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Volume 2 Number 5
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COMMENTARY VIEW FROM THE PEANUT GALLERY OF PEDIATRIC
RHEUMATOLOGY: A TYPICAL NORTH AMERICAN PEDIATRIC
What are the characteristics of the typical pediatric rheumatology
center in
I will add that the issues surveyed may seem to some to be the
problems of a developed pediatric rheumatology system that other areas
of the world might like to have. I am sensitive to that view. But for
those of us in DEMOGRAPHY The centers employed
79 board-certified pediatric rheumatologists (PR) in 35 centers, either
full-time or part-time, or 2.1 PR per center. Ten centers (29%) had
only one pediatric rheumatologist. The
pediatric rheumatologists practiced in metropolitan areas that supported
another 27 PR at other centers. The
metropolitan area catchments included 1 area of less than 1 million,
20 between 1-3 million, 8 between 3-5 million, 5 between 5-10 million,
and 3 greater than 10 million. The mean age of a typical PR was 47 years.
Fifteen percent were between 30-40 years of age, 40% between 40-50 years,
34% between 50-60 years, 7% between 60-70 years, and 2% between 70-80
years. CHARACTERISTICS
OF PR PRACTICE IN
In 25 of the 34 centers, the PR’s spend at least 80% of their
time in pediatric rheumatology activities. Only
2/34 centers had PR activities comprising 25% or less of their time.
A typical PR carried a mean of 268 patients in their case load with
71% of PR’s case load falling between 150-400 patients in their practice.
Each PR took on a mean of 80 new patients into their practice per year
with 30% absorbing over 100 new patients per year (highest 175, lowest
25). The PR inpatient services at these centers ranged between 0 to
8 children with rheumatic disease hospitalized per week (mean=2.8) with
65% with less than 3 admissions per week (highest of 8 per week-2 centers).
Inpatients consults per week averaged 3.0 per center (range 0.5-8).
The number of outpatient visits per week varied widely from a low of
6 to a high of 125 visits per center (mean=45). The number of patient
visits per week per individual pediatric rheumatologist averaged 23
visits. Patient care and teaching
dominated pediatric rheumatology responsibilities with 24/33 centers
reporting >50% time spent on these duties. Only 6/28 centers had
any PR doing lab research while 21/28 centers had ongoing clinical research.
Administrative duties had a prominent role in many of the routines of
the responding rheumatologists with a mean of 18% of their time spent
in this activity with a range of 2% to 80% (2 at 80%, one at 60%). Ten
centers had fellows in training (2.5 per center). The centers averaged
1.5 nurses per center (range 0-4). Thirteen of 33 centers had a physical
or occupational therapist specifically assigned to their section. Most
family help associations were the expected local or state Arthritis
Foundation, American Juvenile Arthritis Foundation, Ronald McDonald
houses in the DRUG
TRIALS Drug trial clinical
research was very common in the centers surveyed. Thirty-one of 35 (89%)
North American PR centers have recently participated
in drug trials at an average of 4 in the last 4 years. All but one trial
was pediatric. Twenty-four of 32 centers surveyed are currently participating
in trials. Twenty-four of 26 centers stated that they could run one
trial in parallel with another. Nineteen of 27 stated that they could
handle more than 2 trials in parallel or at one time. Thirty-four of
35 stated that they were willing to participate in future PR clinical
trials if these were trials that only required a minimal amount of work
usually related to a drug already on the market. Twenty of 28 centers
suggested that they would participate in a future PR trial that was
sponsored by a pharmaceutical company that usually required an extensive
amount of work. Of the four centers who offered a reason for why they
could not do a pharmaceutical-sponsored trial, the explanations mentioned
were no time (3), no support (4), or not enough patients (1). WORKFORCE Questions for the workforce issues
were modeled after the survey utilized by the Competition/complexity of illness- Competition was not
a concern. Twenty-eight of 33 respondents believed that they were not
experiencing greater competition than previously. Twenty-nine of thirty-two
pediatric rheumatologists stated they he/she had not had to alter their
practice at all due to competition. The complexity of a patients’ illness,
though, had been increasing for 20/32 respondents. Need for pediatric rheumatologists Thirty of 33 pediatric
rheumatologists completing the survey believed that their PR practice
was expanding, 3 thought the practice was staying the same, and none
believed that the practice was decreasing in size. From their perspective,
21/33 PR’s believed that jobs for PR’s were
increasing, 11 staying the same, and 1 decreasing. The impression of
job flow was evenly mixed. Ten PR’s thought that more PR’s were entering
the field than leaving PR (e.g., retiring, administration, pharmaceutical
jobs), 10 believed that more were leaving than entering, and ten believed
that the job flow was staying the same, no increase in PR’s, no decrease. Morale
Most PR’s believed that our morale is good to excellent (16/30
good, 4/30 excellent). Nine considered the mood to be fair and one poor.
Twelve of thirty of the respondents assessed the situation in PR in
Support from the hospital and/or university administration was
a big concern. Seventeen of 30 PR’s felt insufficiently supported to
one degree or another. The deficits were in support for the team approach
(mentioned by 8/17 PR’s), time for academic activities (2/17), inadequate
funding for fellowships (3/17), insufficient funding support for research
(3/17), low salary (3/17), and support for another PR faculty member
(1/17). ANALYSIS
AND COMMENTS What to make of all this? Sampling: Most North American
centers had the opportunity to fill out this questionnaire. Some chose
not to do so, possibly due to its length and its voluntary nature. Thus
we have compiled data on only about a third of the PR centers in the
Demography: We work in medical
centers in big cities-no surprise. We average 2 PR’s per center, well-below an optimal
5-6 per center for an academic practice, pointing out an academic vulnerability.
Ten centers were especially vulnerable and at risk, with only one pediatric
rheumatologist. We are a mean of 47 years old, which compares well to
pediatricians in the Characteristics
of our PR practice: Most of us are nearly full-time or fulltime PR’s (80-100% time).
Some may have side duties of attending in general pediatrics or running
the residency program. Our patient responsibilities and inpatient/outpatient
workload vary widely with the mean of 268 patient
caseload. We increase our caseload by 80 children per year and
we have about 3 inpatients at any one time with 3 admissions per week
with a mean of 3 inpatient consults per week. Our centers have a mean
of 45 outpatient visits per week with a high of 125 in any one center.
We are clinicians mainly doing clinical research and administrative
duties. One-third of the centers queried train fellows, about
2 per center. We do not do much basic
science work and that is a major problem. We have 1.5 nurses per center
and more than one-third of the centers had a PT or OT specifically assigned
to their patients. We have some help from outside organizations, mainly
the local Arthritis Foundation or Arthritis Society. Drug
Trials
We do a lot of drug trials with 31/36 centers very active in
drug trials in the last 4 years and 80% currently involved in at least
one trial. Most centers are willing to do multiple trials at once. For
the few centers unable to participate, a lack of time, staff, or patients
were given as the explanations. Workforce Most of the pediatric rheumatologists
did not feel threatened by competition though we do note that our patients
were increasing complex. The great majority of the PR’s believed that
pediatric rheumatology is a growth industry with enlarging practices
and increasing job opportunities. Morale was good to excellent for most
PR respondents with more PR’s believing that the PR situation in North
America is improving than not. A perceived lack of support from the
hospitals and universities is a major concern for a majority of the
rheumatologists, especially team support. IN SUMMARY-SNAPSHOT
PEDIATRIC RHEUMATOLOGY CENTERS IN 2002-2003 Pediatric rheumatologists in North America work in very
big cities with a mean of 3 million people, have a mean of two pediatric
rheumatologists per center, as a group are well-distributed by age,
do full-time PR, work very hard, do a lot of drug trials, face a large
and growing workload, anticipate
increasing job opportunities, are optimistic with good morale despite
the workload, and need more support from hospital/university administration.
Many thanks to the faculty and staff of the 35 following
Pediatric Rheumatology Centers for their tremendous help in filling
out these long and complicated surveys: University of Connecticut, University
of Pennsylvania/CHOP, Hackensack University Medical Center, University
of Rochester, Dupont Institute, Hospital for Special Surgery, University
of Vermont, University of Minnesota, Mayo Clinic, Indiana University,
Ohio State University, St. Louis University, Creighton University, University
of Kansas, University of Chicago/La Rabida Childrens Hospital, Michigan
State University, University of Cincinnati, University of Wisconsin-Milwaukee,
Childrens Hospital of Michigan, University of Iowa, University of Washington,
Childrens Hospital of Los Angeles/USC, Childrens Hospital of Orange
County, Childrens Hospital of San Diego, Kaiser Permanente-Sacramento,
University of Arkansas, Richmond, VA (HG), LSU/Childrens Hospital of
New Orleans, Scottish Rite Childrens Hospital in Dallas TX, University
of Mississippi, University of Georgia, Sick Childrens of Toronto, McGill
University, Royal University Hospital of Saskatoon, and Childrens Hospital
of Eastern Ontario. Two center’s data could not be used due to technical
computer and fax problems and for this we apologize. Charles H. Spencer |
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