By Cole Epley
Regina Moschitta of Atoka teaches middle school math at Central Day School in Collierville and knows too well the challenges associated with arthritis.
It’s not because she herself has the rheumatic condition that affects the joints. Nor is it because she has a colleague with arthritis — it’s because her seven-year-old daughter, Alison, has been battling the painful affliction, named juvenile arthritis, for over two years.
“We were sad for her, we were very sad. We struggled with getting her diagnosed, and we struggled with the guilt of her pain,” Moschitta said.
The mother of three said before getting Alison diagnosed, the then-five-year-old would cringe and be reduced to sobs because of the pain in her joints that resulted from simple hugs and affection. More than six months would pass before the family knew what was causing their daughter such enormous pain.
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With an insufficient amount of rheumatologists currently in training, the burgeoning population of Americans over the age of 65 is finding it increasingly difficult to get expedient, comprehensive specialty care for rheumatic conditions. The decreasing number of practicing rheumatologists reflects the reality of a field that shrinks every year, despite an increasing pool of patients.
Often overlooked and in even more critical need of rheumatologists is the population of more than 300,000 children diagnosed with juvenile arthritis — a disease that gives no indication of when or why it sets in.
Measures have been implemented to decelerate the dwindling population of pediatric rheumatologists, but to little avail. Competing with the often higher salaries of more lucrative in-patient specialties such as cardiology, where physicians make up to twice as much annually than those in rheumatology, the field has struggled for years to populate its ranks with fresh faces.
Nationally, professional groups like the American College of Rheumatology have lobbied Congress to improve reimbursements and compensation to rheumatologists as well as to propose loan repayment programs for prospective pediatric rheumatologists. The Arthritis Foundation has adopted similar initiatives, funding fellowships for physicians willing to enter the pediatric rheumatology subspecialty.
Monica Brown, one of two practicing pediatric rheumatologists in Memphis, is a fellow of the national Arthritis Foundation.
“Dr. Brown, as one of only two pediatric rheumatologists in Memphis, is only able to see patients on Thursday afternoons,” Meghan Beasy, development and services coordinator for the West Tennessee Arthritis Foundation, said. “With a new patient waiting list extending into September or October, many families are forced to take their children to Nashville for care.”
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The Moschittas know all about traveling to Nashville. It took the family six months of bouncing Alison from physician to physician before the arthritis diagnosis was officially applied, and they still had to travel 200 miles to Vanderbilt Medical Group, where one of the state’s fewer than five pediatric rheumatologists practices.
Moschitta says that one of the most shocking revelations after her daughter received the diagnosis was hearing doctors tell her that they couldn’t fathom the amount of pain the girl was experiencing. The arthritis had invaded every joint in the five-year-old’s delicate frame, and she got to the point where she had to use her thumbs and teeth to get dressed in the mornings.
The results of Alison’s treatment, which lasted for a week and included a chemotherapy drug called methotrexate, were immediate. She also received cortisone injections in her wrists, ankles and knees.
“The first thing she said that day that she had the injections was, ‘I want to bungee jump,’” Alison’s mother says.
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“This is a big problem, and it will get worse rather than better as the population ages and develops arthritic diseases,” says Andrew Kang, professor of rheumatology in the College of Medicine at University of Tennessee Health Science Center.
Kang, who has spent his life teaching rheumatology, is especially cognizant of the problems facing juvenile arthritis patients.
“To the best of my knowledge, there are fewer pediatric rheumatologists in the state than you could count on one hand,” Kang said.
In Tennessee, where more than 26 percent of the adult population is diagnosed with arthritis or other rheumatic conditions, the average wait time for a new patient to see a rheumatologist can last up to one year. Without treatment, rheumatic conditions often lead to irreversible joint or organ damage. The problem is compounded when growing children face the same repercussions.
Kang said the deficient “pipeline” of rheumatologists in training is equally discouraging for juvenile as well as adult patients.
He notes rheumatology’s relatively low pay when compared with inpatient medical specialties: cardiologists earned an average of $402,000 in 2010 and gastroenterology specialists earned $405,000.
“Not that money is everything,” he says, “but it does drive the behavior of many students.”
The dynamic between physicians in the subspecialty and compensation has exacerbated problems in treating new patients. On average, physicians specializing in rheumatology earned $224,000 in 2010, up from $219,400 in 2009.
Rising tuition costs have long been at the forefront of higher education discussion, and 85 percent of graduating medical students carry a loan burden of some sort after graduation. The American Medical Association reports the average debt load for a graduating medical student in 2010 was nearly $157,944.
Further complicating matters is the discordance between physicians and insurers. Kang says there are very few practicing rheumatologists in the state that will accept as new patients those on TennCare or Medicare programs. This provides another face to the conflict that, to Kang, reflects both the shortage of specialists as well as the deeper-rooted problem of compensation issues that all rheumatologists face.
Despite awareness and activity within the local and national spheres, Kang forecasts a grim outlook for both adult and pediatric rheumatology subspecialties.
“I am afraid that I don¹t see anything on the immediate, visible horizon that would significantly address or rectify the problems facing [rheumatology],” he said.
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Fortunately for the Moschitta family, the outlook for Alison is much better than for the field as a whole.
Moschitta and her husband, Keith, a radiological technician at Methodist University Hospitals, now take their daughter to see a Vanderbilt Medical Group physician every two months. Her course of treatment includes oral medication as well as injections twice a week.
She performs various calisthenics every morning to stay limber in her muscles and joints, and is also the catcher for her softball team, The Firecrackers. Her mother says that she is able to sit through a movie, though she typically will get up and move around a couple times to alleviate some discomfort.
“The longer she’s been on the medication, especially the injections, the more fluid her movements have become,” Moschitta said.
Having a resource such as the West Tennessee chapter of the Arthritis Foundation has provided the family with support and networking opportunities, which Moschitta said has helped put things into perspective for her as a mother.
Recently, Alison found out she will be the 2011Honoree at this year’s local Arthritis Walk. Her team has recruited 22 members and is on pace to eclipse its fundraising goal of $1000.
When asked if she is excited about being at the center of attention for the June 4 event, the seven-year-old with her mother’s eyes lights up and nods her head in affirmation. Through a mouthful of Chick-fil-A chicken nuggets, Alison manages a shy but confident yes.
Her mother, sitting where she can keep an eye on her, sends her to play in the restaurant’s jungle gym — something the child would have been unable to tolerate just two years ago.
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