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The best of times the worst of timesRheumatology 2001.

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ARTHRITIS & RHEUMATISM
Vol. 46, No. 3, March 2002, pp 567–573
DOI 10.1002/art.10171
© 2002, American College of Rheumatology
Arthritis & Rheumatism
An Official Journal of the American College of Rheumatology
www.arthritisrheum.org and www.interscience.wiley.com
ACR PRESIDENTIAL ADDRESS
The Best of Times, the Worst of Times
Rheumatology 2001
Michael E. Weinblatt
arthritis. No longer is our meeting dominated by pessimism on our lack of success in the treatment of rheumatoid arthritis. We have exciting new therapeutic interventions including cytokine modulators and new oral
immunosuppressive therapies. We are more aggressive
about initiating DMARD therapy, and we have reversed
the traditional pyramid approach to rheumatoid arthritis. With earlier initiation of DMARDs, including the
use of methotrexate and our newer drugs, we are
changing the natural history of this disease. I challenge
each of you to think of the last case of serious extraarticular disease, such as medium-size vasculitis or corneal
melt syndrome, that you have seen in your practice. The
ultimate judge of a change in the natural history will be
an improvement in survival rates and a reduction in the
need for joint replacement surgeries—a goal, I might
add, not shared by our orthopedic colleagues! Our
patients and our specialty owe all of the researchers in
RA, including those in industry, academics, and community practice, a debt of gratitude. It is now fun and
exciting to care for a patient with rheumatoid arthritis—
rheumatologists do make a difference!
The excitement regarding our specialty is at an
all-time high. This is reflected in the attendance at our
meetings. For this meeting there were 3,416 submitted
abstracts—a record number! I want to personally thank
Jane Salmon for her superb leadership as chair of the
Abstract Selection Committee. We again have had an
outstanding scientific program for which I am grateful to
Jon Kay and the Annual Meeting Planning Committee.
Submissions to our two journals, Arthritis & Rheumatism
and Arthritis Care & Research, are exceeding all projections. Both David Pisetsky, editor of A&R, and Gene
Hunder, editor of AC&R, have done an excellent job in
The tradition of the presidential address dates
back to 1932 and the first meeting of the American
Committee for the Control of Rheumatism, presided
over by Dr. Ralph Pemberton (Figure 1). This speech
provides the outgoing president an opportunity to address the membership. In recent years the presidential
themes ranged from issues regarding workforce, ethics,
organizational structure, and professionalism. How
many of you can recall the projection of one past
president, 15 years ago, that there would be a deficit of
rheumatologists by the turn of the century (how right he
was) or that of another former president that we should
offer 1-year training for internists with an interest in
rheumatology as a way to respond to workforce issues. I
hope that my comments today will also generate lively
discussion—as a soon to be past president, I now
welcome controversy!
I’m going to take the liberty of using one of the
great English novelists, Charles Dickens, and his historical novel A Tale of Two Cities (Figure 2), as the
metaphor for my address. To paraphrase, “This was the
best of times. . .this was the worst of times.”
As a specialty we are experiencing the best of
times (Figure 3). We have made great progress in the
care of patients, particularly those with inflammatory
Presented at the 65th Annual Scientific Meeting of the
American College of Rheumatology, San Francisco, CA, November
14, 2001.
Michael E. Weinblatt, MD, Brigham and Women’s Hospital
and Harvard Medical School, Boston, Massachusetts: President,
American College of Rheumatology, 2000–2001.
Address correspondence and reprint requests to Michael E.
Weinblatt, MD, Brigham and Women’s Hospital, 75 Francis Street,
Boston, MA 02115. E-mail: mweinblatt@partners.org.
Submitted for publication November 20, 2001; accepted November 20, 2001.
567
568
WEINBLATT
Figure 3. The best of times.
Figure 1. Dr. Ralph Pemberton.
taking both journals to the next level of excellence.
Arthritis & Rheumatism remains the most cited rheumatology journal worldwide.
There is an expanding developmental pipeline of
Figure 2. A Tale of Two Cities.
new therapeutics for rheumatoid arthritis and osteoarthritis. There is increased cooperation and interaction
between our members and those in the pharmaceutical
and the biotechnology field. Funding for arthritis research by the National Institutes of Health has increased, and there remains a very strong research commitment from the Arthritis Foundation.
Figure 4. Cover of September 3, 2001 edition of Newsweek magazine.
ACR PRESIDENTIAL ADDRESS
569
Figure 7. Number of trainees enrolled in adult rheumatology training
programs, 1996–2001.
Figure 5. Supplement to the November 12, 2001 edition of USA
Today.
There is greater public awareness of our specialty
and of our diseases. “Rheumatologist” is now mentioned
in direct-to-consumer advertising, and arthritis was featured as a recent cover story in Newsweek magazine
(Figure 4). On Monday there was a full supplement
devoted to our specialty in USA Today (Figure 5). I
would like to thank those members of our Industry
Roundtable who supported this effort, our Communications and Marketing Committee chaired by Eric Schned,
and Tammy Cussimanio, Director of Communications in
Atlanta, for developing this excellent communication
vehicle.
Figure 6. The worst of times.
There have been greater interactions of rheumatologists worldwide. I again want to thank all of you for
your kind words and thoughts following the events of
September 11. There is an increase in the number of our
international colleagues attending and presenting at our
annual meeting and publishing in our journals. Welcome
and thank you for your commitment to education and
science. I invite all of you to join the ACR as international members!
There is increased potential for revenue enhancement for practicing rheumatologists by participation in
clinical studies, performance and interpretation of DXA
scans, and the use of appropriate infusion therapies.
And lastly, as an organization this is the best of
times for the ACR. We are the sole professional organization for rheumatologists in the United States. This is
important to highlight since in other specialties such as
endocrinology, oncology, and nephrology there are multiple societies and no unified voice. Having one society
whose mission is to represent our entire specialty is
crucial for our small specialty to interact with other
specialty societies, third-party payers, and funding agencies. The ACR this year committed significant financial
resources to improve our technology capabilities, including a new Web site with online educational programming including video streaming from this meeting, and
the selection of Ernie Brahn as our first-ever Web
editor. The finances of the college are excellent. The
ACR has accumulated sufficient reserves in excess of
13.8 million dollars, as you will hear later from our
secretary-treasurer, to weather any crisis. Thanks to our
executive vice president Mark Andrejeski and to Colleen
Merkel, Vice President of Operations and Finance and
570
Figure 8. Number of trainees enrolled in pediatric rheumatology
training programs, 1997–2001.
to the ACR Finance Committee and our secretarytreasurer Betsy Tindall for their leadership in this area.
Just as in the novel A Tale of Two Cities it was
the best of times, this is also the worst of times, not only
for our members, but also for our specialty and patients
(Figure 6). There is limited access for some of our
patients to our new therapies due to the expense of these
treatments, restriction in insurance plans, and in some
cases drug availability. All of our patients should be able
to receive the appropriate therapy for their disease,
irrespective of their insurance status! There needs to be
an expansion of existing industry-supported indigent
programs for our patients who cannot afford these new
and exciting therapies. The need for prior authorization
approvals and for providing detailed followup reports of
patient response for many of our new therapies to
third-party payers is an increased burden for our colleagues and staff. Need I mention that all of this
documentation is not reimbursable?
There is only a small therapeutic pipeline for
several core diseases, including scleroderma, lupus, and
vasculitis. The commercial potential for these illnesses
may be limited and developmental programs are risky,
with perhaps a small return on investment.
There is a need for increased professionalism
between industry and our members. These lines are
blurred with greater involvement by companies now in
the academics of clinical trials, such as abstract and
manuscript preparation. Additionally, the selection and
the position of authors on abstracts and papers based
solely on recruitment success is academically indefensible. Investigators should be permitted to submit studies
that have negative outcomes. Investigators should also
have full access to all data from clinical trials for
WEINBLATT
preparation of scientific papers. I support the recommendations of the editors of the major medical journals
including the New England Journal of Medicine about
authorship and accountability. I urge our Committee on
Journal Publications to adopt these principles.
The increased excitement regarding our specialty
has not translated into an increase in the numbers of
physicians and researchers entering our field. There is a
nationwide shortage of rheumatologists at both the
practice level and in the academic medical center. Just
look at the classified ads in any issue of A&R.
Over the past decade there has been a reduction
in the number of trainees pursuing rheumatology (1)
(Figure 7). Since 1995 the Residency Review Committee
has reduced the number of rheumatology fellowship
positions by 10%. Over the same period of time we have
seen a reduction of 18% in the number of fellows in
training programs. Over the past decade the percentage
of international medical graduates in rheumatology
training also increased from 13% to a high of 59%. Due
to visa issues, the majority of international medical
graduates may need to return to their country of origin
and will be lost to the workforce in the United States.
The issues of workforce are even more critical in
pediatric rheumatology. In 2001, of 25 positions available there were 7 first-year fellows, which is an improvement over the 4 in 1999 (Figure 8). Fifty-seven percent
of the first-year fellows are international medical graduates.
Our specialty is also aging—just look around the
room! In fact, the mean age of our membership is 51!
Figure 9. Projected membership in the American College of Rheumatology.
ACR PRESIDENTIAL ADDRESS
Figure 10. Strategies for rheumatology to avoid the guillotine.
Without a significant increase in trainees we face a
situation in 2016, where the number leaving our specialty due to retirement will be greater than the number
entering the field (Figure 9). This limited number of
adult and pediatric trainees has implications not just for
our organization but also, more importantly, for our
patients.
Inadequate reimbursement for patient care remains a major problem for rheumatologists. We are not
compensated appropriately for the time and expertise
we provide to patients with chronic systemic rheumatic
disease. Just as there is limited reimbursement for the
clinical adult rheumatologist, reimbursement for the
pediatric rheumatologist is almost nonexistent. In fact, I
have been told that it is virtually impossible to make a
living as a full-time practicing pediatric rheumatologist.
Increasing documentation due to coding requirements
leads to diminished time with the patient with less
patient and provider satisfaction, and downcoding leads
to less revenue for a specialty that is already undercompensated. There is a greater dependence on revenueenhancing strategies such as DXA scans, clinical studies,
and infusion centers. This may place us in a difficult
ethical crossroad between revenue enhancement and
care of our patients.
To avoid a fate similar to the one that occurred to
Sydney Carton in A Tale of Two Cities, I would like to
share with you my thoughts about what we should do
over the next several years to escape the guillotine
(Figure 10).
For academic rheumatology to survive, we should
align our clinical practice with orthopedic surgery in
combined arthritis and orthopedic centers. We are the
largest referral source to orthopedic surgery of patients
571
who require joint reconstructive surgery. Rheumatology
by itself is not a profitable cost center, but aligned with
orthopedics it is a valuable and profitable resource for
the hospital. Since our revenue stream is limited, our
value may not be evident to chairs of departments of
medicine, but it should be to orthopedic surgeons and
hospital administrators. We need to create shared and
dedicated space with our orthopedic colleagues. Integrating our finances might also prove to be mutually
beneficial!! These centers will also enhance exposure for
medical students to rheumatic diseases.
For pediatric rheumatology there needs to be a
careful evaluation of the role of the pediatric rheumatologist inside and out of the academic medical center.
The pediatric rheumatology community needs to evaluate the continued need for a 3-year fellowship. If this
3-year board requirement is not essential and is a
disincentive for attracting candidates into the field, then
the ACR and other interested groups, including the
Arthritis Foundation and the American Juvenile Arthritis Organization need to lobby the pediatric societies for
a change. Incentive programs such as loan repayment
plans as a way to attract pediatric residents to the field
need to be evaluated. A proposal by the pediatric section
for a loan repayment has been sent to the American
College of Rheumatology Research and Education
Foundation (REF)—I urge a careful review of this
thoughtful proposal.
For the clinical rheumatologist we need to evaluate the value of enhanced technology such as computerized ambulatory medical records, hand-held technology, and voice recognition systems to make our practices
more efficient and perhaps more cost effective. This is
an area of particular interest to Mark Robbins and the
Committee on Rheumatologic Care (CORC) and was
the subject of this week’s CORC forum. In light of our
workforce issues we need to look at the role of physician
extenders such as nurse specialists and physician assistants for our practice. We need to get out of the business
of primary care for patients with rheumatic disease. Our
value is in the care of the rheumatologic aspects of a
patient’s illness rather than trying to be both the primary
care physician and the specialist. Studies show that we
do a better job in managing the rheumatology aspects of
care rather than doing both health maintenance and
rheumatology care (2). We need to reevaluate the type
of patients that are identified with our specialty. We
should see every patient with rheumatoid arthritis since
this is an illness that we can impact, whereas most of us
provide very little value to the patient with chronic
fatigue syndrome and fibromyalgia. Restricting followup
572
visits to this group of patients might increase available
time slots to see patients with systemic rheumatic disease. We also need to consider whether we wish to be
identified as the specialists in the use of biologic response modifiers and immunosuppressive therapies for
nonmalignant disease. The excitement regarding these
therapies has translated into increased enthusiasm in
our field.
We must attract a greater number of wellqualified residents into the field of rheumatology. We
must expand the efforts of the REF in these efforts
through our multiple programs including medical student preceptorships, medical student awards, the Clinician Educator award, and the endowed Immunex Pediatric Visiting Professor Program. The REF also provides
support for formal training in clinical investigation and
health services research and support of research training
positions through our contribution to the Arthritis
Foundation. For the upcoming year the REF will provide support to the Arthritis Foundation in excess of
$615,000 for Physician Scientist Development Awards
and Arthritis Investigator awards. Additionally, at the
request of the Arthritis Foundation leadership, the REF
will contribute an additional $750,000 this year to fund 5
new Physician Scientist Development Awards. The Physician Scientist Development Award is an award for the
entry-level research rheumatologist and is critical for
academic rheumatology. This year I am also happy to
report that we have received support from Amgen to
begin to provide partial support for fellowship training.
The REF, through contributions by our members, patients, and the Industry Roundtable, has been able to
support research and training with grants in excess of 1.9
million dollars for this year. My thanks to all of you who
support this effort. Special thanks to Stanley Cohen,
president of the REF, and Connie Herndon for their
leadership at the REF.
I also want to acknowledge the leadership of Dr.
Ephraim Engleman and the support of the past presidents of the ACR in our efforts towards endowing the
Presidential Gold Medal.
Finally, as rheumatologists and allied health professionals our primary goal is the care of the patient. As
heath care providers and as a professional society we
need to continue to follow ethical standards. The ACR
has approved a code of ethics, which is an important step
for our professional society and members. I want to
extend my personal thanks to Richard Panush and his
Subcommittee on Ethics for leading the College in this
effort. The complexity of interactions of industry with
the ACR and the REF and the individual rheumatolo-
WEINBLATT
Figure 11. Dr. Mary Betty Stevens.
gist, as well as the remunerative opportunities in the
practice setting such as DXA scans and infusion centers,
may lead to situations of potential conflicts. We never
should be placed in a position in which our actions are
questioned because of a direct financial advantage. We
have always taken the high road both with regard to our
interactions with industry at an organizational level as
well as in our day-to-day practice environment. The
challenge as we move forward is to maintain this high
level of ethics and professionalism.
Many times I have been asked why I chose
rheumatology. I relate my experiences as a house officer
at the University of Maryland and my rotation at the
Good Samaritan Hospital, where my attending physician
and mentor was Mary Betty Stevens (Figure 11). Mary
Betty Stevens was able to communicate the excitement
of rheumatology. In fact, there are over 100 rheumatologists that were influenced or trained by Mary Betty. We
need more mentors like Mary Betty to attract residents
into the field.
ACR PRESIDENTIAL ADDRESS
I have greatly enjoyed the privilege of serving as
your president of the American College of Rheumatology. Our staff in Atlanta is superb, and our executive
vice president Mark Andrejeski is outstanding and is a
great mentor and friend. In this era of limited time due
to practice constraints and competition for research
funding I owe a debt of gratitude to all of you who
volunteer for the College and REF, with special thanks
to an exceptional board of directors and officers of both
the ACR and the REF. I also want to acknowledge the
strong support and efforts of our Association of Rheumatology Health Professionals and their outgoing president, Basia Belza. Thanks also to my colleagues at the
573
Brigham for their support and care of my patients. I also
want to thank the many donors to the REF and the
members of our Industry Roundtable for your continued
support of our mission. Finally to my wife Barbara and
my children Hillary and Courtney, you can stop renting
out my room—I will now be home on weekends!
REFERENCES
1. Graduate Medical Education: appendix II. JAMA 2001;286:
1095–107.
2. MacLean CH, Louie R, Leake B, McCaffrey DF, Paulus HE, Brook
RH, et al. Quality of care for patients with rheumatoid arthritis.
JAMA 2000;284:984–92.
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