SLE Perspectives: Past, Present, Future Save

From fellowship through current times to looking ahead to the future, here are my lupus perspectives.

PAST: 
I was a fellow at Cedars-Sinai and UCLA from 1977-1979 under Jim Klinenberg (who discovered allopurinol at the NIH and never got a penny from it) and Carl Pearson. We had methotrexate, azathioprine and cyclophosphamide but also went to the weekly gold clinic. There were 14 rheum fellows at UCLA, now there are 7. We had no fax machines, did our progress notes using Larry Weed’s SOAP system, and all the private doctors went to the hospital and did not work for them. We were just starting to develop classification systems for rheumatic diseases (e.g., Bohan and Peter criteria for myositis) and none of the efforts were ACR sponsored. The ACR had just split off from the Arthritis Foundation. Hepatitis C, antiphospholipid syndrome, Lyme disease, silicone implant disease and HIV did not yet exist. Fibrositis was becoming fibromyalgia.

PRESENT:  
I had the chance to buy stock in Epic in 1987, but foolishly passed on the opportunity. We now have electronic medical records, physician assistants, some of our infusion centers are being purchased by venture capitalists. Biologics have been with us for 20 years. Biosimilars have become a curse as they make us spend too much time filling out forms, most of our fellows are now female. Private practice centers are phasing out clinical trials, and over half of us work for hospitals or health plans. Some rheums are establishing concierge practices (cash only). We are dependent on hospitalists rather than primary care physicians. Half of all free standing infusion centers have closed due to reimbursement issues. Almost none of us practice internal medicine now.

FUTURE:  
Lab panels will give way to RNA seq type biomarkers that will tell us what treatments patients will respond to. Precision medicine is ascendant. Combination therapies will become more common. New medications will be developed based on T cell vaccinations, peptide toleragens, promotion of T reg cells, gene therapies, cellular therapies, complement activation, and NETosis among others. More emphasis will be placed on quality of life improvements. Access to rheumatologists will decrease, we will have fewer rheumatology fellows and the management of osteoarthritis will remain frustrating and disappointing. Fewer rheums will manage fibromyalgia and almost all of us will work for somebody!