In a recent interview, Eric L. Matteson, MD, Chair of the Division of Rheumatology at Mayo Clinic, Rochester, MN, and Professor of Medicine, discussed the Division of Rheumatology. The staff consists of 18 rheumatologists, including 2 pediatric rheumatologists or joint pediatric-adult rheumatologists. It also includes several mid-level providers, including nurse practitioners, physician assistants, and nurses.
The practice in Rochester is divided into subspecialty clinics, including inflammatory arthritis, connective tissue diseases, vasculitis, and inflammatory muscle disease. In addition, the Division of Rheumatology includes a joint clinic with orthopedics and physical medicine, and rehabilitation for the assessment and management of regional musculoskeletal pain comprising nonoperative rotator cuff problems, as well as knee and hip problems. Mayo Clinic also includes a vasculitis center as well as a cardiology rheumatology clinic shared with the division for cardiovascular diseases.
“We have personnel who work in this clinic to assess patients who have vasculitis together with our cardiology colleagues,” Dr Matteson explained. “Then we have another joint clinic with cardiology that is called the Cardio-Rheumatology Clinic.” That clinic is dedicated to the evaluation of patients with systemic rheumatic diseases to determine their cardiovascular risk factors, because patients with rheumatic diseases have higher heart disease risk.
In addition to the clinical aspect of the practice, Mayo Clinic also comprises research laboratories currently focusing on the immunogenetics of rheumatic diseases and immunogenetics of drug metabolism of drugs that we use for treating rheumatic diseases. Mayo Clinic Rheumatology also uses resources of the Rochester Epidemiology Project to understand the epidemiology of rheumatic diseases and how this impacts clinical needs and treatment approaches.
What is the approach to care at Mayo Clinic?
Eric L. Matteson (ELM): As a general principle, our approach to care is integrative. We have integrated clinics in several areas in orthopedics, physical medicine, cardiovascular diseases, and vasculitis that are unique.
We work very closely in the management of chronic pain, which is a major issue for patients with rheumatic diseases. With our pain rehabilitation center—we have a fibromyalgia center as well, a fibromyalgia clinic—that is part of the integrated approach to the management of our patients with rheumatic diseases.
The approach to the patients that distinguishes Mayo Clinic is that we are truly an integrated practice. That means we have a single record for all of our patients. We have combined clinics and easy access to all of the services and providers that are required for patients with rheumatic diseases.
I think if I were to describe in 1 phrase the approach to the patient that we pursue here in the division, it is the approach that we value at Mayo Clinic, and that is that our fundamental principle is that the needs of our patients come first. That is the ethos of the Mayo Clinic, and of our division, and that is what makes Mayo Clinic unique.
How does this approach to care translate to better outcomes?
ELM: What we have been able to identify in rheumatoid arthritis, for example, is that over the years since we have been following patients systematically through the Rochester Epidemiology Project since 1955, we were the first to show that this integrated management of patients with rheumatoid arthritis has led to an improvement of patients’ life expectancy and a decrease in the need for orthopedic surgeries, because of better disease management.
We also have—because we work very closely with our orthopedic colleagues—been able to have better outcomes from orthopedic surgeries, as well; for example, very low complication and infection rates following a joint orthoclastic surgery.
Those are just a couple of examples of very concrete improvements in the outcomes of patients who have rheumatic diseases as a result of how we approach our patients.
What advice would you give to physicians when referring a patient to Mayo Clinic?
ELM: We value very highly the relationships that we have with physicians across the country and actually all around the world. The principal advice that we give to physicians considering referring patients is to have a clear question for us that they would like to ask us to address and to resolve.
We ask them to provide as much information about the patients as they can. The physicians who refer patients to us have high standards themselves. They have, very often, done very thorough evaluations of the patients, but still the diagnosis and management questions are open.
Providing us with as complete information as possible about the patients is extremely helpful to setting up the evaluation here, to have it be efficient and timely and also as helpful to them as possible.
What is the biggest challenge you are facing in the profession?
ELM: Without a doubt, the biggest challenge that we have in rheumatology is access. It is access to medications and access to rheumatologists. We, as a field, are seeing that the number of people in rheumatology or going into rheumatology has been fairly stagnant in the last several years. Rheumatologists, as a group, are pretty senior. I think the average age of a rheumatologist is around 55 or so these days.
Patient access to rheumatologists is becoming a major issue. Access to services like medications is a major issue. That access is limited by cost. That is a major issue now that patients and physicians have. Access to effective medications is limited by the insurance plans and cost of the drugs and access to procedures that are helpful in assessing patients. Access to advanced imaging procedures, in particular, are becoming a real problem.
How has the specialty changed since you first joined the profession?
ELM: I have been in rheumatology for 28 years. In that time, there has been a dramatic improvement in the outcomes of patients who have rheumatic diseases driven by better understanding of the disease process, better medications, and the more rational and scientific application of those medications.
Globally, we are seeing less joint damage in patients with rheumatoid arthritis. In the field of vasculitis, for example, patients now live longer and better than they have in the past because of better diagnosis and better approaches to the management.
I think that those are some things that have happened that have been very positive. That has also driven a lot of enthusiasm for rheumatology for the field in general because we are able to be effective in treating our patients now much more than in the past.
What advice would you give to a rheumatologist just starting out?
ELM: I think that, most importantly, it is to not only have a good understanding of the diseases, but also a good understanding of the business of medicine and the business of rheumatology. That is very important and it is still not adequately taught.
In the end, I would have to say though, that the most important advice I can give is advice that a very famous physician—William Osler—already gave more than 100 years ago that still applies today. A rheumatologist starting out should care more for his or her individual patient than the special features of the disease. The patient comes first.
What key opportunities lie ahead in the field?
ELM: Some of the major opportunities that we have are in the field of individualized medicine. By that, I mean developing and using biomarkers that will help us to understand the prognosis of all the rheumatic diseases.
This applies to all of the systemic rheumatic diseases that we deal with, and biomarkers that will help us to understand which drug therapies will be the best. By “the best,” I mean both in terms of how well they work for an individual patient and choosing the right drug, as well as understanding which drugs are actually going to be problems and should be avoided. I think that those are major opportunities that we have.
We are going to continue to see advances in understanding of the pathobiology of these diseases, and I am looking forward to translating those discoveries into benefits for patients.
I also think that a key area of opportunity in rheumatology is in regenerative medicine. We know that a lot of our diseases are very destructive to not only joints, but other internal organs. Being able to restore function of joints beyond joint replacement and doing so in a biologic way, for example, restoring lung function or kidney function in patients who have had damage from rheumatic diseases, is a major opportunity.
To that point, at Mayo Clinic, we collaborate with our colleagues in our Center for Regenerative Medicine, Center for Individualized Medicine, and Center for the Science of Health Care Delivery, to improve outcomes in our patients.
How have patients with rheumatologic conditions been affected by the implementation of the Affordable Care Act?
ELM: In general, I think that it has improved access. We are seeing patients now that we would not have seen before, because they didn’t have the means to be seen.
A change that is not so favorable, it appears that the cost of medications for patients is increasing. This is mainly reflected in higher premiums now.
The good news seems to be that more people are becoming insured, but the bad news is that the insurance rates are becoming so high that it’s still very much a concern for patients, particularly patients who are working. I think that there are a lot of ongoing challenges with that.
“In my view the excellence of the clinical care that we have here at Mayo Clinic, we can attribute to lots of things,” Dr Matteson concluded. “But in the end it's the people here, their commitment to the patients that matter the most, the way that our organization is set up to provide care in this integrated fashion.”