THE INNOVATIONS, PEOPLE, AND TECHNOLOGY INSIDE OUR NATION’S LEADING HOSPITALS
The Mayo Brothers’ Clinic: A History of Excellence By James Prudden
SPOTLIGHT ON:
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hrough extensive on-site interviews with several members of Mayo Clinic’s Rheumatology Division, an impression of this celebrated hospital was formed, but the overall
nuanced picture did not come without the addition of 3 unlikely, diverse factors: the parking lot, the piano, and the necktie. Each one shined a surprising light on the impressive care to be found at Mayo that gives the patient experience there such depth. There is clinical expertise aplenty, surely, but there is more to it than that. First, the parking lot.
It might come as a surprise to some that a nonclinical item like the placement of a new parking lot would demand the attention of an esteemed member of the Mayo rheumatology staff, but there she was, Sherine E. Gabriel, MD, former president of the American Academy of Rheumatology, engaged in a long conversation about the wisdom of placing a parking lot in a particular area of the Mayo campus. “I am continually visiting other centers and I talk to people, both patients and physicians, and it really is different here,” she said. “I was at a meeting where we were talking about where to place a parking lot, and even for a decision like that it all comes down to how it impacts patients and how it impacts the needs of patients. We really do mean it when we say we put the needs of the patient first.” It turns out that rheumatology patient populations, whose movements are hindered by painful joints, greatly appreciate a reduced distance between car and care.
Excellence Recognized In a continuation of a series that has already taken us to the Cleveland Clinic and Johns Hopkins, Rheumatology Practice News has set out to explore how certain institutions consistently rank among the top tier for rheumatologic care in the United States. To get and stay at this highest level requires maintaining a strong
reputation among rheumatologists throughout the country. Mayo Clinic continues to solidify its reputation as an excellent destination for clinical rheumatologic care, and is also an acknowledged center for world-class research in rheumatology. The reputation of Mayo Clinic’s rheumatology research was memorably lauded in 1950 with the awarding of the Nobel Prize in physiology and medicine to 2 of its researchers for the discovery of cortisone. Phillip Hench, MD, and Edward Kendall, PhD, had observed that patients’ arthritis symptoms improved with the advent of jaundice, following unrelated surgery, or during pregnancy, indicating that a natural antirheumatic was secreted in those instances. Years of research followed, but eventually Drs. Hench and Kendall were able to synthesize targeted compounds, one of which was labeled “compound E.” A patient at nearby Saint Mary’s Hospital was injected with compound E on Sept. 21, 1948, and 3 days later experienced reduced muscular stiffness and soreness. Other tests on the compound, named cortisone, followed, with the end result being a trip to Stockholm, Sweden. Upon receiving the prize, Dr. Hench said: “In our opinion, the awards we received belong truly to all the men and women of the Mayo Clinic because it was the spirit of cooperative endeavor, the fundamental credo of the institution,
RHEUMATOLOGY PRACTICE NEWS SPECIAL EDITION • JUNE 2013
which made possible the work….” Research at Mayo has been and continues to be focused on the cooperative endeavor of translational medicine, in which questions that are brought up through patient care are explored through research that, hopefully, leads to discovery, which in turn enhances patient care. “Our general philosophy with respect to rheumatology research is to bring the insights from our patients to our research work and bring the research back to the patient with immediacy,” said Eric Matteson, MD, chair of the division. He offered a recent example. “A major focus of our research has been population epidemiology—how rheumatic diseases affect the population and how people fare over a long period of time. We have an unparalleled resource here at Mayo called the Rochester Epidemiology Project (REP), with which we can track every patient with any rheumatic disease for decades and follow their entire disease course because we have access to his or her complete medical information (sidebar). This resource enables us to find out how we are doing with the management of our patients with rheumatic disease.” Data from REP revealed that patients with rheumatoid arthritis (RA) live longer today than in the past and undergo fewer joint surgeries than they used to, but the data also revealed that there is more heart disease than expected among these patients, a finding that has become a major focus of research at Mayo. Researchers brought their insights back to patient care with the creation of a cardio-rheumatology clinic that focuses on such problems. “That is how we translate our insights from research back to the patients,” Dr. Matteson said. “That is our philosophy.” Dr. Gabriel has been interested in the link between RA and heart disease for many years. “Over the past 15 years or so I have been
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focusing very hard, with funding from the National Institutes of Health, to try to understand which kinds of heart disease people with RA are particularly susceptible to, and why. And most importantly, what can we do to decrease that risk.” Kenneth Warrington, MD, called the REP a “phenomenal resource,” and cited an example of his work on giant cell arteritis. “We have tracked over 200 patients starting from about 1950 to the present with this disorder, and we know each individual person who has developed that disease in Olmstead County [Minnesota]. It is a priceless tool to be able to look at what happens to people over time—to look at disease outcomes, disease complications and responses to treatment.” “Research is driven by each investigator’s interests in the field, based on their assessment of unmet needs and opportunities for innovative new studies and treatments,” explained John M. Davis III, MD, current chair of the research committee. “We come together as a committee, and in general the philosophy is to be innovative, to try to apply new studies that can either give us new insights into how we can manage diseases better or to better predict
“The needs of the patient come first here. That is the ethos of this place; it is what makes Mayo unique.” — Dr. Eric Matteson outcomes of the disease, ultimately striving for new test strategies and new means of individualizing patient care, which is one of the great problems,” Dr. Davis said. Ann Reed, MD, who was the prior research chair, also cited innovation. “Our goal was always to work on translational medicine. Our strength here is that we have a lot of patients and have a large number of ongoing trials, so we focus on that strength. We have an interest in biomarkers of disease, which we are doing in myositis, vasculitis, RA, and lupus, among others,” she said. “Many of the clinicians in the division are focused on epidemiologic or outcomes research. What we do is partner with our basic science colleagues who work with us on these questions.” Tim Bongartz, MD, added, “I wouldn’t say that our research committee is dictating a certain scientific theme. You have individuals with certain talents and interests and you try to enable them to follow those interests.”
Varied Research Interests The research interests of the rheumatologists at Mayo encompass the full spectrum of rheumatic disorders. For instance, Vaidehi Chowdhary, MD, is interested in triggers that
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prompt lupus. “The work is predominantly in mice. I am interested in the bacteria Staphylococcus aureus, which releases the superantigen Staphylococcal enterotoxin B, or SEB. That protein is unique in that it stimulates T cells. So we want to see if we infect these mice with Staph aureus will they develop lupus, and are patients with lupus more colonized with Staph aureus, and does that colonization cause flares, and is it possible to prevent something like that.” Shreyasee Amin, MD, has examined the bone loss seen in the microgravity environment of space. “Loss of bone loading is one of the key regulators that contributes to bone loss in microgravity,” she said. “Astronauts lose about 1% of bone per month in space, whereas normally we would lose the equivalent amount of bone with aging in about a year. So attempts to reload the skeleton in the microgravity environment are being researched, although it has been a challenge. Exercise and bisphosphonates can help.” Other interests include exploring the unique immunologic milieu of pregnancy, which can ameliorate RA symptoms but worsen those for lupus, and the heightened risk for fractures in patients with RA. “The REP has found that young women who have RA are at increased risk for fragility frac- tailor treatments for individual patients. “We tures even before the age of 50. These will probably end up with not one single markfractures are at the typical osteoporotic er but rather a prediction model that relies on sites, but the fractures are also induced several biomarkers, some of them genetic, some by very low trauma. Indeed, osteoporosis of them clinical, that together will help us premay actually be a disease from childhood dict whether someone is likely or unlikely to that manifests in older age. We look at respond.” For example, Dr. Bongartz is currently distal forearm fractures in children, which using a model of 300 separate, fully genotyped might tell us that there are genetic fac- cell lines that are exposed to methotrexate. tors that predispose them to lower bone density Response is noted and the genetic characterisor bone structure changes. We found that young tics are explored. “We have put together a very boys who had a distal forearm fracture had an large international consortium of sites that have increased risk for future osteoporotic fractures participated in studies where patients with RA in old age, although we didn’t see the same phe- receive treatment with methotrexate. Their DNA information is collected as well as detailed clinnomenon in women.” Dr. Reed’s focus is on adult and pediatric der- ical response data, so we can link the patients’ matomyositis. She has partnered with other clinical responses to their genetic equipment to rheumatology centers in large international clin- find candidate genes that may help us predict ical trials, trying to find biomarkers to predict responses or side effects.” who will respond. Anoth“We can link the patients’ clinical er area of interest is putative environmental links to responses to their genetic equipment myositis. “Myositis is a rare to find candidate genes that may help disease, yet we are seeing us predict responses or side effects.” increases here at Mayo. We are not sure if this is from —Dr. Tim Bongartz increased incidence of the Dr. Warrington’s interest in disease or whether we are simply seeing more referrals. However, we do know that sometimes giant cell arteritis is assisted by Mayo’s memyou will get a group of patients that presents at bership in the Vasculitis Clinical Research Conthe same time from the same region, so we do sortium, a nationwide collaboration with several major rheumatology centers. The goal is to pool think that environmental factors play a roll.” Dr. Bongartz is currently working on refin- data and resources to help advance understanding personalized treatment strategies for ing of these rare diseases and find better treatpatients with RA by trying to identify genomic ments. “We are looking at outcomes and what and other predictors of therapy that will better complications may arise. One of the notorious
RHEUMATOLOGY PRACTICE NEWSNEWS SPECIAL EDITION • JUNE• 2013 RHEUMATOLOGY PRACTICE SPECIAL EDITION
THE INNOVATIONS, PEOPLE AND TECHNOLOGY INSIDE OUR NATION’S LEADING HOSPITALS
Mayo Clinic has its rheumatologists sites in Arizona, Florida and Minnesota. complications of giant cell arteritis is formation of aortic aneurysms, so we are looking at predictors of aortic aneurysm formation and trying to understand risk factors for that. We are also involved in translational studies where we collect blood samples from patients with giant cell arteritis and explore their cytokine profiles.” Dr. Davis has participated in a number of epidemiologic studies of RA. The cardio-rheumatology work described by Dr. Gabriel has led to further examination of the characteristics of patients with RA who have congestive heart failure. “In these patients the heart failure is more commonly due to a problem with filling or stiffening of the heart than in the general, non-RA population, which leads us to think that there is something about the autoimmunologic nature of RA, or the inflammation seen in RA, that leads to this problem. We also realize that the congestive heart failure in RA patients does not present in the same way as in nonRA patients so that it is harder to recognize in people with RA. This may be explained by the fact that patients with RA become more sedentary and do not have the same pattern of symptoms.” Dr. Davis has also looked at REP data and found that the relatively recent increase in the prevalence of obesity is one of the factors that is leading to the rise in the prevalence of RA. “This is an important public health problem,” he said. “If we can eliminate at least some of the excess obesity through changes in dietary habits and increases in exercise, we might reduce the numbers of people who go on to develop RA.” Dr. Matteson has done extensive research
The Epidemiology System The Rochester Epidemiology Project (REP) is a system for accessing medical records whose roots go all the way back to the beginning of the last century when Mayo Clinic medical files were first organized and a unique Mayo identification number was applied in order to protect patient confidentiality. The system was soon expanded to include a 5”x 8” card system, and a more comprehensive indexing system was added still later. Time went on, but in 1966, epidemiologist Leonard Kurland, MD, obtained National Institutes of Health (NIH) funding to link the health records of all health care providers in the Mayo Clinic’s home county, Olmsted. The records were eventually computerized in 1975, and the NIH’s National Institute on Aging has funded the REP since 2010. The REP now includes health records for all county residents dating back decades, and the trends reflected in its data can be extrapolated to reach conclusions about the health of the population of the United States at large. The REP has followed the health of a half-million lives since its inception, and the project is growing as health care providers in 7 nearby counties have begun adding their patients’ records to the system. The reputation of the REP is outsized, as is its influence on research. REP data have supported more than 2,000 studies.
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“If we can eliminate at least some of the excess obesity through changes in dietary habits and increases in exercise, we might reduce the numbers of people who go on to develop RA.” —Dr. John M. Davis,lll in drug safety and toxicity, particularly looking at instances of cancer, infection, and pulmonary disorders in patients with RA. “We are identifying lung disease in these patients more frequently than in the past. We recently published a study that demonstrated that persons who have RA and interstitial pulmonary fibrosis have a life expectancy that is significantly diminished compared with patients with RA who don’t have the lung disease. Their likelihood of dying prematurely is about 3-fold higher than patients who don’t have lung disease, which is on the same order as the increased risk for premature death among patients with RA who have heart disease.” S Second, the piano. At Mayo Clinic’s big glass atrium in the Gondo Building there sits a grand piano. When you first see it, you might think how odd, and wonder why it’s there. Then, when a patient or hospital volunteer saddles up to it and bangs out an upbeat tune, you think, how nice, and wonder at the fact that patients and family
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members, who were before sitting around talking in low voices, are now actually up, crowding around the piano, actually calling out requests, and even dancing. Indeed, that piano is not the only one located on Mayo’s Minnesota campus, and it speaks of a different approach to patient care. There is healing emanating from the ivories, with people made happy by the sound of the music redounding in the big atrium.
Clinical Care Paramount Dr. Matteson explained the overall approach to clinical care at Mayo. “The needs of the patient come first here. That is the thing that characterizes us, that is the thing that is most meaningful to us, and that is the thing that drives us. It is a Mayo brothers’ legacy (sidebar). It is something that every person here, from the CEO to the janitor, knows. That is the ethos of this place; it is what makes Mayo unique.” The excellence of clinical care at Mayo can be attributed to many things, most notably its people and its organizational setup. Dr. Reed said, “I had worked at several other places before I worked at Mayo, and one of the things I noted here are the systems that Mayo has established. I can easily see a patient at the beginning of the week and in a few days have my full evaluation completed and other consultations performed. Imaging will be performed and read, biopsies can be obtained and reviewed, lab tests can be finished—and soon I can develop a good picture of what is happening with the patient. This is possible because of the infrastructure that we have here. If I need a consultation in a particular area, there are people around to help me with that consultation.” Dr. Warrington mentioned Mayo’s multidisciplinary approach. “We can provide patients with a comprehensive approach tackling a problem from different angles and doing that efficiently, and that makes a big difference. Our vasculitis center was really born out of the idea of having all different specialists working together in one location for these patients. Most of our vasculitis patients take advantage of the fact that in one location you have these diverse specialists, including vascular medicine, vascular surgery, rheumatology, ultrasound, and other diagnostic specialties like vascular radiology, for example. So instead of having the patient go to all different areas of the hospital, we have multiple different specialists who work together as a team in one location.” The vasculitis center is formally integrated with cardiology. The Mayo Clinic’s Rheumatology Division includes other subspecialty clinics like that for vasculitis, including one for dermatomyositis, in which a group of physicians, nurses, nurse practitioners, and other allied health care professionals work with study coordinators.
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“We do know that sometimes Another similar clinic is for inflammatory arthritis, which concentrates you will get a group of patients on psoriatic arthritis, RA, and polythat presents at the same time myalgia rheumatica, for example. from the same region, so we do There is a connective tissue diseases clinic that focuses on systemthink that environmental factors ic lupus erythematosus, Sjögren’s play a roll.” — Dr. Ann Reed syndrome, mixed connective tissue disease, and other such disorders, and a sep- divisions,” explained Dr. Matteson, “and which arate section focuses on pediatric rheumatol- is where we evaluate patients with shoulogy. “We also have a regional musculoskeletal der, hip and ankle problems that generally do clinic that we share with the Physical Medicine not reflect a systemic rheumatic problem. As and Rehabilitation (PM&R) and Orthopedics part of that we maintain a very strong level of collaboration in research, in the clinic and in medical education with our colleagues in “The Mayos’ Clinic” orthopedics and PM&R.” Praise easily can be lavished on the worldDr. William Worrall Mayo, born in class rheumatologists at Mayo, but Dr. Davis Salford, England, arrived and set up a medical practice in Rochester, Minnesota, in 1863, was quick to praise the many other employees and his sons, Drs. William James Mayo and who make the place tick. “The allied health staff, Charles Horace Mayo, joined his practice in which really includes all individuals who in whatthe 1880s. Medicine was part of the boys’ ever way participate in health care, knows that early education, as evidenced by the fact we care for people as a team. So that includes that young William accompanied his father all our nursing colleagues; our clinical assistants, to perform an autopsy at the age of 16. who are administrative people who help things A killer tornado struck Rochester on Aug. run smoothly and keep patients moving along 21, 1883, which served as the impetus for from one appointment to the next; our medithe founding in 1889 of Saint Mary’s Hospical assistants, who can help out in certain protal, with crucial assistance from the Sisters cedures; and even the custodial staff who keep of Saint Francis. The Mayo father and sons these facilities looking polished—and people played foundational roles in this work. are always complimenting us on how clean the “The Mayos’ Clinic” or “the Mayo Brothplace looks. Every person at Mayo Clinic underers’ Clinic,” as it was then called, was the stands the needs of the patient come first and it first private integrated group practice, is important that we all participate in caring for with other physicians and basic science people as a team.” researchers joining the Mayos’ largely surTo the perhaps jaded reader the idea of a gical practice to create a novel teamwork top-flight rheumatologist taking time out to approach. praise the janitorial staff sounds like, well, The Mayo brothers grew by taking on good copy, but probably not firmly embedded partners, but in 1919 they changed the in reality. Except that on our visit I witnessed, structure of the practice and created the more than once, one of these top-flight rheuforerunner of the Mayo Foundation, a nonmatologists acknowledging with a friendprofit whose fundamental structure continues today. ly greeting and a “Good job” the janitorial The brothers were unusually close, so staff that is one part of the big, multifacetclose in fact that they had but one bank ed machine that works together to become a account for both. During the year they world-class institution. It may be that at your would take out whatever they needed with institution such things are not reality, but at no formal accounting to the other brother, Mayo they are, and that fact might be a clue to and at the end of the year they would split how they got to be where they are. what was left. Death too proved egalitarian, with “Dr. Charlie” passing away on May 26, And third, the necktie 1939 and his older brother, “Dr. Will,” passI have a particular necktie I often wear, a kind ing away 2 months later, on July 28. They of lucky necktie, which has American and Swedwere 73 and 78, respectively. ish flags on it. (My mother was born in Sweden.) Mayo Clinic now has more than 55,000 It is a distinctive tie, and I’ve worn it dozens of physicians, nurses, scientists, and allied times, but no one has ever mentioned it—nor health staff at Rochester as well as at Mayo should they, it is a minor thing. branches in Arizona and Florida. There are Still, rheumatology, perhaps foremost of all 15 rheumatologists located at the campus specialties, is a diagnostic art requiring keen in Rochester, 5 in Florida, and 4 in Arizoobservation, so it made an impression on me na. The rheumatologists at Mayo see almost that, as I sat to begin my interview with Dr. 20,000 patients annually and treat more Chowdhary, she smiled and said, first thing, “I than 100 types of disorders. like your Swedish tie.” n
RHEUMATOLOGY PRACTICE NEWS SPECIAL EDITION • JUNE 2013