ACR Presidential Address: Embracing Change and Dreaming Big (Big Audacious Goals): What Has Made the American College of Rheumatology Great Over the Last Decade? And What Will Continue to Make Us the Leader Going Forward?†
James R. O'Dell
President, American College of Rheumatology, 2011–2012, Corresponding author
Good evening. I'm Jim O'Dell, and it is my good fortune to be President of the American College of Rheumatology. On behalf of the volunteers and staff who have worked to put this annual meeting together, I am thrilled to warmly welcome you. I am delighted to see so many members of the worldwide rheumatology community assembled here in Washington, DC. This year, we have an exceptionally talented roster of speakers and a truly wonderful program.
I want to start by thanking all of you members of the ACR for allowing me to be your President this last year—it has been a tremendous honor to have had a small part in the College's official mission: Advancing Rheumatology. It is a humbling experience to try to provide a modicum of leadership to the great organization that the ACR has become—no one person can hope to represent or do justice to the needs of all of our diverse constituencies, so it really is a team effort (more on that later). It is a particular honor and at the same time humbling to share the stage with all of the distinguished Masters and award winners, many of whom have been personal role models, mentors, and friends. They have provided me with inspiration and invaluable insight and advice through the years. What an extraordinary privilege it is for me to be on the podium to present Herb Kaplan his Gold Medal—Herb, since my fellowship at the University of Colorado, has been one of my most enthusiastic mentors and role models and was the reason I got involved in the ACR. I have a great picture of Herb with Art Weaver, ACR President in 1996. Art, of course, like me, is from Nebraska and was the reason I decided on a career in rheumatology in the first place.
Over the past year I have done my best to represent all of our membership. Time really has flown both literally and figuratively. I have had the singular privilege of representing the ACR not only all around the US but in Velore, India at the annual Indian rheumatology meeting. Of course it wasn't all work—Sharad Lakhanpal took me to see the Taj Mahal. I represented the ACR at the European League Against Rheumatism (EULAR) meeting in Berlin—where our lapel fork was worn by many, including EULAR President Maxime Dougados. Additionally, I traveled to the Pan American League of Associations for Rheumatology meeting in the Dominican Republic and to the Brazilian national meeting, where we were graciously hosted by Geraldo Castelar, President of the Brazilian society. Lest you think being President of the ACR is a glamorous job, it involves quite a bit of heavy lifting—including visiting the beaches in Brazil and the Dominican Republic.
“Dream big and set great big hairy audacious goals” is the theme of my talk. The question is, how will the ACR continue to be a model for subspecialty societies and maximally Advance Rheumatology in the years to come? As many of you know I have borrowed the “great big hairy audacious goals” theme from Jim Collins' book Built to Last. The ACR is an outstanding organization and it will continue to be if we continue to dream big and set audacious goals. I cannot hope to do justice to all of the important things that the ACR has accomplished over the last few years, but tonight I want to remind you of a few recent amazing accomplishments of the ACR and hopefully inspire as well as encourage you to continue to embrace audacious goals and importantly, to strive for excellence and credibility in all we do.
There is no more concrete example of great big audacious ideas or goals than the ACR's home in Atlanta: In 2007 in the midst of truly awful economic times, despite the ACR's running a deficit budget (for the first and only time in 25 years—a remarkable feat in its own right), Mark Andrejeski recognized an opportunity. The economic times had hit Atlanta particularly hard, and real estate was available at great prices. Despite or because of the struggling economic times, the Board of Directors (BOD) embraced the audacious goal of owning our own building. Loans were hard to come by, but with our exceptionally strong economic reserves we were able to make a large down payment and secure the loan. Many feared the debt burden that this would cause for years to come. They need not have worried—the building was paid off in two years and we now have our very own beautiful home. The cost savings from holding meetings there and not paying rent have been and will continue to be substantial and are available to fund other audacious goals.
Quality of Care Committee.
Perhaps no area of our medical lives has changed or is changing more dramatically than the Quality arena. The ACR, through our Quality of Care Committee (QoC), which didn't even exist 8 years ago, has provided strong leadership in all areas that affect rheumatology. The QoC growth has been nothing short of remarkable—starting from nothing in 2004, the QoC and its 4 subcommittees now involve 3–4 full-time staff and 66 volunteers on a regular basis, not to mention the 150+ ad hoc volunteers for individual projects during last year alone. From the beginning, these efforts have been guided by the audacious goal to be the source of credible information for all things related to rheumatology. We do not want requirements to come down from the government or elsewhere without our having played a central role in their development, assuring that they make sense for our members and our patients.
Because of our credibility, we have forged important relationships with key players, including the National Quality Forum, the American Medical Association (AMA) Physician Consortium for Performance Improvement, the National Committee for Quality Assurance, Centers for Medicare and Medicaid Services, the Food and Drug Administration, EULAR, and others in both the national and international arenas. We have completely updated the methodology and processes by which we develop and update criteria, guidelines, and quality measures that are the foundation for all these efforts—thus assuring that everything we put the ACR stamp on meets the most rigorous guidelines set forth by the Council for Medical Specialty Societies, the Institute of Medicine, and other important standard-setters, protecting the integrity and creditability of the ACR, ensuring wide acceptance of our products, and allowing us to continue to gain the respect of key national decision-makers. The ACR has been successful in significantly increasing rheumatology involvement at national and international tables where important quality-related discussions occur.
Tangible results of our quality projects in the last few years include new classification criteria for rheumatoid arthritis, polymyalgia rheumatica, and Sjögren's syndrome; new remission criteria and trial guidance for rheumatoid arthritis; new clinical practice guidelines for rheumatoid arthritis, osteoarthritis, glucocorticoid-induced osteoporosis, juvenile idiopathic arthritis, lupus nephritis, and gout; and new recommendations for the use of musculoskeletal ultrasound and the use of disease activity measures in rheumatoid arthritis. And last, but not least, the ACR has participated in the American Board of Internal Medicine Foundation's national “Choosing Wisely” campaign, with the Rheumatology Top 5 list coming out in February.
Only by being willing to lead and continuing to assure the credibility of everything we put our stamp on will we be able to control this important area for our members and patients going forward.
The Simple Tasks campaign.
What is a rheumatologist?
How often do we hear this question or suffer because so many do not know? Simple Tasks, the powerful campaign launched in Times Square in September 2011 by the ACR, is changing all that. Many did not believe that with the limited resources we have, even with approving the largest budgeted project in our history (three-quarters of a million dollars per year for five years), we could make a difference here. Another truly audacious goal! From the start, this was not a grassroots campaign but was aimed at lawmakers, insurers, referring health professionals, and others whose decisions influence rheumatology. The campaign has already won three prestigious advertising awards.
The bent fork.
As more and more of us wear our bent forks and explain rheumatology to the many who ask about them, the word is spreading. Certainly the folks on Capitol Hill know us by our forks. The fork seen in Figure 1 is on the lapel of a US Representative from Georgia but has been worn by many in Congress. Because of its wide popularity and success, the fork is being copyrighted as property of the ACR. And as I have shown, it is now being worn on several continents and we have had discussions about the potential for this campaign, in part or whole, being used in other countries and with other societies around the world. Additionally, when our pharmaceutical industry roundtable partners mention in their direct-to-consumer ads “See your rheumatologist”—we have asked them to add “the specialist in rheumatic diseases” or a similar phrase. It is a big job but we are making progress. Get a fork and wear it and you will see what I mean—people cannot resist asking about them.
Information and data are power.
It has been said that whoever controls the information/data has the power. It is critically important that the ACR is in control of our own destiny. Again the BOD recognized this truth and embraced the great big audacious vision that the ACR would support the development of a nationwide registry of rheumatic diseases. The vision of the Registry is to allow rheumatologists to collect data once and then facilitate its use in a multitude of ways. To this end the ACR Registry and Health Information Technology Committee, since its inception 4 short years ago, has made significant progress to assure that the ACR has this information.
Some of the goals of the Registry are outlined on Figure 2. The Registry is still several years away from maturity, but progress is being made: The Rheumatology Clinical Registry now has data from over 26,000 RA patients, from over 750 providers and 350 practice sites. It has been expanded to support practice improvement models, and improved practice benchmarking has been added.
The next step is integration with electronic health records, and this is occurring through Rheumatology Information Systems for Effectiveness, or RISE. This year integration with two of the most popular electronic health record systems has occurred, with wide-scale rollout planned for 2014.
Most importantly, when the Registry matures it will allow us to control our destiny. We will have the data to demonstrate the tremendous value that rheumatologists bring to the table. This will be essential, with all the health care changes that we all know are coming.
Lobbying, building relationships.
How will the ACR continue to have influence on Capitol Hill, with the National Institutes of Health (NIH), with third-party payors, and in all the other important places? It is certainly an understatement to say that health care is changing and will continue to do so—we have to be at as many of the important tables as possible. This last year we have set new records in the number of Capitol Hill visits we have made (145 in September alone) and the number of states represented (Figures 3 and 4). Importantly, through the leadership of Gary Bryant, RheumPAC, in the 5 short years of its existence, has grown dramatically in terms of both dollars contributed (now over $120,000 annually) and number of donations to candidates. Simple Tasks is taking hold, and many of the folks on the Hill recognize us by the bent forks on our lapels!
As with many things in life it comes down to relationships—we must build and foster them. We have built new and expanded relationships with the American College of Physicians (ACP) (after all, they have 130,000 members to our 9,000), and in large part because of our interactions with them over the last year they have convened a special Subspecialty Summit that will occur later this month. Significantly, they have asked us to make a presentation and lead the discussion on challenges for cognitive subspecialists. In this regard we have also built relationships with other like-minded cognitive subspecialties. The Cognitive Specialty Coalition represents 70,000 specialists who provide face-to-face patient care—and besides us includes endocrinology, infectious disease, neurology, allergy, and neuro-ophthalmology. We need to continue to align lobbying issues with the Arthritis Foundation (AF) where possible. We have been successful in keeping a rheumatology seat at the AMA (thanks to all of you last-minute joiners). I have already highlighted the many key relationships we are building in the Quality arena.
These collaborations have led to tangible results, with the introduction of important bills including an SGR fix—the Medicare Physician Payment Innovation Act, or Schwartz/Heck bill HR 5707. Everyone agrees the SGR must be fixed, but it is critically important how it is fixed. This bill for the first time recognizes the value of cognitive specialists and is a product of the ACR collaboration with the ACP and the Subspecialty Society Coalition.
The second bill is the Patients' Access to Treatments Act, or McKinley/Capps bill HR 4209—which prohibits tier IV pricing. Spearheaded by the ACR and our partner the AF, a strong coalition of 14 organizations has pushed the introduction of this bill and has been lining up support.
These are all important but we need to do much better, and with your continued help we can and will.
Within Our Reach and Journey to Cure.
In 2004 the ACR Committee on Research, spearheaded by Mike Holers and Jane Salmon, recognized a tremendous funding opportunity—that of disease-targeted research. This ultimately resulted in the Foundation's creation of the Within Our Reach campaign. Many inside and outside the organization did not believe that we could reach the truly audacious goal of raising and giving away 30 million dollars in 5 years. After all, this had never been done by a medical society. With the jump-start that the ACR gave this campaign with its pinnacle 5 million dollar gift the Within Our Reach campaign did just that—in fact raising 30.7 million dollars. These funds have translated into 60 grants and to date more than 690 publications, and have been leveraged into 69.2 million dollars of NIH funding. Not stopping there, the Foundation is now 18 months into the Journey to Cure campaign to raise 60 million dollars—and true to form, we are already halfway home. To illustrate the dramatic growth of the Foundation, the budget has increased over 20-fold since the year 2000 and is now at 14 million dollars. Importantly, these efforts by the Foundation not only have resulted in huge successes in the research area, but have resulted in a doubling of the number of rheumatology trainees over the last decade—assuring that our patients will have access to rheumatologists and you and I will have partners.
The annual meeting (speaking of great big and audacious).
Our goal is and has always been to have the biggest and the best rheumatology meeting in the world. Last year's meeting in Chicago, with over 16,000 attendees, was just that—the biggest ever. Even better news: this year's meeting, despite Hurricane Sandy, is on pace to pass that world record!
What does the ACR need to do in the future?
Continue to set great big strategic audacious goals.
Under the leadership of Sharad Lakhanpal and Will Harvey we will, over the next year, complete the next update of our strategic plan. Two major efforts of the College over the last several years will inform this plan. Final reports from both our 2020 Task Force and the Blue Ribbon Panel on Academic Rheumatology were scheduled to be received by the Board earlier today. I want to acknowledge and thank Peter Embi and David Fox and Mike Holers for their outstanding leadership of these efforts. Both of these documents and their recommendations will be key informers of the new strategic plan.
Take advantage of our members' wisdom and participation, and nurture our strategic alliances.
One of the major reasons the ACR is great is because, unlike the vast majority of other specialties, we have one specialty society. Despite the fact that over 90% of US rheumatologists are ACR members and we hit the 9,000 membership mark this year for the first time, we are still small. It is imperative that we continue to strive to meet the needs of all of our members: practice and academic, adult and pediatric, male and female, and young and old. This is not always easy and will not be easy going forward—as my kids get tired of me saying, “if it was easy, anyone could do it”—it is not easy, but we have done it! None of us will be happy with everything that the ACR is doing or with all of the things it is not doing, nor should we be. That is one of the big reasons we need everyone's contributions—it is easy to complain but not always easy to bring solutions to the table. Even with all 9,000 of us we must reach out and continue to build strategic alliances with the AMA, the ACP, the Subspecialty Society Coalition, and the AF, to name just a few.
Be the credible source for all rheumatologic information.
Aristotle said, “We are what we repeatedly do; excellence, then, is not an act, but a habit.” Whether it is guidelines, criteria, quality measures, reasonableness criteria for musculoskeletal ultrasound, or the Rheumatology Top 5, we must maintain our habit of excellence and credibility in everything that we put our name on. We must have control of the information that will be necessary to prove our worth, and continued efforts to build the ACR Registry will assure that we have it.
Be a force on Capitol Hill.
We must expand our own lobbying efforts and our legislative alliances with like-minded cognitive subspecialists. In addition, we must greatly expand our efforts in raising funds for RheumPAC, to increase our ability to influence legislation that can benefit our patients and members.
Continue our fundraising efforts for the Foundation.
The Foundation's continued and expanded ability to support research in the rheumatic diseases and the careers of those performing this work will assure the future of rheumatology.
Through all of the above we would be wise to always remember that it is about the patient. Recall the sagacious words from the presidential address of John Sergent: “It's the patient, stupid.” If we frame everything we do with that in mind, whether it be access to rheumatologic care, improving quality of care, or research to better understand our diseases, we will be credible and well received.
Jim Collins wrote another book: Good to Great. In that book he emphasized the importance of getting the right people on the bus. I want to assure you that the ACR has the right people on its bus, and I want to take this opportunity to thank a few of them.
The ACR BOD and committee chairs are an amazing group of people. They are responsible for many of the things I have spoken about tonight. Give them your thanks and, more importantly, your support.
The ACR and Mark Andrejeski over the last 25 years have assembled a truly remarkable staff. We are very fortunate to have them—please thank them all. Some time this week raise a glass and toast Mark and thank him for his 25 years of service to the ACR.
The Executive Committee this last year has truly been a blessing to me and to the ACR. I could not have made it through the year without them. The ACR truly is in wonderful hands going forward.
I also need to thank the terrific members of the Division of Rheumatology at University of Nebraska Medical Center for all their support and help over the last few years. They kept smiling all year even as I asked them to yet again cover for me.
The ACR has become a second family to me and I will truly miss all of you—but I do have an incredibly wonderful and supportive family who, through their advice, love, indulgence, and understanding have made it possible for me to be away so much these last few years. I owe a huge debt to my three wonderful children and their equally terrific spouses and of course my beautiful and understanding wife Deb. Last but not least I have two 15-month-old grandchildren, and I'm looking forward to spending more time with them—if you want to gain perspective, spend time with your kids or grandkids. I have a picture of my grandkids with UCSF medical school class of 2037 hats on—granted early admission courtesy of my wonderful friend and role model and soon to be ACR Master David Wofsy, Dean of Admissions at UCSF. No longer being President of the ACR I will have a lot of time on my hands—so come visit us in Omaha and visit the family clothing boutiques and video game stores.
Joe Croft, a good friend and former ACR President, took me aside last year at this meeting and told me to remember that it was not about me: you are only President for a year—don't screw it up. I hope that I have been able to follow his advice. We are the happiest specialty (Figure 5). Keep smiling, keep wearing your forks, and keep donating your time, talent, and money to the ACR and the Foundation. Again, thanks for all of your support this last year.