Rheumatic diseases (RD) have an important impact because they are associated with physical disability and high costs. As the prevalence of these diseases is increasing, the lack of rheumatologists is becoming more evident, and this problem is shared by many countries worldwide. Because RD have such an important impact, the European Alliance of Associations for Rheumatology designated the years 2000 to 2010 as the decade of bone and joints. Strategies were implemented to reduce this impact, chiefly in diseases such as rheumatoid arthritis (RA), osteoarthrosis and lumbalgia.1,2 Moreover, in 2003 the WHO published a technical report on the impact of RDs, underlining that they are common diseases which are associated with physical disability, as more than 30% of the individuals of productive age who have arthritis become disabled, giving rise to a high cost.3 It has been said that the cost in the United States of America may amount to 2.5% of gross domestic product.3,4 Nevertheless, RD may be effectively controlled if they are diagnosed early and receive appropriate treatment.

In spite of these data, in Mexico the health authorities have not considered RD to be important. There is no mention of RD in the report sent to the WHO in 2004 on priority health interventions in Mexico.5 Although there is little information about RD in México, previous publications have described the economic impact of these diseases in México; this is the case for RA, which may cause catastrophic expenses and plunge affected families into poverty.6–8 A study which included 19,213 individuals in 5 regions of México found a 10.5% prevalence of osteoarthritis, a prevalence of 5.8% of lumbar pain, 3.8% of regional painful syndrome, 1.6% of RA, 0.7% of fibromyalgia and 0.3% of gout.9 These rates of prevalence varied geographically: for example, the prevalence of RA in Nuevo León, in the north of México, amounts to 0.7%, while it stands at 2.8% in Yucatán, in the south.

One factor which contributes to the problem of the late diagnosis and treatment of RD is the fact that there is no formal course of rheumatology in many universities, so that the doctors who first see patients may not be fully trained in musculoskeletal examination,10,11 so they will not identify the initial alterations caused by these diseases, delaying diagnosis and referral to a specialist.12,13 Another important factor is the unequal distribution of rheumatologists within the country, as there are more in the large cities, creating areas that are unattended by medical professionals, so that many patients have to travel long distances to be seen by a rheumatologist.14–16 A previous study described the distribution of specialists in the country, stating that as a whole there were fewer specialists than is internationally recommended to cover the health needs of the country, although it did not describe the distribution of rheumatologists.17 A systematic review of the literature found that the estimated number of rheumatologists in different Western countries varied from 0.7 rheumatologists per 100,000 inhabitants in the United Kingdom to 3.5 in Spain.18 Another review that covered 19 Latin American countries reported densities of rheumatologists from 0.16 per 100,000 inhabitants in Nicaragua to 3.65 in Uruguay. There was only more than one rheumatologist per 100,000 inhabitants in 5 countries (26.32%)19 (Table 1).

The objectives of this study were to describe the distribution of adult as well as paediatric rheumatologists in México and the factors associated with this distribution, and finally to describe the characteristics of the certification that is currently in force (CIF).

A cross-sectional study was performed. The information was obtained from a review of the databases of the Mexican Council of Rheumatology and the Mexican College of Rheumatology (CMR). The Mexican Council of Rheumatology is an institution composed of representatives of the community of rheumatologists who are selected for the responsibility of establishing the certification process for doctors who have fulfilled the academic requirements to work as a rheumatologist in México. The CMR is the association composed of professionals to seek academic excellence and leadership in the field of rheumatology. Sociodemographic variables were obtained, such as age, sex, nationality, year of graduation, educational institution, professional domicile, certification validity and years of experience. The number of rheumatologists per 100,000 inhabitants of each state in the Mexican Republic was calculated. The 2020 population by the National Institute of Statistics, Geography and Computing was consulted to discover the number of inhabitants in each state.20 The number of rheumatologists with a CIF was calculated for each state, age and sex, and the factors associated with CIF were determined.

We found that most of the states in the Mexican Republic lack rheumatologists, particularly paediatric rheumatologists. The majority of healthcare systems in the world face the challenge of improving the disparities in medical staffing. Imbalances may be caused by a lack of staff in a specific speciality, geographic factors (rural areas in comparison with urban ones, or regions with differences in their economic growth), or they may be caused by institutional factors due to differences in resources and installations. Imbalances may also arise between the sexes; women in some regions may face greater difficulty in gaining professional work.14 The regional lack of doctors has been generally identified, and it also exists in several specialities. It seems to be a global problem that also affects rheumatology. Several definitions have been used to determine which areas are poor in medical resources or lack medical staff. The threshold suggested by Lewin of 1.67 professionals/100,000 inhabitants has also been defined in terms of distance (>120.7 km) or travelling time (>90 min), although the standard most often used is one recommended by the WHO of one professional/100,000 inhabitants.15,16,21 In 2012 a ratio of 0.47 rheumatologists/100,000 inhabitants was reported in México. Although this study found an improved figure of 0.67/100,000, there are still too few rheumatologists to meet the growing demand for care by patients with RD. Moreover, in state terms only México City and Jalisco have a proportion higher than one, and many regions in the country lack rheumatologists. This lack is even more market in the case of paediatric rheumatologists: the proportion of these is only higher than one in México City, and in 16 states there are none. This phenomenon is similar to reports in the literature.13,22Table 1 shows the density of rheumatologists/100,000 inhabitants in several countries, and only one third of these (9/27) have a density >1/100,000 inhabitants. Only 4 countries (France, Uruguay, Argentina and Spain) have more than 2 rheumatologists/100,000 inhabitants.18,19,23 The distribution of rheumatologists is very uneven, and there are more in large cities or close to educational centres, and fewer in small towns or rural areas.

In 2009, Badía Flores and Arévalo Martínez estimated that in 2020, if the number of rheumatologists being created remained constant, there would be 733 specialists in this area but still a deficit, as the ideal would be to have 1157 rheumatologists.24 Fortunately this estimate was surpassed, and in 2020 there was a total of 1002 rheumatologists, as the number graduating had gradually risen, even though this was insufficient because the population had also increased. In spite of the increase in the training of human resources, there is still a problem with having too few positions for rheumatologists in institutions, as this is considered to be a tertiary care sub-speciality. Positions in secondary care could be created, thereby improving the situation with a better balance between the regions in the speciality.

Certification is a process that seeks to guarantee that medical activity will be beneficial, with a regulatory framework to guide actions. Certification is governed by the General Health Law, and the National Normative Committee of Medical Speciality Councils regulates and unifies the processes for certification and recertification (CIF).25 It is estimated that 93% of Mexican rheumatologists with CIF are members of the CMR.26 This percentage is similar to the one reported in Spain (where 95% of rheumatologists are members of the Spanish Society of Rheumatology).23. Heinze-Martin et al. report in their study that CIF in adult as well as paediatric rheumatologists as a whole stand at 78% (73.3% in women and 56.4% in men), which is slightly higher than the overall average for specialists, which was 69%.17 CIF in our study was 65% for adult rheumatologists and 70% for paediatric rheumatologists. The factors associated with a higher probability of CIF were a lower age, female sex and geographical location.

Men clearly predominate in the majority of medical specialities (above all in surgical specialities), with an overall ratio of 1.7 men for every woman. This work documents the increasing number of women in this speciality, above all in the last 5 years, and women now predominate over men in adult rheumatology. As Heinze-Martin et al.17 report in their study, women predominate in paediatric specialities. The study by Sánchez-Piedra et al. also reports the increasing number of women in rheumatology in Spain, with a proportion of 59.7% women that is even higher among the younger specialists.23 In China women predominate among the specialists aged under 40 years, with a male/female ratio of 1:1.7.27 Nevertheless, the PANLAR report states that in the majority of Latin American countries men still predominate, with a ratio of 0.97 women for each man; however, they do not report if this changes among the younger specialists.19 Although women now play an increasingly predominant role in rheumatology, some barriers still have to be overcome. A survey by Serna-Peña et al. of 127 female rheumatologists reported that 54.3% considered that they suffered discrimination due to their sex, and participated less in research activities and medical associations.28 There is also still a “glass ceiling”, as in the CMR, only 4 of its 48 presidents have been women (8.3%), while in the Mexican Council of Rheumatology, only 9 of 41 presidents have been women (21.95%).29

The strong points of this study are that as it reviews the databases of the CMR and the Mexican Council of Rheumatology, it gains a clearer record and location of the rheumatologists in the country. It is also important to separate the results of adult and paediatric rheumatologists, without examining them as a whole. The weak points of this study are that it lacks sufficient information to describe the type of care activity (public or private), whether all of the individuals registered are still working, and whether they work exclusively in rheumatology, given that some work as internal medicine specialists or for the pharmaceutical industry, so that a more detailed survey would be necessary.

To conclude, there is a lack of rheumatologists in the majority of Mexican states, and this is even more pronounced in the paediatric area. It is important for health policies to consider the availability of rheumatology positions in a way that would allow this speciality to work in a more balanced and efficient way, taking into account the economic impact of RD and their association with physical disability. Although the majority of rheumatologists have a CIF, strategies should be implemented to increase this proportion.

The authors have no conflict of interests to declare.