Last month’s column promised you a solution to rheumatology’s dual problem of a shrinking workforce and rapidly expanding patient population. Without further ado, here is the solution for rheumatology’s crisis that my colleagues and I devised at the EULAR congress in Barcelona: The members of the ACR, through the Research and Education Foundation, should cooperate with stakeholders – patients, patient organizations, foundations, industry, civic groups, medical schools, hospitals, and government – to raise money so that every academic rheumatology division in the country has an endowment to support its mission.
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Explore This IssueSeptember 2007
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What is the mission and why is it important? At its core, this mission is to train the next generation of rheumatologists to provide outstanding care to patients and to continue the momentum in treatment advances that our specialty currently enjoys.
This initiative differs fundamentally from other funding mechanisms that focus on raising money for research. Research funding is often a proxy for academic activities and serves as a channel for support of rheumatology divisions. In this model, efforts to bolster the academic units are predicated on grant programs that target rheumatic disease. While grant programs have enormous importance, they do not address the need for the infrastructure for training programs or the presence of clinician-educators to lead, mentor, and inspire trainees. Alas, research programs can involve cost shifting, with funds designated for clinical or laboratory investigation subsidizing the time for teaching.
I can easily argue that, at present, there is no shortage of funding for research in rheumatology and there is likely no shortage of investigators. The issue is distribution. While the ranks of rheumatologists in academic centers may be thin, those in industry are booming. The companies are the source of terrific research and are filling the pipeline with myriad new products, some of which will no doubt be very successful.
Pharmaceutical companies employ large numbers of basic and clinical investigators in rheumatology. Indeed, there has been a remarkable flux of academic rheumatologists to the companies, a trend discussed by ACR past president Peggy Crow in her presidential address. These individuals contribute enormously to the field but their mission is distinct. They do not train rheumatologists for the future.
The other difficulty in trying to help academic centers through research programs is that disease-related research is not the sole province of rheumatologists – nor should it be. Research grants should be awarded to the people with the best ideas, whatever their discipline or academic affiliation. There are many PhD scientists who are outstanding rheumatology investigators and there is every reason to support their research as well as that conducted by physicians.
Fund Education Directly
To support training programs, we have to develop a different funding model that separates research from the education and training missions. The need is especially pressing given the location of training programs in large medical centers. With the movement of rheumatology care into the outpatient arena in these centers, our specialty will be ineluctably threatened in an environment where the big inpatient specialties dominate and the proceduralists generate the largest flow of money.
The more our group of lounge lizards chewed on the idea of the endowments, the better it seemed. Indeed, we became downright giddy as we conjured this appealing path to financial stability for our mission.
Inevitably, reality had to set in. “How much do you think it would cost?” one of the more sober members of our group asked.
Quickly, we did some calculations on the back of a napkin. To make the enterprise succeed, each academic unit would need an endowment of about $4 million: $1 million for an endowment for a fellow each year and $3 million for an endowed rheumatology chair. Let us project the need for 200 endowments to fund existing adult and pediatrics program as well as a healthy boost in the number of pediatrics programs. That way we are well stocked to take care of babies and baby boomers alike. The price tag for that plan would be about $800 million, but we can round off to an even $1 billion.
Depending on your point of view, that is or is not a big sum of money. I will not get into making comparisons between expenditures on healthcare and other societal outlays (like bombers, bridges, or space flights), but – for the whole endowment enchilada – we are in the range of salary for the New York Yankees for a few years. As everybody knows, they are now big losers, despite the millions of dollars thrust upon A-Rod and Roger Clemens.
Nevertheless, $1 billion is a lot of money and would take about 10 million bake sales to raise. As the magnitude of the task sunk in, it seemed that the thinking of our group had run amok outside the protective walls of our usual boxes. Maybe we were jet-lagged or had let our heads bake in the sun or had imbibed too many free drinks. The executive lounge, you see, had an open bar that provided libations gratis to the lucky inhabitants of the executive floor. Imbued with the warmth and ease of Southern Europe, perhaps some of us had overindulged and lost our bearings.
Whatever the source of our extravagant musings, it was time to get back inside the box, or at least inside the bus for the trip across old Barcelona to EULAR’s 60th birthday party in the Parc Guell.
Good Things Are Worth the Work – and the Wait
If nothing else, the party was lively and energetic. It was held in a lush, sprawling park high above the city. The park was designed by Gaudi, a visionary architect who also created the Sagrada Família, a magnificent church that has been under construction for more than 100 years. As I learned when I toured the church, at the current pace, it will likely take at least another 20 years for completion. Even in its unfinished state, however, the church is one of Europe’s most famous attractions. Suffice it to say, Gaudi thought outside the box and created a style that is variously organic and quirky, outrageous and thrilling in its ambition.
The party at the park had a carnival atmosphere worthy of Mardi Gras. Lipsticked men in green satin shirts sang and mimed. Dancers with large puppets on their shoulders paraded through the crowded park grounds. The dinner was tapas city as the partygoers sampled a mélange of Spanish food – octopus, sausage, beans – all fragrant and boldly seasoned with peppers. Fortunately, Rioja was in abundance to smooth the taste of the spicy food.
At dusk, drums thumped as a large procession of dancers and musicians descended from a grove of trees that overlooked the large expanse where we ate. Leading the procession were women with streaming black hair and iridescent blue body paint. To raucous music, they paraded in a conga line. As the women danced around the park grounds, the night air exploded with a barrage of flash bulbs amidst “ohs” and “ahs” of awe and disbelief at the women’s attire.
As many walked to gaze upon the blue women, I went in the opposite direction to the edge of the park and looked into the distance. As the sun set over the Mediterranean, the jagged edge of Sagrada Família inscribed a blue-black line against the red glow of the evening sky. With my fifth glass of Rioja jazzing my mind, I returned to the conversation with my colleagues in the lounge and I became convinced – if not enthralled – by the endowment idea that we had conjured earlier in the day.
No doubt about it, I said to myself as the sound of drums pummeled the air and the lights of Barcelona shimmered in the falling darkness, it is time to think outside the box. Let us create a grand vision for rheumatology and raise $1 billion for our future.
As I learned from visiting Sagrada Família, if it takes a hundred years, so what? For something great in the world, it is more important when we start than when we finish.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center.