ORIGINAL ARTICLE

Rheumatology Training in Latin America

A Collaborative Study by the Pan American League of Associations
for Rheumatology
Daniel G. Fernández-Ávila, MD, MSc, PhD, (c),* Daniela Patino-Hernandez, MD,† Sergio Kowalskii, MD,‡
Alfredo Vargas-Caselles, MD,§ Ana Maria Sapag, MD,|| Antonio Cachafeiro-Vilar, MD,¶ Belia Meléndez, MD,#
Carlos Santiago-Pastelín, MD,** Cesar Graf, MD,†† Chayanne Rossetto, MD,‡‡ Daniel Palleiro, MD,§§
Daniela Trincado, MD,|||| Diana Carolina Fernández-Ávila, MD,¶¶ Dina Arrieta, MD,## Gil Reyes, MD,***
Jossiel Then Baez, MD,††† Manuel F. Ugarte-Gil, MD, MSc,‡‡‡ Mario Cardiel, MD,§§§
Nelly Colman, MD,|||||| Nilmo Chávez, MD,¶¶¶ Paula I. Burgos, MD,### Ruben Montufar, MD,****
Sayonara Sandino, MD,†††† Yurilis Fuentes-Silva, MD,‡‡‡‡ and Enrique R. Soriano, MSc, MD§§§§

Brazil (n = 126) and Argentina (n = 36). To be admitted into rheumatology

Background/Objective: Demand for rheumatology care has steadily training, candidates were required to have completed graduate studies in in-
increased in recent years. The number of specialists in this field, however, ternal medicine in 42.1% of the programs. In 8 countries (42.1%), residents
seems insufficient. No recent studies have diagnosed the attributes of rheu- are not required to pay tuition; the median cost of tuition in the remaining
matology training in Latin America. countries is US $528 (interquartile range, US $2153).
Methods: This is a descriptive cross-sectional study. We obtained data on Conclusions: Conditions associated with rheumatology training in Latin
each country through local rheumatologists of the Pan-American League America vary. Significant differences exist in income and tuition fees for
Against Rheumatism, who acted as principal investigators for participating residents, for example, and 4 countries in Latin America do not currently
countries. Our sample was analyzed and described through means and standard offer programs. Information collected in this study will be useful when
deviations or through frequencies and percentages, depending on the variable. comparing the status of rheumatology services offered in Latin America
Results: Countries with the most rheumatology-training programs were with those in other countries. Most countries require a wider offering of
Brazil (n = 50), Argentina (n = 18), and Mexico (n = 15). Ecuador, rheumatology-training programs, as well as more available slots.
Honduras, and Nicaragua do not have rheumatology-training programs.
The countries with the most available slots for rheumatology residents were Key Words: epidemiology, rheumatology, training
(J Clin Rheumatol 2021;00: 00–00)
From the *Unidad de Reumatología, Hospital Universitario San Ignacio–
Facultad de Medicina, Pontificia Universidad Javeriana, Unidad de
Investigación PANLAR; †Departamento de Medicina Interna, Hospital
Universitario San Ignacio–Pontificia Universidad Javeriana, Bogotá,
Colombia; ‡Universidade Federal do Paraná, Unidad de Investigación
D emand for rheumatology care has steadily increased in recent
years. The number of specialists in this field, however, seems
insufficient.1 Also, a significant number of general practitioners
PANLAR, Paraná, Brasil; §Hospital Italiano de Buenos Aires, Buenos admit to having deficient competencies when confronted with
Aires, Argentina; ||Hospital Universitario Japonés, Santa Cruz, Bolivia;
¶Pacífica Salud–Hospital Punta Pacífica, Ciudad de Panamá, Panamá; rheumatic conditions. This situation may be at least partly explained
#Hospital de la Policía Nacional N1 Quito, Quito, Ecuador; **Instituto by a lack of content on rheumatic diseases in medical school curric-
Hondureño de Seguridad Social, Tegucigalpa, Honduras; †† Sociedad ula.2 Content scarcity is relevant, as limited exposure to this specialty
Argentina de Reumatología, Buenos Aires, Argentina; ‡‡Universidade Fed- in early medical training is one of the main causes of decreased in-
eral do Paraná, Paraná, Brasil; §§Instituto Nacional de Reumatología del
Uruguay–Universidad de la República, Montevideo, Uruguay; ||||Pontificia terest in enrollment in rheumatology-training programs.3
Universidad Católica de Chile, Departamento de Inmunología Clínica y The rheumatology specialty calls for a multidisciplinary ap-
Reumatología, Santiago de Chile, Chile; ¶¶Hospital Italiano de Buenos proach. It is not clear, however, if curricula are thoroughly followed
Aires, Buenos Aires, Argentina; ##Hospital México, Caja Costarricense in rheumatology-training programs, or if the acquired competencies
del Seguro Social, San José de Costa Rica, Costa Rica; ***Universidad
de Ciencias Médicas de La Habana, La Habana, Cuba; †††Hospital are adequate to prepare physicians for daily practice. In 2014, 91%
Metropolitano de Santiago, Santiago, República Dominicana; ‡‡‡Hospital of the European League Against Rheumatism member countries of-
Guillermo Almenara Irigoyen–Universidad Científica del Sur, Lima, Perú; fered rheumatology-training programs, although significant varia-
§§§Centro de Investigación Clínica de Morelia, Morelia, México; ||||||Hos- tions were found regarding the content of programs, program
pital de Clínicas–Universidad Nacional de Asunción, Asunción, Paraguay;
¶¶¶Universidad San Carlos de Guatemala–Instituto Guatemalteco de Seguridad duration, and requirements for admission.4 Further, no data exist on
Social, Ciudad de Guatemala, Guatemala; ###Pontificia Universidad Católica the minimal time required for training a rheumatologist, and specific
de Chile, Departamento de Inmunología Clínica y Reumatología, Santiago de components of curricula vary significantly among different countries.
Chile, Chile; ****Consultorio de Especialidades del Instituto Salvadoreño For instance, some programs have a greater outpatient versus inpa-
del Seguro Social, San Salvador, El Salvador; ††††Instituto Médico
GANNA, Managua, Nicaragua; ‡‡‡‡Universidad de Oriente, Ciudad tient component, relevant when analyzing the competencies required
Bolívar, Venezuela; and §§§§Hospital Italiano de Buenos Aires, Buenos for the clinical practice of rheumatologists after graduation. Special-
Aires, Argentina. ized human resources and their training in rheumatology have not
The authors declare no conflict of interest. been recently assessed in Latin America. Our study diagnoses the at-
Correspondence: Daniel Gerardo Fernández-Ávila, MD, MSc, PhD, (c), Unidad
de Reumatología, Hospital Universitario San Ignacio–Facultad de tributes of rheumatology training in the region.
Medicina, Pontificia Universidad Javeriana, Unidad de Investigación
PANLAR, Cra 7 # 40-62, Piso 7, Bogotá 110231, Colombia.
E‐mail: daniel.fernandez@javeriana.edu.co. METHODS
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-1608 This is a descriptive cross-sectional study. It relies on data
DOI: 10.1097/RHU.0000000000001774 obtained from each country through local rheumatologists of the

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Fernández-Ávila et al JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2021

Pan-American League Against Rheumatism (PANLAR), who

acted as principal investigators for participating countries. They TABLE. Number of Rheumatology Training Programs
collected information from local rheumatology societies,
Country Total Public Programs Private Programs
universities, and other sources they considered relevant. Each
rheumatologist completed an online survey using the RedCap Brazil 50 50 0
platform, a program that securely captures and stores data. The Mexico 15 15 0
survey sample was analyzed through STATA 15 software. Data Argentina 18 12 6
were described through means and standard deviations, or Peru 8 4 4
through frequencies and percentages, depending on the variable.
Colombia 8 3 5
Guatemala 3 2 1
RESULTS Bolivia 2 2 0
This study's sample comprises all the Latin American coun- Dominican Republic 2 2 0
tries registered as PANLAR members (n = 19). Currently, 122 Venezuela 2 2 0
rheumatology-training programs exist in Latin America, 105 private Chile 2 1 1
and 17 public. The countries with the most rheumatology-training Paraguay 2 1 1
programs are Brazil (n = 50), Argentina (n = 18), and Mexico El Salvador 2 2 0
(n = 15) (Fig. 1). All rheumatology-training programs offered in Uruguay 1 1 0
Bolivia, Brazil, Costa Rica, Cuba, El Salvador, Mexico, Panama, Costa Rica 1 1 0
the Dominican Republic, Uruguay, and Venezuela are public. In
Panama 1 1 0
Argentina, most rheumatology-training programs are also public
(12 public, 6 private). In Chile, Paraguay, and Peru, the ratio be- Cuba 1 1 0
tween public and private programs is 1:1. Colombia is the only Honduras 0 0 0
country in Latin America in which private rheumatology-training Nicaragua 0 0 0
programs predominated (5 private, 3 public). Ecuador, Honduras, Ecuador 0 0 0
and Nicaragua do not currently offer rheumatology-training pro-
grams (Table). median annual tuition fee is US $528 (interquartile range, US
The countries with the most yearly slots for rheumatology- $2153) (Fig. 2).
training programs are Brazil (n = 126), Argentina (n = 36), Mexico
(n = 30), Peru (n = 24), and Colombia (n = 17). Graduate studies
in internal medicine are required for admission in 42.1% of the DISCUSSION
programs. The duration of the rheumatology-training programs Formal training in rheumatology may be described as an
varies: 2 years (72.2% of cases), 3 years (24.6%), 4 years (1.6%), educational process where a general practitioner or specialist
5 years (0.8%), and 6 years (0.8%). in internal medicine becomes a rheumatologist. The specific
For monthly compensation to trainees, the median is US requirements for obtaining this title vary considerably among
$528 (interquartile range, US $774). The countries with the different countries, and globally, this study reveals that rheumatol-
highest payments to trainees are Costa Rica (US $2,637), ogy training in Latin America can be from 2 to 6 years in duration.
Panama (US $2200), and Peru (US $1574). Programs in Cuba, These findings are similar to those of previous studies reporting
Chile, and Colombia do not pay trainees. Finally, in 8 countries that the duration of rheumatology-training programs is not uni-
(42.1%), trainees are not responsible for tuition fees for postgrad- form. The explanation is that “direct” programs (those not requir-
uate studies in rheumatology; in the remaining 11 countries, the ing previous completion of an internal medicine residency) have a

FIGURE 1. Spots available for rheumatology-training programs per country. Color online-figure is available at http://www.jclinrheum.com.

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JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2021 Rheumatology Training in Latin America

Interest in studying rheumatology is generally low compared

with other subspecialties of internal medicine. In Canada, from
2004 to 2007, 114 physicians were admitted into fellowship pro-
grams. Just 1% of these new fellows in internal medicine subspe-
cialties chose to enroll in a rheumatology-training program.20 This
lower interest in studying rheumatology was also documented by
Louthrenoo in Thailand, who noted that most internists in that
country prefer to continue studies in other subspecialties such as
cardiology, pulmonology, gastroenterology, and nephrology. This
may be due to the greater challenge that procedures inherent to
these specialties pose, as well as the higher economic income they
FIGURE 2. Mean tuition fees for rheumatology residents in Latin bring.21 The differences in income can be corroborated in the lat-
American countries. *In Argentina, this value reflects the cost for est Medscape report, which ranks rheumatology sixth among the
locals. Foreign students have higher tuition fees of about US $1000 per internal medicine subspecialties in the United States, with a yearly
year. Color online-figure is available at http://www.jclinrheum.com. compensation of US $259,000. This falls beneath incomes for
other specialties such as cardiology (US $430,000), gastroenterol-
ogy (US $417,000), oncology (US $359,000), pulmonology (US
minimal duration of 4 years, whereas programs aimed at special- $331,000), and nephrology (US $305,000). Rheumatology ranks
ists in internal medicine require 2 to 3 years of training.4 A study above only epidemiology (US $239,000) and endocrinology (US
conducted in 2014 found a mean training duration of 3.75 years $236,000).22
(45 months; SD, 19 months). Programs may even have durations The distribution of rheumatology-training programs in most
as short as 3 months (Ukraine) or as long as 6 years (European countries is concentrated in major cities, contributing to an in-
countries, with 80% of the programs). equitable distribution of rheumatologists. A study conducted in
The differences among curricula composition in rheumatol- the United States reported that most graduates of rheumatology
ogy residency programs, as well as the competencies required specialization programs remain geographically near the cities
for a resident to become a rheumatologist, have been previously where they train, perpetuating the centralization problem of
assessed.5–8 Although this study did not evaluate aspects of rheumatologists.23,24
curricula and academic training profiles of rheumatology pro- The results of this study prove that the numbers of rheuma-
grams in Latin America, heterogeneity on this matter among tology programs and available spots for residents in this field are
different countries may become an issue. For instance, in insufficient in Latin America. This finding suggests that strategies
Europe, the socioeconomic characteristics of the European to increase the admission of doctors into rheumatology-training
Economic Community allow professionals to move and prac- programs should be implemented. Previously proposed strategies
tice medicine in different countries of the region even though include increasing exposure to rheumatology in undergraduate
a homogeneous and harmonized training system for rheumatol- and graduate internal medicine training programs,25 harmonizing
ogy residents has not been created.9 Recognizing this, European and unifying the contents of rheumatology curricula for under-
League Against Rheumatism recently published the most relevant graduate students,26 expanding access to scholarships, and gener-
aspects for the evaluation of competencies in training specialists ating new recruitment mechanisms.27 These strategies become
in rheumatology, with the goal of harmonizing rheumatology relevant when reviewing research such as the WRIST study in
training in the region.10 Canada,25 in which 239 medical students, 34 internal medicine
There is also evidence of heterogeneity in the training of residents, 9 rheumatology fellows, and 209 rheumatologists were
rheumatologists in Latin America. This may be found in different interviewed. The study documented that senior medical students
countries, as shown in this study, but also within each country, as and internal medicine residents who had taken a rheumatology
in Argentina11,12 and Brazil.13 Although in Latin America it is clerkship during undergraduate training were more likely to con-
necessary to homologate professional titles to practice medicine sider enrolling in a rheumatology-training program, compared
in another country of the region, it is important to consider imple- with those without a clerkship (p < 0.001). The clerkship in-
menting minimum requirements in the training of rheumatology creased interest in rheumatology for 70% of the interviewees.
residents, as previously suggested in Europe14 and the United Also, 81.3% of medical students and 65.5% of residents cited a
States.15 This initiative could be led by PANLAR. medical mentor as an influence in considering rheumatology as
This study shows that 4 Latin American countries currently a medical specialty. These results lead one to consider the rele-
do not offer rheumatology-training programs. Previous reports vance of implementing clerkships in rheumatology at the under-
suggest that existing rheumatology-training programs are insuffi- graduate and graduate levels. This is not only due to the
cient to meet rising demand.16 A study conducted in Canada esti- importance of this specialty in the training of general practitioners
mated a 64% shortfall in the minimum number of rheumatologists and internists, but also as an opportunity for rheumatology to be
required to meet needs of the population by 2026.17 Recently, considered by future generations as a career.
PANLAR published a study disclosing that, in Latin America, The authors of this article believe, to the best of their knowl-
only 1 rheumatologist is available per 106,838 inhabitants, clearly edge, this is the first study describing attributes of rheumatology
an insufficient number to meet rheumatology demands.18 India training in Latin America. The study updates information on the
offers another case displaying a critically low availability of rheu- numbers of programs and spots available for rheumatology train-
matology specialists. That country has increased the number of ing. The study's main weakness is a lack of information on the
rheumatology training programs in the last few years, yet the num- curricular structure of different programs, which would demon-
ber of specialists continues to be insufficient: of 2368 specialists strate how rheumatologists are being trained. Even so, the infor-
in internal medicine, only 26 entered rheumatology-training pro- mation yields broader knowledge on the status of rheumatology
grams (cardiology residency programs drew 282). Only 26 spots training in Latin America. This information should be useful as
available in a country with 1.3 billion inhabitants seem dramati- a base when conducting future studies in each country and at the
cally low.19 level of PANLAR.

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Fernández-Ávila et al JCR: Journal of Clinical Rheumatology • Volume 00, Number 00, Month 2021

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