Significant heterogeneity in the current rheumatology workforce was observed among the Arab countries, ranging from an extremely low (0.06 rheumatologists per 100,000 inhabitants) in Sudan to a much acceptable level (1.86 per 100,000 inhabitants) in Tunisia. This considerable heterogeneity is probably related to differences in healthcare and education systems, in addition to the countries’ economic levels. Nevertheless, the global number of 0.84 rheumatologists per 100,000 inhabitants is still below the arbitrarily desirable level of 1 to 2 rheumatologists per 100,000 [4, 16]. It falls behind the numbers reported by others such as Spain (3.44), the USA (1.74), Canada (1.42), the UK (1.02), and Latin America (0.94) [1, 6, 17, 18]. The disparities in the number of rheumatologists among countries don’t seem to mirror trends in total physicians per country. For instance, the five countries with the highest number of rheumatologists (> 1 per 100,000 inhabitants) have a range of total physicians of 70 to 971 per 100,000 inhabitants.
Moreover, the projected increase in the workforce in ten years (an increase of the crude number of rheumatologists by around 50%) would still be insufficient to match the quantitative (increase in population by around 20%) and qualitative increase in demand (increase of the prevalence of patients with RMDs due to multiple lifestyle risk factors, improvement in diagnostic and therapeutic tools, and rising life expectancy of patients with RMDs much further), as it will not reach the above-mentioned arbitrary desirable level.
Furthermore, the female-to-male rheumatologist ratio is very high in some countries and is expected to rise in the future [19]. This might raise some concerns for the workforce in general as the ACR workforce study showed that women rheumatologists tend to work more as part-time physicians compared to their male counterparts [1], yet, this was not observed in the current study. The high discrepancy in female/ male ratios observed among countries might be explained by differences in education systems or cultural habits and highlight the importance of taking local demographics into account when assessing the workforce.
Despite this apparent workforce shortage, the average waiting time for a rheumatology consultation, i.e., 19.9 days in the current study, is relatively acceptable. Although the waiting time ranged widely from 0 to 300 days, the average was still shorter than the one observed in other regions of the world, which is typically over two months [20–23]. This potential efficiency in rheumatology care might be related to multiple factors, including the high prevalence of private practices (47.2%), availability of the rheumatologist over the phone (90.2% accept to use their personal phones for a medical consultation, which might decrease the need for some patients to go to the clinic), late retirement age with even no limit in some countries, and self-referral of patients to rheumatology (most countries do not have a mandatory transit through a primary care physician). However, and in the absence of indicators of lower prevalence of RMDs in the Arab countries, the seemingly lower waiting time might also indicate a lack of proper referral of the patients with RMDs to the rheumatologist, as other specialists, such as internists or orthopedic surgeons, might see them. This possible low referral of patients with RMDs should be addressed further in future dedicated studies.
Additionally, the current study provided insights on how to optimize the current rheumatology workforce. Now equipped with concrete figures and targets, societies must urge local health and education authorities to increase the number of rheumatology trainees. For example, based on the current and projected number of rheumatologists, societies could estimate the number of new rheumatologists needed in ten years to reach a target of 1 to 2 rheumatologists / 100,000 inhabitants. Also, training rheumatology nurses and qualified assistants would also support the rheumatology workforce and improve its efficiency [3]. Moreover, proper motivation should be provided to decrease the exodus of young rheumatologists from countries with lower and/or unstable socio-economic conditions by improving their working situations. For example, in some countries like Egypt, the lack of laws that protect physicians from verbal offense and even allowing to send them to jails just upon accusation of malpractice, has been a major reason for the immigration of young physicians in the past five years, and should be addressed seriously.
The strengths of the present work are the large sample size and being the first of its kind to our knowledge. Furthermore, although the study aimed to address unmet needs, some specific positive findings were found worth citing. Many rheumatologists were trained locally, and work regionally and this could enhance the regional collaboration. Also, the use of ultrasound by more than 50% of respondents might be an indicator of high-quality rheumatology care and continuous medical training.
There are, however, some limitations. The population to which surveys are distributed cannot be clearly described, and their demographic data might not be validated, as would happen in anonymous surveys. Respondents with biases cannot be ruled out. The survey being distributed via online platforms would necessarily reflect those who are online-oriented and not necessarily the wider rheumatology community. Another specific limitation of the current study was the inclusion of part-time rheumatologists in the workforce estimation without considering the number of full-time equivalents (FTEs), which probably induced an overestimation of the current and future workforce. Although 27.6% reported working part-time, the actual percentage of working time was not available to calculate FTEs. Additional limitations for the projected workforce are the lack of raw data from nine out of 16 countries and the calculation of the workforce demand based solely on the population’s age. Except for a few studies [10, 11, 24], a precise estimation of the prevalence of the RMDs in the region is not available; therefore, the demand increase might have been underestimated in the current study.
In conclusion, the number of rheumatologists in the Arab countries is currently estimated to be 0.84 per 100,000 inhabitants, indicating a shortage in the rheumatology workforce when compared to the desirable threshold of 1 to 2 rheumatologists per 100,000 inhabitants, with significant heterogeneity among the countries. The projected increase in rheumatologists will undoubtedly not match the rising demand for rheumatology care. The relatively acceptable waiting time for a consultation (19.9 days) might indicate a lack of proper referral to rheumatology and should be addressed in further dedicated studies. Considering the local demographic disparities, healthcare system differences, and geographical mobilities, national health and education authorities are advised to implement effective intervention plans to expand and optimize the rheumatology workforce to meet the growing demand.