Arthritis & Rheumatism Official Journal of the American College of Rheumatology
ACR PRESIDENTIAL ADDRESS /-
LOOKING BACK AND LOOKING AHEAD Five Years of the American College of Rheumatology ROBERT F. MEENAN This year marks the fifth anniversary of the American College of Rheumatology as an independent organization. I would like to use the occasion of this 1991 ACR Presidential Address to look at what the College has accomplished in the past five years, to take stock of its current status as a professional association, and to point out the main issues that I think the ACR must address during the next five years. From July I, 1965 until January I , 1986, the American Rheumatism Association operated as a section of the Arthritis Foundation. By the mid-I980s, however, it became clear that the ARA needed more freedom and flexibility, and so it was decided that the ARA should separate from the Arthritis Foundation. A formal agreement to that effect was drawn up, add the ARA became a separate and independent entity on January 1, 1986. Many of you recall that this was a time of some consternation (Table 1). The most obvious concem for the new ARA was: Can we do it? Can the ARA really survive, never mind thrive, as an independent oqanization. This pessimism was fed by other attitudes that Presented at the 55th Annual Meeting of the American College of Rheurnatology, Boston, MA, November 1991. Robert F. Meenan, MD, MPH, MBA: Professor of Medicine and Director, Multipurpose Arthritis Center, Boston University School of Medicine, Boston, Massachusetts, and President, American College of Rheumatology, l!XW-1991. Address renrint reauests to Robert F. Meenan. MD. MPH. MBA, Boston UniGersity h h r i t i s Center, 80 East Concord'Street; Boston, MA 021 18. Submitted for publication December 5, 1991; accepted December 5. 1991.
,
Arthritis and Rheumatism, Vol. 35, No. 3 (March 1992)
349
were prevalent at the time. Could our academic-based members and our practice-based members agree on the goals and programs of the new professional association? In other medical subspecialties, town-gown conflicts had led to schisms and the development of separate organizations for research and clinical members. Many in the ARA were concerned that the same thing could happen to rheumatology, and some actually felt that it should happen. Another prevailing attitude was that rheumatologists were an endangered species. We had no special recognition from third-party payors, we had no defining procedures to perform, and it was difficult if not impossible to demonstrate the effectiveness of our cognitive and management skills. Feeding into all of these negative attitudes was an overriding concern about the current and future status of medicine as a profession. Researchers bemoaned the tightening of research dollars, while clinicians were depressed and angry over increasing practice restrictions and decreasing practice incomes. Many physicians, seeing an erosion of their professional and economic status and comparing their lot with the riches and upbeat attitudes of colleagues in business and finance,-expressed second thoughts about their career choice and began to Steer their children away from medicine. All in all, January of 1986 was perhaps not the most propitious time to be achieving independence. Yet the mowth of the ACR in the past five Years, the strength of its organizational & st &e a n d finances, and the effectivenessOf its pro@ms the wisdom of that decision. When one looks at what
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Table 1. Prevailing attitudes: 1986
Can we do it? Towwown codicts Rheumatologists as an endangered species Medicine no longer an appealing career
has been accomplished, it is clear that the ACR has flourished, rather than floundered. Let us pause at this point in our brief history as an independent organization to look at what has been accomplished. It is an impressive list of achievements, and I will only consider some of the highlights. Organizational planning has been perhaps the most basic and important new development within our organization during the past five years. Planning is not dramatic, but it is absolutely essential. An effective planning process requires lots of hard work, but the long-term returns are enormous. One of the first things that the leadership of the new ARA did was to make a serious commitment to both short- and long-term planning. A specific committee, the Planning Group of the Board of Directors, was assigned the responsibility for this task. This group submitted its first formal report to the ARA Board of Directors on June 1,1986. It was entitled Toward the Year 2000-A Report and Plan. This report looked at trends in medicine in general and in rheumatology in particular, defined short- and long-term goals for the ARA and its major councils, and set down specific, quantified objectives that could be used to assess the attainment of these goals. During the past five years, a formal and highly effective planning process has been implemented that combines short- and long-term planning activities. Once each year, the Planning Group meets to review projects proposed by the major councils and committees of the organization. Each proposal is assigned a grade based on its relevance to the goals of the organization, its feasibility, and its costs. Since there are always many more projects proposed than there are project dollars available, only the most relevant and meritorious projects receive high enough grades to earn funding. This process ensures that projects are not initiated without broad support, and it guarantees that proposed projects will be thought out in enough detail to permit evaluation. At a separate meeting each year, the Planning Group focuses on long-range planning discussions. At these meetings the overall goals of the organization are considered in light of developing trends, and goals and
objectives are appropriately updated. The ARA began with four goals in the initial Planning Group report of 1986. We now have ten goals, each of which relates directly to the overall mission of our organization, which is to be the single professional society for rheumatologists, dedicated to the needs of its members and providing unified leadership in research, in education, and in the care of people with rheumatic diseases. One example of the impact of planning has been the development of a communications capability within our professional association. The initial discussions of the Planning Group clearly indicated that both internal and external communications would be vital in achieving the goals of the new organization. These discussions led to a change in our name and our logo. In late 1988 the American Rheumatism Association became the American College of Rheumatology (Figure 1). The new name was chosen carefully, with much thought given to how it communicated our professionalism and our field of interest. The new logo was also chosen with careful attention to how it communicated our vision and our major areas of activity. The round, somewhat passive logo of the ARA, with its caduceus and Greek lettering, was replaced by a bold, upwardpointing triangle in which research at the base illuminates and supports education and treatment along the arms. The new Communications and Marketing Committee of the College has made other contributions during the past few years. ACR News has been established as a formal and indispensable organ of internal communications between the leadership and membership. A Hotline bulletin has been developed to rapidly inform the membership about medical news items that patients may ask about. Various activities in media and public relations have been undertaken, including the provision of media training for leaders and interested members, the development of standard definitions and messages for volunteers and staff involved in media contacts, and expansion of the media relations
AKERICAN
BHEUHATISN ASSOCUTIOU
AMERICAN COLLEGE OF
RHEUMATOLOGY
Figure 1. Organization names and logos: 19861991.
ACR PRESIDENTIAL ADDRESS
efforts associated with our Annual Meeting. These activities have resulted in increased media coverage for the ACR and for rheumatology. The Communications Committee has also conducted periodic membership surveys. The 1989 survey provided the ACR with a wealth of information on its members and their activities. This information has been immensely helpful to the College in evaluating ongoing activities and in assessing support for proposed activities. The Communications and Marketing Committee plans to carry out a second membership survey in 1992. Continued participation by the membership and appropriate responses from the leadership are critical to the success of this effort. Education programs were always a major focus of the old ARA, and they have continued to be an important focus for the new ACR. The College’s Education Council and its Professional Meetings Committee have worked over the past five years to put on better and better educational meetings for the membership. The annual meeting has substantially improved in terms of both quality and quantity, so that it now truly serves as a valuable meeting for the entire membership. At any time during the meeting, researchoriented members and practice-oriented members can find sessions that are relevant to their interests. The Education Council has also worked to strengthen the regional meetings and to develop a series of new educational offerings. The Council has achieved accreditation from the Accrediting Council for Graduate Medical Education. ACGME accreditation means that the ACR can now provide CME credits for members and other physicians who attend the College’s educational programs, including the national and regional meetings. The Education Council has helped develop a new publication entitled Primary Care Rheumatology. PCR is designed to educate non-rheumatologists, especially general internists and family physicians, about the diagnosis and treatment of musculoskeletal diseases. It currently has a circulation of 30,000 physicians. PCR, which earns a profit for the College via drug advertisements, also conveys our messages about the role of the rheumatologist and the benefits of appropriate subspecialty referral. The Education Council has also developed a model curriculum for teaching rheumatology to medical students and house officers. The new model curriculum has been reviewed by the many medical students who were invited by the ACR to attend this national meeting. It will be modified based on their input.
25 1
The Council on Rheumatologic Care (or CORC), which focuses on issues that relate to the practice of rheumatology, has been one of the most active components of the ACR during the past five years. CORC has developed a strong lobbying capability that has been used to influence health policy decisions that have a bearing on rheumatology in particular, and the cognitive and management aspects of internal medicine in general. The ACR has lobbied steadily on such issues as the Resource-Based Relative Value Scale, changes in coding for office visits and procedures, and the recognition of rheumatology as a distinct subspecialty of internal medicine for reimbursement purposes. In some activities, such as the initial Relative Value Scale study conducted by the Harvard School of Public Health and the Physician Log Diary Project, rheumatology has been the only subspecialty of internal medicine designated to participate. The activities of CORC have produced some very important results. The Health Care Financing Administration recently released its revised list of recognized subspecialties to be used by third-party payors for developing practice profiles and evaluating claims. For the first time, rheumatology is included on this list, which is expected to be utilized by virtually all payors. This recognition will have some important effects, such as allowing a rheumatologist to be paid for a consult the same day that a patient is seen by his or her general internist. It will also result in the development of more relevant practice profiles so, for example, our patients will not have payment denied when they receive frequent tests to monitor the drugs that we use. CORC efforts have resulted in improvements in coding for different types of office visits and consultations. Visits will now be more clearly coded based on the amount of thought and effort devoted to the patient. Specific scenarios have been developed to help rheumatologists learn how to code more appropriately for the complex and lengthy encounters that we often have with patients. CORC lobbying, in concert with the efforts of other medical associations, has also led the Health Care Financing Administration to reconsider its global fee proposal. As a result, rheumatologists will likely be allowed to bill for an office visit and an arthrocentesis on the same day, rather than having the procedure included within a single global fee. A modifier code number will be developed to clearly indicate that the carrier should also pay for the arthrocentesis as a separate and significant procedure.
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Table 2. American College of Rheumatology growth: 1986-1991
1986
People Members Volunteers Staff Finances (%) Income Expenses Reserves Annual Meeting Attendees Abstracts submitted Abstracts accepted Concurrent sessions Study groups Meet-the-Professor
1991
3,879 150 13
5,150 300 20
2,263,000 2,187,000 446,000
4,300,000 3,700,000 3,950,000
2,264 879 550 28 9 8
3,500 I .83 I 952 37 19 58
The ACR Research Council has also developed a lobbying capability. For the past few years, the ACR has given written and verbal testimony to both the House and Senate Appropriations Committees that consider the NIH budget. The Research Council also participates with CORC in a formal program in which a research member and a practitioner member join with a patient from the appropriate voting district. They pay conjoint visits to key Senators and Representatives in Washington when the NIH budget and other issues relevant to rheumatology are being considered. In fiscal year 1992, these efforts helped produce a 25-million-dollar increase in the research budget of the Arthritis Institute, the second-largest increase at NIH. The Research Council has overseen the efforts of the ACR to become involved in the direct funding of research. The Council developed the plans and guidelines for the ACR Arthritis Investigator Award, a $70,000-per-year grant to a promising young physicianinvestigator. The first such award was given this year. The Research Council has also been the driving force behind a plan to increase the funding of the ACR Research and Education Foundation and to use these funds to support additional research training. Other components of the ACR have also played a role in our successes during the past five years. Arthritis und Rheumutism has solidified its stature as the world’s premiere rheumatology journal. The Directors of Rheumatology Training Programs has produced a directory of training programs to aid and inform prospective fellows. The training directors group has also produced an important study of rheumatology manpower that clearly indicates the need for more arthritis specialists.
The effects of these various ACR activities can be summarized by examining a series of key numbers (Table 2). In terms of human resources, the membership of the College has increased by roughly one-third, from 3,900 to nearly 5,200. Over 300 members now work as volunteers on ACR committees and other activities, which represents a substantial increase from 1986. The number of full-time staff based at the College’s new administrative offices in Atlanta has increased by half, and the quality of the staff has increased as well. All of the individuals who head departments within the ACR are highly competent professionals. The financial growth and strength of the ACR are also quite impressive. In the past five years, the annual income of the College has nearly doubled, while membership dues and annual meeting registration fees have increased by less than 80% each. The expenses of the College have also increased, but to a lesser extent. These trends have resulted in a healthy annual surplus, which has been used to fund the reserves of the College. Each year, a substantial portion of these reserves is assigned to the Research and Education Foundation to build the ACR’s capacity to support rzsearch and other worthwhile activities. The changes in our annual meeting serve as additional indications of the important growth that has occurred in the ACR over the past five years. Attendance at the meeting has grown steadily, increasing by over 50% in the past five years. A growing number of attendees come from overseas, testifying to the fact that the ACR annual meeting is fast becoming the most important international meeting in our specialty. The vitality of rheumatology research and the importance of the ACR annual meeting as a forum for presenting that research are attested to by the remarkable increase in the number of abstracts submitted. This number has grown steadily over the past few years, with 1,000 abstracts being submitted in 1988, 1,200 in 1989, 1,400 in 1990, and over 1,800 in 1991. The meeting has been expanded to accommodate this growth in attendance and in submitted abstracts. This year 952 abstracts will be presented in either oral or poster sessions. The number of concurrent sessions and symposia has been greatly increased to meet the diverse educational needs of our many attendees. The number of study groups has more than doubled in an attempt to provide a common meeting ground for those with particular clinical and research interests, and the highly popular Meet-the-Professor program has been greatly expanded.
ACR PRESIDENTIAL ADDRESS
But something else has happened over the past five years that is more important and, I believe, more impressive than the changes in the numbers themselves. The prevailing attitudes within our organization have changed (Table 3). While we remain realistic and recognize the evolution that continues to occur in medicine, the prevailing attitudes tend to be much more optimistic than they were in 1986. The most important change has been in our attitude about the potential of this organization. Whereas in 1986 we asked, “Can we do it?” we now state emphatically “We can do it!” The last five years have confirmed the wisdom of our separation from the Arthritis Foundation. Steady growth in membership and in financial reserves clearly demonstrates the strength and vitality of our professional issociation. Other important attitudes have also changed for the positive in the past five years. We have come to recognize that there is strength in unity. The potential for town-gown conflicts has given way to the reality of town-gown collaboration. Researchers and practitioners have recognized the merit of each other’s craft, and they now work together in a variety of ACR activities. Whereas in 1986 we thought of ourselves as an endangered species, we can now look Gith pride on ourselves as a “dangerous” species. Our unity, our energy, and our skills have made it clear to many in the health-care arena that we are a highly effective organization that consistently has an impact that exceeds the size of our membership. We have also come to recognize that the disabling effects of the rheumatic diseases and the steady aging of the population make the need for rheumatologists more apparent with each passing year. Last but not least, many of us have begun to recognize that medicine, while it is clearly changing, still has unique appeals as a profession. We recognize that we are fortunate to spend most of our professional activities in trying to help others, and we are all continually inspired by the human contact and gratitude of our patients. Many of us, myself included, now encourage our children when they express an interest in a medical career. We have indeed come a long way in the past five years, in terms of both our activities and our Table 3. Prevailing attitudes: 1991
We can do it! ! Town-gown collaboration Rheumatologists as a “dangerous” species Medicine has unique appeals
253
Table 4. Key American College of Rheumatology issues: 19911996
Rheumatology manpower Practice guidelines Outcomes research Research funding Arthroscopy Access to care
attitudes. But now it is time to look ahead at the next five years. The health-care environment is changing steadily, and we must keep pace. We must identify the issues that will require our attention over the next five years, and we must take steps to deal with them. Although predicting the future, even just a few years ahead, is always chancy, I believe that certain issues will be the critical ones for the ACR during its next five years (Table 4). Our specialty needs to deal forcefully with a growing manpower problem. Medical students continue to forsake careers in rheumatology for careers in higher-paying, procedure-oriented medical specialties or to forsake internal medicine completely for the very lucrative surgical specialties. Relative value-based reimbursement will only slightly reduce the relative financial appeal of other specialties to students and house officers saddled with huge education debts. As a professional association, we need to rekindle the interest of students and internal medicine trainees in rheumatology. We need to become model teachers and use every opportunity to convey the excitement of what we do. We need to emphasize the important personal and lifestyle advantages of our cognitive and management specialty. We need to examine more closely what we do in our practices. The old axiom that the practice of medicine is an art rather than a science is increasingly less valid. As Jack Stobo pointed out in his 1990 ACR Presidential Address, one of the characteristics of a profession is that it establishes and enforces a set of standards. While we have long done this in education and training, we must now begin to do it in rheumatology practice as well. We need to work as a group to develop consensus guidelines for the practice of rheumatology. We also need to begin looking formally at the cost and effectiveness of the services we provide. This can only be done by the ongoing collection of data in practice. I believe that the ACR needs to be on the forefront of using office-based computer approaches to collect those data. Such an effort will involve us even more explicitly in another activity that distinguishes a
254
profession: addressing issues that affect the public good. We must also remain active in efforts to increase funding for rheumatology research. This work must include continued efforts on the political front to increase the budget for the NIH Arthritis Institute. However, we must also work on other fronts by actively seeking corporate sponsorship of ACR research programs and by contributing as individuals to the ACR Foundation. Two other issues, arthroscopy and access to care, will clearly require our attention. The technology of arthroscopy has advanced to the point where officebased, diagnostic arthroscopy with local anesthesia is now a practical procedure. It is not clear whether and to what extent rheumatologists should or will become involved with arthroscopy in their practices or in their training programs. On the one hand, the adoption of arthroscopes by rheumatologists has the potential to change our subspecialty the way that endoscopes and bronchoscopes changed gastroenterology and pulmonology. On the other hand, if the new type of arthroscopy comes into widespread use before its indications and potential benefits are more clearly defined, then we may as a subspecialty contribute to the serious national problems of overutilization and rising medical costs. The access-to-care issue will involve us as citizens and as physicians, and not just as rheumatologists. Millions of Americans, including families and working people, do not have adequate access to health care because they do not have health insurance. The ACR is already a member of a major coalition of physicians’ organizations that supports improved access to care. However, recent election results and steady attention by the media clearly indicate that medical care costs and health insurance reform will be important national issues during the next five years. The ACR will need to make decisions on which general approaches and which specific legislation it will support. In order to continue our success over the next five years, we must build on our organizational strengths. First and foremost, the ACR must continue to support a strong and formal planning process that has both short- and long-term elements. We must judge our proposed activities critically, and we must continually reexamine our goals and objectives. The purpose of planning is to draw a map for movement. During the past five years, the planning map of the ACR has indeed inspired, directed, and facilitated
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movement. It must continue to do so if we are to be nearly as successful over the next five years. We must continue to develop committed and talented leadership that will work to set the directions and policies of the College. We must encourage members to participate in the activities of the College. Committed members are the ACR’s most important asset. The College must also continue to protect and strengthen its professional staff and its financial resources. If we continue to work together and build on our strengths, then I firmly believe that the fortunate individual who serves as ACR President in 1996 might proudly focus his or her Presidential Address on the accomplishments of the ACR during its first ten years as an independent professional association. I once thought that thanks at the end of an address such as this were perfunctory. But I now realize how appropriate they really are. First of all, I want to thank you, the membership of the ACR, for giving me the opportunity to serve as your President for the past year. I thank all of you for your support, and I thank many of you for your efforts as ACR volunteers. 1 want to thank the ACR staff for all their hard work. I especially want to acknowledge the work of Mark Andrejeski, the Executive Vice-president of the College. Mark was an invaluable help to me during the year as 1 sought to carry out my duties as President. He is a true professional, and his efforts on our behalf have been a key to the success of the ACR during the past five years. Thanks are also due to my colleagues at the Boston University Arthritis Center, who supported me through the year not only with their encouraging words but also with their time, as they covered for me whenever I needed to be away on ACR business. And finally, thanks to my family for all of their help and support. My wife, Lynda, and my children, Molly and Mark, tolerated my busy schedule and remained the type of family that I was always happy to come home to. My parents, both of whom turn 81 this year, have given me a lifetime of encouragement and support. They have also helped me develop an attribute that we all want for our children: the ability to feel good about oneself and one’s work. After five years of independence, the ACR has every right to feel good about itself and its work. Much has been accomplished in the past five years. With continued planning, dedicated leadership, and sustained effort, much more will be accomplished in the next five years.
ACR PRESIDENTIAL ADDRESS /-
LOOKING BACK AND LOOKING AHEAD Five Years of the American College of Rheumatology ROBERT F. MEENAN This year marks the fifth anniversary of the American College of Rheumatology as an independent organization. I would like to use the occasion of this 1991 ACR Presidential Address to look at what the College has accomplished in the past five years, to take stock of its current status as a professional association, and to point out the main issues that I think the ACR must address during the next five years. From July I, 1965 until January I , 1986, the American Rheumatism Association operated as a section of the Arthritis Foundation. By the mid-I980s, however, it became clear that the ARA needed more freedom and flexibility, and so it was decided that the ARA should separate from the Arthritis Foundation. A formal agreement to that effect was drawn up, add the ARA became a separate and independent entity on January 1, 1986. Many of you recall that this was a time of some consternation (Table 1). The most obvious concem for the new ARA was: Can we do it? Can the ARA really survive, never mind thrive, as an independent oqanization. This pessimism was fed by other attitudes that Presented at the 55th Annual Meeting of the American College of Rheurnatology, Boston, MA, November 1991. Robert F. Meenan, MD, MPH, MBA: Professor of Medicine and Director, Multipurpose Arthritis Center, Boston University School of Medicine, Boston, Massachusetts, and President, American College of Rheumatology, l!XW-1991. Address renrint reauests to Robert F. Meenan. MD. MPH. MBA, Boston UniGersity h h r i t i s Center, 80 East Concord'Street; Boston, MA 021 18. Submitted for publication December 5, 1991; accepted December 5. 1991.
,
Arthritis and Rheumatism, Vol. 35, No. 3 (March 1992)
349
were prevalent at the time. Could our academic-based members and our practice-based members agree on the goals and programs of the new professional association? In other medical subspecialties, town-gown conflicts had led to schisms and the development of separate organizations for research and clinical members. Many in the ARA were concerned that the same thing could happen to rheumatology, and some actually felt that it should happen. Another prevailing attitude was that rheumatologists were an endangered species. We had no special recognition from third-party payors, we had no defining procedures to perform, and it was difficult if not impossible to demonstrate the effectiveness of our cognitive and management skills. Feeding into all of these negative attitudes was an overriding concern about the current and future status of medicine as a profession. Researchers bemoaned the tightening of research dollars, while clinicians were depressed and angry over increasing practice restrictions and decreasing practice incomes. Many physicians, seeing an erosion of their professional and economic status and comparing their lot with the riches and upbeat attitudes of colleagues in business and finance,-expressed second thoughts about their career choice and began to Steer their children away from medicine. All in all, January of 1986 was perhaps not the most propitious time to be achieving independence. Yet the mowth of the ACR in the past five Years, the strength of its organizational & st &e a n d finances, and the effectivenessOf its pro@ms the wisdom of that decision. When one looks at what
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Table 1. Prevailing attitudes: 1986
Can we do it? Towwown codicts Rheumatologists as an endangered species Medicine no longer an appealing career
has been accomplished, it is clear that the ACR has flourished, rather than floundered. Let us pause at this point in our brief history as an independent organization to look at what has been accomplished. It is an impressive list of achievements, and I will only consider some of the highlights. Organizational planning has been perhaps the most basic and important new development within our organization during the past five years. Planning is not dramatic, but it is absolutely essential. An effective planning process requires lots of hard work, but the long-term returns are enormous. One of the first things that the leadership of the new ARA did was to make a serious commitment to both short- and long-term planning. A specific committee, the Planning Group of the Board of Directors, was assigned the responsibility for this task. This group submitted its first formal report to the ARA Board of Directors on June 1,1986. It was entitled Toward the Year 2000-A Report and Plan. This report looked at trends in medicine in general and in rheumatology in particular, defined short- and long-term goals for the ARA and its major councils, and set down specific, quantified objectives that could be used to assess the attainment of these goals. During the past five years, a formal and highly effective planning process has been implemented that combines short- and long-term planning activities. Once each year, the Planning Group meets to review projects proposed by the major councils and committees of the organization. Each proposal is assigned a grade based on its relevance to the goals of the organization, its feasibility, and its costs. Since there are always many more projects proposed than there are project dollars available, only the most relevant and meritorious projects receive high enough grades to earn funding. This process ensures that projects are not initiated without broad support, and it guarantees that proposed projects will be thought out in enough detail to permit evaluation. At a separate meeting each year, the Planning Group focuses on long-range planning discussions. At these meetings the overall goals of the organization are considered in light of developing trends, and goals and
objectives are appropriately updated. The ARA began with four goals in the initial Planning Group report of 1986. We now have ten goals, each of which relates directly to the overall mission of our organization, which is to be the single professional society for rheumatologists, dedicated to the needs of its members and providing unified leadership in research, in education, and in the care of people with rheumatic diseases. One example of the impact of planning has been the development of a communications capability within our professional association. The initial discussions of the Planning Group clearly indicated that both internal and external communications would be vital in achieving the goals of the new organization. These discussions led to a change in our name and our logo. In late 1988 the American Rheumatism Association became the American College of Rheumatology (Figure 1). The new name was chosen carefully, with much thought given to how it communicated our professionalism and our field of interest. The new logo was also chosen with careful attention to how it communicated our vision and our major areas of activity. The round, somewhat passive logo of the ARA, with its caduceus and Greek lettering, was replaced by a bold, upwardpointing triangle in which research at the base illuminates and supports education and treatment along the arms. The new Communications and Marketing Committee of the College has made other contributions during the past few years. ACR News has been established as a formal and indispensable organ of internal communications between the leadership and membership. A Hotline bulletin has been developed to rapidly inform the membership about medical news items that patients may ask about. Various activities in media and public relations have been undertaken, including the provision of media training for leaders and interested members, the development of standard definitions and messages for volunteers and staff involved in media contacts, and expansion of the media relations
AKERICAN
BHEUHATISN ASSOCUTIOU
AMERICAN COLLEGE OF
RHEUMATOLOGY
Figure 1. Organization names and logos: 19861991.
ACR PRESIDENTIAL ADDRESS
efforts associated with our Annual Meeting. These activities have resulted in increased media coverage for the ACR and for rheumatology. The Communications Committee has also conducted periodic membership surveys. The 1989 survey provided the ACR with a wealth of information on its members and their activities. This information has been immensely helpful to the College in evaluating ongoing activities and in assessing support for proposed activities. The Communications and Marketing Committee plans to carry out a second membership survey in 1992. Continued participation by the membership and appropriate responses from the leadership are critical to the success of this effort. Education programs were always a major focus of the old ARA, and they have continued to be an important focus for the new ACR. The College’s Education Council and its Professional Meetings Committee have worked over the past five years to put on better and better educational meetings for the membership. The annual meeting has substantially improved in terms of both quality and quantity, so that it now truly serves as a valuable meeting for the entire membership. At any time during the meeting, researchoriented members and practice-oriented members can find sessions that are relevant to their interests. The Education Council has also worked to strengthen the regional meetings and to develop a series of new educational offerings. The Council has achieved accreditation from the Accrediting Council for Graduate Medical Education. ACGME accreditation means that the ACR can now provide CME credits for members and other physicians who attend the College’s educational programs, including the national and regional meetings. The Education Council has helped develop a new publication entitled Primary Care Rheumatology. PCR is designed to educate non-rheumatologists, especially general internists and family physicians, about the diagnosis and treatment of musculoskeletal diseases. It currently has a circulation of 30,000 physicians. PCR, which earns a profit for the College via drug advertisements, also conveys our messages about the role of the rheumatologist and the benefits of appropriate subspecialty referral. The Education Council has also developed a model curriculum for teaching rheumatology to medical students and house officers. The new model curriculum has been reviewed by the many medical students who were invited by the ACR to attend this national meeting. It will be modified based on their input.
25 1
The Council on Rheumatologic Care (or CORC), which focuses on issues that relate to the practice of rheumatology, has been one of the most active components of the ACR during the past five years. CORC has developed a strong lobbying capability that has been used to influence health policy decisions that have a bearing on rheumatology in particular, and the cognitive and management aspects of internal medicine in general. The ACR has lobbied steadily on such issues as the Resource-Based Relative Value Scale, changes in coding for office visits and procedures, and the recognition of rheumatology as a distinct subspecialty of internal medicine for reimbursement purposes. In some activities, such as the initial Relative Value Scale study conducted by the Harvard School of Public Health and the Physician Log Diary Project, rheumatology has been the only subspecialty of internal medicine designated to participate. The activities of CORC have produced some very important results. The Health Care Financing Administration recently released its revised list of recognized subspecialties to be used by third-party payors for developing practice profiles and evaluating claims. For the first time, rheumatology is included on this list, which is expected to be utilized by virtually all payors. This recognition will have some important effects, such as allowing a rheumatologist to be paid for a consult the same day that a patient is seen by his or her general internist. It will also result in the development of more relevant practice profiles so, for example, our patients will not have payment denied when they receive frequent tests to monitor the drugs that we use. CORC efforts have resulted in improvements in coding for different types of office visits and consultations. Visits will now be more clearly coded based on the amount of thought and effort devoted to the patient. Specific scenarios have been developed to help rheumatologists learn how to code more appropriately for the complex and lengthy encounters that we often have with patients. CORC lobbying, in concert with the efforts of other medical associations, has also led the Health Care Financing Administration to reconsider its global fee proposal. As a result, rheumatologists will likely be allowed to bill for an office visit and an arthrocentesis on the same day, rather than having the procedure included within a single global fee. A modifier code number will be developed to clearly indicate that the carrier should also pay for the arthrocentesis as a separate and significant procedure.
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Table 2. American College of Rheumatology growth: 1986-1991
1986
People Members Volunteers Staff Finances (%) Income Expenses Reserves Annual Meeting Attendees Abstracts submitted Abstracts accepted Concurrent sessions Study groups Meet-the-Professor
1991
3,879 150 13
5,150 300 20
2,263,000 2,187,000 446,000
4,300,000 3,700,000 3,950,000
2,264 879 550 28 9 8
3,500 I .83 I 952 37 19 58
The ACR Research Council has also developed a lobbying capability. For the past few years, the ACR has given written and verbal testimony to both the House and Senate Appropriations Committees that consider the NIH budget. The Research Council also participates with CORC in a formal program in which a research member and a practitioner member join with a patient from the appropriate voting district. They pay conjoint visits to key Senators and Representatives in Washington when the NIH budget and other issues relevant to rheumatology are being considered. In fiscal year 1992, these efforts helped produce a 25-million-dollar increase in the research budget of the Arthritis Institute, the second-largest increase at NIH. The Research Council has overseen the efforts of the ACR to become involved in the direct funding of research. The Council developed the plans and guidelines for the ACR Arthritis Investigator Award, a $70,000-per-year grant to a promising young physicianinvestigator. The first such award was given this year. The Research Council has also been the driving force behind a plan to increase the funding of the ACR Research and Education Foundation and to use these funds to support additional research training. Other components of the ACR have also played a role in our successes during the past five years. Arthritis und Rheumutism has solidified its stature as the world’s premiere rheumatology journal. The Directors of Rheumatology Training Programs has produced a directory of training programs to aid and inform prospective fellows. The training directors group has also produced an important study of rheumatology manpower that clearly indicates the need for more arthritis specialists.
The effects of these various ACR activities can be summarized by examining a series of key numbers (Table 2). In terms of human resources, the membership of the College has increased by roughly one-third, from 3,900 to nearly 5,200. Over 300 members now work as volunteers on ACR committees and other activities, which represents a substantial increase from 1986. The number of full-time staff based at the College’s new administrative offices in Atlanta has increased by half, and the quality of the staff has increased as well. All of the individuals who head departments within the ACR are highly competent professionals. The financial growth and strength of the ACR are also quite impressive. In the past five years, the annual income of the College has nearly doubled, while membership dues and annual meeting registration fees have increased by less than 80% each. The expenses of the College have also increased, but to a lesser extent. These trends have resulted in a healthy annual surplus, which has been used to fund the reserves of the College. Each year, a substantial portion of these reserves is assigned to the Research and Education Foundation to build the ACR’s capacity to support rzsearch and other worthwhile activities. The changes in our annual meeting serve as additional indications of the important growth that has occurred in the ACR over the past five years. Attendance at the meeting has grown steadily, increasing by over 50% in the past five years. A growing number of attendees come from overseas, testifying to the fact that the ACR annual meeting is fast becoming the most important international meeting in our specialty. The vitality of rheumatology research and the importance of the ACR annual meeting as a forum for presenting that research are attested to by the remarkable increase in the number of abstracts submitted. This number has grown steadily over the past few years, with 1,000 abstracts being submitted in 1988, 1,200 in 1989, 1,400 in 1990, and over 1,800 in 1991. The meeting has been expanded to accommodate this growth in attendance and in submitted abstracts. This year 952 abstracts will be presented in either oral or poster sessions. The number of concurrent sessions and symposia has been greatly increased to meet the diverse educational needs of our many attendees. The number of study groups has more than doubled in an attempt to provide a common meeting ground for those with particular clinical and research interests, and the highly popular Meet-the-Professor program has been greatly expanded.
ACR PRESIDENTIAL ADDRESS
But something else has happened over the past five years that is more important and, I believe, more impressive than the changes in the numbers themselves. The prevailing attitudes within our organization have changed (Table 3). While we remain realistic and recognize the evolution that continues to occur in medicine, the prevailing attitudes tend to be much more optimistic than they were in 1986. The most important change has been in our attitude about the potential of this organization. Whereas in 1986 we asked, “Can we do it?” we now state emphatically “We can do it!” The last five years have confirmed the wisdom of our separation from the Arthritis Foundation. Steady growth in membership and in financial reserves clearly demonstrates the strength and vitality of our professional issociation. Other important attitudes have also changed for the positive in the past five years. We have come to recognize that there is strength in unity. The potential for town-gown conflicts has given way to the reality of town-gown collaboration. Researchers and practitioners have recognized the merit of each other’s craft, and they now work together in a variety of ACR activities. Whereas in 1986 we thought of ourselves as an endangered species, we can now look Gith pride on ourselves as a “dangerous” species. Our unity, our energy, and our skills have made it clear to many in the health-care arena that we are a highly effective organization that consistently has an impact that exceeds the size of our membership. We have also come to recognize that the disabling effects of the rheumatic diseases and the steady aging of the population make the need for rheumatologists more apparent with each passing year. Last but not least, many of us have begun to recognize that medicine, while it is clearly changing, still has unique appeals as a profession. We recognize that we are fortunate to spend most of our professional activities in trying to help others, and we are all continually inspired by the human contact and gratitude of our patients. Many of us, myself included, now encourage our children when they express an interest in a medical career. We have indeed come a long way in the past five years, in terms of both our activities and our Table 3. Prevailing attitudes: 1991
We can do it! ! Town-gown collaboration Rheumatologists as a “dangerous” species Medicine has unique appeals
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Table 4. Key American College of Rheumatology issues: 19911996
Rheumatology manpower Practice guidelines Outcomes research Research funding Arthroscopy Access to care
attitudes. But now it is time to look ahead at the next five years. The health-care environment is changing steadily, and we must keep pace. We must identify the issues that will require our attention over the next five years, and we must take steps to deal with them. Although predicting the future, even just a few years ahead, is always chancy, I believe that certain issues will be the critical ones for the ACR during its next five years (Table 4). Our specialty needs to deal forcefully with a growing manpower problem. Medical students continue to forsake careers in rheumatology for careers in higher-paying, procedure-oriented medical specialties or to forsake internal medicine completely for the very lucrative surgical specialties. Relative value-based reimbursement will only slightly reduce the relative financial appeal of other specialties to students and house officers saddled with huge education debts. As a professional association, we need to rekindle the interest of students and internal medicine trainees in rheumatology. We need to become model teachers and use every opportunity to convey the excitement of what we do. We need to emphasize the important personal and lifestyle advantages of our cognitive and management specialty. We need to examine more closely what we do in our practices. The old axiom that the practice of medicine is an art rather than a science is increasingly less valid. As Jack Stobo pointed out in his 1990 ACR Presidential Address, one of the characteristics of a profession is that it establishes and enforces a set of standards. While we have long done this in education and training, we must now begin to do it in rheumatology practice as well. We need to work as a group to develop consensus guidelines for the practice of rheumatology. We also need to begin looking formally at the cost and effectiveness of the services we provide. This can only be done by the ongoing collection of data in practice. I believe that the ACR needs to be on the forefront of using office-based computer approaches to collect those data. Such an effort will involve us even more explicitly in another activity that distinguishes a
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profession: addressing issues that affect the public good. We must also remain active in efforts to increase funding for rheumatology research. This work must include continued efforts on the political front to increase the budget for the NIH Arthritis Institute. However, we must also work on other fronts by actively seeking corporate sponsorship of ACR research programs and by contributing as individuals to the ACR Foundation. Two other issues, arthroscopy and access to care, will clearly require our attention. The technology of arthroscopy has advanced to the point where officebased, diagnostic arthroscopy with local anesthesia is now a practical procedure. It is not clear whether and to what extent rheumatologists should or will become involved with arthroscopy in their practices or in their training programs. On the one hand, the adoption of arthroscopes by rheumatologists has the potential to change our subspecialty the way that endoscopes and bronchoscopes changed gastroenterology and pulmonology. On the other hand, if the new type of arthroscopy comes into widespread use before its indications and potential benefits are more clearly defined, then we may as a subspecialty contribute to the serious national problems of overutilization and rising medical costs. The access-to-care issue will involve us as citizens and as physicians, and not just as rheumatologists. Millions of Americans, including families and working people, do not have adequate access to health care because they do not have health insurance. The ACR is already a member of a major coalition of physicians’ organizations that supports improved access to care. However, recent election results and steady attention by the media clearly indicate that medical care costs and health insurance reform will be important national issues during the next five years. The ACR will need to make decisions on which general approaches and which specific legislation it will support. In order to continue our success over the next five years, we must build on our organizational strengths. First and foremost, the ACR must continue to support a strong and formal planning process that has both short- and long-term elements. We must judge our proposed activities critically, and we must continually reexamine our goals and objectives. The purpose of planning is to draw a map for movement. During the past five years, the planning map of the ACR has indeed inspired, directed, and facilitated
MEENAN
movement. It must continue to do so if we are to be nearly as successful over the next five years. We must continue to develop committed and talented leadership that will work to set the directions and policies of the College. We must encourage members to participate in the activities of the College. Committed members are the ACR’s most important asset. The College must also continue to protect and strengthen its professional staff and its financial resources. If we continue to work together and build on our strengths, then I firmly believe that the fortunate individual who serves as ACR President in 1996 might proudly focus his or her Presidential Address on the accomplishments of the ACR during its first ten years as an independent professional association. I once thought that thanks at the end of an address such as this were perfunctory. But I now realize how appropriate they really are. First of all, I want to thank you, the membership of the ACR, for giving me the opportunity to serve as your President for the past year. I thank all of you for your support, and I thank many of you for your efforts as ACR volunteers. 1 want to thank the ACR staff for all their hard work. I especially want to acknowledge the work of Mark Andrejeski, the Executive Vice-president of the College. Mark was an invaluable help to me during the year as 1 sought to carry out my duties as President. He is a true professional, and his efforts on our behalf have been a key to the success of the ACR during the past five years. Thanks are also due to my colleagues at the Boston University Arthritis Center, who supported me through the year not only with their encouraging words but also with their time, as they covered for me whenever I needed to be away on ACR business. And finally, thanks to my family for all of their help and support. My wife, Lynda, and my children, Molly and Mark, tolerated my busy schedule and remained the type of family that I was always happy to come home to. My parents, both of whom turn 81 this year, have given me a lifetime of encouragement and support. They have also helped me develop an attribute that we all want for our children: the ability to feel good about oneself and one’s work. After five years of independence, the ACR has every right to feel good about itself and its work. Much has been accomplished in the past five years. With continued planning, dedicated leadership, and sustained effort, much more will be accomplished in the next five years.
