Susan Manzi, MD, MPH, is Co-Director of the Lupus Center of Excellence and serves as Chair of the Department of Medicine of West Penn Allegheny Health System in Wexford, PA. She is also Vice Chair and Professor at Temple University School of Medicine in Philadelphia, PA.
Value-Based Care in Rheumatology asked Manzi to reflect on the North American Young Rheumatology Investigator Forum (NYRIF), the major issues facing rheumatologists today, and the challenges of treating lupus. NYRIF preceded the 2015 annual Congress of Clinical Rheumatology.
Manzi: This is the first year I’ve participated in [NYRIF] and I think what stands out to me is that there are a lot of young people not going into academia anymore because funding from the NIH [National Institutes of Health] has gone down. They’re concerned about making a career doing research or staying in academic medical centers. They need mentorship and they need encouragement, and these kinds of national forums where they can come and present their work and have people ask them questions and they have to get up and do an oral presentation is invaluable. And what I also love about this is that it wasn’t just rheumatology fellows, who are already differentiated into rheumatology, but residents, too. And so the top prize this year went to an internal medicine resident, so the first thing I asked her was “What do you want to do with your life?” and she said, “I’m definitely going into rheumatology.” So that says it all.
Why is that important?
Because we need more workforce in rheumatology. Rheumatology has never been one of the sexy specialties to go into. It’s not cardiology. It’s not procedure oriented. It’s very cognitive. But, it’s such a great time to be in rheumatology, with all the new agents and the biologics and such incredibly difficult diseases to treat. So, having all these young people so excited about our diseases and research in this area—I think it’s just extraordinary. And there are not a lot of forums to do it, so this is unique for them.
Understanding the Whole System
What would draw someone into rheumatology?
I’m biased because I’m a rheumatologist, but I think we generally have to know every organ system, because our diseases aren’t “the heart” or “the kidney” or “the lung,” they are the whole system. Our diseases, like lupus, which I take care of, affects the heart, the kidneys, the brain, so you have to be a very good internist. You have to understand medicine in all those areas—that’s number 1. Number 2: the whole spectrum of patients can get these diseases, from kids (pediatrics) to the elderly (geriatrics) and all the way in between. They’re very tough to diagnose, they’re very difficult to treat, and these patients often get very sick, and they’re not easy to identify. So we always say when there’s a case no one can figure out, like on [the TV show] House, the rheumatologist is the last person, and it could be lupus…(laughing) “It’s not lupus. It’s never lupus!” Exactly. So that just goes to show how unique that disease can be, because it could have been all those cases on House, so I think rheumatologists have to be curious. They have to love the cognitive part of it, because you’re not doing a lot of hands on—other than exams and maybe injections—but you have to be able to solve mysteries and enjoy the intellectual curiosity of trying to figure out why people get these diseases. And great new drug discovery is taking place right now, so it’s for the intellectually curious.
The Challenges of Lupus
Very inspiring. Can you address the issue that lupus might be multiple diseases or a spectrum disorder?
For years we have clumped everybody into the general category of lupus—and there’s some thread of similarity—but when you start looking at treatment and risk factors for developing it and what’s going to happen to you once you get it, I think patients start splitting. So we clump under one umbrella to capture everybody, but then we split when it comes to “what treatments should we use?”, “why did you get the disease?,” and “what’s going to happen to you?”, because that’s important. There’s a little group of lupus patients that are going to do really well, probably live until they’re 90, and then there’s this group that is going to die in a few years if you don’t intervene. So, you have to figure out who they are when they’re walking through the door and try to manage them appropriately.
How do you do that?
That’s why these biomarkers—markers that will give you a better idea what’s going to happen to these patients and how sick they’re going to get—that’s why these biomarkers are so important. And then, like in House, a lot of these people are going undiagnosed, because even he can’t diagnose them correctly. So they’re living for years, going from doctor to doctor to doctor, and no one knows what they have. That doesn’t help, because by the time we figure it out, a lot of damage has been done. So, early diagnosis, figuring out what’s going to happen to them, and trying to intervene with what we call “personalized medicine,” in terms of treatment based on the person, not the disease. There’s value to “clumping and splitting.”
So there’s a possibility that genetic testing may reveal the fact that lupus is several distinct diseases?
Absolutely. And I think we’re starting to see a little bit of that. We’re starting to see genes more closely resemble one disease and then another, so we think, “Maybe we should be directing our treatments differently?,” because this gene is responsible for this and this gene is responsible for that. So there’s a lot of fun stuff, and that’s again why I think, especially for young people, what a great time to be in rheumatology! It’s not like we have it all figured out. We’re still discovering.