ACR Presidential Address: When You Come to a Fork in the Road, Choose Wisely


  • Audrey B. Uknis

    President, American College of Rheumatology, 2012–2013, Corresponding author
    1. Temple University, Philadelphia, Pennsylvania
    • Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140. E-mail:

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  • Presented at the 77th Annual Scientific Meeting of the American College of Rheumatology, October 26, 2013.

As I reflect on my past year, I think about the challenges and opportunities, the external threats—and there have been more than a few this year—and the strength from within that I have had the privilege to experience: core principles, a common vision, strategic thinking, responsible stewardship … I am humbled by this experience. I have a deep appreciation for the enormous scope of work that the capable, creative staff and the many hundreds of passionate volunteers are engaged in each year, and that scope continues to grow. We often wonder if the external pressures on the field will overwhelm us, or if our young colleagues will have the passion and commitment to write the next chapter in our profession—to continue to write the history of our great College. The recent past has been dotted with complex issues and uncertain solutions. My thoughts have transitioned in the past several weeks as we have witnessed almost unimaginable insanity, the potential for chaos when order—imperfect though it may be—is clearly within reach.

As physicians and community leaders, we have a moral imperative—it is at the core of who we are and what we do. Our external environment is chaotic—an economy in transition, political unrest around the world, poverty ever-present not just in the developing world but right here in our own backyards, barriers to access to health care and education, the cost of health care that threatens our nation's economic stability. Opinions and belief systems may vary—they should vary—that's the beauty of our democracy, and it should be an example for all around the world. In our external environment as in our profession, for each of these issues there are many choices to make and there are various roads to follow. We can focus on achieving a commonly agreed-upon goal, and come to collaborative solutions. Idealism is good—it helps us to set our vision and establish a related mission—but realism must rule the day. An inflexible, dogmatic approach, especially when combined with opportunism and self-interest, leads to chaos… . everyone loses. The intransigence of our Congress, their prevailing philosophy that a collaborative solution means that we have failed, the lack of a vision for the future that includes supporting success for all, having visual impairment—inability to see the big picture/the collateral moving pieces that lead to instability and failure to achieve the ultimate goal if ignored… . all pitfalls to avoid.

My message today: When you come to a fork in the road, choose wisely (Figure 1).

Figure 1.

The bent fork: symbol of the ACR's Simple Tasks campaign.

As FDR so eloquently said, “Democracy cannot succeed unless those who express their choice are prepared to choose wisely. The real safeguard of democracy, therefore, is education.” Two slogans—two campaigns—with which we are familiar. Think about the greater meaning for us today. Each new challenge presents an opportunity to choose wisely… . this is our window of opportunity. Excellence in rheumatology education and commitment to lifelong learning, discussion of the most important scientific discoveries in our journals, advocacy for our patients, our members, and our field… . this is who we are and what we do.

How do we reconcile the reality of limited resources with the promise of seemingly limitless potential? (Figure 2). Our College has established the connections and the collaborations that enable the machinery of change. Consistency and an unwavering commitment to our mission, to “Advance Rheumatology”—always taking the “high ground”—has given the ACR a much-deserved reputation as the authority in our field. We must continue to honor this reputation if we wish to continue to use it as “capital” in our quest to have a meaningful voice in the monumental change in our health care system.

Figure 2.

Rheumatologists are uniquely qualified to choose wisely on behalf of our patients.

Our recent experience with sudden restriction to access for necessary medications—the Self-Administered Drug, or SAD, fiasco (aptly named)—is but a single example of how the forces of the ACR quickly mobilize to effect a change. We experienced a purely remarkable collaboration around a central principle, that patient care should never be compromised for financial gain. ACR staff in multiple units, including Government Affairs, Practice (Committee on Rheumatologic Care) with the insurance subcommittee and the network of the Affiliate Societies Council, and Public Relations, all jumped into action with our volunteer leadership—your volunteer leadership: Charles King, Elizabeth Perkins, Angus Worthing, Tim Laing, Will Harvey, Ed Herzig, along with myself and Joseph Flood. We enlisted help from our lobbyists and our colleagues at the Arthritis Foundation. We heard the voices of our members through our Affiliate Society Council leaders and on our listservs.

We may have won this battle, but the war wages on. No other single person or individual group can achieve what we have achieved—the force in numbers, in sterling reputation, in effective collaboration … this is the strength of the ACR. There is much work ahead. When we are invited to “the table” (CMS, Senate Finance Committee, House Ways and Means, NIH, NQF, ABIM, ACGME, and AMA to name a few) to help establish new standards for quality, new mechanisms for health care financing, new programs for lifelong learning and improvement, new programs to advance the science of our field, we have to bring expert, well-prepared staff and volunteers—our staff and volunteers—to those tables. There is much work to be done, and I feel secure that we are ready for the continuing challenge… . but we must choose wisely.

Advocacy has never been more important (Figure 3). Consider this a call to action: connect with your Congress members, participate in our visits to Capitol Hill, visit our web site to learn more about what you can do, contribute to RheumPAC to strengthen our voice. Contact us when the next call for volunteers goes out in the spring—let us know how you wish to share your skills and abilities with your College. This is not a spectator sport!

Figure 3.

Left, Advocacy and mentorship in action: a day on Capitol Hill with Dr. Uknis and son, Benjamin Budenstein. Right, A Capitol Hill visit with the Executive Committee (Drs. Uknis, St.Clair, O'Dell, and Flood) in March 2012.

Education and fellowship bring us to the 77th Annual Scientific Meeting of the ACR. As we welcome colleagues from around the world—as we initiate the premier educational offering in rheumatology—I invite you to make the most of our portfolio. Chet Oddis and our Annual Meeting Planning Committee have considered a wide range of learners' needs in planning this multifaceted event … there's something for everyone. If you seem overwhelmed by too many options, don't despair: SessionSelect will allow you to experience additional content wherever you may be, whenever you may find the time. More Maintenance of Certification content has been incorporated into our meeting, and I would encourage our colleagues from around the world to think about our Maintenance of Certification programs—here at our Annual Scientific Meeting or from any location via web-based tools and programs—as a mechanism to demonstrate your own commitment to quality and lifelong learning and improvement. American Board of Internal Medicine–approved programs in rheumatology offered exclusively by the American College of Rheumatology provide a unique opportunity to demonstrate your commitment to advancing rheumatology in your own community.

Join us as a participant in our Registry. Stay tuned for the introduction of the EHR-enabled capability—interoperability isn't just a dream—facilitating data-sharing without any extra work on your part. Contribute to our understanding of our field, of our patients: the very principles of patient-centered care provided by those committed to lifelong learning. The second call to action: Join us in advancing rheumatology through a demonstrated commitment to continuous quality improvement—knowledge and practice.

The final call to action: help us ensure the future of rheumatology. The Foundation—the Rheumatology Research Foundation—supports the training and the discovery that will advance rheumatology. Now the largest private funding mechanism for our field, the Foundation was created when we recognized the critical deficiencies that we faced: real and projected workforce shortages, and inadequate funding opportunities with which to expand discovery and encourage career development. Help us to grow the Foundation's capability to grow our field. Think about your own commitment and get others involved—your colleagues, your grateful patients, your friends and family.

Help us get the message out about who we are—who you are—and what we do. Wear your Simple Tasks pin on your lapel, send your patients and colleagues to our web site to learn more, use our materials when you speak in your communities, join us and our colleagues in the British Medical Society to help us achieve our vision: Everyone will know the essential role and value of rheumatology.

No discussion about ensuring the future would be complete without remembering how each of us has arrived here today. Education is certainly the key, but we all know the enormous value of mentorship and having those around you believe in your potential. Don't underestimate the value of making yourself available to young people in your community to share your love of learning, to encourage the potential that you may see, to show the next generation the joy that we have known in our own careers. Every child should have the advantage that I had: parents who instilled the love of learning, the importance of compassion, commitment, and hard work … and that anything is possible with hard work! I am so proud to thank them—Harvey and Rochelle Uknis—in this public forum today. I have had the good fortune to have shared my vision and dreams with a true partner—my better half, Richard—without whom much of this would not have been possible… . and our sons, Matthew and Benjamin Budenstein. They have taught me so much: patience, resilience, optimism, tolerance, and that creativity comes in all shapes, sizes, and flavors. My mentors: Master of the ACR Dr. Steven Berney and our ACR Executive Vice President, Mark Andrejeski … they shared their passion for their work, a vision for rheumatology and for our great College that I had to be a part of, and finally, their belief in me. To them, I offer my deepest gratitude.

As I reflect on my past year and on each of our critical missions, I see no simple tasks. As I look toward the future, I am confident that the strength of our College and our commitment to excellence and innovation at every turn will serve us well. I am encouraged by the energy, vision, and dedication of our young colleagues—Will Harvey (Young Member, Board of Directors), Erin Arnold (Board of Directors), Elizabeth Perkins (Chair, Insurance Subcommittee), Peter Embi (Chair, Registry and Health IT), Zsuzsanna McMahan (incoming Young Member, Board of Directors), and Angus Worthing, to name just a few. I have been fortunate to have been a member of an amazing Executive Committee: Joseph Flood, Bill St.Clair, Joan Von Feldt, Jan Richardson, David Daikh, and David Karp. I am in awe of the dream team of senior staff that our Executive Vice President, Mark Andrejeski, has assembled. I am confident that the vision, passion, and commitment of our volunteers and staff place us in an excellent position to Advance Rheumatology!

And so, in closing, I would like us all to reflect on the wisdom of Martin Luther King, Jr., who said, “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” To paraphrase Somerset Maugham: Life is change. Growth is optional. … … The next time you come to a fork in the road, choose wisely!