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What role rheumatology.

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496
LETTERS
What role rheumatology?
To the Editor:
What role rheumatology? Just as we asked this
question during the last decade (l), so again we look to the
new decade as others, with new concerns, ask the same
question (2,3). In the previous decade, we were initially
concerned with the role of the rheumatologist as the exemplar of the physician-scientist. By the latter part of the
decade, the practice of medicine had changed greatly; it was
far more competitive. Fewer young physicians were entering
the field of rheumatology, since the economics of medical
practice dictated that alternative subspecialties, with more
“procedures,” offered greater earnings. At the same time,
the American College of Rheumatology (ACR) organized the
Committee on Rheumatology Practice as a mechanism to
emphasize marketing techniques in rheumatology-the business of the practice of medicine, if you will. This conflict,
i.e., the practice of medicine versus the practice of business,
in no small part occasioned the necessity of ACR’s separation from the voluntary agency, the Arthritis Foundation.
And thus, the debate on the new role for rheumatology began. On one side is the claim that marketing is
somehow necessary for the survival of our subspecialty in
these difficult times (2). However, a countercharge is made
that rheumatologists are actually moving toward an “MBA”
mentality, distracting them from medicine, apparently in
response to a decreasing number of referrals and a waning
interest in the subspecialty ( 3 ) .
I would agree that rheumatology does indeed face a
difficult challenge in today’s altered medical marketplace.
But I would also like to suggest that the appropriate response
to that challenge is not new, though it is not fully developed,
and that it is central to the issue of the role of rheumatology
today. It is the very art and science of the effective treatment
of the difficult, and often lifelong, rheumatic diseases.
I believe our history reveals our mistakes. When I
entered rheumatology more than 25 years ago, the agents
available for the treatment of rheumatic diseases were limited. It was common for doctors to encourage their patients
to take aspirin (in antiinflammatory doses) and “learn to live
with it” (arthritis). Gold salt therapy was reserved for the
more advanced stages of rheumatic disease. Corticosteroids
were generally relegated to last-ditch situations and were
frowned upon as an ongoing therapy.
Since that time, more than 100 antirheumatic therapies (nonsteroidal antiinflammatory drugs [NSAIDS] and
disease-modifying antirheumatic drugs) have been researched and clinically studied. Rheumatic disease therapeutics has become one of the most intensively productive areas
of new drug development.
Yet, during this time of rapid expansion of the
number and type of therapeutic agents used in the rheumatic
diseases, the ACR abandoned its annual clinical session
(separate from the biennial scientific session) for a single
annual combined session. For the most part, the result,
continuing today, has been the relegation of intensive peer
review and discussion on therapeutics to industry-sponsored
sessions. Concomitantly, very little of this work has ever
graced the pages of our only rheumatology publication,
Arthritis and Rheumatism.
Arthritis and Rheumatism, Vol. 34, No. 4 (April 1991)
There were plenty of timely issues that could have
been discussed in our councils and chambers: the “at-risk
populations,” the elderly, concomitant diseases, the problems of cotherapies, which left us a legacy of the benoxaprofen scandal, and, most recently, the continuing controversy on gastropathy, which has led to the class labeling of
all of our NSAIDS. NSAID gastropathy accounts for more
incidences of serious adverse events reported to the US
Food and Drug Administration than adverse events associated with all other classes of drugs combined. And yet, in the
only article on NSAID gastrotoxicity to be published in a
rheumatology journal, a Current Controversy by 2 gastroenterologists (4) worked to downplay this issue. In contrast,
there is an avalanche of articles in other peer-reviewed
journals worldwide covering the problems of difficult-todiagnose silent bleeds, ulcers, and perforations, importantly
identifying types of patients who are at greatest risk (not
uncommonly, our patients) (5). We still await articles or
letters responding to the Current Controversy in Arthritis
and Rheumatism.
I suggest that we can effectively respond to all of this
and restore therapeutics to its proper and central role in
rheumatology by doing the following: 1) Reestablish the
previously dropped and unfunded committee on drugs and
therapeutics as a full council with full political clout within
the ACR, in order to establish policies and maintain balance.
2 ) Far too many of the clinical therapeutics papers submitted
for our annual meeting are rejected within the meeting’s
limited format. This is at a time when our understanding of
drug pharmacokinetics and interactions on rheumatic disease events has evolved and appears to be challenging
traditional therapeutic approaches (6). Yet, at the 1989
meeting in Cincinnati, no papers on the development and use
of the various therapeutic agents in rheumatic diseases were
actually discussed. Once more, they were relegated to the
back-room pasteboards of the exhibit hall. Either significant
concurrent session time should be provided for such peer
discussion, or a return to a separate biennial clinical session
should be considered. 3) This additional serious peer attention to clinical therapeutics should result in concurrently
expanded space in Arthritis and Rheumatism. If our publication cannot find such space for therapeutics and drug
development, then we may require an additional publication
specifically devoted to this important work.
And so, what role rheumatology in the 1990s? Were
we not correct in the first instance in assuming that the heart
of rheumatology was not a PhD nor has it become an MBA,
but rather, it has always been an MD? A clinician who is
committed to the difficult long-term management of patients
with rheumatic diseases and is skilled in the use of the
evolving therapeutic modalities, as well as in handling the
inevitable problems associated with that long-term use, is,
and should be. that role model.
Sanford H. Roth, MD
Arthritis Center and
Phoenix Humana Hospital
Phoenix, A Z
1. Roth SH: What role rheumatology? (editorial). Arch Intern Med
142:27, 1982
2. Meenan RF: Marketing and the American College of Rheumatol-
LETTERS
3.
4.
5.
6.
ogy: a professional approach for a professional society. Arthritis
Rheum 33:439440, 1990
Hadler NM: Another colloquy at Delphi: an unabashed parody.
Arthritis Rheum 33:436-438, 1990
Barrier CH, Hirschowitz BI: Controversies in the detection and
management of nonsteroidal antiinflammatory drug-induced side
effects of the upper gastrointestinal tract. Arthritis Rheum 32:
926-932, 1989
Roth SH: Nonsteroidal anti-inflammatory drugs: gastropathy,
deaths, and medical practice. Ann Intern Med 109:353-354, 1988
Roth SH: Rethinking rheumatic disease therapy (editorial). J
Rheumatol 16:1408-1409. 1989
Reply
To the Editor:
As “a clinician who is committed to the difficult
long-term management of patients with rheumatic diseases,”
I feel qualified to respond to Dr. Roth’s eloquent plea. I
further qualify by having no designs on an MBA. I too am
concerned about the waning interest in our subspecialty, and
in my voluntary teaching capacity I strive to be the role
model that Dr. Roth would like me to be. As an eyewitness
to the era referred to, I offer the following observations.
The Committee on Rheumatologic Practice (CORP)
was not a child of the 80s, but was conceived in the 70s,
thanks to the foresight of its first chairman, Dr. Louis A.
Healey. This committee never dealt with marketing techniques or the practice of business. The committee was
certainly responsible, however, for broadening the interests
and concerns of the then American Rheumatism Association
(ARA) to include issues involving patient care in the deliberations of an organization that, until then, had been concerned primarily with research and education issues. Early
publications from CORP, such as the results of a survey of
diagnoses seen in a representative group of private rheumatology practices (1) and guidelines for the management of
patients with rheumatic diseases ( 2 ) are indicative of these
interests. (The latter document may have been the first
example of the more recently recognized “practice parameters,’’ and Dr. Healey’s foresight in recommending these
then-revolutionary activities should be duly recognized.)
More recent activities of the Council on Rheumatologic Care (CORC) include participation in the Harvard
Resource-Based Relative Value Scales study, publication of
Guidelines For Reviewers of Rheumatic Disease Care, a
state-by-state project to have rheumatology recognized as a
subspecialty on a par with other internal medicine subspecialties, and the development of practice guidelines. CORC
representatives, members of other American College of
Rheumatology (ACR) councils, and ACR Presidents have
testified before Congressional committees on a variety of
issues, including the danger that would result from discontinuation of physician office laboratories and the needs of our
patients regarding adequate insurance coverage. I submit
that an awareness on the part of government regulators,
third-party payers, other physicians, and patients, that rheumatologists not only exist but are the foremost authorities on
rheumatic diseases and the care of people with those diseases, will result in the improvement in patient care that Dr.
Roth desires. The dissemination of this information is therefore therapeutic, not marketing, in nature.
Dr. Roth’s reference to an “annual clinical session”
497
must refer to an activity abandoned after a vote of the ARA
membership in the early 70s. To revive the clinicah-esearch
schism would be counter to the ecumenical camaraderie that
is currently sweeping our College. Rheumatology is possibly
unique among the medical subspecialties in having only one
national organization to represent it to the various publics (a
“marketing” word, but I like it), i.e., patients, legislators,
third-party payers, other medical organizations, and nonrheumatology physicians. To do anything to weaken this
united front could only be to the detriment of our subspecialty and our patients.
The Editors of Arthritis and Rheumatism report that
in a recent 15-month interval, 380 clinical articles were
submitted and 80 accepted. In the same interval, 423 basic
science articles were submitted, with 149 being accepted.
While Dr. Roth’s “clinical therapeutics” was not given a
separate category, these numbers do not suggest to me an
unfair selection bias against the clinical area. Further evidence of the Editor’s interest in publishing a diversity of
articles is demonstrated by the appearance of Clinical Reviews, Radiologic Vignettes, and Current Controversy in
Rheumatology articles, which totaled 18 in the past 18
months. I would commend the Editor of Arthritis and
Rheumatism for noticing the “avalanche” of articles in other
journals regarding the gastrointestinal problems associated
with nonsteroidal antiinflammatory drugs and, when there
were no worthy submissions to Arthritis and Rheumatism on
this topic, to then solicit a Current Controversy in Rheumatology article on the subject (3).
Dr. Roth is inaccurate when he states that the ACR
annual meeting relegates presentations concerning therapeutics to the “back-room pasteboards of the exhibit hall.” At
the 1990 annual session there were 6 podium presentations
dealing with the treatment of rheumatoid arthritis and 10
dealing with the clinical features and treatment of systemic
lupus erythematosus. The acceptance rate of both of these
categories equaled or exceeded that of other, non-clinical,
categories. Dr. Roth himself chaired sessions dealing with
the treatment of rheumatoid arthritis, at both the 1989 and
1990 annual meetings.
What role rheumatology? A leading role! If we are
indeed to lead, individual rheumatologists must recognize
that the ACR triangle logo is not merely a result of some ad
man’s enthusiasm, but an accurate representation that recognizes the interdependency of the research, education, and
treatment constituencies of the ACR membership. We must
not disrupt this triangle.
Herbert Kaplan, MD
Denver, CO
Secretary, American College of Rheumatology
I. The American Rheumatism Association Committee on Rheumatologic Practice: A description of rheumatology practice. Arthritis Rheum 20:1278-1281, 1977
2. Healey LA, Croft JD, Epstein WV, Fremont-Smith K, Goehrs
H, Harrington JT, Irvin WS, Kaplan H, Lightfoot RW, Meenan
RF, Solomon SD: Guidelines for rheumatic disease management.
Bull Rheum Dis 31:ll-14, 1981
3. Barrier CH, Hirschowitz BI: Controversies in the detection and
management of nonsteroidal antiinflammatory drug-induced side
effects of the upper gastrointestinal tract. Arthritis Rheum 32:
926-932, 1989
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