Robert Jackson

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Robert Jackson

About Robert Jackson

Dr. Robert Jackson, D.O., F.A.C.O.I., has served as the Associate Dean of Campus Academic Affairs, and as Chairman and Associate Professor of Internal Medicine at the Kirksville College of Osteopathic Medicine. He is board certified in the specialty of Internal Medicine as well as the sub-specialty of Rheumatology.

Rheumatology Workforce Opportunities Flourish Amid Shortage

In the winter quarter of 2018, a pair of studies published in Arthritis Care & Research and Arthritis & Rheumatology detailed a unfavorable prediction for the Rheumatology workforce: By 2030, the need for Rheumatologists will far surpass the projected growth of the Rheumatology workforce, determining that the demand for Rheumatology services is expected to exceed the supply of providers by more than 100% in 2030.

Within those investigations, the findings elaborated on many problems that were an elemental component in the bridging of the gap in Rheumatology care issue which included points such as the  number of full-time rheumatology providers, the uneven circulation of rheumatologists in the nation and the need for additional rheumatology fellowship openings over the current US allotted amount.

These disturbing reports have initiated the request for action from organizations such as the American College of Rheumatology and the Rheumatology Research Foundation to launch new initiatives to mitigate the projected workforce deficiency, including the recently proposed legislation for additional loan forgiveness programs, increased support and flexibility for foreign physicians to work in the U.S., and improved financial backing for rheumatology fellowships.

While the lack has uncovered different architectural defects in the U.S. human services framework, it has likewise divulged a claim to fame overflowing with potential for new rheumatologists or those keen on entering the workforce.

As need for both rheumatologists and advanced practice clinicians is extremely high, newcomers into the field of rheumatology will discover that the hiring market extremely inviting. Opportunities for advancement are also progressively accessible. Numerous positions of authority are being held at this time by baby boomers who are reaching the age of retirement; as these professionals phase out of the medical field, younger rheumatologists will be have the chance to venture in.

“Trained rheumatologists now entering the workforce have many opportunities at many different practices. This is a great time to become a rheumatologist because you know you are guaranteed a job and will most likely have your pick of a number of different jobs. Even in the highly-clustered areas in the Northeast, there is tremendous demand for rheumatologist services,” she noted. “Although there will be many more opportunities in the rural areas, there are a great deal of opportunities in even the major metropolitan centers.”, says Beth L. Jonas, MD, chief of the Division of Rheumatology, Allergy and Immunology at the University of North Carolina, Chapel Hill and chair of the ACR Committee on Training and Workforce Issues.

Premier Specialty Network intends to further research and clarify if current rheumatology service providers and those entering the field should be cautious, viewing the shortage as a warning or as a clear opportunity.

Rheumatology by Location

Shortage in RheumatologyOne of the three focus points honed in on by the studies, was the indication that certain areas of the country are going to feel this shortage of rheumatologists more directly. Currently, the highest concentration of rheumatologists can be found in the northeastern region of the U.S., while portions of the South and West have fewer doctors. This is because “a lot of people tend to train in an area and then stay pretty close – within 100 miles of that area. The clustering of rheumatologists around metropolitan areas often leaves other areas of the state with too few providers.

The outlook for access to pediatric rheumatologists is even worse. There are portions of our nation where you could drive north to south across the U.S. without ever going through an area that had access to a pediatric rheumatologist within a 4- or 5-hour drive. Addressing the nation’s critical shortage of pediatric rheumatologists is long overdue and something that we can’t afford to delay any longer.

Although the question of availability and accessibility of rheumatology services continues to pervade providers working in underserved areas, the good news may be that the workforce shortage has pushed the health care industry to seek out a basic economic solution: Increased compensation, benefits and opportunities to entice rheumatologists outside of their comfortable cluster.

A Question of Finance

With the continued growing shortage of U.S. physicians, understanding physician compensation is a starting point in understanding various factors at play in health care today. A recent survey published in the Doximity 2018 Physician Compensation Report showed that rheumatology was among the 20 lowest paid specialties, just above psychiatry with an average annual compensation of $268,000. Surprisingly, rural and lower-cost cities tended to have higher physician compensation than higher-cost areas such as New York, San Francisco and Chicago.

According to the 2018 Medscape Physician Compensation Survey, rheumatologists in the U.S. saw compensation growths for the third consecutive year, with an above average 12% increase in 2016, 1% in 2017, and 9% in 2018. Although some surveyed rheumatologists attributed their increases to rising patient volume or productivity, others noted that promotions, raises and/or bonuses factored heavily into the increased compensation.

“In rheumatology, we have seen 2 years with a roughly 10% increase in compensation, which is crazy. Typically, you don’t see 10% over 3 or 4 years, which tells you that this is a highly competitive market. Clients are having to guarantee compensation higher than the American Medical Group Association or Medical Group Managers Association says rheumatologists should even make. The recruitment market is moving faster than the numbers, and one that is heavily weighted to the candidate side.”

Pipelines for Solutions

Another solution to the workforce issue has been to expand the number of fellowship positions available to train more rheumatologists. In an effort to grow interest in the field overall, the Rheumatology Research Foundation implemented various awards for medical students and residents curious about rheumatology research and developed the Preceptorship Program to foster greater awareness of rheumatology at earlier levels of medical training — efforts that are now paying off in a big way.

Researchers from George Washington University determined that student interest in rheumatology typically declined from the first to second year of medical school. However, the researchers also found that a student’s experience with a particular specialty in school as well as interactions with a mentoring faculty member heavily influenced their commitment to the specialty.

However, the growth of interest in rheumatology is only half of a small battle in an ongoing war against the workforce deficit. The lack of rheumatology fellowship slots for eager medical students represents a significant stumbling block to getting additional rheumatologists into the field, and training programs hinge on funding.

It costs money to train rheumatologists and with health care financing the way it is right now, has been and will continue to be in this country, the amount of money for rheumatology programs is limited. Many programs have the desire and ability to train more rheumatologists, but the challenge is how to support the education?

A Push for Incentives

To mitigate the shortage, several rheumatology organizations have pressed in hard, advocating for a variety of incentives to tempt young rheumatologists beyond the comfort zones of the states in which they received their training, and branch out to medically underserved areas. Incentive programs, such as loan repayment and loan forgiveness, are crucial in attracting medical students to new opportunities outside their home states. Success will require that provider incentives at least balance losses in incomes and cover practice overhead.

Nevertheless, the outlook for the rheumatology job market appears strong. It’s hard to see rheumatologist compensation going anywhere but up based on basic supply and demand principles; more competition is going to continue to drive higher salaries.

Premier Specialty Network is focused on the delivery of the best combination of simplicity, reliability and value both physicians and hospitals.

More reading on this matter can be done here and here.

FDA proposes new fluoride standard for bottled water

The US Food and Drug Administration is proposing a lower concentration level normal for fluoride in bottled drinking water, however some scientists and environmental teams believe that the planned limit remains too high and poses a danger to human health.

If finalized, the new regulation can lower allowable levels of fluoride in domestically prepacked and foreign drinking water to 0.7 milligrams per liter, a small reduction from the present normal range of between 0.8 and 1.7 milligrams per liter allowed by the government agency.

The planned standard would apply solely to bottled drinking water with additional fluoride, and would not have an effect on allowable levels of fluoride in bottled drinking water which contains fluoride from source water.

Dental health

The FDA’s projected rule aligns with a 2015 recommendation from the US Public Health Service, a part of the US Department of Health and Human Services, that implies that 0.7 milligrams per liter is the best fluoride concentration for community water systems that add fluoride.

The new rule “is supported by findings from evolving analysis on the best concentrations of fluoride that balances fluoride’s advantages in preventing decay without the risk of inflicting dental fluorosis, a condition most frequently characterized by white patches on teeth,” the Food and Drug Administration said in its statement. Dental fluorosis is caused by taking in an excessive amount of fluoride over an extended amount of time while adult teeth are forming underneath the gums.

But some scientists’ issues extend way beyond fluorosis.

Flourosis“Given that fluoride can harm brain development, I advocate that the most fluoride concentration in drinking water be kept at a lower level than 0.7 mg/L,” Dr. Philippe Grandjean, an Adjunct Professor of Environmental Health at the Harvard TH Chan School of Public Health, wrote in associate degree email.

Christopher Neurath, research director of the American Environmental Health Studies Project, that is connected to the Fluoride Action Network, an environmental support organization, said “currently, there are speedily increasing scientific studies showing neurotoxicity to fluoride,” with analysis showing an immediate link between children’s intelligence quotient and their level of fluoride exposure within the womb: “That is our largest concern.”

The american Dental Association noted that “science-based organizations,” together with itself and the american Academy of pediatrics, “fully support the general public health advantages of community water fluoridation.” The association conjointly noted that the recently planned level helps stop decay, while not increasing the chance of dental fluorosis, that among Americans is primarily a cosmetic condition that does not have an effect on the health or function of teeth.

“Even with the supply of alternative sources of fluoride, community water fluoridation prevents decay by at least 25% in both kids and adults,” the association said.

Behavioral and cognitive health effects

Morteza Bashash, an assistant professor in the Dalla Lana School of Public Health at the University of Toronto, found that higher fluoride levels as measured in urine samples of pregnant women are related to both lower ratio and exaggerated risk of attention-deficit disorder disorder among children in Mexico.

Specifically, Bashash found a decline in children’s scores on intelligence tests for each 0.5 milligram-per-liter increase in fluoride exposure beyond 0.8 milligrams per liter detected in a pregnant mother’s urine. it’s not clear whether or not this can be analysis applicable to the US population, he said.

In Mexico, as an example, the government delivers cavity-reducing fluoride by adding it to salt, not water, as many of us avoid drinking tap water.

Still, his analysis findings were “based on a verity measuring of fluoride absorbed within the body.” A Canadian study given at a conference last year and studies conducted in China showed intelligence quotient losses associated with fluoride levels at intervals in an identical order of magnitude.

Due to similar fluoride sources, laws and diet, Canada’s findings in urine levels, are in all probability, the same as those in America, Bashash said.

Neurath trusts that both the Mexican and Canadian study results would typically apply to the united states as a result of “urine fluoride is best measure of total fluoride intake.”

Canadian information from the past fifteen years has shown women living in cities with fluoridated water supplies had “almost double” urine fluoride concentrations levels as women living in non-fluorinated cities. “Drinking water fluoride is the major supply of fluoride for these women,” he said.

The impact of prenatal exposure to fluoride on intelligence quotient is “very massive,” Neurath believes. “And on a population basis, that is terribly concerning.”

Proposed rule might not be adequate

Floride Water

Neurath revealed in a study of dental fluorosis this year, based on National Health and Nutrition Examination Survey information, a “dramatic increase in fluorosis” over results from a decade ago. (The study, although published in a peer-reviewed journal, is co-authored by attorney representing the Fluoride Action Network in proceedings concerning the regulation of fluoridation chemicals by the US Environmental Protection Agency.)

More than thirty percent of adolescents within the study showed moderate to severe dental fluorosis (an extra thirty fifth of kids showed lesser signs of the condition), “a immense increase” over a survey conducted a couple of decade prior, Neurath said. He believes that the planned standard is unlikely to cut back dental fluorosis to acceptable levels.

However, he includes a larger concern. “Dental fluorosis is a visible sign of overexposure to fluoride, however there are different nonvisible signs and adverse health effects that are far more serious,” Neurath said based on the work of Bashash and Grandjean.

Grandjean’s work was funded by the National Institute of Environmental Health Sciences. “Our review of studies from China and our own field study is in accordance with a recent study by US researchers administered in Mexico that elevated exposure to fluoride throughout pregnancy is related to toxicity to brain development.

“Given that fluoride is added to toothpaste to secure that the enamel surface of the teeth is correctly protected against tooth decay, there’s no need to supplement the dietary fluoride intake,” he said.

Alternatively, Bashash said, fluoride in water is considered one of the “biggest public health victories” in preventing cavities.

While his job as a man of science is to review a given topic, it’s the duty of policymakers to come up with the general understanding of what is necessary. The Food and Drug Administration looks “at the big picture” by gathering the proof and evaluating the pros and cons based on national priorities. “This has been a hot topic for sixty years.”

Linda Birnbaum, director of the National Institute of Environmental Health Sciences, explained that a “large, cross-government operating group” checked out the information on the market in 2010 to 2011 and concluded that 0.7 milligrams per liter was the suitable level of fluoride concentration in bottled drinking water, one that “balances protection from tooth decay while limiting the risk from dental fluorosis.”

The institute has funded studies that explore different health effects, she said, “and we are observing the data in a very systematic review currently.”

The International bottled water Association, a trade group, said it supports the FDA proposal to revise the standard of quality for fluoride added to drinking water.

“Most corporations are well below” the recently planned limit, according to Jill Culora, a spokesperson for the association. “The planned rule takes into account the various sources of halide in people’s diets and can any cut back the chance of dental pathology, whereas still providing associate degree best level of halide to assist stop decay.”

Cavities don’t seem to be the sole concern, Neurath said: “The projected rule isn’t adequate.”

Rheumatologist joins PSN in Kentucky

PSN Welcomes Dr. Cara Hammonds to the Rheumatology Team

Premier Specialty Network is proud to announce that we have expanded our presence and service in Kentucky with the additions of Benton, Kentucky based Rheumatologist, Dr. Cara Hammonds to the PSN Team.

By extending our reach into new territory at Marshall County Hospital, in Benton as well as Crittenden Health System in Marion, PSN is helping to bring much needed rheumatology services to an undeserved area.

Dr. Hammonds is originally from western Kentucky.  She graduated from the University of Louisville School of Medicine in 2005. She completed specialty training in Internal Medicine at the University of Cincinnati and Rheumatology at Vanderbilt University in Nashville, Tennessee.  Dr. Hammonds is Board Certified in Internal Medicine and Rheumatology.

She is a member of the American College of Rheumatology.

Dr. Hammonds specializes in the treatment of pain from Arthritis, Osteoarthritis, Fibromyalgia, and Rheumatoid Arthritis (RA).

When Should I See a Rheumatologist?

If you think you have a rheumatic disease, call to make an appointment. The sooner you get diagnosed and begin treatment, the sooner you will feel better. We are here to help you through your journey.

Rheumatological Conditions

Comprehensive care is provided for patients with a wide variety of complex rheumatic diseases, including Rheumatoid Arthritis, Osteoarthritis, Osteoporosis, Psoriatic Arthritis, Lupus, Vasculitis, Polymyositis, Sjogren’s Syndrome, Polymyalgia Rheumatica, Temporal Arteritis, Fibromyalgia, Gout and Pseudogout, Dermatomyositis, Behcet’s disease, Ankylosing Spondylitis, Scleroderma, Mixed Connective Tissue Disease, and Granulomatous Polyangiitis.

PSN Growth in 2015

To all the members, affiliates and friends of Premier Specialty Network, LLC.  It has been a great year of growth for Premier Specialty Network.

PSN has grown into six states with no signs of slowing down in 2016.

We have a diverse range of physicians, health care centers and staff that are networked together to give PSN the competitive advantage that we need in today’s highly competitive medical industry.

Premier Specialty Network is excited to share many of the people, events and partnerships that made 2015 such a great year for PSN. exceptional opportunities in 2016.

We recognize PSN physicians for their hard and noble work, and that of our PSN staff: Dr. Anne Winkler, Kelly Barger, Robert Groszewski, David Young, and Laura Hansel, RN.

PSN physicians have more fun and a better quality work-life balance!

Moving into New Year

I would like to talk about things I’d like you to keep in mind and things I’d like for you to share to create a common vision in the New Year.

First, I would like you to embrace a sense of ownership. A sense of ownership is necessary in order for you to accomplish anything. That is a determination to “do your work” and an awareness that “work is something that you must do”.  We are in a time when changes take place really fast, so it is crucial that all we all think and act with a sense of ownership.

Second, I have always believed that a trusting relationship between a provider and the facility he serves is key, not in a one-way fashion, but by having both sides commit to their duties. This means that the facility will promise to create an ideal working place for our providers, and our providers will demonstrate maximum performance in that environment. Both will be responsible for their results and commitments. I believe that some pressure is essential in a good relationship.

Lastly, I wish for all of you to take care of your health and to gain success in many areas. More than anything, let us be cheerful and enjoy work. Great ideas and good performances do not come from a dismal workplace. The key phrase is “be cheerful and enjoy”.  Let’s create a work atmosphere filled with smiles and vigor, and with a healthy amount of pressure.

I would like to wish you all and your families another healthy and successful year. Thank you.

The Future of Rural Rheumatology

Robert Jackson, DO, is a practicing rheumatologist and president of Premier Specialty Network. His company works with more than 30 rheumatologists, who provide services to more than 60 rural hospitals in six states. The Rheumatologist recently asked Dr. Jackson to comment on the future of rheumatology in rural areas.

Q: What do you see as the future of rural rheumatology between now and 2021?
A: I don’t think that the need for our specialty in rural areas is going to lessen. Instead it will increase. This demand will, likely, keep reimbursement levels competitive and make it a good business model to go outside the city.

Q: There is a concern that government healthcare reform was not favorable to rural locations, and a number of rural hospitals have closed. How does that fit in with the scenario you seem to see?
A: [That has been] unfortunate. … There are many areas with only one hospital left. Losing that facility can have a [devastating] impact on communities both immediately, as one of the area’s largest employers, and longer term [because the] lack of a hospital can make it harder to bring in new employers.

Because of this, I think political pressure on, and by, both parties will [create] an incentive for Congress to keep small hospitals alive even as the rest of the government seems to be applying pressure to close them.

In some areas, they may be lost as a provider of in-patient acute care services, but in most cases, they will still be providing outpatient and urgent care [services]—some of which can be provided by rheumatology specialists.

Q: What are some of the other pluses you see in this area of practice going forward?
A: Technology is likely to get better in rural areas. This [fact] will mean top-level care is available quicker and easier in rural and suburban areas and increase the ability of practitioners to make good professional decisions. It should also help with concerns about professional isolation.

Q: Speaking of technology, you seem to suggest that electronic medical records(EMRs) are somewhat of a two-edged sword.
A: The old way of closing down your office, grabbing your paper records and driving down the road to another community is not all that productive. On the other hand, it isn’t unusual for a rheumatologist to practice at more than one hospital, with limited ability to exchange information between them, and each may have different ways of entering information.

We also have the same problems that our colleagues in urban areas do. Most EMRs were made with primary care physicians in mind and don’t work well with the needs of specialists.

Q: What are some of the things you are concerned about?
A: I am worried about healthcare reform and its impact on the pipeline for new graduates in all specialties. Those of us already in the business talk about the economic impact, grumble about lifestyles and dissatisfaction at work. Will that affect whether people choose the healthcare field as a profession? It may be that medicine in general, and rheumatology in particular, is not viewed as a job with a future.

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