Paget: Tom, this hospital is renowned for its multidisciplinary approach to difficult medical and surgical problems. Can you give us a little history of what was previously called the Comprehensive Arthritis Program and is now called The Surgical Arthritis Service.
Sculco: This is a unique service to the Hospital for Special Surgery. As you know, in many hospitals in the United States, rheumatology and orthopaedic surgery work independently; often not a lot of collaboration exists. About thirty years ago, this service was founded at HSS to bring the two disciplines together to improve the care of patients with severe arthritic problems. At this point I don't know that there is another service in the United States that works as closely as we do in providing comprehensive care to rheumatoid arthritis patients.
Paget: What is it about these patients that demands this type of approach?
Sculco: As you know, rheumatoid arthritis is a disease that can affect multiple joints, including both the upper and lower extremities. In the past, these patients would often get “lost” in the shuffle between the hand surgeon, the hip surgeon or the back surgeon. What we are trying to do is to address all of the very complex problems these patients confront, in terms of medications, rehabilitation, and social-economic issues, through a single service.
Paget: Where did this concept come from?
Sculco: It was a concept that was conceived by a very far-sighted rheumatologist, in this case, Dr. Richard Frieberg, with Dr. Charles Christian and Dr. Ramsey Straub, who was an orthopaedic surgeon at Hospital for Special Surgery. They worked very closely together and saw a lot of patients together and they asked why not do this in a more formal, structured way. That began what was called the comprehensive arthritis program which has evolved into the surgical arthritis service.
Paget: As you said before, there are rheumatologists and orthopaedic surgeons all over the country and all over the world. Why hasn’t this approach been adopted in other places?
Sculco: It’s interesting that you raise that question. I have asked it many times as I go from one academic center to another. I think it has to do with each discipline being accustomed to working independently; not a lot of interaction occurs. But certainly for the care of patients, comprehensive care is the ideal way to go. We have found it very successful here at the hospital. I think this approach also works well for rheumatologists and orthopaedic surgeons who are working with the Arthritis Foundation to advance the future of musculoskeletal care.
Paget: You know our research mission includes prevention, cure, and then eventually rehabilitation through the use of surgery. Although extraordinary things happen here for patients who were once bedbound or wheelchair bound, the continued need for surgery is a demonstration of the failure of prevention and medical cure. So really this type of service lends itself so beautifully to the use of some of the newer, powerful medications, and addresses the fact that the patient is not a joint but a whole organism in which a joint plays a major role in limitation of function. For now, there are those people who, unfortunately, have either bad disease or who have failed medical therapies, who will need to undergo surgery in order to improve their lives.
Sculco: I think that is well said. The other real strength of this service is that we work together: rheumatologist, physical therapist, social worker, residents—both the orthopaedic surgery and the medical residents, rheumatology fellows, and orthopaedic fellows. We sit for an hour and a half to two hours a week discussing cases and we learn from each other. The orthopaedic surgeons learn from their rheumatology colleagues and I think the rheumatologists learn what the orthopedists can do. It is a very healthy environment that is created both in terms of the patient care and then on the educational side in terms of how we educate each other.
Paget: And over the years research has arisen from these discussions hasn't it?
Sculco: Absolutely, from this hospital and this service, we have some of the real classic studies that were done on outcomes in rheumatoid arthritis, surgical outcome as well as that which arises from medical management of these more complex patients. We look at long-term results in our most severe rheumatoid patients in terms of infections and other complications and we have done this with our rheumatology colleagues.
Paget: It is interesting, Tom, that over the years, especially with our newer medications such as methotrexate and biological agents, the number of patients with rheumatoid arthritis needing surgery has decreased and yet there is that spectrum and those people with more severe disease that continue to need our care.
Sculco: I think you're right. I think the new remitive agents, particularly Enbrel and Remicade, and some of the newer agents have really shut down disease activity in many patients. Of course, along with that positive result has come a subset of potential problems should the patient need surgery. This is an educational process for the rheumatologist and orthopaedic surgeon who need to be concerned about the potential for infection in the patient who is on immunosuppressive drugs and maybe one of these new biological medications.
Paget: Do you find that the residents that come through Hospital for Special Surgery, and they are quite special in so many ways, go forward and do likewise and try to stimulate this type of interplay and collaborative work wherever they go?
Sculco: I think they do. In some hospital settings there may be structural problems that may not allow the kind of collegiality that we have here. But certainly I think our residents leave here with an appreciation of the medical and surgical sides of the patient with rheumatoid arthritis and inflammatory arthritis--far more so than most other programs in the United States. I think they see that the rheumatologists and orthopaedic surgeons in the service collaborate in all aspects of patient care. And they see the close relationships that we have when we work together with our patients. I think they take that with them and that it does influence them.
Paget: How do you see our study of outcomes as being helpful in this situation?
Sculco: Again I think these are the most complex patients and the outcomes from the surgical management of these patients is influenced by many factors associated with their disease. Certainly when you look at the outcomes of polyarticular-involved patient with rheumatoid arthritis, the outcome is going to be far different in terms of function than it is in an osteoarthritic patient who maybe has one joint affected.
So certain outcomes are important to measure and the expectation is going to be much different as we go forward in these complex patients.
Paget: And you believe until we find that cure for inflammatory arthritis, or we find an effective immunization, that clearly certain patients will still need the multidisciplinary approach to address their difficult problems?
Sculco: Well hopefully we will come up with some kind of medication or treatment or something biological that will help patients with rheumatoid arthritis and prevent the progression of the disease. That is what we are all hoping for, but I think that may be far off. There are certainly a lot of patients who have mechanical disease which is the end-point of their inflammatory disease, which is going to require ongoing care.
Paget: You have an extraordinary historical perspective on this institution, where it came from, what it has done over time. What about this institution impresses you most?
Sculco: Well this is a very unique hospital in that the thrust is caring for patients who have musculoskeletal disease. There are, perhaps, two or three hospitals in the world that are as focused on these conditions as we are. As a result, we are more efficient, we are more comprehensive and certainly we are better at taking care of patients with musculoskeletal afflictions than many institutions. That is what makes HSS a wonderful place to work, what makes it a wonderful place for a patient to come to. They are not coming to a large hospital, academic or nonacademic, where there are general surgery patients, pediatric patients, urological—all kinds of other disciplines. This is a hospital, where, when you walk through the door, the entire effort is focused on the patient with musculoskeletal disease and damage to joints and bones. That is unique.
Paget: I think Tom has given a good overview of what this institution—and the Surgical Arthritis Service is all about. Obviously until the cure comes, we will continue to focus on our patients in this multidisciplinary way and also to appreciate the fact that it is necessary to interact, to be collaborative, and to communicate with our patients as well as physicians in our community.
Sculco: Thank you.