ACR President Discusses NIH Budget Cuts, Workforce Shortages, Untapped Potential for Rheumatologists

Issue: February 2018

David Daikh

As a nonprofit organization dedicated to improving care for patients with rheumatic disease and promoting the success of its professional members, the American College of Rheumatology relies on its volunteer leaders to offer direction and support.

Serving more than 9,500 physicians, health professionals and scientists across the globe, the ACR provides its members with educational, research, advocacy and practice support through various initiatives and resources. The organization’s Board of Directors consists of member volunteers who work on various committees dedicated to the advancement of the subspecialty of rheumatology.

Spearheading these efforts in 2018 will be the newly-elected 81st president, David Daikh, MD, a long-time ACR veteran who has served in numerous organizational capacities: chair of the Committee on Training and Workforce, member of the Scientific Advisory Council on the ACR’s Rheumatology Research Foundation, Foundation president, member of the Foundation board of directors, and most recently, ACR secretary and president-elect.

“It’s a bit of a cliché, but it is an honor and a privilege to be working with such a diverse group of colleagues and representing them,” Daikh told Healio.com Rheumatology. “It’s just an amazing group of people in the field of rheumatology who are committed, smart and engaged.”

Serving as the director of Rheumatology Fellowship Program at the University of California, San Francisco (UCSF) and chief of the rheumatology division at SFVA Medical Center, Daikh has overseen research chiefly related to immune mechanisms of rheumatic disease, with a focus on the role of both effector and regulatory T cells in systemic lupus erythematosus.

In leading the ACR, Daikh intends to focus his tenure on advancing the organization’s initiative to improve medical education and prepare students for today’s changing health care system, support community rheumatology practice sustainability, and provide viable opportunities for the next generation of rheumatologists. Daikh sat down with Healio.com Rheumatology to discuss both the untapped potential in the rheumatology field and the challenges for the field in the coming year.

Q. What are your educational, advocacy and research priorities as ACR president?

Last year, the ACR issued a new strategic plan with a mission of empowering rheumatology professionals to excel in their specialty, and advancing rheumatology research was included as a key focus. I think ongoing research into the causes and treatments of rheumatic diseases is absolutely critical for providing our members with more options for improving the lives of our patients with these diseases. Fundamental research, which is basic and translational, has been an integral part of the rheumatology specialty since its beginning.

Rheumatologists have been leaders in understanding immune mechanisms of disease and identifying new treatment approaches — it really is the lifeblood of our specialty. However, as NIH funding for rheumatology research has continued to fall in recent years, the percentage of funded research grants has also been declining. There is great need in the community to support research, which remains the backbone of our academic divisions of rheumatology.

Q. What is the connection between research and academics in rheumatology?

There is a link between research and education in terms of the training of our fellows who are going to become the clinical providers caring for patients. Their training happens in the context of these academic divisions. As part of their training, rheumatology fellows learn the immune mechanisms underlying many rheumatic diseases and are exposed to the methods and principles of research. This helps them learn a rigorous approach to designing and evaluating treatments for their patients. The faculty who are doing research and providing high-level care in academic centers are also the faculty that train the majority of our fellows.

All of us, even if we eventually practice rheumatology in the community, have come up through our academic divisions. Supporting research doesn’t only mean supporting the research enterprise itself, but also supporting the entire training and academic enterprise as well. I think this an extremely high priority.

This, in turn, has become an important agenda for our advocacy efforts, to really educate our lawmakers about the importance of these issues — not only funding research, but the importance of access and funding for graduate medical education.

Q. Beyond funding, what are some other goals for rheumatology education?

Rheumatic and musculoskeletal diseases are, in aggregate, among the most common reasons for patients to seek medical care, not only in hospitals but even more commonly in outpatient clinics. The patients are seen in general medicine and primary care clinics, and hopefully, when a patient presents with a complex problem, they are referred to a rheumatologist.

In many of our programs, physicians who go into primary care are not exposed to enough education about rheumatic and musculoskeletal diseases. There is a severe mismatch between the frequency of these conditions and the amount of exposure that physicians have in their training, a disparity the ACR is now trying to address. One of the ways we do that is through training and support, eventually producing medical educators that will go out and teach students, residents and fellows. Continuing to support education in these areas is also important.

The ACR has been a leader in education about rheumatic and musculoskeletal diseases, not only at the trainee level, but for continuing medical education among practitioners at our annual meeting, which is the focal point of many of our educational efforts. The reach of our education extends worldwide, and we want to continue that.

Q. What have been your personal areas of focus and interest in your career as a rheumatologist, and how might these have influenced your goals as ACR president?

There is no doubt that my own experience influences my priorities. However, I’m also very quick to say that I think my own temperament — and certainly my view of my role as president — is to support and advocate for all of the various facets of our profession and for patients.

My own background as an academic rheumatologist has been in research and in training, and I am also a trainee program director. Those are definitely personal priorities, but all of us tend to see the value and the impact of what we are working on. Aside from being my areas of focus, I do believe these priorities are important, in part for their foundational and supporting role for clinical practice.

However, I would add that support for research and training is not the ACR’s only agenda for advocacy. There are many items on our advocacy agenda, many of which are directed at supporting and sustaining the clinical practice of rheumatology in the community.

Practicing rheumatologists are challenged to keep their doors open and provide care. We support efforts to provide adequate compensation for the evaluation and management of patients with complex diseases. We seek to understand and promote the factors that lead to the highest quality most cost-effective care. We advocate for physicians receiving credit for providing this high quality of care.

Disease factores graphic

Q. Are you/do you plan to be involved in efforts to recruit new rheumatologists and strengthen the workforce?

The ACR has funded two workforce studies, the most recent of which was published in 2016. Those studies have consistently shown that there is an impending and ongoing shortage of rheumatologists, and many regions of the country are underserved, in adult rheumatology and especially in pediatric rheumatology. The workforce issue is therefore a very important one to rheumatology and to the ACR.

I mentioned earlier the importance of exposing trainees at the medical school level to these diseases and to the practice of rheumatology — this certainly has a crucial educational function, but it is also important for recruitment. A few years ago, Medscape News released the results of an online survey which had asked a variety of different health care providers about their quality of life and whether they were happy in their practices. According to survey results, the happiest providers are rheumatologists, followed closely by dermatologists and urologists.

There is a real satisfaction that comes from both understanding and being able to deliver effective complex care for patients. Making a diagnosis and providing ongoing care, while truly getting to know your patients — frequently over the course of a year or in some cases many years — is very satisfying. There is intellectual satisfaction to what we do as well as the rewards of providing care to patients that rheumatologists really enjoy.

We are trying to get that message out — recruiting people to our field is very important.

We also try to provide funding support for the fellows who are in training. Many hospital systems and programs don’t provide adequate graduate medical funding to support the fellows in training. We know we can expand the workforce if we can expand the number of training slots.

Q. What direction do you see the profession of rheumatology taking in the future?

Part of what the workforce studies look at is demand, and it is clear there will be a rising demand for the treatment of rheumatic and musculoskeletal diseases. These diseases tend to occur later in life, so in an aging population, we see the prevalence of these diseases increasing across the board. Many of the musculoskeletal conditions are activity-related, and so we see more kinds of soft tissue injuries and more arthritis as the older population remains, or in some cases becomes, active. Part of the future of rheumatology will be this ongoing and increasing demand for our services.

As we learn more about the immune system and understand the various ways in which immune activation and dysregulation can lead to disease, we are finding that the immune system can contribute not only to rheumatic disease, but to other problems like cardiovascular disease. We are also learning about the important role the immune system plays in combatting cancer; by therapeutically turning on the immune system — or ‘revving up’ the immune system — we now can actually help the immune system fight cancer. However, this immune system activation can also increase the probability of immune-related side effects, leading to new forms of autoimmune disease.

Part of our unique expertise comes foundationally from the way we train our fellows to understand the immune system. Rheumatologists have been critically important in the evolving understanding of immune mediated diseases. We specialize in autoimmune diseases: rheumatoid arthritis, lupus, scleroderma, mixed connective tissue disease, ankylosing spondylitis — the list goes on and on. I believe that an important part of our future is going to be in providing expertise to patients and other providers about immune mediated disease.

We provide significant leadership in this area already, with many rheumatologists pioneering new therapies that target the immune system. There will be an increasing need for experts to guide physicians in using these medications; similarly, as these therapies increase the risk of immune-related side effects, there will be a need for expertise in appropriately modulating the immune system. We are seeing a lot of increasing interest in this, because medical students and other health care trainees are hearing about these new targeted therapies, and realizing they can truly have an impact on a variety of diseases. I think it will continue to be very exciting and worthwhile to be involved in rheumatology in the future. – by Jennifer Byrne

Disclosure: Daikh reported no relevant financial disclosures.

For more information
David Daikh, MD, can be reached at Arthritis/Immunology 111R, 4150 Clement St., San Francisco, Calif.; 94121; email: JGivens@rheumatology.org.