Background
Planning for future physician needs in Canada is a challenging endeavor. While there have been attempts to examine the need for training positions in some specialties in British Columbia,[1] there have been few attempts to examine demographics and practice issues in rheumatology. 

The field of rheumatology has faced a number of changes to clinical practice in recent years, many of which stem from the marked enhancement in the options to control inflammatory arthritides. Rheu­matology has also faced increasing concerns about recruitment and retention. It is clear that more information is required about the demand for rheumatological services and the practice patterns of rheumatologists in BC. 

National attempts at characterizing physician practices and demogra­phics are well documented.[2] Although past studies have provided valuable information about trends in the Canadian physician workforce regarding family practice and the larger clinical specialties, little detailed information about these trends is available for rheumatology. 

Rheumatologists are subspecialists within internal medicine, caring for patients with systemic inflammatory diseases, such as rheumatoid arthritis, lupus, vasculitis, and spondyloarthro­pathies. In addition, rheumatologists deal with the full range of noninflammatory musculoskeletal diseases, including osteoarthritis and complicated mechanical back pain. They frequently work with a team of health care professionals, including physiotherapists, occupational therapists, and nurses, predominantly in an outpatient setting. 

After completing medical school, 3 years of internal med­icine training are required, followed by at least 2 years of rheumatology fellowship training. The Canadian Resident Matching Service oversees the fourth-year residency medicine subspecialty match nationwide. 

In 2010 only 15 available residency positions in adult rheumatology were filled. By comparison, there were 58 available residency positions filled in cardiology, 38 in gastroenterology, and 35 in res­pirology for the same year (www.carms.ca/eng/operations_R4reports_10_e.shtml [10]).

Recognizing that a more comprehensive analysis of the BC rheuma­tologist population was needed to guide future training program requirements and to determine trends in the rheumatology workforce, the British Columbia Society of Rheumatologists (BCSR) decided to survey rheumatologists working in British Columbia and, where possible, to compare the results with those from the most recent Canadian National Physician Survey (NPS).[2]

Methods
The British Columbia Society of Rheumatologists conducted a membership survey in early 2010. The Internet-based survey was sent to all members of the BCSR. This group constitutes all specialists in the pro­vince who practise rheumatology. Complete details on the survey are available from the BCSR. 

The following demographic characteristics were gathered: years since first licensed to practise medicine, sex, medical practice setting, and primary population served. Information was also gathered about time dedicated to patient care as represented by the number of half-day outpatient clinics worked per week and predicted retirement times. 

Data regarding years since first licensed to practise medicine were compared with the NPS data for clinical specialists available through the collaboration of the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Canadian Medical Association.

Results
The survey response rate was 98.0%. Forty-nine completed questionnaires were returned and analyzed. 

Analysis of the basic demographic characteristics showed that 31% of the respondents were female, compared with 69% male. The majority of respondents (55%) consider themselves private practice solo physicians. Another 23% were in private practice with a group, while another 16% were in academic practice; 2% of respondents were not actively practising rheumatology and 4% did not respond to the question (Figure 1 [11]). 
Rheumatologists were found to practise in overwhelmingly urban settings: 66.7% of respondents work in a region of more than 500000 people, while another 12.5% practise in a region of 300000 to 499999 people (Figure 2 [12]). 

Data were also collected on the amount of time respondents spent in direct clinical outpatient care: 32.6% of respondents reported full-time practice of nine to ten half-day clinics a week and another 23.9% indicated they conducted seven to eight half-day clinics a week. 

For the purposes of full-time equivalent (FTE) phy­sician comparisons, we calculated the number of FTE rheumatologists providing outpatient rheumatological care. Based on practice information from the 49 res­pondents, the number of FTE rheumatologists was 32. That is, the amount of clinical rheumatological outpatient care available in BC today is equivalent to 32 rheum­atolgists working 5 days a week in a strictly outpatient setting. 

Respondents were asked the year they were licensed to practise medicine in Canada. The median year for first licence to practise medicine for BC rheumatologists was 1983 (1966–2008), and the majority of rheumatologists were licensed more than 20 years ago. When these licensing figures were compared with results from the Canadian 2007 National Physi­cian Survey, BC rheumatologists were found to have been licensed earlier than the national average for clinical specialists (Table [13]). 

While 67.3% of BC rheumatologists were licensed more than 20 years ago, the national average for clinical specialists licens­ed more than 20 years ago was only 56.2%. Similarly, there were fewer recent graduates in rheumatology in BC compared with the national data for the past 10 years. 

Intentions for retirement were also gathered in the survey, with 23.4% of practising BC rheumatologists indicating they plan to retire in the next 5 years and another 27.7% planning to retire in the next 10 years (Figure 3 [14]). These figures mean that soon 24 fewer rheumatologists will be practising in the province.

Conclusions
Our study is the first to characterize the rheumatologist population in Bri­tish Columbia. The survey had a very high response rate (98%) and was missing data only from one member. Our findings indicate that the vast majority of rheumatologists practise in urban centres in British Columbia. 

Calculations based on the time the 49 respondents reported spending on clinical outpatient care indicate that BC has 32 FTE rheumatologists serving a population of over 4 million.[3] The discrepancy between the number of respondents and the number of calculated FTEs may stem from the fact that a number of rheumatologists, particularly those in academic practice, participate in research or are involved in teaching or administration. 

Others may practise a portion of general internal medicine and some are partially retired. The FTE calculation does not include care provided by rheumatologists in inpatient settings, but this is likely a relatively small amount of time, as the majority of rheumatic diseases are managed in outpatient settings. 

The Canadian Rheumatology As­soc­iation recommends a ratio of one rheumatologist for every 75000 people (oral communication with the Hu­man Resources Committee, Canadian Rheu­­matology Association, November 2010). In 1990 the American College of Rheu­matology conducted an extensive study of rheumatology care models and workforce requirements. 

The results in the United States at the time indicated a rheumatologist to population ratio of 1 to 85000 and estimates for the year 2000 placed the ratio at 1 to 67 000 based on trends in enrolment and training.4 Based on a 2010 population estimate of 4494232 and 32 FTE rheumatologists in BC, the current ratio is approximately 1:140 000. This means the present number of FTE rheumatologists is about 30 fewer than recommended for the province. 

Our study shows that rheumatologists were licensed to practise earlier than the national average for clinical specialists. This indicates that they have been practising for more years and supports the fact that there is an aging rheumatologist workforce. Anti­cipated retirements are going to have a massive effect on access to rheumatological care.

Historically, the University of Bri­tish Columbia has trained one or two rheumatologists per year. Even if every graduate from the UBC rheumatology training program remained in the province during the next 10 years, current numbers of trainees graduating would not keep pace with the estimated 24 retirements. 

The net deficit of practising rheumatologists will inevitably worsen. This does not take into consideration population growth, outward physician migration, the already limited access to rheumatology care in the province, or new recommendations for adequate delivery of care. 

In fact, there were no new Canadian internal medicine graduates entering UBC rheumatology training for 2005–2006, 2007–2008, or 2008–2009.[5] Nor does this take into consideration the fact that most rheumatologists in BC are male (68.8%), while the majority of medical school graduates in Canada are female.[6] This shift in demographics will eventually have an impact on practice patterns.[7] Exactly what the impact will be on rheumatology is unknown. 

Recruiting and retaining trainees is not made easier by the fact that rheumatology is one of the most un­derserviced subspecialties of internal medicine and one with the lowest remuneration. Rheumatologists have witnessed the demand for rheumatology services increase exponentially, and at the same time the burden of rheumatological care has shifted to office practice.

Possible solutions
Initiatives to promote the sustainability of the subspecialty and to recruit and retain trainees will be required in BC if rheumatologists are to deliver the best possible care to patients, particularly those with complex inflammatory and autoimmune diseases. Some possible strategies for improving this situation include:

• Correcting the inequality of remuneration that exists between procedural and nonprocedural specialties. Despite similar training requirements, a large discrepancy in remuneration exists between procedural and nonprocedural specialties. This, combined with the burdensome ov­erhead costs involved in outpatient medicine, is driving new trainees to other fields, such as anesthesia, cardiology, and gastroenterology, at high rates.

• Directing Ministry of Health funding to allied health practitioners with extra training in arthritis to assist rheumatologists in the delivery of outpatient care. Such models exist in other parts of the country. The main constraint to broader implementation is the absence of stable funding. This treatment model would in­crease the ability of the rheumatologist to provide care to a wider spectrum of patients and have an impact on the lengthy waits that exist for access to rheumatology consultation.

• Consistently increasing the number of funded positions for rheumatology trainees at UBC from the present total of two per year.
Since failure to address the dwindling supply of rheumatologists in British Columbia will lead to severely hampered access to care, these strategies and others must be considered.

Competing interests
None declared.

Dr Kur is a clinical assistant professor in the Division of Rheumatology at the University of British Columbia. He is also on the clinical staff of Vancouver General Hospital, and is president of the British Columbia Society of Rheumatologists. Dr Koehler is clinical professor emeritus in the Division of Rheumatology at UBC and chair of the Human Resources Committee of the Canadian Rheumatology Association.