EMJ Podcast Interview With Dr. Jack Cush Save

Hello, and welcome to the EMJ podcast with me your host, doctor Jonathan Sakia. Today, we have a real pleasure of being joined by Doctor John Cush, he goes by Jack, and he's the executive editor of roomnow.com amongst many other achievements. Doctor Cush is a leading figure in rheumatology, known for his extensive contributions to clinical research, medical education and digital platforms. He currently serves, as I say, as the executive editor of rheumnow.com, which is a premier news and education network dedicated to, the field of rheumatology. And he's also co editor of the online textbook Rheumatology, great name.

With a focus on translational immunology, drug development and safety, Doctor Cush has published over 150 journal articles and has been a key player in numerous clinical trials contributing to the development of critical therapies in rheumatoid arthritis. His recent work includes evaluating the impact of telemedicine in rheumatology, the management of reproductive health in rheumatic diseases, the safety of JAK inhibitors, the, Janus kinase inhibitors, great name. When he's not furthering the field of rheumatology, you can find him fostering his talent for creative writing, and we're gonna get into some of his other creative juices. And the writing was, a passion that began back in his college days when he completed a writing assignment, And that's the first thing I'm gonna ask him about. He's currently writing the script about the challenges of getting into and getting through medical school.

The good doctor is joining us now. So doctor Jack Cush, real pleasure to have you on the show.

Jonathan, thank you so much, to join the podcast. This is a real pleasure for me too.

You know, when one first gets to see someone sort of in the flesh, I wish we were sitting side by side, with a cup of coffee or something. But, I noticed the background and I was first of all going to say to you, please tell us about the writing assignment on the subject of beer, which is, you know, you're clearly a man after my own heart. But I also noticed you've got a lot of guitars in the background. My guitar teacher told me it would be a service to humanity if I put the guitar down and didn't play it. You obviously do play.

Tell us a little bit about beer and your affection for music.

Well, knowing people in music, they do seem to go together, the spirits and the talents. Beer was really probably the job that I held longest before I got into medicine. And that was that when I was in high school, I was employed by a beer distributor. And I stayed there all through high school and college and right into the beginning of medical school. And so I was a bit of a beer jockey.

And when I first went to university at St. John's University in New York, one of my freshmen courses, first courses was on public speaking, which I don't know why I took it, but I'm glad I did because I've been gabbing ever since. And the first assignment was to give a speech on anything. And my first writing effort and speaking engagement was on the history of beer. Thomas Jefferson brought it over on the Mayflower and after that Budweiser took over.

And, you know, it was sort of like about the different types of beer, but it was light and it was funny and little did I know it was not only a public speaking training, but it was also a writing training thing. So, and interestingly, while I had as much access to beer as one could ever want, I don't drink much alcohol at all. I might have two or three beers a year. I appreciate beer, but I don't drink much alcohol at all.

But writing about it. But what about the music, Jack? What got you into playing the guitar and what kind of music, you know, like your desert island discs, if you could take just a few records with you, what would they be? Or play only a certain number of songs, what would they be?

Well, I wish I still had my old posters that I had in my childhood teenage room wall. One was Jackson Brown, the other was the Eagles, the other one was Linda Ronstadt. The whole 1970s was sort of indie rock, but it was called country rock and that sort of thing. Those would be my favorite albums, Warren, Zevon, The Beatles, because you can't go anywhere without them. Yeah.

I mean, I think it's simple rock and roll and it's still, while I like to listen to a lot of new music and live music today, I still revert to the past. And that love of music led to just curiosity and peers who were hacking around on guitars. And we had a bad garage band and played the talent show and finished a proud fourth place when we played in the midnight hour. And it's just now an avocation and something I resort to when I'm wanting to chill out.

Yeah, well, the associations between medicine and music go back a long way and there's a lot of physicians, surgeons who play music and I have high regard for anyone who can do anything well, but people that can do two things even passingly well, have my respect. So you mentioned about, I mentioned actually, and we talked about your project, the challenges of medical school. Can you address that in the current state of medical education, transitioning from traditional to digital? I visited my medical school not too long ago, and they've drastically reduced the amount of time dedicated to anatomy. We used to do eighteen months when I was at med school, eighteen months of anatomy, and that which they do teach, they use a computer screen and not a cadaver.

Is there a danger that we are changing to new things and maybe dangerously throwing out things which we believe definitely did work? So a bit of an open ended question for you.

Well, if you ask a gray haired semi retiring Luddite what their thoughts are on medical education, they're going to hold firm to the belief that their way was the right way, the best way. And I don't know that that's really true. There's clearly a transition going on here. If you see how medical students are learning, we carried around big old heavy textbooks. They're all behind you.

And the current students have none of these. They're learning in electronic forms, portable forms, short forms, and they seem to be keeping up. In fact, they seem to be surpassing us in skill sets that are new. So medical education is changing. Formal medical education, especially in medical schools, I think has been slow to change.

The curriculums have changed as they've become more strained by greater demands. But I do think that the reliance on the old way, the didactic one hour lecture, the four pound telephone book textbook, you know, the doctor's bag, these are part of the past and they're part of the rear view mirror. And the question is, will medicine suffer? If anything, it might suffer from the going digital may lead to greater impersonalization that we're not as hands on, not as face to face, not as eye to eye with our patients as we should be. But I think that the true educators that are out there are paying attention to this and are worried about this.

Yeah, I'm a firm believer in that. One of the first people that inspired me to become a doctor was my general practitioner. And I remember how he was when I was a kid and I had acute appendicitis, making the diagnosis and managing my transfer to the care of a surgeon and how not kind the surgeon was. And I think that element of humanity, that connection, all the knowledge in the world, you can't replace that for a kind hand. Osler said that a good physician should be able, that's obvious, available and affable.

And some of the interactions with the digital domain, standing and looking at a computer screen and not taking the time to look at a patient who is scared and hold their hand and just be kind to them. So I think a lot of those things personally.

In the last few, doctors often learn a little bit too late in life about what medicine really is and what practice should really be. And I must say in the last few years in not having any major medical problems myself, I had a number of family members. I went through things. So I was accompanying them on all their doctor visits and I could quickly spot the great doctor, whether it was young or old. And the unifying feature was eye to eye cares, really cares.

As my uncle said, when he was visiting a neurosurgeon, you know, that guy really gives a damn. And it's very clear. And yet you can still be, you know, advanced in how you learn and the tools you use and whatnot, but caring is still has to be at the root of what we do.

Yeah, and it's called healthcare after all. So let's get into some of the meat of some of the things that you're up to. So I mentioned you're the executive editor of roomnow.com, which also has its own fascinating podcast. I listened to several. You certainly have the a voice made for radio.

You really do. You you you know you've got a very good speaking voice, and it's very engaging in an engaging style. And in in our communication, this is that I'm a one take guy. You come across as very natural and very well informed and not, you know, tightly scripted. It comes across as conversational, which is how we as professionals have always communicated one with another rather than a didactic and bombastic approach.

So I loved the recent one, I Can't Treat Ugly, which I thought was a great title. Very engaging. I love the Neil Young reference. Now I know why you were referencing that. So we'll put a link in the show notes actually to your site, your podcast.

But can you talk to us about topic, one of the topics that you covered in the podcast, SLE and the SLIC index, to give our listeners a sense of what you cover, but first explain the phrase, I can't treat ugly, what you meant by it and how you applied it, then go into SLE.

Yeah, and actually I thought of a line this morning. The line is disease is when imperfection comes to fruition. Sometimes, you know, we're born imperfect and we're gonna flame out at some point or from something and how much that's controllable. And I think that a lot of disease that we treat is we get too late, it's end stage, you really can't treat it. You know, a good example would be osteoarthritis, a degenerative condition of joints.

While someone has pain and disability, I can lessen that, but I can't fix it unless I replace it. And there's so many other conditions that we can get frustrated with. In my world, can be Sjogren's syndrome or fibromyalgia or whatever. And some things I can change and some things I can't. And that's the line I can't treat ugly is ugly is ugly and put a hat on it, put lipstick on it and it's still going to be ugly, but you got to learn to live with it.

So that's the challenge in medical care is bringing in the resources that are at your disposal. And then when you have the resources, you don't give up, you still have to, you know, the people are looking for assistance and help and care. So it was just a funny way of saying that know your limitations, but don't give up. So that's kind of what, and again, the podcast that I do a mistake actually. My website is really an email service that goes out every day to over 10,000 people.

And it was getting hard to come up with five news items a day. And my editor said, well, why don't you just put it do a compilation at the end of the week, you know, of the things that you thought were important this week. What she meant was I should write it down and make it into a written article. I said, heck no, I'm going to do that on YouTube as a video. And then we later turned that into a podcast.

And next thing you know, we have a podcast and that basically is our chance to review the news and things that I thought were important, whether it's a new drug approval or a study that may change practice. And then I, A, report it, but then B, give the perspective that I think people in the field that do what I do will appreciate. So I'm speaking to rheumatologists or anybody that's interested in musculoskeletal medicine. And hopefully my perspective is interesting or helpful.

Well, as someone who's not a rheumatologist and I had to look up a number of the things that you mentioned, but you know, I love going to bed less stupid. It's very engaging. And the SLE, talk to us about SLE and tell us what the SLIC index is, which I didn't know about until I heard it.

I don't remember that report, but SLE is a common disorder. Actually it's more commonly spoken of than it is dealt with meaning that The United States, lupus foundation says there's five million people with lupus, but there isn't, there's only two hundred and ninety nine thousand. And most people don't have enough experience.

Why would the numbers be so radically different?

The foundation wants to get more enrollment and support. Bigger numbers mean more donations and whatever, but they're largely basing that on ANA positivity. And the ANA is wildly inaccurate. I mean, it's uber sensitive, but poorly specific. There are better tests for lupus than is the ANA.

That's the nuclear antibody, yes.

Right, right. As a serologic test for lupus. So again, United States, three thirty million people, there's probably twenty million with a positive ANA, but as I said, only two hundred and ninety nine thousand. So only one in 100 ANAs, if you just scanned everybody or tested everybody, only one in one hundred ANAs means you have lupus. So that's one challenge making the diagnosis.

The other challenge is assessing the activity because lupus is a multisystem disorder. It can affect almost every organ, almost any manifestation could be due to lupus, but those who manage lupus can spot what is really lupus and what is something else. So assessing the disease in a qualitative way or quantitative way. So there are tools and the SLIC index is one tool and it can be used in many ways, both diagnostically, but also to assess the amount of damage. And so these tools become important when you're looking at newer interventions.

And I like tools that are outcome measures that are really superlative. Not that, you know, your sniffles were a little bit better when you use this or that, but the hard outcomes, hospitalization, death, need for surgery. And organ damage is a hard outcome, right? Either you have kidney involvement and glomerulonephritis and lupus, or you don't. And so you're looking at that and that's what's picked up by something like the SLIC index, damage index in lupus.

Very, very cool. And talk to us about a recent approval by FDA of an IL-five, an interleukin-five inhibitor for eosinophilic granulomatosis with polyangiitis, EGPA, also known as Churg Strauss syndrome, I believe.

Right, right, right. Yeah, the nomenclature got to change for a lot of the vasculitides because they were eponyms based on people who we shouldn't be giving eponyms to. And so Wegener's became GPA, granulomatosis with polyangiitis and Chuck Strauss became this EGPA, the eosinophilic form of polyangiitis. And so that's an allergic vasculitis, multisystem vasculitis loves to affect lungs and heart and other systems and can have disastrous outcomes. And in the, you know, in the Tony Fauci days, Tony was working as a rheumatologist and working on vasculitis, it was steroids and cyclophosphamide.

But we've come a long way and now we're having new tools to treat inflammation. And these new, there are two new drugs that have been approved. This one just recently, benralizumab also called Fasenra, it's an IL-five inhibitor. It goes after the allergic component to the vasculitis. So allergic manifestations to this will, and this is usually meant for people with hyper eosinophilic states and also with refractory asthmatic states, but again, its utility in allergic forms of vasculitis.

And so this is an advance to treat a very rare but devastating disease. And you know what, and again, that's what I like to do. I like to keep the audience up to date on the new regulatory things that are happening. Either new drugs are going into trials or they're seeking a new indication or there is actually a new indication. And we learn not just, you know, from what's done at the FDA, but also what's done at Health Canada and NICE and the EMA in Europe, because often what's happening, you know, on your side of the pond is gonna happen on my side of the pond and vice versa.

Yeah, well, it'd also be nice if we could have a little bit more unification of the process to get drugs to the people who need them a lot faster. Irritates the heck out of me. You also mentioned on the podcast, blackcurrants for inflammatory conditions and talked about the gut microbiome and interleukin-one and the role that all berries might play. People have tended, I mean, I was at medical school, who the hell knew about the microbiome, right? And it finds its way into the world of general communications and it gets dumbed down and it's almost certainly extremely complex.

And we know that eating a healthy diet or we believe eating a healthy diet is better than eating garbage in garbage out. But when we come across something specific like this, my ears prick up. Tell us about blackcurrants for inflammatory conditions and berries and inflammatory markers.

Well, would say that that particular report was a small pilot study that looked at postmenopausal women and wanted to look at whether or not black currants might have an effect on bone health and ultimately osteoporosis. I put it up there because I have an interest in berries and cherries and that is a natural product. I mean, I've learned from my patients and my friends that, you know, not all homeopathy and not all nutraceuticals are nonsense, that there is often a science to them. So, you know, dark tart Montemorency cherries are highly effective in treating gout and preventing gout. And there's a biology to that that looks a little bit like celecoxib and the COX-two inhibitors.

And here, the whole berry world is really rich an anti inflammatory and immunologic effects that are surprising. And this particular study, it looked at the fact that black currants did seem to lower IL-one and you look in one beta pro inflammatory cytokine and rank ligand, important in bone health and osteoclast function. And that it turns out that in those women, their bone mineral densities were inversely correlated with rank ligand changes, which meant that theoretically black currants could be healthy for bone health in women at risk for osteoporosis. Those with osteopenia, those who are postmenopausal, white, thin, fair skinned, you know, at high risk, it might make some sense. Other than being touted in a throwaway magazine that, you know, this nutraceutical works, you know, here's some science behind it.

And it's up to the clinician to know the science behind nutraceuticals. I tell my patients, you know, just because it sounds good on a TV advert, or your cousin telling you they want to sell you something out of their trunk of their car. My Cush rule number one is when it comes to over the counter products, the more it costs, the less it works. Meaning, you know, there's an opportunist trying to seek, gain based on your worry and not knowing what to do.

Yeah, and there's a morality issue about that. Actually, I just very recently went to visit a garden sort of in the center of London opened in, I think sixteen seventy something or another, the Chelsea Physic Garden.

And it

was a garden of herbs and you walk around and it's fascinating. You've got belladonna and hyacinth and sativa, you know, the cannabinoids and all the different lime plants that find their way. And of course, elm, elm bark and, you know, source of aspirin. And And then of course, what's the most poisonous plant in this garden? Well, it's the tobacco plant, of course.

It was absolutely fascinating to me how many of them there are and how this has been, you know, foxglove tea was being used to treat dropsy hundreds of years ago. And then of course we discover that, yes, digoxin actually does work. So there's something in this and presumably broader studies are being done with berries and cherries and blackcurrants.

I would assume, I don't know that this 40 patient study was going to change the science world, but obviously you'll get the attention of those who are interested in bone health and those are interested on the other side of the magazine, the nutraceutical people.

Yeah, yeah. But you're better off probably going and buying a punnet of berries or going berry picking. Yeah, might as well do you good as well. Changing subject a little bit, you recently called for the publication on telemedicine in rheumatology. Can you talk to us about the role it can play and where the technology might go?

Easier for patients, right? They don't have to travel, especially if they've got infirmity, more for doctors. It's better for the environment, less paths on the road. Take it away, telemedicine.

Yeah, I'm a big proponent of telemedicine. And I was curious prior to 2020 and then with the pandemic, if you're in medicine, you had to be in telemedicine. Most of us badly and unwantingly into telemedicine. And that shows up today, here we are three, four years later, the pandemic's over and everyone's gone back to their usual way of practice and very few have stayed in the telemedicine industry. But the future of telemedicine is going to be big just as the future of digital learning, virtual learning is going to be important.

I think we have to figure out ways of harnessing telemedicine. I think it expands our capabilities. I think it's a better way of ensuring compliance and engagement. I think that our, we had a committee, American College of Rheumatology funded a committee to study this and that became our publication. And I think when we reviewed the literature, it was clear that telemedicine can be done, can be done with great skill, even though I'm in rheumatology and most of what I do is the careful examination of joints and squeezing to figure out what's swollen, what's malformed, whatever.

I can do a lot and almost the same even by video, right? So yeah, A, telemedicine has to be the right technology. It has to be video and audio, and there has to be an expectation between the doctor and the patient. And there has to be a belief that this is valuable. And then it has to be correctly employed in that it can be very effective for interim visits in people who have an established diagnosis, who are generally stable.

It can be used to quickly assess people who have become out of control or have new complaints and you have to, and they may live, you know, in a different parish or a different County. And the question is, should they make the long trip to come see you or not? Well, a telemedicine screening visit done by an advanced practice provider or done by the doctor or even by the clinic nurse. And the other thing in The United States is we can be paid for remote healthcare and remote health monitoring. You know, previously we thought if we're all, you know, all that stuff we do is uncompensated care, bring the patient in.

So we make sure at least we, you know, can support our effort and what we're doing here. Well, there are pathways now that even remote assessment can be compensated and also quantified and enrolled in, put into your electronic record.

Yeah, absolutely. Yeah, I'm a huge believer as well. And don't want to get the number wrong. Chap I was talking to in the Midwest was saying that they had quantified the impact on the department and said it had been a financial lifesaver for the department because obviously reimbursements have tumbled, in The United States as they have everywhere pretty much. And that they had, tallied the number of miles not traveled.

Right. And made an estimate of the impact on the environment and the impact on the economy of the patients who weren't having to pay for gas for their cars or for public transport. Again, you're dealing with people who've got chronic illness. It's a drag.

So two more things on this one, in 2020, most of us were doing it. By 2022, it was like thirty, forty percent. But at this point, the only people who are doing telemedicine in high numbers is psychiatry and rheumatology is like second or third on the list. And we're like way below fifteen percent. And it tends to be cognitive disciplines as opposed to procedural disciplines.

And that sort of makes some sense, does it not? But the one that cracks me up is dermatology. Every dermatologist I know says, no, we're not going to do telemedicine. Yet the research shows emphatically and clearly that digital camera photos of rashes and skin lesions has great diagnostic utility. So if you're non procedural and you're a visual art or pattern recognition discipline, telemedicine's built for you.

Why turn your back on it? Well, it's the business model and what you're used to and whether you're willing to learn new technology.

Yeah, yeah, it's fascinating. So, Jack, I noticed that you give a talk entitled Five Patients and Five Lessons in RA Care, Rheumatoid Arthritis Care. Can you bullet point the lessons learned, maybe just give us a couple of examples.

Well, I didn't look up that lecture and it is a lecture I've done. Maybe the last time I did that was about nine months ago. Yeah, I think that we learned from patients, number one. And I think that each case, as simple as it may be, has tremendous instructive value. And so that particular lecture has to do with one proper, a case where what's the utility of the labs that were sent to you, patients sent to you by a community doc with a whole bunch of labs and some are misleading and some have great specificity to them.

And then if you don't have a specific lab, should you order them? And where do they go in decision making? Not every person, for instance, who has a new joint ache or pain or bone that's not working right needs to have an x-ray. Know, x rays are only useful if you're ruling out fracture on a new complaint, if you're ruling out a fracture or if you want to establish a baseline assessment for someone. So I can't look at an x-ray and say, ah, you have rheumatoid arthritis, not when your symptoms are six or 12 old, that's not really like likely.

So there's lessons in that lessons on when to switch and where to switch. I mean, one of the major events in the history of rheumatology would be the use of aspirin at the turn of the century, the use of gold in the 1930s, the use of methotrexate in 1984, the advent of TNF inhibitors in 2000. And then we have five TNF inhibitors. And since then we now have like, I don't know, 17 biologics to treat rheumatoid. And the question is, when do you go from the TNF inhibitors to a newer biologic?

Rheumatologists, I use the line dance with the one that brung you, meaning methotrexate made us look good. It delivered us from evil. TNF inhibitors, everyone to get some patients love us because they get this born again feeling and they're back to being functional. And if one fails, do you go to a second one? Do you go to a third one?

Or when do you go to a new one? So that's one of the cases like figuring out when is it prudent to switch your mechanism of action to a different biologic and not just another TNF inhibitor. One of my early research efforts was on the drug called fluorbiprofen made by Upjohn who called the drug NSAID, meaning A N S A I D, which stood for another NSAID. So switching within the same class is really more of the same, and you're going get more of what you got in the past. So I'm kind of a proponent for knowing when to switch.

Yeah,

I've spoken to other of your colleagues over the years about the biosimilars and the use of them and the implications for those, for healthcare systems because of the enormous cost of some of these drugs. And, you know, was talking to a friend of mine who's a fellow surgeon in California, who was bemoaning the fact that within his subspecialty, CMS Medicare reimbursements have dropped eleven percent in the past year. I believe that was the number. And, he said the implications for the I mean, he's a chairman of a department, and he said the implications for his department are dire. They're grim.

Great. And they've got to look at cost savings. Another of my friends who who's a very senior physician over here, and I practiced in The States for many years, he said to me, the only difference between the British and American healthcare systems is Britain is broke and know it, America's broke and hasn't quite figured it out yet. You know, we've got to do something about the cost and in your profession, I know how much it's changed in my professional lifetime. You've got all these amazing new drugs that are life changing for patients, but how do you pay for them?

How do we, as a society reconcile that disconnect?

Well, there's with biosimilars, which are for the lay public, that's like generic medicines that are for the generic version of these very expensive biologic drugs like Humira or Adalimumab and Enbrel or etanercept, which are in many ways lifesaving. And also United States can cost 50 to $70,000 a year. But these generic versions, the biosimilar versions come at a steep discount. So first they really took off in Europe and there was resistance in many of the European countries to use them. And now it's standard.

And most patients go on biologics or going on biosimilars when they're available. In The United States, they've only recently started to take off. And that's because we're complicated by a payer system that's screwy. We have middlemen that jack up the price of the drugs who are called pharmacy benefit managers. And you know, these drugs are incredibly expensive, and they keep increasing the cost of the patient from their co pays.

But the people that run those companies are making billions of dollars. And so we have a very broken system. We're writing checks that we can't pay for. And so now we're getting to the point where biosimilars are now getting adopted. So just for Humira, a drug that in 2022, I believe this is the right number, 2022 sold $22,000,000,000 of drug worldwide.

And that's in 11 different indicated inflammatory conditions, right? It's been biosimilar and there's like a dozen versions of that, 11 versions of that available worldwide, but only in 2023 did they become available in The United States. So here we are almost a year later, we have 11 biosimilars in the market and they've made a big impact, but yet the number one selling version of adalimumab still is Humira, the brand version. So the people who made the brand version dropped their drug costs to compete with the cheaper versions. Why didn't they do that in the beginning?

Right? And then, so there's a lot of lessons that have to be learned the hard way, the painful way, hopefully a less expensive way, but biosimilars are great advances that most of my peers are very much in favor of.

Yeah, sure, fascinating. So Jack, what key advances in the treatment of RA and similar diseases? And I have a couple of dear friends who live with RA, and I've gone on that journey with them. What treatments are at or just over the horizon? Is it going to be, you know, are the new classes of drugs coming?

Are there new diagnostic modalities? What does the future hold?

Well, I think as I mentioned, you know, the milestone advances were aspirin, gold, methotrexate, TNF inhibitors as the first introduction of biologics, the first one approved in 1999. We were working on biologics at Southwestern in Texas in early as 1994. And we've learned a lot. And I think that the biologics and combination drug use, just like in cancer have become the mainstay, the corner cornerstone and change outcomes dramatically. I think the newer things, we're getting a lot more me too drugs, you know, and that's great for business and marketing and, you know, but it's not really changing the outcomes, right?

And a brand new drug gets approved. It's only going to be used in a small margin of people. And will it be a major advancement? We don't know. So finding better ways of using existing drugs, I think that the new recent advances are treatment of preclinical disease.

So rheumatoid arthritis is when you have a polyarthritis, five, six, seven joints involving right and left sides, small and large joints, chronic with inflammation. But what about when a relative of one of those people has just joint pain with no swollen joints? Oh, and their blood tests for rheumatoid are positive. We tend to call that, preclinical, disease or clinically suspect arthralgia and will interventions make a difference there? So there's a lot of research in this area.

There's still a lot of concern in this area. A recent publication I've put on RheumNow was it is cost effective to use a drug like methotrexate in those people because you can prevent disease in a subset up to twenty percent of those people. So that seems to be interesting, but not everybody needs aggressive therapy and not everybody needs expensive therapy. The other thing is, you reset the immune response? Do you know what an etch a sketch is?

Yeah, yeah, yeah.

Okay, can you etch a sketch a disease? Can you shake the patient up and let them have a reset to their immune system where it's not going to go back to normal? And that I think is happening now with this advance in CAR T cell therapies, which where you're designing, engineering, very specific interventions. And, you know, colleagues, my colleague in Erlangen, Doctor. Georg Schett and his colleagues have a tremendous set of data on lupus patients and autoimmune patients where, they're three, four years after treating a cohort of like 10 patients, 15 patients, I think now.

And those people stop taking all their anti rheumatic therapies, stop their immunosuppressive, stop their loop, their prednisone, their disease went to zero. Their labs went to zero. They've been in remission. They've done a reset on the immune system and they're following these people serially. And now there's like 40 companies getting involved in the CAR T cell business.

Will that be a major advance? I think it sounds really, really exciting at this point. I don't know what's going to live up to the hype at this point. And then in the future, you know, what's the next major advance? I think that's going to come from probably another discipline rather than within rheumatology and probably different thinking and maybe through AI and systems thinking, because it's a little bit like anatomy.

If we take apart the body and understand each muscle tendon, whatever, do you understand the whole? And that's not really true, right? I mean, you can understand the parts, but do you really understand the whole because you can name every little organ or tissue. And I think it's the same with the immune system. We're taking it apart, we're dissecting it, and we're finding certain advantages, but it doesn't yet go to whole, meaning it still only treats a subset of people.

It still doesn't work in the vast majority of people. More importantly, the more specific the therapies get with biologic or genetic interventions, we're not given the tools to know who exactly to give it to. That it will not just work in half the people, which was better than the twenty percent who got placebo, but it will work in ninety percent of people with the right biomarker, with the right genetic marker. So those are the advances that we're waiting on that I think are on the horizon.

Yeah, so using AI more as a means of, well, of gathering big data and projecting and then deploying resources appropriately, which is going to be more cost effective and also stop people taking drugs that if a drug works, it almost certainly has side effects. And if it has side effects, they may be tolerable if they help your disease, but if they don't help your disease, that's not on, is it?

Yeah, AI is going to help drug development. It's going to shorten timeline of drug development and the cost of drugs being developed. It's going to minimize adverse events. There are so many advantages from the development side and the research side in making new therapies for disease. AI is going to be a model.

And this is sort of like where I like AI and futuristic medicine. AI is called, it's generative AI, meaning it takes all the information out there and puts it together. But if I ask a specific question of AI and it comes back to me with a lot of novel suggestions, it's not supplanting what I do because now I take that sometimes ridiculous recommendations, sometimes brilliant recommendation, but I can now put it in perspective. And as an expert in whatever area, I can put that to work and build something better. So I see AI as a very important tool in many areas of medicine.

Yeah, I'll put it akin to you and I can both remember that days of going to the medical library and getting an index medicus and then trying to find that journal in the stack. And if it wasn't there ordering it from a central library and photocopying it and then having to read it. Now you can just go and Google the whole darn thing and get a list of references and all will keep

All on your phone while you're at McDonald's, Yeah,

well, or even better at the local whole food, fruit shop eating There you go. So Jack, to close out, finally a question that I like to ask everyone. If you had three wishes for the future of rheumatology, what might your wishes be?

Number one, wider use of APPs, advanced practice providers, nurse practitioners, and physician assistants. But with that must come appropriate training so that they can hit the ground running and become very competent practitioners as they do wherever they land, whether it's in orthopedics or dermatology or whatever. And that's going to fix our major problem, which is a manpower problem. Second would be greater use of, as I said, AI and rules for drug use. I keep watching the movie Moneyball and reading the book Moneyball by Michael Lewis, which is about how do you recognize the right people for the right situation and using big data to get there.

And as great as I'd like to think I am, or that I might sound like I think I am, When I'm prescribing my next disease modifying drug, I really am flipping a coin. I really am flipping a coin. So you're hoping your doctor's got a lot of experience and knows based on what happened to you, the patient before that he's going to know the right choice going forward based on what failed in the past. And that is a real skill. But at the same time, need money ball and data integration into decision making to make me even better.

And my last wish would be that that the learners learn that the way that they learn before, needs to change if they want to stay abreast. Meaning, how are you going to do virtual learning versus on-site learning? Are you going to still go with the textbooks or are you going to subscribe to more journals? Are you going to get them on your phone? Are you going to go with new services that can curate that information for you?

And then how are you going to learn when you go to a big conference? RheumNow, we cover a big conference in teams and we do these team efforts. And I'll tell you the people who learn the most going to a four day conference in a foreign city where 2,000 abstracts are being presented. The people who learn the most are the people that work for RheumNow because they work in teams and they share information and they do crosstalk panels and whatever. And as opposed to, I'm just going to the meeting to meet up with my friends.

I'm just going to free wheel it and see what I stumble upon. And that session wasn't very good and this session could have been better, whatever. But I think finding a better way of learning would be my hope for the future.

Very practical wishes. And I rather sense that you're going to be the guy to help bring these things to the fore. Unfortunately, that's all we've got time for today. I really want to thank, doctor Jack Cush for being with us today. Real pleasure chatting to you, and I wish that we could, chat further and maybe get together and maybe maybe on that occasion you could have one of your two annual beers with me.

And bring a guitar while we're there.

Oh God, God forbid. You could teach me something. I very much doubt that. But thank you very much, Jackie.

Thank you, Jonathan.

So folks, please check out the podcast, the EMJ podcast and subscribe. And that way you'll never miss an episode. And if you like it, and if you're listening to me, my voice drone on at this point, you probably Subscribe so you never miss an episode. Tell your friends, leave a review, blah, blah, blah. You know the score.

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