In Memoriam: James F. Fries, MD

James F. Fries, MD: 1938–2021

James Franklin Fries was born on Aug. 25, 1938, in Normal, Ill. His mother taught middle school English and his father was a college business professor. Jim graduated from Stanford University in 1960 with a major in philosophy, and received his MD at Johns Hopkins Uni­versity, Baltimore, in 1964. He pursued internal medicine and rheumatology training at the Johns Hopkins before returning to Stanford in 1969, where he advanced to professor of medicine and remained until his retirement in 2017.

Jim Fries made at least four seminal contributions, not only to rheumatology, but also to medical care in general, as well as to general health in the population:

1) In 1976, Jim and Donald M. Vickery, MD, published the first of 10 editions of Take Care of Yourself: A Consumer’s Guide to Medical Care.¹ This book presented the importance of early recognition of symptoms by an individual—whether well with no recognized diagnosis or a patient with a disease—prior to consulting with a physician and/or other health professional in the management of health and disease. More than 20 million copies of the 10 editions have been sold over the years, including versions specifically devoted to arthritis, pediatrics and illustrated guides. The 10th edition, published in 2017, is available as an audiobook.

2) Also in 1976, Jim received the first grant from the National Institutes of Health (NIH) to create a national databank of chronic diseases: ARAMIS (American Rheumatism Association [i.e., now the ACR] Medical Information System, later amended to Arthritis, Rheumatism and Aging Medical Information System).^2-5 ARAMIS was designed as a framework for enrolling and monitoring patients with rheumatic diseases over a lifetime according to standard information.

Jim recognized that much information concerning the course and outcomes of chronic diseases could be found within the medical record but was not collected quanti­tatively or systematically. Therefore, hours of painstaking chart review was required to retrieve the information, and even after hours, extensive data were missing. Standard, quantitative information in ARAMIS, beyond a simple narrative, was designed to be collected systematically into a database to facilitate advances in patient care and outcomes.

ARAMIS provided a home for longitudinal research at sites around the U.S., particularly with data from Frederick Wolfe, MD, and others. Many advances emerged over the years, including improved survival in management of scleroderma renal crisis and recognition of severe gastrointestinal adverse events associated with non-steroidal anti-inflammatory drugs (NSAIDs; i.e., NSAID gastropathy). ARAMIS also served as a focus for novel incorporation of the patient into clinical care at Stanford, such as in the Arthritis Self-Help Course designed by public health nurse Kate Lorig, DrPH. The effectiveness of the course was documented in clinical trials. The importance of self-efficacy, which was described at Stanford by Albert Bandura, PhD, OC, was also recognized in clinical outcomes.

3) In 1980, Jim published “Measure­ment of Patient Outcome in Arthritis,” in collaboration with Patricia Spitz, RN, R. Guy Kraines, MS, and Halsted R. Holman, MD, which presented the health assessment questionnaire (HAQ).⁶ Patient questionnaires had been reported in the rehabilitation literature to provide ancil­lary information to care. Jim introduced the concept of collecting a patient self-report questionnaire in routine clinical care to enhance clinical decisions.

The initial impetus for the HAQ was that about 80% of physician-collected data in ARAMIS remained incomplete. The patient proved a substantially better source than the physician for more complete data. As Jim stated in a 2007 article in The Rheumatologist, “we had been accidentally compelled to invent patient-reported outcomes.” Information provided by the patient in a structured question­naire format was not only more complete, but could also be tracked over time con­siderably more effectively than narrative descriptions entered into a medical record by a physician. Further, information in a standard format completed by patient self-report, without instruction or any inter­action with a health professional, was more reproducible than when collected by a physician or other health professional, a counterintuitive concept that remains unknown or unaccepted even at this time.⁶

The HAQ remains the gold standard for measurement of functional status in clinical trials and many clinical settings, as well as in longitudinal databases, 42 years later, with more than 5,000 citations in the medical literature. Physical function assessed by self-report on an HAQ or derivative was found to be far more significant than laboratory tests or imaging in the prognosis of the most severe outcomes of rheumatoid arthritis, including work disability, costs, joint replacement surgery and premature mortality.

4) The above accomplishments alone would have described a very productive career, but Jim’s most important contribution may have been his conception of the “compression of morbidity,” also published in 1980, with many follow-up publications over the years.^7,8 This idea involves a goal to maintain full functional status and faculties through exercise, diet and other lifestyle considerations available to the individual for as long as possible before one’s inevitable demise. The concept of the compression of morbidity has had a major impact on management of wellness and chronic diseases.

Jim maintained an active lifestyle, including running and mountain climbing, and dispelled some erroneous concepts concerning possible deleterious effects of running in longitudinal studies.⁹

In 1992, Jim and his wife Sarah established the Fries Family Foundation to make annual awards to an individual making a major contribution to the improvement of public health. The prize is presented at the annual conference of the American Public Health Association (APHA). Selection of the recipient is made by a distinguished Prize Jury. Recipients of the prize have included C. Everett Koop, MD, DSc, and David Satcher, MD, PhD, the 13th and 16th U.S. Surgeons General.

Jim endured several personal setbacks. His daughter, Elizabeth, died of breast cancer in 2005. The Fries Family Foundation has also presented an annual Health Education award honoring Elizabeth, presented at the Society for Public Health Education (SOPHE). The prizes of the Fries Foundation are now administered through the CDC Foundation.

Also, in 2005, Sarah developed metastatic melanoma, which left her requiring a wheelchair. Jim insisted they continue to travel extensively, taking cruises and walking tours around the world. His devotion to Sarah was extraordinary—one of us met him once by chance at Heathrow Airport wheeling her around on a European trip—and their optimism and enthusiasm were remarkable.

Jim suffered a debilitating stroke in 2017, and Sarah died within days. A few months later, he moved to Colorado to be near his son, Greg, and died at 83 on Nov. 7, 2021, at an assisted living home in Boulder, Colo. His death was attributed to end-stage dementia. He is survived by Greg and his brother, Ken.

Jim’s legacy is felt daily—in activities in rheumatology, general medicine, public health, and actions of millions of well people and those with arthritis and other diseases whose lives have been improved through Jim’s ideas, vision and accomplishments.

About the Authors

Halsted R. Holman, MD, chaired the Depart­ment of Medicine at Stanford University from 1960, shortly after the medical school moved from San Francisco to Palo Alto, until 1971. He was responsible for the development of a new faculty of young physician/investigators, and together with Hugh McDevitt, MD, chair of the Division of Rheumatology and Immunology, recruited to Stanford James F. Fries, MD, in 1969, Samuel Strober, MD, in 1970 and Theodore Pincus, MD, in 1971. They were the initial five faculty members of the division at Stanford in the 1970s, a group in which each was characterized in some way as the “smartest guy in the room”—Dr. Holman for his incredible organiza­tional and people skills; Dr. McDevitt as one of the founders of immunogenetics; Dr. Fries, a pioneer in outcomes research; Dr. Strober a pioneer in drug-free organ transplantation; and Dr. Pincus for ongoing advances in laboratory and clinical measure­ment of patients with rheumatic diseases. These obituaries are a tribute to the memory of the camaraderie and intellectual excitement of that group.

References

1. Vickery DM, Fries JF. Take Care of Yourself: A Consumer’s Guide to Medical Care. Reading, Mass.: Addison-Wesley Publishing Co.; 1976.
2. Fries JF, Vickery DM. Take Care of Yourself: The Complete Illustrated Guide to Medical Self-Care, tenth ed. Boston: Da Capo/Lifelong Books; 2017.
3. Wolfe F, Fries JF. ARAMIS today: Moving toward internationally distributed databank systems for follow-up studies. Clin Rheumatol. 1987 Sep;6 Suppl 2:93–102.
4. Hess EV, Fries JF, Klinenberg JR. A uniform database for rheumatic diseases. Arthritis Rheum. 1979 Sep;22(9):1029–1033.
5. Weyl S, Fries J, Wiederhold G, Germano F. A modular self-describing clinical databank system. Comput Biomed Res. 1975 Jun;8(3):279–293.
6. Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum. 1980 Feb;23(2):137–145.
7. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. 1980 Jul 17;303(3):130–135.
8. Fries JF. The theory and practice of active aging. Curr Gerontol Geriatr Res. 2012;2012:420637.
9. Lane NE, Oehlert JW, Bloch DA, Fries JF. The relationship of running to osteoarthritis of the knee and hip and bone mineral density of the lumbar spine: A 9 year longitudinal study. J Rheumatol. 1998 Feb;25(2):334–341.