Friday, 17 Nov 2017

You are here

The Greatest Rheumatologist - Part I

Who is the greatest rheumatologist? What makes for a great rheum?

Is it clinical acumen, scientific achievement, educational prowess or years of unrivaled service or mentoring?

Rheumatologists are quite opinionated on this subject and very nostalgic about their mentors and leaders. When I’ve posed this question in small groups, it’s plain to see how moved they become when discussing mentors or peers who influenced them.  

Thus, I posed this question to many of our leaders and mentors: who do you think of as the greatest rheumatologist?

I told them they could define “great” however they wished - a visionary or leader of change, a role model clinician, an inspirational mentor or just simply the rheumatologist you aspire to emulate. Alive, deceased, imaginary.  The hope was to find, in their answers, inspiration for our next generation of young rheumatologists. 

Today you can read below and see who the “Greats” are and what mattered most to these notable respondents.  Tomorrow I'll weigh in with my vote for the Greatest Rheumatologist.

Dr. Peter Merkel: “The greatest rheumatologist I have worked with in my career, and I have had the privilege to work many exceptional physicians, was Dr. John Mills of the Massachusetts General Hospital, now retired.  Dr. Mills epitomized a scholarly clinician who comprehensively evaluates each patient, systemically reviews all available data, and develops diagnostic and management strategies that avoid logical heuristics, while incorporating both experience and scientific evidence.  Dr. Mills was doggedly diligent at working (and reworking) to arrive at the best answer to any clinical problem to provide patients with outstanding and compassionate care.”  “The greatest rheumatologist I know may be the next trainee with whom I work.  I hope to help nurture his or her enthusiasm for our fascinating field, guide a lifelong pursuit of learning, and provide the education and circumstances for this new rheumatologist to deliver exceptional care for many decades.”

Dr. Janet Pope: I think that a current great rheumatologist is Professor Joseph Smolen from Vienna for many reasons. He has been instrumental in encouraging rheumatologists worldwide to treat to a target in RA; he has been involved in guidelines; he writes and reviews; and is editor for many prestigious publications, including his new post as the editor of Annals of Rheumatic Disease. He is extremely knowledgeable and a thought leader in other areas, such as SLE.  The reason I am suggesting him is that he mentors and promotes/encourages his young faculty. It is one thing to be great but another to deliberately share the spotlight with others.  

Dr. Bruce Cronstein:  Gerry Weissmann, my mentor, President of the ARA (ACR) 1980s and long-time director Rheumatology at NYU School of Medicine. Gerald Weissmann, who is still writing, brings a remarkable sense of creative curiosity to everything he does. Gerry can hear a talk or read an article and have the facts rattle around inside his brain and come out imaginatively embellished and changed. I have found his ability to take in the world and find something new in everything inspirational. As a scientist Gerry was also both inspirational and instructive; Gerry always had more ideas than any group of people could ever pursue. Importantly, as a scientist he was willing to be convinced by the experimental results and was never captured by the last brilliant idea, a characteristic that keeps the science honest (although at the cost of “slaughtering your intellectual children”).

Dr. Michael Weissman: Nate Zvaifler – never asked us to do something he wouldn’t do himself - always repeated every experiment - bonded with patients in a special way, and questioned everything that we did by asking “why”? 

Dr. Kelly Krohn: My biggest influence was Howard Polley from the Mayo Clinic.  He was retired and came to Indy when I was a fellow with Ken Brandt.   Howard focused on teaching us the physical exam of the musculoskeletal system.   He wrote a great text with Gene Hunder that has some of the best anatomical illustrations especially of bursae.  He chastised the fellows if they said "active synovitis" saying it was redundant.  I also used that line many times with my fellows.   

Howard taught me to respect the power and toxicity of glucocorticoids. He was the young clinician at Mayo with Hensch and Kendall when they gave the first patients cortisol that Kendall extracted from adrenal tissue. Of course they got the Nobel prize.  Polley was the clinician who actually took care of the patients and saw psychosis, cushinoid features, diabetes and quickly compression fractures while Hensch was traveling the world getting rewards. Some of the fellows complained about late Friday afternoon rounds with Dr. Polley. I enjoyed him and gained tremendous insights into the use of glucocorticoids from one of the pioneers.  

Dr. Arthur Kavanaugh: Martin Lidsky from Baylor and the Houston VA Medical Center!  He was the one of the greatest teachers and doctors and rheumatologists and humans I have ever met. Humble to a fault. Everyone who had the pleasure of working with him remembers that way in the old days, before we had drugs that could affect X-ray progression, Dr. Lidsky was one of the few rheumatologists who would get regular hand and foot x-rays. He pioneered the work with John Sharp defining x-ray progression in RA (see the original paper by Sharp and Lidksy). I asked John about this one time – John was quick to heap incredible praise on Martin, and said “Martin loved to take care of patients… he didn’t care so much about writing articles”.

As residents working in his clinic, he amazed us all with his work habits and dedication. He would be there at the VA rheumatology ward, where his clinic was, before any of us got there to do clinic. He would work all day in the clinic. Then, when we were leaving at 5 pm to go home, he was heading over to Baylor to see private patients in the evening.

Dr. Larry Edwards: When I arrived at the University of Michigan in 1976, William D Robinson had just stepped down as Chairman of the Department of Medicine and was replaced by William N Kelley. Bill Robinson, however, never really retired. He came to work every day from 1975 until he died in 1988 to sit with the Rheumatology fellows in the outpatient clinic seeing the walk-in and urgent cases. His clinical decision-making and knowledge of the literature of the time are unmatched by any person in the field of Medicine I have ever met. He was a gentle teacher and patiently brought even the densest of the fellows (i.e., myself) around to a more logical differential. Similarly, at the weekly clinical conference after the fellow had presented a puzzling case and all of the 14 faculty members had expressed their opinions (frequently in a rather heated fashion), all eyes would turn to Dr. Robinson. Everyone knew they were about to hear the right answer and we were never disappointed in his incredible grasp of the field of Rheumatology. Occasionally his diagnosis would be challenged by one of the faculty luminaries in the audience (like Giles Bole, Bill Kelley, Sara Walker or Bill Castor). Dr Robinson would then say something like, “The great thing about Rheumatology is that cases can be so wonderfully complex that even smart clinicians might disagree about a particular patient”. The fellow would then write the opposing positions and patient’s name on the blackboard where it stayed until time enough had passed to reveal the correct diagnosis. I don’t ever remember Dr Robinson’s position not being the one that won out. He was a remarkable man and I still attribute whatever clinical acumen I have in Rheumatology to Bill Robinson.

Dr. David Fox: (re: Dr. William Robinson) Also, there was the time when he finished a telephone call with a patient, turned to Tom Pallela, and said “I was just chatting with your patient who has acromegaly”. This patient had not previously carried a diagnosis of acromegaly. Bill diagnosed it (correctly) based on the voice, and explained to Tom the nuances of distinguishing the effects of acromegaly vs myxedema on the vocal timbre.

Daniel Lovell, MD: The greatest rheumatologist from my perspective is Dr. Earl Brewer from Baylor College of Medicine.  His broad influence in pediatric rheumatology is present even today.  He had an international vision for pediatric rheumatology and brought clinical trials to pediatric rheumatology.  He was always thinking and planning strategically internationally and years down the road.  As a fellow you quickly learned that you needed to pull him back to this moment in this place if you wished to discuss a particular patient.  His vision was that children with pediatric onset arthritis should be treated with medications formally tested and found to be effective in this population and not be left to extrapolated effectiveness from adult studies.  To that end he formed a national organization, the Pediatric Rheumatology Collaborative Study Group (PRCSG), and the clinical methodologies to perform the trials in children with JIA.  The PRCSG remains active today with the same focus.

Dr. Ronan Kavanaugh: Whereas I have met many great rheumatologists in my career, the greatest in my mind is Dr. Stanley Roberts who is a retired rheumatologist from Belfast. I worked with him for a year in about 1990.  Although degree of romantic nostalgia probably influences my memories of the man, he had a huge influence on my decision to be a rheumatologist and the way in which I practice medicine.  Stanley's greatness came from his extraordinary broad AND deep knowledge of rheumatology and general medicine, his enthusiasm for rheumatology and his bedside manner.   The relaxed chatty way he interacted with patients in the manner old friends belied his perfectionism and attention to detail. He wore his knowledge lightly in a quiet self-deprecating way which made it easy to underestimate him (he was a hawk as an examiner).  He always had an interest in the lives of his patients and his trainees, was great fun to be around, and inspired more than one generation of rheumatologists to join our specialty.  Stanley received many awards in his career (he was honored by the BSR to give the Heberden Oration in 1997 was also elected President of The Irish College of Physicians) but his legacy will be the affection he is held in by his former patients and the rheumatologists like me who he inspired to follow in his footsteps.

Sergio Schwartzman, MD: Harry Spiera (Mount Sinai) was the  Proverbial Clinician with a skill in managing patients  and a clear background of knowing all of  the literature – not only a great rheumatologist, more importantly an outstanding human being.   Also, Charles Christian (Hospital for Special surgery). Interestingly, Harry Spiera was Dr. Christian’s first fellow at Columbia- One of the few physicians who is a “master clinician”, “master researcher /basic scientist” – had a complement lab and identified the association between vasculitis and hepatitis and a “master at academic politics” Had a capacity to succeed and drive the decisions in a predominant orthopedic hospital

Allan Gibofsky, MD: Dr. Charles L. Christian immediately comes to mind as "the greatest rheumatologist." He was Director of the Division of Rheumatology at Hospital for Special Surgery from 1970-1995, and is responsible for training numerous individuals who themselves went on to become division chiefs, scientists and clinicians, including 3 ACR Presidents, an NIH Division Director and an A&R Editor. (He also trained one lawyer, but would probably not want to add that to his list of accomplishments).    Known for his clinical observations on SLE, he is a thoughtful and insightful scientist and inspiring physician. He led us by example, never asking us to do anything that he, himself, was unwilling to do. He was uncannily and immediately available to every Fellow, even at odd hours. Many of us who were trained by him can recount incidents when we were called to the ER to see a patient in the middle of the night, only to see him arrive a few minutes later, inquiring cheerfully "Hullo...need some help? I happened to be around." (We were sure he paid the ER staff to call him first!)   Though retired for nearly 20 years, it will take most of us at least that long to learn what he has forgotten---if, in fact, he has forgotten anything. Though never seeking recognition, he has received the highest honors of our profession and is certainly deserving of the title "the greatest rheumatologist."

True story: He never wanted us to celebrate his birthday--even modestly--and would often avoid the lab or division office if he sensed we were planning anything. As you might imagine, then, I was always the one "assigned" to get him to where the party was being held. One year, he agreed to allow me to host a small reception at my apartment nearby, to welcome the incoming Fellows. It turned out the reception was the same day as his birthday.  He called me into his office and said: "Gibo, I want your word that you are not planning  anything for my birthday at this welcoming reception!" I replied "Dr. Christian, you have my word as an Officer of the Court that there is nothing planned for your birthday tonight!" He laughed and said "Nice try, but not good enough. I want your word as a Rheumatogist!"

Another story: We always let him think we "drew straws" for Holiday Coverage assignments. One year, he was present and actually "drew " Christmas weekend. His secretary called me when she was typing it up for distribution and said "What am I going to do?" I erased his name and substituted mine. She said "He's going to come looking for you when he sees this."   I replied "I’ll be expecting him".  Sure enough about 15 minutes later, he came to the lab.  He said to me "What do you think you're doing? I drew Christmas and I plan to work that weekend".   I said "YOU are NOT working Christmas!"  He persisted "But I drew Christmas and it’s only fair that I cover that weekend."   Again I said "YOU are NOT working Christmas!"   Again he said "But that's not right, that's the Holiday I drew!"   I said "Dr. Christian, did you work the weekend of September 22-23?"   "Yes, why?" he answered, puzzled.  I replied "Well that was my Holiday, Rosh Hashanah and I didn't work. Last I looked, Christmas was a Christian holiday AND YOURE a Christian and YOURE NOT WORKING Christmas but I am! 

Phillip Gardiner MD: Verna Wright gets my vote!

Gerd Burmester, MD: Many thanks for your initiative. It gives me a great pleasure to nominate Dr. Robert Winchester, New York City, Columbia University, for being included to be among the “Greatest Rheumatologists” in recognition of his outstanding achievements and his contributions in research, education, administration over his entire career.  I have known Robert Winchester for many years, since I had the great privilege to be accepted as a Postdoctoral Fellow in his laboratory from 1980 to 1982, first in the Rockefeller University and subsequently the Hospital for Joint Diseases. I have since then followed and admired his remarkable achievements not only in rheumatology, but also in the field of immunology.

Robert Winchester started his research career in the laboratory of the late Henry G Kunkel at the Rockefeller University in 1966. This laboratory was a remarkable place, since it was not only an excellent research environment, but also had access to patients with complex diseases on a small ward of this institution. The spirit there was to carefully study the patients´ diseases along with interesting laboratory and experimental findings. The focus was on autoimmune systemic diseases and inflammatory joint disorders. Starting with innovative research in humoral inflammatory mechanisms in the joints of RA patients, he moved into the cellular aspects of immunology, and here was interested in the newly detected HLA system, most notably the DR/class II molecules which were much more difficult to study, since they are present on only a minority of (usually immunologically very relevant) cells. Here, he took advantage of the also newly detected tools of monoclonal antibodies which for the first time allowed a comprehensive and highly specific analysis of these important antigens. Thus, he was the pioneer in detecting these molecules on cells of the monocyte/macrophage system, on B cells and interestingly also on T cells which normally do not bear these proteins, however did so in rheumatoid arthritis, especially in intraarticular sites. 

He could then greatly expand his investigations when he moved to become Director of the Rheumatology Department of the Hospital for Joint Diseases in New York. There, it was a unique interaction between surgeons, pathologists and rheumatologists that allowed gaining insight into the disease mechanisms of especially rheumatoid arthritis and psoriatic arthritis, but also systemic lupus erythematosus. A particular focus was on the generation of monoclonal antibodies against Class II molecules showing that HLA-DR and HLA-DQ are distinct molecules. In the course of these investigations there was one particularly interesting reagent, which reacted with over 70% of the RA patients, some of whom lacked DR4 positivity. A further careful analysis of individuals with different ethnic background finally led to the ground breaking discovery of the “shared epitopes” showing that the Class II antigens characteristic of RA susceptibility share a region of high sequence similarity with major potential implications on the presentation of “arthritogenic” peptides. A further major research area was the “immunologic tissue architecture” of the rheumatoid synovium, again using newly generated monoclonal antibodies against distinct cell types such as macrophages, fibroblasts and T cells. Interestingly, using this panel of tools, his group was the first to show that the osteoclast like cells in the giant cell tumor of bone are of monocyte origin raising the hypothesis that osteoclasts in general are derived from this lineage.  

However, Robert Winchester was not only interested in autoimmune diseases, but also in the immune system in general, particularly also in relation to infections. Thus, he utilized the close neighborhood to the Bernstein Institute in New York to study an at that time “strange” disease that primarily involved particular male patient populations and haemophilic patients. Later, it was found out that this disease was caused by the HI-virus, but even before this knowledge, Robert Winchester, gained deep insight into the pathologic T cell reactions and distinct disease manifestations such as a “Sjögren’s” like disease with clonal T cell expansions. The interesting co-occurrence of HIV and psoriasis/psoriatic arthritis then led to remarkable findings in the HLA association of this inflammatory joint disease which is completely different from rheumatoid arthritis with susceptibility conferred by three major HLA class I allele groups, HLA-B*08, HLAB*27/B*39, and HLA-C*06, an area of his very active research as could be witnessed recently by his excellent key note lecture at the ACR congress in San Diego in 2013.

He never lost interest, however, in the key disease of his Rockefeller years, systemic lupus erythematosus using transcriptome analysis of isolated glomeruli from patients with severe lupus nephritis and T cell analysis in chronic SLE demonstrating clonal expansion of CD8+ cells.

Robert Winchester is one of the best mentors in rheumatology as I had the privilege to experience during my great years in his laboratory. The very long list of his trainees includes eminent rheumatologists and scientist such as Alan Gibofsky, Peter K. Gregersen, Jill P. Buyon and Edward Dwyer to name just a few. He is gifted to analyze the results of simple or complex experiments and immediately get a grasp what they could mean in general terms stimulating further research with great enthusiasm. He was able to spend hours in a dark microscope room to help finding the best reagents. He loves modern technology, and it was a particular pleasure to see him with his new “toys” such as the fluorescence activated cell sorter where he was greatly involved in the development of advanced techniques, and it was only natural that he rapidly embarked on the new technologies in molecular biology.  Suffice it to say that Robert Winchester is a one of the best lecturers in medicine with his clear statements about even very complex findings in immunology and molecular biology greatly fascinating his audience. His publication list is very impressive and encompasses some of the finest and most important papers ever written in rheumatology and immunology. Naturally, this is reflected by a long list of prizes, most notably the recently awarded Craaford Prize of the Royal Swedish Academy of Sciences. 

Therefore, I truly believe that Dr. Robert Winchester is one of the most outstanding members of the rheumatologic community and he exemplified the best in his research, mentoring, service and administration.

Frank Wollheim, MD: Responding to your intriguing question regarding the greatest rheumatologist a number of candidates emerge. I am thinking of names like Henry Kunkel and several of his students like Bob Winchester, Ralph C Williams, Eng Tan, Morris Ziff Phil Hench, Walter Bauer, Gerry Rodnan, Carwyle LeRoy. I am of course thinking  of Eric G L Bywaters and also of Watson Buchanan, Paul Bacon, George Nuki, Arnold Cats, Josef Smolen, Jochen Kalden, Harry  Moutsopoulos and many others.

But my  choice nevertheless  is Jan Gösta Waldenström, without  whom I would not  have become an internist, and certainly  not a rheumatologist. He was a giant among all the good professors, his charisma attracted us as students, we were fascinated by his skill in communicating with patients and remembering the essential details found in their history or physical examination. He made seminal discoveries by observations of only a couple patients. Jan introduced me to gammopathies and having spent time training with him opened the world, not least in the US.  I have written on JA in Hektoen International, freely available on the web.  

The anecdote is when I returned from my years in Minneapolis in 1965 and told him of the GI tract associated IgA he said. “Very interesting, now I understand why dogs lick their wounds”

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Rheumatologists' Comments

My choice is Newt Rothenberg. Went to Mayo in the early 50s to be a cardiologist. He was still impressed with Dr Hench he became a rheumatologist. He practiced as a solo doc decades and later in his practice he took an associate. He was very supportive of the AF, ACF, Lupus and Scleroderma foundations, volunteered at an indigent rheum clinic at the Detroit medical center, attended virtually every ACR and many international meetings and essentially died in his office. At 78 years old suffered an MI in the office, took aspirin and nitro, saw one more patient and then went to the hospital and never left. He cared for thousands of patients and remained under the radar for decades and known by many of you. And he was my uncle and I miss him. And he deserved to be a master
My choice is Newt Rothenberg. Went to Mayo in the early 50s to be a cardiologist. He was still impressed with Dr Hench he became a rheumatologist. He practiced as a solo doc decades and later in his practice he took an associate. He was very supportive of the AF, ACF, Lupus and Scleroderma foundations, volunteered at an indigent rheum clinic at the Detroit medical center, attended virtually every ACR and many international meetings and essentially died in his office. At 78 years old suffered an MI in the office, took aspirin and nitro, saw one more patient and then went to the hospital and never left. He cared for thousands of patients and remained under the radar for decades and known by many of you. And he was my uncle and I miss him. And he deserved to be a master

More Like This

ACR 2017 - Day 1 Highlights

Curtis and colleagues presented a plenary session that analyzed the duration of drug holidays and the risk of subsequent fractures (FX) in women starting bisphosphonates (BP). They looked at 156,236 women taking BP for 3 years (median 2.1 yrs.) and then discontinuing BP.  20% stopped BP for > 6 mos. and 12.7% restarted BP and 11% died. For those off BP for >2 yrs. there was a 40% increased risk of Hip Fx.

Top 16 Drugs in Rheumatology 2016

Using data compiled from annual reports, SEC filings, press releases, company websites, recently released sales figures show that in 2016, 11 of the top 16 rheumatology drugs demonstrated blockbuster sales (>$1 billion per annum).  Highlights from this report include:

Rheumatologists are Slow to Change DMARDs

The paradigm of rheumatoid arthritis (RA) therapy mandates early diagnosis and aggressive treatment.  Yet a recent cohort study has shown that RA patients with moderate to high disease activity (MHDAS) were met with infrequent DMARD adjustments; with median time to DMARD adjustment being 5 months and median time to low disease activity (LDAS) was roughly 10 months. 

Novel Gel Drug Delivery Developed for Rheumatoid Arthritis

Scientists at the Institute for Basic Science have invented a hydrogel capable of delivering drug at sites of inflammation in disorders such as rheumatoid arthritis. Published in Advanced Materials, this jelly-like material could be used to absorb extra fluids in swelling joints and release drugs wherever nitric oxide is produced in abundance.

2016 EULAR Guidelines on RA Management

The management of rheumatoid arthritis (RA) has evolved significantly with time.  Nevertheless, there are still some uncertainties - such as when, what and which biologic or novel therapy should be used.