When Karen Holloway, 61, first noticed the swelling in her knuckles and the fatigue that refused to lift no matter how much she slept, her primary care doctor suspected rheumatoid arthritis and referred her to a rheumatologist. The wait for an appointment: four and a half months.
"I was in pain every single day," she said. "And I just kept being told to wait."
Holloway's experience is not unusual. Across the country, patients with lupus, rheumatoid arthritis, psoriatic arthritis, and dozens of other autoimmune and inflammatory diseases are waiting longer and traveling farther to see a doctor who specializes in treating them. The reason is straightforward and alarming: the United States does not have nearly enough rheumatologists, and the gap between supply and demand is growing wider every year.
A perfect storm decades in the making
Rheumatology has long been one of medicine's quieter specialties — less glamorous than cardiology, less lucrative than orthopedic surgery, and therefore, historically, harder to fill. But the underlying pressures building against it are anything but quiet.
The American College of Rheumatology (ACR) has been sounding the alarm for years. Its landmark 2015 workforce study projected that the supply of adult rheumatologists would drop by roughly 31% by 2030, even as demand surged by nearly 138%. The math is brutal: more patients, fewer doctors.
A more recent study published in 2024 in Arthritis & Rheumatology offered some cautious optimism — the number of clinically active rheumatologists did grow by about 23% between 2009 and 2020, reaching roughly 5,667 physicians. But researchers were quick to qualify the finding. Even if that rate of growth continued steadily, the U.S. would have approximately 7,000 rheumatologists by 2030 — still well short of the 8,100 the ACR projects will be needed.
"The workforce shortage is an existential threat to the field of rheumatology and to the care we deliver to our patients."
— Dr. Kenneth Saag, President, American College of RheumatologyAging doctors, aging patients
One of the most significant drivers of the shortage is retirements. The ACR's 2015 study estimated that roughly half of all practicing rheumatologists would retire by the end of 2030. Many of them are baby boomers who entered the field decades ago — and as they leave, the pipeline to replace them simply cannot keep pace.
At the same time, the population they serve is getting older and sicker. Nearly a quarter of all American adults — some 58.5 million people — report having arthritis. Among Americans 65 and older, that figure climbs to more than 50%. As life expectancy increases, so does the prevalence of conditions that rheumatologists are uniquely trained to manage: rheumatoid arthritis, lupus, ankylosing spondylitis, vasculitis, gout, and Sjögren's syndrome, among others.
Many of these diseases are driven or worsened by immune dysfunction that tends to accumulate with age. And unlike a broken bone, they rarely resolve — they require ongoing, sophisticated management from doctors who understand the intricate relationship between the immune system and the body it is supposed to protect.
Where the shortage bites hardest
The shortage is not evenly distributed. Rheumatologists, like many specialists, tend to cluster in urban and suburban centers — particularly in the Northeast, where medical training programs are concentrated. Rural communities bear a disproportionate share of the burden.
Research has found that in some parts of the country, the nearest rheumatologist may be more than 100 miles away. Several regions with populations of 200,000 or more have no practicing rheumatologist at all. Meanwhile, rural areas often have higher rates of arthritis-related activity limitations — meaning the patients who need care the most are frequently the ones with the least access to it.
Burnout compounds the problem. A Medscape survey found that rheumatology ranked second among 29 medical specialties in physician burnout, with roughly half of respondents saying they were experiencing it. "Burnout is a poison to every element in the workforce equation," Dr. Leonard Calabrese of the Cleveland Clinic said at a 2024 ACR conference session dedicated entirely to the workforce crisis.
What can be done
Experts agree that no single solution will be enough. What's needed is a coordinated, multi-pronged response — and some pieces are already moving into place.
- Expand fellowship training. The number of accredited adult rheumatology fellowship programs grew to 129 by the 2023–2024 academic year, and fellowship applicants increased 49% between 2015 and 2019. But 10 states still have no fellowship program, and funding for graduate medical education — primarily driven by Medicare and Medicaid — remains a bottleneck.
- Grow the advanced practice workforce. Nurse practitioners and physician assistants in rheumatology increased by 141% between 2009 and 2020. Expanding and better integrating these providers into rheumatology practices is widely seen as one of the most scalable near-term solutions.
- Scale up telemedicine. The COVID-19 pandemic forced a rapid expansion of telehealth in rheumatology, and for many patients — particularly in rural areas — remote consultations can be life-changing. Sustaining and expanding those models could extend the reach of existing specialists significantly.
- Reduce burnout and improve retention. Keeping experienced rheumatologists in practice longer matters as much as training new ones. That means addressing administrative burdens, prior authorization demands, and the working conditions that are driving doctors out of medicine altogether.
- Educate primary care. Training primary care physicians to co-manage common rheumatic conditions could reduce the volume of referrals that must be absorbed by an already-strained specialist workforce.
The ACR has been actively lobbying Congress on all of these fronts. But experts caution that policy changes take time — and the patients showing up at clinic doors with swollen joints and exhausted immune systems cannot wait indefinitely.
For Holloway, the four-and-a-half-month wait eventually ended, the diagnosis was confirmed, and treatment began. Her disease is now managed. But she thinks about others who might not be as persistent, or as fortunate.
"What happens to the person who just gives up waiting?" she asked. "What happens to them?"
Data sourced from the American College of Rheumatology Workforce Studies (2015, 2024), Arthritis & Rheumatology, and the Association of American Medical Colleges.