Results From the 2020 Canadian Rheumatology Association’s Workforce and Wellness Survey

DISCUSSION

This workforce survey provides a timely update of the Canadian rheumatology workforce for use in planning, recruitment, and retention strategies. Our findings also provide physician perspectives on the pandemic effect. To our knowledge, this is the first Canadian national rheumatology survey to address burnout. While the pandemic affected many of the workforce variables examined in this survey, there continues to be important workforce trends demonstrated that may affect workforce capacity and access to care.

The survey results were used to generate an updated estimate on the overall national deficit of FTE rheumatologists. The current deficit is estimated at 194 rheumatologists using the benchmark of 1 FTE rheumatologist per 75,000 population. This is relatively stable compared to the previously reported deficit of 203 rheumatologists in 2015.¹ These estimates are based on previous consensus-based recommendations that have been endorsed nationally but require additional validation.²² In a sensitivity analysis, a benchmark of 2 FTE rheumatologists per 100,000 population was examined to align with previous published targets,²³ identifying an estimated deficit of 447 rheumatologists. Regional workforce projections should be generated in future work accounting for population characteristics and other practice variables,²⁴ which were not readily available for this study. The results remain aligned with international concerns for workforce shortages such as those in the US in both adult²⁵ and pediatric rheumatology.²⁶

The results of our survey warn of an ongoing workforce shortage as a result of retirement and highlight the changing demographics of the workforce. Presently, 28% of the rheumatology workforce plans to retire between 2025–2030. This is comparable to the results from the 2015 survey, which reported 32% planned to retire between 2020–2025.¹ The CMA¹⁸ reported 10 retirements over a 3-year period from 2016 to 2018. Although these data may not be complete, it suggests a discrepancy between retirement plans and actual retirements. Current nonvisa rheumatology trainee numbers from the Canadian Post-MD Education Registry (CAPER)²⁷ indicate that in 2019–2020, there were 88 current adult rheumatology trainees and 11 pediatric rheumatology trainees nationally, with 32 adult and 3 pediatric rheumatology trainees completing training. It is likely it will take some time before the deficit is resolved. Further, the female predominance of the Canadian rheumatology workforce is increasing as over half of Canadian rheumatologists are female²⁸ and between 56–68% of adult rheumatology trainees since 2015–2016 are female.²⁷ This feminization has significant implications for workforce supply given that women, on average, see fewer follow-up and new patients per week, and studies on physician billing support this finding.^3,4 However, women rheumatologists do not work fewer clinical hours than males, and thus, likely have different practice patterns including spending more time with patients. Patient outcomes may also be different based on physician sex²⁹ and a dedicated evaluation of this may be of future interest.

Our findings demonstrate ongoing differences in practice characteristics between community- and university-based rheumatologist practices as clinical volumes are nearly double in the community compared to the university setting. This difference is likely because of increased teaching, research, and administrative demands in university-based settings and potential complexity of cases referred to university-based clinics. Similarly, adult rheumatology practices see higher volumes, in part, as most pediatric practices remain in university-based clinics. The present survey did not inquire about models of arthritis care involving other healthcare professionals in advanced practice roles as this was previously published nationally.³⁰

The pandemic had a predictable effect on rheumatologist work patterns. Most notable was the large increase in virtual care. Compared to the 2015 survey, only 14% of respondents at that time participated in telehealth or e-consultation.¹ Our results are aligned with findings from other practices around the world, which also reported a large increase in virtual care.^15,16,31,32 Delivering care virtually allowed for provision of rheumatology care despite pandemic-related lockdowns, although many reported that it was difficult to assess a patient’s disease activity without being able to complete a physical exam in person.¹⁶ Providers were more comfortable providing virtual care for patients with established, stable disease.¹⁵

Historically, rheumatology has been considered by many to be a relatively “happy specialty” and one that allows for a good work–life balance. One study found that 92% of rheumatologists in the US were satisfied with their job³³ and yet, this present survey shows that burnout is a significant issue, with over half of rheumatologists reporting burnout. This is higher than the national (prepandemic) average of 30% reported in the CMA’s National Physician Health Survey.¹⁴ Although our findings are likely affected by the pandemic, this is the present reality, and it is anticipated that the pandemic will have a lasting effect on the workforce. Interestingly, Medscape, which had previously found rheumatologists to be among the happiest specialists, now reports that rheumatologists have the second highest level of burnout among 29 subspecialties.^11,13 This survey goes on to identify administrative/bureaucratic tasks as the main source of burnout. While there have been some concerns reported with the methodology of the Medscape inquiry,³⁴ the results echo a survey of rheumatologists on burnout that was conducted prepandemic, in which 54% of rheumatologists reported burnout according to the MBI.¹² Further, in our study, women were more likely to report burnout, and both sex/gender and age were significantly associated with burnout. We did not find ethnicity or race to be associated with burnout in our sample. This may be because the number of respondents was low or that there were unique challenges not addressed in the burnout questionnaires. In a large study from American physicians, minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic White physicians.³⁵ In contrast, higher burnout was reported in Canadian ethnic minority internal medicine residents during the pandemic compared to White residents.³⁶ We did not examine resident burnout given the low sample size. Burnout in rheumatology is poorly studied, perhaps as it was historically not considered a significant issue. However, this work suggests potential workforce implications.

While this is the only national Canadian rheumatology survey of its kind, to our knowledge, we recognize several limitations. First, as the survey was sent only to CRA members, nonmember rheumatologists did not have access unless they were ORA members and accessed it through the ORA website. Unfortunately, there is no single comprehensive list of rheumatologists in Canada. Therefore, the CRA membership list was considered a reasonable sample for survey dissemination. This also created challenges for determining an appropriate denominator for our estimate of FTE rheumatologists. We elected to use the CMA master file as it is compiled from multiple sources and was also used for our 2015 survey.¹ However, it is possible there are inaccuracies in these data and a 2020 version was not available at the time of analysis. Additionally, the CMA numbers were prepandemic and would not have captured any changes to the workforce that were precipitated by the pandemic, such as possible increased retirements. Given the incomplete response rate, generalizability may be a concern because of a higher representation of female respondents and higher numbers with academic affiliation in comparison to the CMA master file.¹⁸ Indeed, female pediatric rheumatologists may see lower patient volumes, affecting some overall estimates. Additionally, surveys may have a response bias such that respondents may have different characteristics compared to nonrespondents. Respondents may also over- or underestimate practice volumes, and in future, linkage to physician billing data would make for an interesting evaluation.

Further, the accepted CRA benchmark of 1:75,000 population was used for our calculations of rheumatologist deficits and as discussed above, this is not a proven benchmark based upon population estimates of rheumatic disease prevalence and healthcare use. Last, the COVID-19 pandemic likely influenced several aspects of this survey. We attempted to quantify physician perception of the pandemic’s effect but with many pandemic waves, this was difficult. The survey was deployed just after the “first wave” in Canada and remained open many months to improve the response rate. Language in the survey questions such as “prepandemic” and “peak pandemic” may have been difficult to interpret for survey respondents and may have influenced our results. It is possible that the pandemic resulted in higher reported rates of burnout than would usually be present in the workforce, and that levels of pandemic-related burnout varied by COVID-19 case numbers and vaccine development and rollout.

In conclusion, our findings highlight the ongoing shortage of rheumatologists in Canada and that this deficit will worsen without increasing new graduates to cover retirements. This problem may be compounded by the threat of burnout to the retention and the productivity of the current workforce. The pandemic created an immediate threat to the workforce by significantly affecting patient volume, likely affecting rheumatologist remuneration and contributing to delayed care. A further evaluation of the effect of the pandemic and increasing virtual care on rheumatology practices and patient outcomes is warranted. Future advocacy and research efforts should also continue to evaluate the predictors of burnout among rheumatologists as well as to develop strategies to address burnout at local, regional, and national levels.