As a medical subspecialty, rheumatology was something of a late bloomer until the late 20th century. Even so, the ACR has, since its origins in the 1920s and 1930s, helped to build rheumatology into one of the most internationally collaborative and inclusive medical specialties in the world.
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Explore This IssueOctober 2009
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The Rheumatologist talked recently with two former leaders of the ACR, both ACR Masters, whose foundational efforts helped put rheumatology on the map. One was initially fascinated with connective tissue disorders, and the other preferred to care for chronically ill people. How their career paths intertwined with the ACR is emblematic of its diverse membership and scientific stature.
Lawrence E. Shulman, MD, PhD, served as president of what was then called the American Rheumatism Association (and was renamed the ACR in 1988) from 1975–1976, and later became the first director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (1986–1994) in Bethesda, Md. Herbert Kaplan, MD, medical director and co-founder of the Denver Arthritis Clinic and first distinguished clinical professor of medicine at the University of Colorado Health Sciences Center in Denver, served as president of the ACR from 1993–1994.
Spanning the Growth of the Field
“I had two careers that related to and mutually fed into one another,” says Dr. Shulman, now director emeritus of NIAMS. His first career in rheumatology, following a degree in biology at Harvard University in Boston and a PhD in public health at Yale University in New Haven, Conn., was at Johns Hopkins University in Baltimore in the early 1950s. “That was quite a wonderful education,” he recalls warmly. “It was at that time that cortisone and ACTH [adrenocorticotropic hormone] were discovered to have the most remarkable effects on rheumatoid arthritis. At the same time, the NIH [National Institutes of Health], in its wisdom, was developing graduate training programs in various medical specialties.” When a graduate training program in rheumatology was proposed at the Johns Hopkins Medical Institutions (JHMI), his mentor Dr. A. McGehee Harvey appointed Dr. Shulman director of the Connective Tissue Division.
“When I had the opportunity to start that division, I decided I would deal from strength,” recalls Dr. Shulman. He emphasized “the exotic diseases rather than the more ‘ordinary’ diseases of rheumatoid arthritis and osteoarthritis. And in that way, I was able to attract the very best and brightest of the young house officers; that’s how I built my division.” The division grew and blossomed, training fellows over the next 20 years who went on to become leading investigators in their own rights (such as former ACR President Bevra Hahn, MD, James Fries, MD, and Frank Arnett, MD). Throughout the 1960s and into the early 70s, Dr. Shulman combined his leadership at JHMI with innumerable other collaborations, serving on ARA committees as well as with the Lupus and Scleroderma Foundations. In 1975–76, he served as president of the ARA.
Despite the flurry of activity at top institutions such as Johns Hopkins, divisions of rheumatology were still in short supply in the 1950s and early 1960s when Dr. Kaplan acquired his medical education. He received little exposure to rheumatology while in training. He completed an internship and residency at Duke University in Durham, N.C., as well as a residency and fellowship at Yale, and then joined the Army. While stationed at the U.S. Army Hospital in Munich, Germany, Dr. Kaplan discovered that arthritis was not just “an old person’s disease.”
When he went into practice, Dr. Kaplan serendipitously landed in Denver, where Charley Smyth, MD, one of the field’s founders, had established a division of rheumatology at the University of Colorado. Making rounds each Tuesday morning with Dr. Smyth, Dr. Kaplan became what he calls “an on-the-job-trained rheumatologist,” and on Dr. Smyth’s recommendation, took the specialty exam the first time it was administered in 1972.
One of Dr. Kaplan’s first achievements with the ACR was to arrange bus transportation and hotel facilities when Denver hosted the then-ARA annual meeting in 1965. As his association with the ARA grew, three themes dominated Dr. Kaplan’s active involvement: promoting awareness of the specialty, fostering unity among the ACR’s stakeholders, and building the workforce.
Early Origins and Development of the ACR
The modern rheumatology movement began in 1925 at a Paris meeting when the International Society of Medical Hydrology appointed an International Committee on Rheumatism, which later became the International League Against Rheumatism (ILAR). Three years later, in 1928, the American Committee for the Control of Rheumatism was founded. The ACR traces its official beginnings to the American Rheumatism Association for the Study and Control of Rheumatic Diseases, which sponsored the Third Conference on Rheumatic Diseases and held its first formal business meeting in Cleveland in June, 1934. That program listed 11 papers. The organization later shortened its name to the American Rheumatism Association in 1937, and helped to sponsor the incorporation of the Arthritis and Rheumatism Foundation (the precursor to the Arthritis Foundation) in 1948. In 1965, the ARA merged with the AF and continued to function as the American Rheumatism Association Section of the AF while retaining its independent internal organization and management. In 1986, the ARA ended its association as a Section of the AF, and became the ACR in 1988. Finally, the Arthritis Health Professionals Association, which had also been a section of the AF, joined with the ACR in January 1994, taking the new name of the Association of Rheumatology Health Professionals.
- History of the ACR. Available on line at www.rheumatology.org/about/history/index.asp. Last accessed September 16, 2009.
- Klippel JH, Ed. Primer on the Rheumatic Diseases, 11th Ed. Arthritis Foundation; Atlanta Georgia. 1997.
Not Just a Heberden’s Node
Dr. Kaplan recalls one particularly memorable meeting during his early involvement with the ACR’s lobbying committee. He and his colleagues had arranged to meet with a Colorado senator to talk about funding needs in arthritis research. “Oh, I know all about arthritis!” exclaimed the senator, holding up a finger with a Heberden’s node to show them. “This was his notion, as a knowledgeable senator, of what he thought bad arthritis was,” notes Dr. Kaplan wryly.
The answer for the ACR, he and others were convinced, was to enlist the services of a professional lobbyist and go to The Hill. In those pre-National Arthritis Act days [the legislation was signed by President Gerald Ford in 1975], Dr. Kaplan recalls, many rheumatologists were uneasy with the lobby effort. Many felt that retaining an organization such as The Lewin Group to help promote the needs of the field would taint their research integrity. With time, that attitude dissipated, and the ACR has been quite successful in advancing awareness at the national level.
The Public Sector
In his second related career, Dr. Shulman was responsible for many national initiatives thrusting arthritis and the rheumatic diseases into the limelight. In 1976, Dr. Shulman moved to the NIH to begin work in the federal research enterprise. Although he missed patient care and his relationships with young trainees, he approached his new position as associate director of arthritis with gusto, and found the NIH to be “an exemplary government agency.” Once he became the first director of the officially established NIAMS in 1986, he increased the visibility for arthritis and rheumatology, undertaking major initiatives in lupus, osteoporosis, and Lyme disease, as well establishing new research centers. “While at the NIH, I was able to have the challenge of raising money from Congress so all my colleagues in the medical schools could get supported. Every year I got to go represent the field and talk about what was going on. That was great fun!”
United on All Fronts
Growth in awareness and advancing science all contributed not just to better patient care, but to an increase in ACR membership. Another reason for the ACR’s success has been the ongoing cooperation with patient advocates, such as the Arthritis Foundation, says Dr. Kaplan. He has always believed that a united front best serves the field, and when the ACR split from the AF organization in 1986, he argued passionately against further bifurcation between the clinical and research communities. “Some of us saw a danger in a split between the academicians and the private practitioners, which was threatened on several occasions,” he recalls. “In order for me to take good care of my patients, I needed someone in the laboratory doing research. And the research people, if they wanted to raise money, needed to show what their efforts could produce—and they needed us to demonstrate that.”
The following was the result of many hours of discussion in the early 1990s and engraved, for posterity, on a memo pad given to Dr. Kaplan as a memento of his many years with the ACR.
“What is a rheumatologist? A rheumatologist is an internist or pediatrician who is qualified by additional training and experience in the diagnosis and treatment of arthritis and related disabling and sometimes fatal disorders of the joints, muscles and bones. The rheumatologist provides accurate information to patients with arthritis and their families and serves as an educator of physicians and other health professionals. Many rheumatologists conduct basic science and clinical research, seeking a better understanding of the causes and cures for the more than 100 types of arthritis.”
Source: Herbert Kaplan, MD
An Expanding Reach
Many other factors—including an exponential growth in effective treatments and industry involvement—have contributed to the current increased participation in the Annual Scientific Meeting. Attendance numbers have always been a source of friendly competition among ACR presidents, notes Dr. Kaplan. “It was sort of unspoken, but we each wanted to see who could get the biggest participation at ‘our’ meeting. I thought I was such a hotshot,” he recalls cheerfully, “when there were over 5,000 attendees who came to the Minneapolis meeting in 1994!” (The 2008 Annual Scientific Meeting had over 14,800 attendees.)
International outreach has also been a hallmark of the ACR in the last 20 years, and both Dr. Shulman and Dr. Kaplan have played a role in this trend. Dr. Shulman served as president of the Pan American League Against Rheumatism (PANLAR) from 1982–1986. At the 1994 Annual Scientific Meeting, Dr. Kaplan organized a gathering of European rheumatology professors invited to encourage their greater participation with the ACR. Everyone, he recalls, fit in one room! Now, as indicated by non-U.S. meeting participants and journal article submissions, that outreach has paid off.
And yet, despite all these positive indicators, Dr. Kaplan still worries about the same theme he advanced in his 1994 Presidential Address entitled “My Granddaughter, The Rheumatologist”: the dearth of practicing rheumatologists. The ACR’s proactive efforts, such as the recently published Workforce Study, are aimed at solutions to this challenge.
The challenges throughout the years have not diminished the passion that rheumatologists have for their specialty—a message that comes through loud and clear in conversation with these two leaders of the field. Paraphrasing an article written by Dr. Arnett, a former fellow at JHMI, Dr. Shulman asserts, “Rheumatology is the most intellectually exciting specialty in medicine!”
Gretchen Henkel is a freelance journalist based in California.