As a function of more effective treatment for the roughly 100 rheumatological conditions, rheumatology became a formal medical specialty in the 1970s. The labor intensity of rheumatology services continues to increase. Unfortunately, the number of rheumatologists is dwindling while the number of effective treatments and the rising use of technology in rheumatology are increasing. Currently, the average age of a rheumatologist in the American College of Rheumatology (ACR) is 57 and the number of retiring rheumatologists is estimated at 200 per year.

This specialist loss is largely due to the retirement of informally trained rheumatologists and constrained by the decreasing number of available fellowships. To counter this shift, a number of medical employment strategies have emerged and the use of physician assistants (PAs) and nurse practitioners (NPs) in healthcare delivery has not gone unnoticed by rheumatologists.

While PAs and NPs are employed in rheumatology settings, little is known about their practice activities. Historically, we know of a university-based NP who was involved in rheumatology clinical trials in 1975. The first mention of a rheumatology NP in the medical literature appears in 1983 and one PA in rheumatology was employed at a large HMO as early as 1978.

Unfortunately, there is scant knowledge about the roles of PAs and NPs in rheumatology settings beyond anecdotal descriptions. The Association of Rheumatology Health Professionals (ARHP) currently lists 20 NPs and 6 PAs. There is reason to believe this number underrepresents the number of PAs and NPs employed in rheumatology practices. The Society of Physician Assistants in Rheumatology (SPAR), which has a membership of 75 PAs, estimates there are at least 120 clinically active PAs in rheumatology.

In a 2003 survey by the American College of Rheumatology (ACR), over one-fifth of respondents employed a PA or NP (whether it was within a group or solo practice). We conservatively estimate that 200 PA/NPs provide some aspect of rheumatology care more than 50 percent of the week. A 2004 survey of rheumatology PAs (both SPAR and non-SPAR members) suggested most of them were in full-time clinical practice, most performed some procedures such as intraarticular injections, and all provided long-term care for patients.

The mean salary for a full-time rheumatology PA more than two years after graduation was $69,833. To the best of our knowledge, there is no currently available data about NPs in rheumatology roles, salary figures or their characteristics.

Formal training for PAs and NPs in rheumatology has been a blind spot for the ACR in spite of the dwindling membership of American rheumatologists. To date, there is only one formal rheumatology fellowship for non-physicians and this is the 12-month PA fellowship in rheumatology at the University of Texas Southwestern Medical Center in Dallas. This fellowship is integrated with the 24-month physician fellowship so it is seen as comparable to a formal first-year fellowship that is clinically oriented. Aside from this formal fellowship (two graduates), all of the training that rheumatology PAs and NPs obtain is presumably on the job.

When it comes to providing care in rheumatology, PAs and NPs remain a “hidden workforce.” No effort has been made to assess their numbers or role. As the number of retiring rheumatologists exceeds their replacements and the rheumatology workforce ages, we believe that opportunities abound for PAs and NPs. There is a need for research to assess their role in this dynamic area of medicine.