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: firstname.lastname@example.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.