent indicates headcount adjusted by the reported proportion of time spent in direct clinical or consultative care.

Close modal

Despite PRH being one of the smallest subspecialties per capita, the baseline model suggests it will grow by approximately 72% by 2040, placing it among the subspecialties expected to see more significant growth rates (≥70%). Nonetheless, given the subspecialty’s relatively small absolute HC, this still leaves the field with less than 0.52 pediatric rheumatologists per 100 000 children, which remains extremely low to provide adequate care for children with rheumatic diseases. In addition, there has been no growth in the number of fellows over the last 5 years in contrast to the expected growth in the model. Pediatric rheumatologists are also geographically maldistributed to meet the US child population’s needs. These findings differ from more stark findings from the 2015 ACR Workforce study model that predicted that the clinical effort of pediatric rheumatologists would decrease to only 231 by 2030, which was approximately half of the predicted demand.7  The differences seen in the 2 models are most likely secondary to differences in supply factor assumptions, such as the potential increase in trainees over time, the percentage of the workforce working part-time, the percentage of IMGs that will continue to work in the United States, the percentage of providers working in academic versus nonacademic settings, and estimates of succession.

In the model, the PRH workforce has fewer clinical providers per 100 000 children than most other pediatric subspecialties despite having comparable numbers of children who need treatment. A potential comparison is pediatric hematology-oncology, which had 1.64 CWE per 100 000 children in 2020, with a projected 2.71 CWE per 100 000 children in 2040. PRH resembles pediatric hematology-oncology with regard to the disease prevalence, complexity, and the need for comprehensive care coordination; thus, it is reasonable to assume the 2 subspecialties should have similar-sized workforces.31,32 

The PRH fellowship fill rate ranged from 55% to 75% over the last 3 years.25  This poor fill rate is a recognized problem in our field, one we strive to improve upon. Reasons for not filling fellowship slots may include (1) having an additional 3 years of training compared with a general pediatrician but with a relatively similar salary; (2) low awareness of the field; (3) perceived irrelevance or competing interests within limited, flexible elective time during residency4 ; (4) concern about working solo or in a small practice; and (5) desire to work outside academic settings. Importantly, educational debt and economic issues are unlikely to be the only factors contributing to the small workforce.5,33,34  Additionally, pediatric residents interested in lower-earning subspecialties valued lifestyle as an important factor in career choice.5,35,36  Working as a solo academic rheumatologist or in a small group cannot be underestimated; the extensive responsibilities for so few pediatric rheumatologists negatively affect professional and quality of life issues, leading to burnout. In contrast to PRH, adult rheumatology (AR) has no difficulty filling their training slots.37  The reasons for this difference are unclear; however, compared with PRH, it is thought that better visibility, higher financial compensation, 2-year training slots, and increased availability of private practice positions are all likely contributing to the increased interest in AR.

The ACR is well aware of the PRH workforce issue and, thus, formed a Workforce Solutions Committee to address workforce challenges for both AR and PRH. The AR workforce issue is unique from the pediatric issue in that there are more qualified applicants for AR fellowships than there are slots; therefore, AR is working to increase the number of training slots.38  As the problem for PRH is much different (lack of interest in the field versus insufficient training slots), the ACR is exploring innovative ways to motivate medical students and pediatric residents to enter the field.

One proposed solution is creating an option for a 2-year clinically-focused PRH fellowship, previously recommended in an independent analysis.5  In brief, fellows who complete this 2-year fellowship would be focused on clinical care and more likely work outside academic hospitals or within a clinical track of an academic institution. Another novel idea would be to create a 5-year combined pediatric residency and PRH fellowship from which, at the end of training, the physician could be eligible to become board-certified for both general pediatrics and PRH. This solution may be more acceptable to the ACGME than a 2-year fellowship since a similar approach has already been accepted for adult cardiology.39 

Alongside developing strategies to increase the size of our workforce, we must focus on increasing the diversity of our workforce. At least two-thirds of the current workforce is white, similar to other pediatric subspecialties.23  The PRH field must intentionally reach out to students at historically Black colleges, universities, and medical schools, targeting premedical and medical interest groups for minority student groups to bring strong candidates from diverse backgrounds to PRH.

In addition, the PRH field must intentionally target geographic regions where the workforce supply is in a comparatively dire condition to improve access to care for children with rheumatic diseases (eg, support the creation of rheumatology fellowship programs in regions with PRH faculty and pediatric residency programs that currently do not have accompanying fellowship programs). Although the fill rate for existing pediatric fellowship slots is approximately 69%, it is common for graduating fellows to stay close to the geographic region where they trained.

Even if these strategies to increase the number of fellows entering the field are successful, their effects will not be seen immediately. Therefore, we also must be creative with solutions that account for the existing workforce size. One such strategy is to recruit and train more nurse practitioners and physician assistant to provide PRH care. We must also educate pediatric residents and primary care providers so they can confidently evaluate musculoskeletal complaints and diagnose and manage common nonrheumatologic causes of musculoskeletal diseases, so as to reduce potentially unnecessary referrals.40  Ultimately, we are unlikely to train enough pediatric rheumatologists now or in the future, so broadening the rheumatology healthcare network will be essential for continuity of care between subspecialty appointments. Primary care providers can significantly enhance rheumatology care with relevant training for the most common rheumatic diseases and monitoring of medical management. Anecdotally, some pediatricians in remote areas have enthusiastically served as rheumatology extenders, working closely with pediatric rheumatologists. Telemedicine has enabled the extension of care to better support patients and family members who must travel long distances to pediatric medical centers. Adult rheumatologists can also assist with PRH care management with additional training or assistance for pediatric-specific issues.

The relatively low salaries of pediatric rheumatologists and other pediatric subspecialists, especially compared with their adult counterparts, cannot be underestimated or minimized as it threatens the filling of training slots. The low salary correlates with low Medicaid reimbursement for children with chronic diseases.41  Either pediatric subspecialty salaries need to be improved to offset Medicaid reimbursements or Medicaid reimbursements must parallel Medicare to sustain these subspecialties in the future. Strategies at the state policy level and community levels may be necessary to better compensate pediatric subspecialties. Loan repayment policy programs that enable all pediatric subspecialty care, now limited to underserved geographic regions, would be beneficial for recruiting fellows. This level of advocacy could come from organizations such as the ABP and ACR, as well as large medical organizations such as the American Medical Association. Pediatric subspecialties must work together to secure the future of many subspecialties and timely access to relevant specialty care.

With the aforementioned interventions to help improve the workforce’s size and access to PRH care, ongoing research is needed to monitor these changes’ impact on children and their families. The ACR is committed to optimizing and preserving the rheumatology workforce for PRH care.

PRH is an exciting and innovative field of medicine in which providers can make a positive, lasting impact on children’s lives. For patients with pediatric rheumatic diseases to have optimal outcomes, they need comprehensive and specialized care from experts who understand their diseases and how they affect a growing and developing child. Pediatric rheumatologists act as expert diagnosticians, provide comprehensive care across the pediatric lifetime, have a wide array of new and effective treatments, and have opportunities to collaborate with national and international colleagues in clinical care and research. These characteristics of medicine should attract the best and the brightest trainees, yet the PRH subspecialty continues to face workforce shortages. Possible reasons for this are lack of awareness, limited exposure, relatively long training, and uninspiring salaries. To sustain and grow the PRH workforce, the field must promote itself to students, increase its diversity, partner with nonrheumatology healthcare providers, and advocate for competitive financial compensation.

The authors thank Emily McCartha, Andrew Knapton, and Adriana R. Gaona for their review of the modeling data presented. We also thank Virginia A. Moyer and Patience Leino for their editorial support. Last, we thank the pediatricians who shared their information with the American Board of Pediatrics Foundation and made this supplement possible.

Dr Correll drafted the initial manuscript; and all authors critically reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: This supplement was funded by the American Board of Pediatrics Foundation. The American Board of Pediatrics Foundation, the Carolina Health Workforce Research Center at the University of North Carolina at Chapel Hill’s Sheps Center for Health Services Research, and the Strategic Modelling Analytics & Planning Ltd partnered in the design and conduct of this study. The content is solely the authors’ responsibility and does not necessarily represent the official views of the American Board of Pediatrics or the American Board of Pediatrics Foundation.

CONFLICT OF INTEREST DISCLOSURES: Dr Orr receives grant funding from the American Board of Pediatrics Foundation; Dr Mehta is a member of the American Board of Pediatrics Pediatric Rheumatology Subboard; and the other authors have no conflicts of interest relevant to this article to disclose.

ABP

American Board of Pediatrics

ACGME

Accreditation Council for Graduate Medical Education

ACR

American College of Rheumatology

AMG

American medical graduate

AR

adult rheumatology

cFTE

clinical full-time equivalent

CWE

clinical workforce equivalent

HC

headcount

IMG

international medical graduate

JIA

juvenile idiopathic arthritis

MD

Doctor of Medicine

PRH

pediatric rheumatology

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