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Modern Rheumatology Can Do Better

Yousef Zarbalian, MD explains that we need to broaden our understanding of autoimmune disease, chronic pain, and restoring function basing it on the best science, not based on our tunnel vision view of what the science says.

My journey from conventional rheumatologist to holistic rheumatologist has been guided by the shared experiences of myself and my patients and my curiosity and striving to do better for my patients.

Being stubborn and a lifelong rebel (tellingly, Raphael was my favorite teenage mutant ninja turtle), perhaps one could have predicted that I wouldn’t accept an entirely standard rheumatologic style of practice.
Let me shed some light on the journey before we get into the why and how of modern rheumatology improving upon itself.

One Saturday morning..

walking the halls of the hospital in which I worked with one of my rheumatology mentors, I mentioned a study of patients with Rheumatoid arthritis comparing the standard of care treatment of methotrexate with the herb Trypterygium wilfordii showing that the latter was non-inferior to methotrexate.

My well-respected attending physician was aware of the findings but quickly brushed the study aside: the doses of methotrexate were subtherapeutic (12.5 mg per week) and the study duration was short (24 weeks).

And that was that.

The lack of further discussion or engagement stuck with me.

I was not and I am not currently advocating for the wide use of this herb whose side effect profile requires the same degree of monitoring as methotrexate and has reproductive side effects as well.

However, curiosity and openness to advancing medical care ask that physicians be aware that the current standard of care may soon change.

Strikingly driving home this point is an article in Mayo Clinic Proceedings by Vinay Prasad et al which reviewed publications in the New England Journal of Medicine from 2001-2010. During this timeframe, 40 % of the published articles that tested standards of care resulted in a reversal in the clinical protocol in question.

The message from my attending physician was that there was one way of treating autoimmune disease and that was the model of well-calibrated immune suppression with a pill or injection coming from the West.

I took his point, but with a grain of salt (and curiosity).

Restrictions on pharmaceutical marketing in academic centers meant that we were literally in the ivory tower during fellowship.

Guarded from marketing, we felt that we could rationally assess the benefits/risks of immunotherapy.
I saw how powerfully beneficial biologics could be in some of my patients who failed conventional immunosuppressive therapies but made a turnaround after initiating biologics.
When I reviewed the risk of demyelination with TNF inhibitors and the likelihood of this being causal and not just an association (using the bradford hill criteria), I was met with resistance and made to feel that I was overly critical of TNF inhibitors.
The resistance made me question myself but I looked harder at the evidence only to become more aware of the drawbacks of so powerfully targeting the immune system without first being open to a broader array of strategies for patients with early onset, milder forms of immune dysfunction that are non-life threatening.

Big Pharma 

When I completed fellowship and entered the real world of private practice rheumatology, I discovered how blatantly the pharmaceutical prism was giving rheumatologists tunnel vision.
Breakfasts, lunches, 4-5 days per week and oftentimes, the majority of the food was wasted.
Worse, the food was provided in plastic, single-use containers, re-enforcing my sense that industrialized medicine is very much a part of our consumerist culture. From this culture flows medicine’s huge environmental footprint as well as a lack of appreciation of environmental exposures as a significant root cause of disease.

I came to annoy the regular flow of drug reps daily bringing samples who many times would try to steal a little face-time while I was between patients, breaking my rhythm.

While rheumatologists may claim that it doesn’t impact their prescribing practices, who you spend time with matters.
If you’re spending time with drug reps, you’re not thinking about much other than drugs.
Your tunnel vision intensifies.
The draining nature of these relationships was apparent to me early on, but as the junior member of a rheumatology private practice my attempts to change the culture there were not taken seriously.
Paradoxically, the marketing efforts targeting me made me more hesitant to prescribe biologics and small molecule inhibitors.
Despite my conservative prescribing, one of the first patients I started on biologics, a smoker with RA recently getting over what seemed to be a mild upper respiratory infection ended up with legionella pneumonia and an empyema, despite following my instructions and waiting a full week after the URI symptoms had cleared.
Thankfully, she survived but flatly told me that she would never use a biologic again.
So, I came to question the powerful tools that I had carefully dissected during fellowship and which were being shoved down my throat by drug salespeople multiple times a day.
I came to crave autonomy, creativity, and a revitalized connection with my patients having better access to me than the drug salespeople.

 

If you're spending time with drug reps, you're not thinking about much other than drugs. Your tunnel vision intensifies. Click To Tweet

Modern rheumatology’s tunnel vision problem

Modern Rheumatology has limited its therapeutic strategies to immunosuppression medications, medications that temporarily reduce pain, joint injections, and then referring patients out who don’t respond to these interventions.
I came to crave autonomy, creativity, and a revitalized connection with my patients having better access to me than the drug salespeople.
While these strategies certainly have their place in protecting organs when an autoimmune disease is out of control, or temporarily alleviating pain so that a patient can function, the restoration of human health and function to a higher level requires a multi-faceted approach which emphasizes the essential importance of lifestyle (nutrition, exercise, and social connection/community), makes use of bodywork strategies such as acupuncture, gua sha, and cupping, and uses herbal medicine to restore our physiology by modulating the microbiome to a better state.

Moreover, emerging recognition of the role of various environmental exposures (known as the exposome) and how these influence the risk and severity of autoimmune disease is an area that deserves more attention from rheumatologists who should be advocates for risk reduction and public health efforts.

Humanity’s millenial co-evolution with our plant and fungal neighbors informs traditional medicine’s experience with herbs and fungi.
By harnessing these strategies, the powerful medications and interventions that we often reach for first in medicine would often not be necessary.
In a series of articles, I will review a few disease conditions for which a multi-faceted approach to care can improve the outcomes beyond that which are obtained in rheumatology clinics across the world.
More to come.

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