ACR president: 6 lessons from COVID

ACR President Professor Ellen Gravallese

COVID-19 has brought disciplines together, increased the reach of rheumatology practice and strengthened its professional organisations – silver linings from the dark cloud of a pandemic, according the head of the American College of Rheumatology.

Speaking in the opening session of ACR Convergence 2020, College president Professor Ellen Gravallese said rheumatologists worldwide have risen to the occasion during this most difficult year.

“You have thought creatively about how to address the challenges faced by this pandemic, how to best serve the patients who depend upon us, and how to continue to move research forward in our field,” she told the virtual meeting.

Professor Ellen Gravallese, chief of Rheumatology, Inflammation and Immunity at the Brigham and Women’s Hospital, outlined six lessons from the pandemic.

Lesson 1. As the content experts in immunology, our knowledge and insights are highly relevant.

She said she could think of no other time in recent history when the work of rheumatologists in immunology, medical research and patient care had been more critical.

“We can provide knowledge that no other specialty has. We have an intimate understanding of immune cell types and pathways, of cytokines, chemokines and their actions. We understand better than any other specialty the pharmacologic and therapeutic issues surrounding cytokine blockade and the risks and benefits of immunosuppressive therapies.”

“This knowledge has been critical in the care of patients with COVID-19, especially in the setting of severe disease. Several of our therapies have been tested in patients with COVID-19 and our input in directing care of these patients has been critical.”

“We should embrace this strength and utilise immunology expertise not only in the direct care of patients but also in the design and implementation of new clinical trials and in the development and use of vaccines. We should always be in the room where it happens.”

Lesson 2. In order to respond rapidly and effectively in a crisis, we need to rethink our organisational structure.

Professor Gravallese said the pandemic had been a stress test for organisations such as ACR as well as for clinical practices and institutions.

She said shortly after the pandemic hit, ACR began receiving calls from members with the most common question: what to do with patients on immunosuppressive therapies in the setting of COVID-19?

“We quickly realised that we needed a more nimble organisational structure to address the concerns of members. We had to address them quickly, in real time, as they arose.”

She said an expert panel was pulled together in March for rapid review of the literature – albeit with limited evidence – and to develop guidelines which were delivered in April.

“We envisaged this as a living document – anticipating the need for frequent updates as new data became available. Two updates have been published since April,” she said.

ACR also later delivered clinical guidance for paediatric patients and specifically on multisystem inflammatory syndrome in children (MIS-C) associated with the SARS-CoV-2 virus.

A practice and advocacy taskforce was established to provide timely information, updates and guidance to members on telehealth, economic support for practices, guiding principles for safe care of patients and comments on vaccine development and allocation.

“We have lobbied for reimbursement of telehealth modalities, for additional federal stimulus dollars, and for decreased administrative burden for those in practice.”

“This experience taught us that the ACR needs mechanisms that will allow for rapid and effective response to issues as they arise in our specialty – and needs to be organised differently to address issues common to multiple committees.”

Lesson 3. We can’t do it alone.

“In caring for patients, in developing clinical guidance documents, in looking ahead to vaccine development and usage, it has become obvious that we can’t and shouldn’t address these challenges alone. Collaboration with experts in other fields of medicine is critical,” she said.

Professor Gravallese said the ACR taskforce responsible for clinical guidance for adults during COVID-19 included infectious diseases experts and epidemiologists. The paediatric taskforce included infectious diseases, cardiology and ICU input.

“These collaborations must extend beyond this pandemic. The artificial silos of the subspecialties and departments definitely needs to break down and we should consider a new structure of medical care focussed on disease mechanisms rather than clinging to the traditional organ-based thinking.”

Lesson 4. Telehealth is changing the way we practise medicine. But is it a ‘virtually perfect’ solution?

Professor Gravallese said an ACR survey in May has shown 85% of respondents did not use telehealth at all prior to the pandemic.

“There were so many obstacles to overcome. Technical issues, documentation, laws … but this same group reported that more than 50% of visits had been converted to telehealth within three months.”

“There is great promise for this modality in the future beyond this pandemic assuming that reimbursement for it can be maintained. Telehealth has the potential to expand our reach to communities underserved by rheumatologists, allowing us to address the current and increasing workforce shortages – a major threat to our specialty.”

“We lobbied hard in Washington DC for adaptations for telehealth during the pandemic. Going forward, telehealth must be maintained to allow us to see our most vulnerable patients without them having to travel.”

However she said rheumatologists had to also to preserve the physical examination which was essential to their practice.

“We should continue to hold the physical exam in high esteem and insist on seeing our patients in person between telehealth visits to identify and confirm suspected physical findings. And we should also embrace new technology that could allow us to conduct certain aspects of the physical exam remotely. Perhaps, for example, by using infrared technology to identify inflamed joints.”

“We will need to prioritise patients who can be seen virtually, and those who require in-person visits and we should always look to preserve another critical cornerstone of our specialty – human contact with our patients.”

Lesson 5. Educational meetings will never be the same.

Professor Gravallese admitted that the ACR initially struggled to deliver critical messages in the early days of the lockdown and travel bans.

“Communication during a pandemic is essential. By necessity we have learned that so much information can be communicated remotely on the computer platforms we are now also so adept at using.”

“And we can harness these platforms to educate. As a result, educational meetings have changed forever.”

“We are rethinking how we deliver lectures, manage Q&A, and allow attendees to discuss critical new scientific concepts. We know that we can do this and yet, there is concern they will be done too well. If we manage to perfect remote learning, … will I ever see my colleagues again?

“We should work to look forward to hybrid meetings, embracing remote learning in part, while maintaining in-person exchanges of knowledge and ideas,” she said.

Lesson 6. We are a global society facing common issues relevant to rheumatology.

“Viruses have no regard for geography, borders or politics. As a global society we are currently facing a common enemy and searching together for ways to protect our elderly populations, to open businesses and schools safely, and to find effective therapies and vaccines.”

“We can no longer think in an isolationist manner. As the pandemic has taught us how easily a virus can move across the globe, it has also taught us how easy it is to communicate with one another globally.”

“We can utilise these almost instantaneous connections to our advantage, to solve problems collaboratively across borders.”

She said many challenges remain including the threat of drug shortages, ongoing vaccine development, its potential side effects and the logistics of allocation – but there was also hope.

“There are more than 160 vaccines currently under development worldwide and we trust that an effective one will be available soon. There will be an end to this pandemic.”

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