Patients with Musculoskeletal Diseases Need Access to Timely Diagnosis and TreatmentAt the recent meeting of the American College of Rheumatology in Washington, DC, I attended a presentation on the severe shortage of rheumatologists in the United States and the likelihood for its persistence in the future. While there are many reasons for this shortage, the situation may be further exacerbated by the uneven geographic distribution of specialists. Specialists tend to concentrate in areas of dense population, leaving the less populated parts of the country with an insufficient number of practitioners skilled in rheumatologic care.
In the face of these problems, there are many potential strategies that can be envisioned although the implementation may be challenging. The first is to increase the number of rheumatologists in training. While this would seem to be a straightforward way to address the workforce shortage, the obstacles will likely be financial. Funds for post-graduate training are limited especially when decisions on allocation are made on the basis of hospital practice. Unlike other subspecialties, rheumatology is primarily based in the outpatient realm. The need for rheumatologic care in the hospital is much less pressing than that for other specialty care (e.g., cardiology); as a result, an increased number of post-graduate training positions may be difficult to obtain.
Another solution is to train physician extenders, either nurse practitioners or physician assistants, to help fill in the gap and assume a greater portion of rheumatologic practice. Indeed, many practices, both community and academic, are incorporating extenders into their activities. Over time, such extenders can play a key role in the delivery of care especially for patients with an established diagnosis on a well-delineated treated plan. Given the success of current therapy for rheumatoid arthritis (RA), many patients can have a clinical remission and remain on stable treatment regimens that may only occasionally need adjustment or “tweaking” by a subspecialist.
A final way to meet the care gap is to refine the referral process and develop new models for the participation of primary care providers in the delivery of musculoskeletal care. There are many examples where new care models can be developed. As discussed in previous columns, primary care providers should know now to recognize the signs and symptoms or early inflammatory arthritis, for example, and to which patients should receive a prompt referral for specialty care. The possibility that treatment of RA has a window of opportunity in which very early therapy can block disease progression is intriguing. This situation requires that primary care providers detect the very earliest signs of RA and that there is sufficient access to rheumatologic care to embark on more aggressive DMARD (disease modifying anti-rheumatic drug) therapy.
Primary care providers also need to be aware of the importance of proper management of conditions such as gout or osteoporosis so that they can appropriately treat these conditions by themselves or refer patients before either joint damage or fractures occurs. Although guidelines for gout treatment can differ among specialty groups, many patients can benefit from more aggressive urate-lowering therapy that can be administered by generalists who are knowledgeable about gout treatment. As I recently discussed, the treatment and prevention of osteoporosis are at a crisis stage in this country with uncertainty about the goals of this therapy and its provision. Osteoporosis management will require a team that should include primary care providers to collaborate with other specialists such as rheumatologists and endocrinologists in care delivery.
As an organization of organizations, the United States Bone and Joint Initiative (USBJI) can play a critical role in improving the outcome of musculoskeletal disease and overcoming workforce shortages by promoting education at all stages of training for a broad range of providers. At present, medical students have very limited exposure to musculoskeletal diseases in their training and may never have learned about even the basic principles in diagnosis and treatment. During medical school, I saw only 4 patients with a rheumatologic condition and my training in orthopedics is not much better. I, for one, have never set a broken bone and know virtually nothing about casting. Similarly, education on diseases of bones and joints during the house staff training in Internal Medicine can be sparse since hospital admission of rheumatologic diseases are not common. In the face of these issues, the USBJI is pursuing important initiatives to boost the education of physicians and other providers in musculoskeletal disease. Project 100/1000 under the leadership of Dr. Joseph Bernstein is seeking to build medical education on musculoskeletal disease by identification of champions in medical schools who can teach and advocate for more time devoted to training. An exciting new initiative led by Dr. Bruce Browner involves a large group of USBJI stakeholders to establish a framework for an elective in musculoskeletal medicine for fourth year medical students. This initiative will incorporate innovative utilization of electronic media to help disseminate educational content. Finally, under the leadership of Dr. Tom Best and Dr. Marc Hochberg, the USBJI is planning a meeting for primary care providers to provide up-to-date and evidence-based information on the management of common musculoskeletal conditions.
In addition to activities focused on medical education, the USBJI has convened teams of stakeholders to develop care plans to facilitate the interdisciplinary management of conditions such as osteoarthritis. COAMI (Chronic Osteoarthritis Management Initiative), under the leadership of Drs. Joanne Jordan, Alexe Page and Kelli Allen, has been highly successful in identifying ways to improve OA care and in disseminating, through outstanding scientific publications, a framework for interdisciplinary care. I view COAMI as a prototype for the management of other chronic musculoskeletal conditions. Indeed, Dr. Marc Hochberg, President-Elect of the USBJI, is now assembling an exciting program to assess best practices in the treatment of inflammatory arthritis and osteoporosis with the goal of developing care plans to facilitate management by primary care providers as well as specialists.
Chronic musculoskeletal diseases are among the most significant causes of pain, disability, lost work and reduced quality of life in the population. Nevertheless, there is a severe shortage of some of the key providers to manage these conditions. In its commitment to improving the lives of those suffering from musculoskeletal disease, USBJI is taking important steps to advancing care by advocacy as well as increasing knowledge of musculoskeletal disease at all levels. Furthermore, the USBJI will continue to foster the creation of interdisciplinary care plans to guide shared decision-making by patients and providers. With a strong vision and a committed membership of key stakeholders, the USBJI is acting decisively to ensure that the health care system can meet the challenges presented by the high prevalence of musculoskeletal disease and promote the development of patient-centered programs based on efficiency, effectiveness and value.