Policy challenges for the pediatric rheumatology workforce

In Part I he reviews the data that demonstrate the under-education of medical students and pediatric residents in musculoskeletal medicine in spite of the fact that children present to their primary care provider with frequent musculoskeletal complaints. Although over three-fourths of residency programs offer pediatric rheumatology (PR) rotations, the rate of participation is low due to a variety of factors including limited elective time, low interest, and lack of information about the subspecialty. He makes a plea for requirement that such a rotation be mandatory.A mandatory requirement would put rheumatology in competition with other pediatric subspecialties, many of which have similar concerns regarding lack of exposure to their own subspecialty. Currently the Accreditation Council for Graduate Medical Education (ACGME) program requirements for general pediatrics do not require any specific non-intensive care subspecialty experience other than behavioral pediatrics and adolescent medicine. All other subspecialty requirements are institution- and program- specific. So, this type of mandatory requirement would be unprecedented and, in my opinion, unachievable in a general form. However, within individual institutions such a requirement can be achieved.He discusses the role inadequate reimbursement or institutional support plays in access to care. The lack of parity of Medicaid-to-Medicare reimbursement in most states (all but 8) limits revenue for service and can be linked to poorer outcomes in Juvenile Rheumatoid Arthritis [4]. The disadvantageous Medicaid-to-Medicare fee index affects all of pediatrics but particularly subspecialties like pediatric rheumatology with limited procedures. In addition to wide-spread health care reform, possible solutions include increased efficiency in rheumatology practices, telemedicine to more rural areas, increased use of physician extenders and limiting low-risk referrals through improved physician education. All of these seem