Volunteering Is Informative—and Fun

For the past three years, I have had the honor of serving on the ACR Board of Directors. Based on that experience, I feel qualified to provide members some insight into the work that our professional organization does on our behalf. The summaries of the board’s activities that are publicly released do not convey the whole story, or the nuances of the board’s work.

Three years ago, I authored an article for The Rheumatologist on my impressions of my first board of directors meeting (“Hard Work Behind the Scenes,” May 2009). Now, I wish to extend that effort. This article will chronicle this rheumatologist’s interpretation of the activities of the board over the past three years. It will not, by any means, catalogue all of the activities or mention all of the contributions made by literally hundreds of individuals involved in the board’s work. Rather, it will highlight a few issues that are likely on the minds of ACR members.

People Are Key

First, some background on the ACR as an organization. The board is the governing body of the ACR and it supervises, controls, and directs the business and affairs of the ACR, its committees, publications, purposes, and funds. The board leads the charge and the committees implement the work. The vast majority of the work is actually performed at the committee and subcommittee levels by the volunteer members and staff, who get their mandates and funding from the board. The organization is very structure oriented. This has advantages and disadvantages. One advantage is that all projects and activities have a home in at least one committee, with the exception of task forces, most of which report directly to the board of directors. The committees take ownership of the project, which facilitates the project’s successful completion. The committee decision-making model of a highly structured organization like the ACR is both an advantage and a disadvantage. The advantage is that decisions are normally made by consensus. Ideas initiated by a small group (e.g., a subcommittee) are improved upon when discussed in the larger group (e.g., the full committee) and finally approved by the board. The disadvantage is that consensus building among rheumatologists can be time consuming (the term “herding cats” is often used). The ACR has never been described as “nimble,” but on the whole, the process works. It has been this consensus-building interaction with colleagues from diverse backgrounds, whom I otherwise might never have met, that has been the most rewarding aspect of my ACR volunteer experience.

Any professional organization is only as good as the volunteers and staff that lead it. When one sits on the board, one has the privilege of working intimately with the president of the ACR, and we have had three fine presidents over the past three years: Sherine Gabriel, MD, MSc, professor of medicine and epidemiology at the Mayo Clinic in Rochester, Minn.; Stanley Cohen, MD, at Rheumatology Associates in Dallas; and David Borenstein, MD, at Arthritis and Rheumatism Associates in Washington, D.C. They each placed their personal stamps on their year. Sherine’s quiet demeanor allowed board members to fully vocalize their views. Nevertheless, she ran efficient and productive meetings. Stan’s year was a contrast in styles. Never shy to confront controversy, Stan had a year notable for considerable heated debate on many issues, but he always found a way to guide the discussion to a fruitful conclusion. David’s year was remarkable for his desire to improve pain management; he set that as an objective for the organization. Note that the presidents often alternate between the “practice oriented” and the “academic oriented” background, in keeping with the all-embracing mission of the ACR to advance rheumatology.

Mark Andrejeski is not only a diehard Pittsburgh Steelers fan (which endears him greatly to me), but has been the ACR’s executive vice-president for the past 25 years. I can only hope he will work for the ACR for a great many more years. His experienced hand has seen the organization through lean financial times to our current strong fiscal position. I am pleased to report the ACR abounds in outstanding and experienced staff in key positions, giving the committees institutional memory and perspective. They assist the committee chairs, who rotate every three years. Turnover among ACR staff is extremely low, a testimony to the organization’s leadership, and staff morale always seems high. Nevertheless, because rheumatology is a relatively small cognitive specialty, when it comes to staffing numbers and projects, we must exercise more budgetary restraint than the much larger primary-care physician organizations and the wealthier procedure specialties. We must always wisely select our staff, our projects, and our battles.

The Committee on Communications and Marketing, chaired by Eric Matteson, MD, chair of rheumatology at the Mayo Clinic, crafted a public relations campaign to promote rheumatology. It is not easy to create a promotional campaign that does not appear to be a self-serving product. The campaign is sophisticated, yet has a very simple targeted message: “Simple tasks can become impossible because of rheumatic disease.” Members should be pleased. I am not sure why the ACR never before conducted such a campaign. The need to inform key stakeholders, collectively referred to as “influencers,” of who we are and what we do seems obvious to me now. The message has even been shown on a jumbo electronic billboard in New York City’s Times Square. Perhaps some day we will not have to explain what a rheumatologist does. And how does Eric have time to do this and still research the history of vasculitis figures like Kussmaul and Wegener, run his unit at the Mayo Clinic, and conduct clinical research, all in his spare time?

Practice and Education

Another issue that has occupied board attention is the role of musculoskeletal ultrasound. It has been in widespread use among European rheumatologists for years, but the use of musculoskeletal ultrasound in the U.S. has been limited. The utility of the procedure was highlighted in an ACR white paper published in 2010.¹

There are many barriers to the utilization of ultrasound by U.S. rheumatologists. Responding to member interest, the board established a Musculoskeletal Ultrasound Task Force, charged with developing a business plan for a musculoskeletal ultrasound certification program. This group, chaired by Ralf Thiele, MD, assistant professor of medicine, allergy/immunology, and rheumatology at the University of Rochester Medical Center in Rochester, N.Y., did a job task analysis, market research, and an environmental scan. Its work led to specific recommendations for a musculoskeletal ultrasound certification program that should lead to recognition by external entities. The task force’s recommendations have now been adopted by the board. The costs involved are not inconsequential, but combined with the courses offered by the ACR and the “Train-the-Trainers” musculoskeletal ultrasonography program designed to train ultrasound champions at each of the fellowship programs, widespread use of this technology will likely become more prevalent in U.S. rheumatology practices. Because it is difficult to teach an old dog new tricks, I doubt that I will learn to do the procedure, but I would like my fellows to have the opportunity to be trained.

The Committee on Training and Workforce (COTW), chaired by Abby Abelson, MD, chair of the department of rheumatic and immunologic diseases at the Cleveland Clinic, has witnessed significant growth among training programs in the number of rheumatology fellows. Some of this growth stems from the ACR Research and Education Foundation’s direct support. The COTW helps fellowship programs stay abreast of the changing requirements for training. Abby can rightly be described as a champion of diversity. She would foster further gender and ethnic diversification in our specialty.

A COTW group led by Marcy Bolster, MD, professor of medicine at the Medical University of South Carolina in Charleston, has developed a standardized rheumatology curriculum that could be used to teach rheumatology to all internal medicine residents. It should be available soon to all training programs. Another group, led by John FitzGerald MD, MBA, MPH, PhD, assistant professor of medicine at the University of California, Los Angeles, has proactively looked at improving access to rheumatologists. Dr. FitzGerald’s subcommittee has systematically analyzed the geographic distribution of rheumatologists, identifying underserved areas throughout the U.S. The next step will be to develop additional and alternative strategies to meet those identified access needs. John not only serves on this committee, but chairs the gout guideline development workgroup, sees patients, and does clinical research at UCLA.

The Committee on Education, chaired by Richard Furie, MD, professor of medicine at Hofstra North Shore-LIJ School of Medicine in Hempstead, New York, continues to improve the ACR Annual Meeting, one of the ACR’s survival functions. The most recent meeting in Chicago last November was the largest and best ever. The meeting continues to grow, and I do not like to miss one. The clinical tracks are easier to navigate, although I must say it is getting more difficult to select which session to attend among all the great choices. The recently board-approved Session­Select, where attendees can view sessions that they missed, will be a much-used option. I wish we could get CME for viewing SessionSelect

The editorial team of The Rheumatologist deserves accolades for nurturing the maturation of the ACR’s newest publication. David Pisetsky, MD, PhD, professor of medicine and immunology at Duke University Medical Center in Durham, N.C, the inaugural editor, guided The Rheumatologist to fill a niche for members offering a smorgasbord of medical reviews, news, commentary, editorials, business practice updates, and general human-interest articles. Where else can you get up-to-the-minute practice management “news I can use”? I read it from cover to cover every month.

Advocacy On Many Fronts

We are a small medical subspecialty, but we now have a much louder voice on Capitol Hill. Through the efforts of RheumPAC, the ACR’s political action committee led by its inaugural chair, Gary Bryant, MD, associate professor of medicine at the University of Minnesota Medical School in Minneapolis, and the Government Affairs Committee, chaired by Timothy Laing, MD, associate professor of medicine at the University of Michigan in Ann Arbor, we have more access to Congressional members and their staff than ever before. Members of Congress now know what a rheumatologist does. The organized yearly trip to the Hill in September has grown to be a successful event. The visits to Congress are a great civics lesson in American politics and I highly recommend that members to go to Washington, D.C., to meet with their representatives and advocate for issues important for rheumatic disease patients and rheumatology. The ACR will pay your way. Gary not only chairs RheumPAC, but is also one of the ACR’s American Medical Association representatives. He does that, sees patients, and runs the department of medicine faculty practice at the University of Minnesota.

The Insurance Subcommittee within the Committee on Rheumatologic Care (CORC) is led with great enthusiasm by Rudy Molina, MD, of Arthritis Associates PA in San Antonio, Texas, now has established working relationships and contacts at many national and regional carriers so that problems with carrier policies, prior authorizations, and coverage issues can be addressed. If you have established contacts with your local carrier, call Rudy if you would like to serve. The carriers will often pay attention to the ACR when they ignore the complaint of a single provider.

Quality of Care

A great change is coming to the practice of rheumatology as “quality of care” occupies center stage. Anticipating the need to establish quality measures and management guidelines before the carriers do, the Quality of Care Committee, currently chaired by Kenneth Saag, MD, MSc, professor of medicine at the University of Alabama at Birmingham, has systematically drafted the guidelines and measures critical to our profession. Most of us understand the ACR had to be proactive to develop these before others less knowledgeable and perhaps not as protective of patient interests drafted them. This has been an extraordinary undertaking, with much more to be done. It would be prudent for all members to become knowledgeable about these guidelines and measures and begin to implement them in their practices. In the near future, provider reimbursement will be tied to how we score on these quality measures. Although there are those that feel this effort only adds more administrative burden without evidence of benefit, I feel that quality of care will significantly improve as a result of these labors.

It has been gratifying to see the progress of the Committee on Rheumatologic Care (CORC) Health Information Technology (HIT) subcommittee, now part of the Committee on Registries and Health Information Technology (RHIT) that was created in 2010. Through the efforts of CORC, chaired by Charles King, MD, of North Mississippi Health Services at Tupelo, Miss., and RHIT, chaired by Peter J. Embi, MD, MS, assistant professor and vice chair of biomedical informatics at The Ohio State University in Columbus, recommendations and advice now flow regularly and frequently to members on such issues as choosing an electronic medical record (EMR) for your office and how to satisfy regulatory requirements for your EMR. They are a great member resource if you have HIT questions. The Registry Task Force—initially chaired by James O’Dell, MD, director of the Internal Medicine Residency Program and division chief of rheumatology at the University of Nebraska, Omaha, who is now the ACR President—developed the infrastructure to capture patient information to help members satisfy their Practice Improvement Module for Maintenance of Certification. It will be important in the future to prove your quality to carriers, and participating in a registry will simplify the process.

Our Organization, Our Future

The small group and solo practice of rheumatology is clearly under attack on many fronts. Just to manage the continually growing administrative burden of prior authorization processes with all the diverse carriers has been difficult enough. Add in the EMR requirements, declining reimbursement for dual-energy X-ray absorptiometry scans, the threat of bounty-hunter audits leading to unfair conclusions, a Sustainable Growth Rate fix that refuses to be fixed, and spiraling overhead, and what is a rheumatologist to do? Now, Congress has promulgated legislation promoting the formation of Accountable Care Organizations (ACOs). The final regulations have been published. Where does the single-specialty group or solo practice of rheumatology fit into this healthcare system redesign? Although the question of whether ACOs will dominate healthcare delivery in the future is a matter of conjecture, one thing is clear: Rheumatologists will need to adopt new strategies to succeed in the changing healthcare environment.

Who better to lead us through the times to come than the ACR? For me, there has been nothing more professionally satisfying than contributing to a cause larger than myself. If you want to contribute your time and energy to your patient’s cause, to the care of rheumatic disease patients, and to your profession, consider volunteering for the ACR. The ACR needs you. I can personally guarantee that your work with colleagues who also want to improve the care of rheumatic disease patients will enrich your life.

I am saddened to rotate off the board. I made many friends that I may now only see at the ACR annual meeting. However, I fully intend to stay active and engaged in the organization. Because I am no longer in private practice and will be taking over the rheumatology fellowship program at Geisinger Medical Center in Danville, Pa., this year, I hope to become actively involved in the COTW. I also have an interest in promoting the development of contacts and working relationships with the carriers, with the hope of finding strategies to reduce the inefficient and energy-sapping carrier barriers to providing quality healthcare for our patients, so I may volunteer for the Insurance Subcommittee. There are lots of choices. My suggestions if you want to volunteer are:

1. Have an idea what you want to do.
2. Get to know someone in the organization who can attest to your interest.
3. Persist. If you send in your application but do not get a committee assignment the first time, try again.
4. Show your enthusiasm. This is fun.

Dr. Denio will head the rheumatology fellowship program at Geisinger Medical Center in Danville, Pa., beginning this July.

Reference

1. American College of Rheumatology Musculoskeletal Ultrasound Task Force. Ultrasound in American rheumatology practice: Report of the American College of Rheumatology musculoskeletal ultrasound task force. Arthritis Care Res. 2010;62:1206-1219.