ARTHRITIS & RHEUMATISM Vol. 65, No. 12, December 2013, pp 3011–3013 DOI 10.1002/art.38169 © 2013, American College of Rheumatology
EDITORIAL
The Regional Distribution of Rheumatologists: What Can We Do, What Should We Do? Chad L. Deal, MD respond to the regional shortage of rheumatology services. At the time of the ACR’s earlier workforce study some data on regional distribution were gathered (2). There were 13 metropolitan statistical areas with a population of ⱖ150,000 with no adult rheumatologist, 18 metropolitan statistical areas with a population of ⱖ700,000 with no pediatric rheumatologist, as well as 10 states with no pediatric rheumatologist. Overall, there were 16 rheumatologists per million population, with large variations in supply. Rochester, MN had 121 rheumatologists per million, Boston 39 per million. Patient access to rheumatology care is affected by demand for services (which will increase as baby boomers age), supply of physicians, and ease of access to specialty care. There is evidence that the distance to a specialist is inversely linked to the probability of care for arthritis (4). We can have a huge impact with biologic therapies, reducing joint damage and improving long-term outcomes in patients with inflammatory arthritis. There is good evidence that early initiation of treatment can limit the impact of adverse effects on physical function, joint damage, as well as social and work participation. The window for early treatment is considered to be within months of disease onset since this is the period when the chance of inducing remission is greatest. Van der Linden et al, in a study of a cohort in The Netherlands, demonstrated that patients whose care was delayed by ⬎12 weeks had significantly more radiologic joint damage over time (5). Delay in seeing a rheumatologist was associated with a hazard ratio of 1.87 for not achieving disease-modifying antirheumatic drug–free remission and a 1.3 times higher rate of joint destruction. Delays in initiation of treatment are multifactorial, but availability and ease of access to a trained specialist in the care of inflammatory arthritis are essential. Approximately 25% of the US population lives in rural areas, yet only 10% of physicians practice in these areas. The ACA includes new resources to increase the
The passage of the Affordable Care Act (ACA) provides the framework for allowing access to medical care for more than 30 million Americans. The physician workforce is predicted to grow by ⬃7% in the next decade, and providing care to 30 million new patients as well as for the increased number of Americans who are over the age of 65 years (expected to grow by 36%) will be a challenge. The American Association of Medical Colleges estimates a potential shortage of 90,000 doctors, including 46,000 specialists, in the next decade. It is surprising to many that the US has fewer primary care doctors—30 per 100,000—than any other industrialized country (e.g., 80 per 100,000 in the UK and 157 per 100,000 in Germany) (1). Primary care physicians do provide arthritis care, especially for osteoarthritis and soft tissue disorders, although advice and support from a specialist is often sought and fully one-third of these patients see specialists. For inflammatory and autoimmune disorders the rheumatologist is often the primary care doctor. The American College of Rheumatology (ACR) 2005–2006 workforce study predicted a shortfall of 2,500 rheumatologists by the year 2025 (2). After the number of first-year rheumatology fellowship positions filled in the US had sunk to a low of 117 in 1997, there were 186 first-year rheumatology fellows in 2012, improving the supply to the workforce. Support of first-year fellow positions by the ACR’s Rheumatology Research Foundation made a significant contribution to this increase. In this issue of Arthritis & Rheumatism, the ACR Committee on Rheumatology Training and Workforce Issues (COTW) provides data on another workforce shortage: too few rheumatologists in rural areas (3). The ACR responded to the 2005–2006 workforce study and should Chad L. Deal, MD: Cleveland Clinic, Cleveland, Ohio. Address correspondence to Chad L. Deal, MD, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: dealc@ ccf.org. Submitted for publication July 24, 2013; accepted in revised form August 20, 2013. 3011
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number of doctors providing primary care services, and incentives for nurses and other health care providers to practice in rural communities through additional scholarships, loan repayment opportunities, and Medicare payment incentives. Agencies can have an impact on supply to rural areas; the number of National Health Service Corps (NHSC) clinicians working in underserved and rural communities across America today is ⬎3 times greater than it was 3 years ago. The NHSC Loan Repayment Program offers fully trained primary care physicians (MD or DO) $60,000 to repay student loans in exchange for 2 years of full-time medical practice in underserved areas. The ACA provides funds to expand telehealth services in order to help patients in rural areas access specialty care, but the amount of money to expand specialty care is limited. The COTW found that ⬃90% of all rheumatologists in the ACR database practiced in metropolitan areas (defined as areas with a population of ⱖ50,000 around a central urban core), while only 10% practiced in rural or micropolitan areas with populations of ⬍50,000. Based on population distribution there were significantly fewer rheumatologists in micropolitan than metropolitan areas (P ⬍ 0.001). Only 9% of metropolitan areas did not have a rheumatologist, while 84% of micropolitan areas had no rheumatologist. Only 1% of metropolitan area residents had to drive ⬎75 miles to see a rheumatologist, while 16% of micropolitan area residents drove ⬎75 miles, and in some areas the average drive was 200 miles. The maldistribution of physicians is not a new problem and may get worse in the coming years. Physicians finishing their residencies are more interested in hospital employment than ever before, according to a Merritt Hawkins survey of 302 final-year residents conducted in 2011 (6). One-third of residents said they would be most interested in becoming a hospital employee, compared with 4% in 2003. The residents in this survey overwhelmingly preferred urban areas, with ⬎50% planning on practicing in an area with ⬎500,000 residents while only 6% were planning on serving an area with ⬍50,000 residents. The COTW suggests several interventions to increase the supply of rheumatologists to underserved communities (3). An important first step would be for the ACR to commit to providing up-to-date information on supply by region as a way to apprise graduates of practice opportunities. This will require ongoing effort using the COTW data as the start of the process, not the end. Methods to increase the supply of trainees in rural areas, such as providing funds to training programs in
DEAL
underserved areas to fund fellow positions and providing financial incentives for trainees to practice in areas with shortages, would require an effort by the ACR to influence federal, state, local, and hospital groups for money. Traveling clinics, telemedicine, and expansion of the number of nurse practitioners (NPs) and physician assistants (PAs) are other methods for providing care in underserved areas. Federal programs allow doctors from other countries with J-1 visas who are trained in the US to remain in this country if they work in a manpower shortage area. Some states provide loan forgiveness for physicians practicing in shortage areas. HealthSpot, a telemedicine platform, provides remote medical diagnostics using a walk-in kiosk that gives patients experiencing acute medical problems live access to board-certified doctors, via high-definition videoconferencing and interactive digital medical devices, usually staffed by an LPN. Many rheumatology services are “hands on,” but it is possible that more routine care could be provided in this manner. The ACA requires that Medicare Part D prescription drug plans include a comprehensive review of medications and a written summary of the review as part of their medication therapy management programs and specifically allows telehealth technology for this purpose. Some rheumatology visits with established patients who live in rural areas could entail telemedicine technology. Financial incentives for return of service that direct physicians to underserved areas (as in the NHSC program) require financing by federal or state authorities, although innovative donor financing has been attempted (7). States have passed rural health acts aimed at attracting medical students who are likely to practice in rural areas. Royston et al studied the factors most associated with medical student intent to practice in a rural area and found that being raised in a rural area for more than half of one’s life and having a spouse or significant other who had lived in a rural area were predictive (P ⬍ 0.05) (8). Residents who are trained in rural areas are 2–3 times more likely to practice in these areas. Students have reported that financial incentives and wage guarantees would increase their interest in practicing in a rural area. Expansion of the numbers of NPs and PAs was suggested in the 2005–2006 ACR workforce study (2) and by the COTW (3) as a means of increasing supply to rural areas. At the time of the 2005–2006 workforce study, only 22.7% of rheumatology practices had an NP or PA provider. Studies have shown that use of NPs and PAs is productive, cost effective, and accepted by pa-
EDITORIAL
tients, and NPs and PAs are more likely to practice in areas where there are doctor shortages. NPs and PAs have been employed in rheumatology settings for more than 30 years, but there have been few studies to delineate their roles. NP and PA representation in the Association of Rheumatology Health Professionals (ARHP) is low, perhaps because the ARHP is allied health oriented and does not have a large clinical practice focus. NP and PA interests are often more closely allied with practice issues, but with few exceptions they cannot be members of the ACR beyond ARHP. A model for expanding PA participation in rheumatology was the initiation of a 12-month fellowship program in 2003 at the University of Texas Southwestern Medical Center and Veterans Administration Medical Center, Dallas, in which the PA fellows were assigned similar responsibilities as the first-year physician fellows (9). The ACR should consider a task force to develop a strategic plan to increase the supply of both NPs and PAs in rheumatology, with special emphasis on supply to rural areas. Training programs for rheumatology NPs and PAs that include loan repayment and other financial incentives as well as selection that puts a premium on applicants with a rural background could be effective. The ACA’s primary care workforce provisions seek to incentivize growth in the number of NPs and PAs. However, the graduation rate for NP providers has remained at ⬃8,000 per year. The ACA seeks to increase person-power for the delivery of primary care services, not specialty care. Rheumatologists have to compete for NPs and PAs with other physicians in specialties (especially in surgical fields) that can offer higher salaries. Expansion of the number of NP and PA providers is not without controversy: a recent report on the perspectives of physicians and nurse practitioners about primary care practice showed how these two groups of health professionals can “work side by side but inhabit different universes” (10). An Institute of Medicine report on the future of nursing identified overly restrictive scope-of-practice restrictions for advanced practice nurses that vary by state as a serious barrier to accessible care, and suggested that the federal government should consider regulation in this area (11). National physician organizations, including the American Medical Association and the American Academy of Family Physicians, withdrew their support for ongoing dialog between nurse and physician organizations. At the end of the day, the ACR would have to decide whether providing increased access to our ser-
3013
vices in underserved areas is a high enough priority (considering the many demands on rheumatology in an ever-changing health care environment) to commit resources to addressing this issue. I believe the ACR should commit to providing up-to-date information on supply by region and apprise fellows in training and early-career rheumatologists, using the COTW data as the start of the process. Since many rheumatology graduates are seeking hospital employment, the ACR should also survey hospitals in rural areas that are interested in investing in a rheumatologist for their residents. In addition, the ACR should consider a task force to develop a strategic plan for the recruitment of NPs and PAs into rheumatology and into rural areas. The COTW should engage program directors and discuss whether selection of fellows with rural backgrounds is a reasonable option. The Government Affairs Committee should add to its agenda efforts directed at state and federal authorities to incentivize rheumatology practice in rural areas. AUTHOR CONTRIBUTIONS Dr. Deal drafted the article, revised it critically for important intellectual content, and approved the final version to be published.
REFERENCES 1. Blumenthal D, Abrams MK. Putting aside preconceptions— time for dialogue among primary care clinicians. N Engl J Med 2013;368:1933–4. 2. Deal CL, Hooker R, Harrington T, Birnbaum N, Hogan P, Bouchery E, et al. The United States rheumatology workforce: supply and demand, 2005–2025. Arthritis Rheum 2007;56:722–9. 3. American College of Rheumatology Committee on Rheumatology Training and Workforce Issues. Regional distribution of adult rheumatologists. Arthritis Rheum 2013;65:3017–25. 4. Boyle E, Badley EM, Glazier RH. The relationship between local availability and first-time use of specialists in an arthritis population. Can J Public Health 2006;97:210–3. 5. Van der Linden MP, le Cessie S, Raza K, van der Woude D, Knevel R, Huizinga TW, et al. Long-term impact of delay in assessment of patients with early arthritis. Arthritis Rheum 2010; 62:3537–46. 6. 2011 survey of final-year medical residents. URL: http://www. merritthawkins.com/pdf/mha2011residentsurvpdf.pdf. 7. Barnighausen T, Bloom DE. Designing financial-incentive programmes for return of medical service in underserved areas: seven management functions. Hum Resour Health 2009;7:52. 8. Royston PJ, Mathieson K, Leafman J, Ojan-Sheehan O. Medical student characteristics predictive of intent for rural practice. Rural Remote Health 2012;12:2107. 9. Hooker RS. The extension of rheumatology services with physician assistants and nurse practitioners. Best Pract Res Clin Rheumatol 2008;22:523–33. 10. Donelan K, DesRoches CM, Dittus RS, Buerhaus P. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med 2013;368:1898–906. 11. Institute of Medicine. The future of nursing: leading change, advancing health. URL: http://www.iom.edu/Reports/2010/TheFuture-of-Nursing-Leading-Change-Advancing-Health.aspx.
Copyright of Arthritis & Rheumatism is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EDITORIAL
The Regional Distribution of Rheumatologists: What Can We Do, What Should We Do? Chad L. Deal, MD respond to the regional shortage of rheumatology services. At the time of the ACR’s earlier workforce study some data on regional distribution were gathered (2). There were 13 metropolitan statistical areas with a population of ⱖ150,000 with no adult rheumatologist, 18 metropolitan statistical areas with a population of ⱖ700,000 with no pediatric rheumatologist, as well as 10 states with no pediatric rheumatologist. Overall, there were 16 rheumatologists per million population, with large variations in supply. Rochester, MN had 121 rheumatologists per million, Boston 39 per million. Patient access to rheumatology care is affected by demand for services (which will increase as baby boomers age), supply of physicians, and ease of access to specialty care. There is evidence that the distance to a specialist is inversely linked to the probability of care for arthritis (4). We can have a huge impact with biologic therapies, reducing joint damage and improving long-term outcomes in patients with inflammatory arthritis. There is good evidence that early initiation of treatment can limit the impact of adverse effects on physical function, joint damage, as well as social and work participation. The window for early treatment is considered to be within months of disease onset since this is the period when the chance of inducing remission is greatest. Van der Linden et al, in a study of a cohort in The Netherlands, demonstrated that patients whose care was delayed by ⬎12 weeks had significantly more radiologic joint damage over time (5). Delay in seeing a rheumatologist was associated with a hazard ratio of 1.87 for not achieving disease-modifying antirheumatic drug–free remission and a 1.3 times higher rate of joint destruction. Delays in initiation of treatment are multifactorial, but availability and ease of access to a trained specialist in the care of inflammatory arthritis are essential. Approximately 25% of the US population lives in rural areas, yet only 10% of physicians practice in these areas. The ACA includes new resources to increase the
The passage of the Affordable Care Act (ACA) provides the framework for allowing access to medical care for more than 30 million Americans. The physician workforce is predicted to grow by ⬃7% in the next decade, and providing care to 30 million new patients as well as for the increased number of Americans who are over the age of 65 years (expected to grow by 36%) will be a challenge. The American Association of Medical Colleges estimates a potential shortage of 90,000 doctors, including 46,000 specialists, in the next decade. It is surprising to many that the US has fewer primary care doctors—30 per 100,000—than any other industrialized country (e.g., 80 per 100,000 in the UK and 157 per 100,000 in Germany) (1). Primary care physicians do provide arthritis care, especially for osteoarthritis and soft tissue disorders, although advice and support from a specialist is often sought and fully one-third of these patients see specialists. For inflammatory and autoimmune disorders the rheumatologist is often the primary care doctor. The American College of Rheumatology (ACR) 2005–2006 workforce study predicted a shortfall of 2,500 rheumatologists by the year 2025 (2). After the number of first-year rheumatology fellowship positions filled in the US had sunk to a low of 117 in 1997, there were 186 first-year rheumatology fellows in 2012, improving the supply to the workforce. Support of first-year fellow positions by the ACR’s Rheumatology Research Foundation made a significant contribution to this increase. In this issue of Arthritis & Rheumatism, the ACR Committee on Rheumatology Training and Workforce Issues (COTW) provides data on another workforce shortage: too few rheumatologists in rural areas (3). The ACR responded to the 2005–2006 workforce study and should Chad L. Deal, MD: Cleveland Clinic, Cleveland, Ohio. Address correspondence to Chad L. Deal, MD, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: dealc@ ccf.org. Submitted for publication July 24, 2013; accepted in revised form August 20, 2013. 3011
3012
number of doctors providing primary care services, and incentives for nurses and other health care providers to practice in rural communities through additional scholarships, loan repayment opportunities, and Medicare payment incentives. Agencies can have an impact on supply to rural areas; the number of National Health Service Corps (NHSC) clinicians working in underserved and rural communities across America today is ⬎3 times greater than it was 3 years ago. The NHSC Loan Repayment Program offers fully trained primary care physicians (MD or DO) $60,000 to repay student loans in exchange for 2 years of full-time medical practice in underserved areas. The ACA provides funds to expand telehealth services in order to help patients in rural areas access specialty care, but the amount of money to expand specialty care is limited. The COTW found that ⬃90% of all rheumatologists in the ACR database practiced in metropolitan areas (defined as areas with a population of ⱖ50,000 around a central urban core), while only 10% practiced in rural or micropolitan areas with populations of ⬍50,000. Based on population distribution there were significantly fewer rheumatologists in micropolitan than metropolitan areas (P ⬍ 0.001). Only 9% of metropolitan areas did not have a rheumatologist, while 84% of micropolitan areas had no rheumatologist. Only 1% of metropolitan area residents had to drive ⬎75 miles to see a rheumatologist, while 16% of micropolitan area residents drove ⬎75 miles, and in some areas the average drive was 200 miles. The maldistribution of physicians is not a new problem and may get worse in the coming years. Physicians finishing their residencies are more interested in hospital employment than ever before, according to a Merritt Hawkins survey of 302 final-year residents conducted in 2011 (6). One-third of residents said they would be most interested in becoming a hospital employee, compared with 4% in 2003. The residents in this survey overwhelmingly preferred urban areas, with ⬎50% planning on practicing in an area with ⬎500,000 residents while only 6% were planning on serving an area with ⬍50,000 residents. The COTW suggests several interventions to increase the supply of rheumatologists to underserved communities (3). An important first step would be for the ACR to commit to providing up-to-date information on supply by region as a way to apprise graduates of practice opportunities. This will require ongoing effort using the COTW data as the start of the process, not the end. Methods to increase the supply of trainees in rural areas, such as providing funds to training programs in
DEAL
underserved areas to fund fellow positions and providing financial incentives for trainees to practice in areas with shortages, would require an effort by the ACR to influence federal, state, local, and hospital groups for money. Traveling clinics, telemedicine, and expansion of the number of nurse practitioners (NPs) and physician assistants (PAs) are other methods for providing care in underserved areas. Federal programs allow doctors from other countries with J-1 visas who are trained in the US to remain in this country if they work in a manpower shortage area. Some states provide loan forgiveness for physicians practicing in shortage areas. HealthSpot, a telemedicine platform, provides remote medical diagnostics using a walk-in kiosk that gives patients experiencing acute medical problems live access to board-certified doctors, via high-definition videoconferencing and interactive digital medical devices, usually staffed by an LPN. Many rheumatology services are “hands on,” but it is possible that more routine care could be provided in this manner. The ACA requires that Medicare Part D prescription drug plans include a comprehensive review of medications and a written summary of the review as part of their medication therapy management programs and specifically allows telehealth technology for this purpose. Some rheumatology visits with established patients who live in rural areas could entail telemedicine technology. Financial incentives for return of service that direct physicians to underserved areas (as in the NHSC program) require financing by federal or state authorities, although innovative donor financing has been attempted (7). States have passed rural health acts aimed at attracting medical students who are likely to practice in rural areas. Royston et al studied the factors most associated with medical student intent to practice in a rural area and found that being raised in a rural area for more than half of one’s life and having a spouse or significant other who had lived in a rural area were predictive (P ⬍ 0.05) (8). Residents who are trained in rural areas are 2–3 times more likely to practice in these areas. Students have reported that financial incentives and wage guarantees would increase their interest in practicing in a rural area. Expansion of the numbers of NPs and PAs was suggested in the 2005–2006 ACR workforce study (2) and by the COTW (3) as a means of increasing supply to rural areas. At the time of the 2005–2006 workforce study, only 22.7% of rheumatology practices had an NP or PA provider. Studies have shown that use of NPs and PAs is productive, cost effective, and accepted by pa-
EDITORIAL
tients, and NPs and PAs are more likely to practice in areas where there are doctor shortages. NPs and PAs have been employed in rheumatology settings for more than 30 years, but there have been few studies to delineate their roles. NP and PA representation in the Association of Rheumatology Health Professionals (ARHP) is low, perhaps because the ARHP is allied health oriented and does not have a large clinical practice focus. NP and PA interests are often more closely allied with practice issues, but with few exceptions they cannot be members of the ACR beyond ARHP. A model for expanding PA participation in rheumatology was the initiation of a 12-month fellowship program in 2003 at the University of Texas Southwestern Medical Center and Veterans Administration Medical Center, Dallas, in which the PA fellows were assigned similar responsibilities as the first-year physician fellows (9). The ACR should consider a task force to develop a strategic plan to increase the supply of both NPs and PAs in rheumatology, with special emphasis on supply to rural areas. Training programs for rheumatology NPs and PAs that include loan repayment and other financial incentives as well as selection that puts a premium on applicants with a rural background could be effective. The ACA’s primary care workforce provisions seek to incentivize growth in the number of NPs and PAs. However, the graduation rate for NP providers has remained at ⬃8,000 per year. The ACA seeks to increase person-power for the delivery of primary care services, not specialty care. Rheumatologists have to compete for NPs and PAs with other physicians in specialties (especially in surgical fields) that can offer higher salaries. Expansion of the number of NP and PA providers is not without controversy: a recent report on the perspectives of physicians and nurse practitioners about primary care practice showed how these two groups of health professionals can “work side by side but inhabit different universes” (10). An Institute of Medicine report on the future of nursing identified overly restrictive scope-of-practice restrictions for advanced practice nurses that vary by state as a serious barrier to accessible care, and suggested that the federal government should consider regulation in this area (11). National physician organizations, including the American Medical Association and the American Academy of Family Physicians, withdrew their support for ongoing dialog between nurse and physician organizations. At the end of the day, the ACR would have to decide whether providing increased access to our ser-
3013
vices in underserved areas is a high enough priority (considering the many demands on rheumatology in an ever-changing health care environment) to commit resources to addressing this issue. I believe the ACR should commit to providing up-to-date information on supply by region and apprise fellows in training and early-career rheumatologists, using the COTW data as the start of the process. Since many rheumatology graduates are seeking hospital employment, the ACR should also survey hospitals in rural areas that are interested in investing in a rheumatologist for their residents. In addition, the ACR should consider a task force to develop a strategic plan for the recruitment of NPs and PAs into rheumatology and into rural areas. The COTW should engage program directors and discuss whether selection of fellows with rural backgrounds is a reasonable option. The Government Affairs Committee should add to its agenda efforts directed at state and federal authorities to incentivize rheumatology practice in rural areas. AUTHOR CONTRIBUTIONS Dr. Deal drafted the article, revised it critically for important intellectual content, and approved the final version to be published.
REFERENCES 1. Blumenthal D, Abrams MK. Putting aside preconceptions— time for dialogue among primary care clinicians. N Engl J Med 2013;368:1933–4. 2. Deal CL, Hooker R, Harrington T, Birnbaum N, Hogan P, Bouchery E, et al. The United States rheumatology workforce: supply and demand, 2005–2025. Arthritis Rheum 2007;56:722–9. 3. American College of Rheumatology Committee on Rheumatology Training and Workforce Issues. Regional distribution of adult rheumatologists. Arthritis Rheum 2013;65:3017–25. 4. Boyle E, Badley EM, Glazier RH. The relationship between local availability and first-time use of specialists in an arthritis population. Can J Public Health 2006;97:210–3. 5. Van der Linden MP, le Cessie S, Raza K, van der Woude D, Knevel R, Huizinga TW, et al. Long-term impact of delay in assessment of patients with early arthritis. Arthritis Rheum 2010; 62:3537–46. 6. 2011 survey of final-year medical residents. URL: http://www. merritthawkins.com/pdf/mha2011residentsurvpdf.pdf. 7. Barnighausen T, Bloom DE. Designing financial-incentive programmes for return of medical service in underserved areas: seven management functions. Hum Resour Health 2009;7:52. 8. Royston PJ, Mathieson K, Leafman J, Ojan-Sheehan O. Medical student characteristics predictive of intent for rural practice. Rural Remote Health 2012;12:2107. 9. Hooker RS. The extension of rheumatology services with physician assistants and nurse practitioners. Best Pract Res Clin Rheumatol 2008;22:523–33. 10. Donelan K, DesRoches CM, Dittus RS, Buerhaus P. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med 2013;368:1898–906. 11. Institute of Medicine. The future of nursing: leading change, advancing health. URL: http://www.iom.edu/Reports/2010/TheFuture-of-Nursing-Leading-Change-Advancing-Health.aspx.
Copyright of Arthritis & Rheumatism is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
