The smartest guys in the rheum

7 minute read

RR met RheumNow founder Dr Jack Cush to talk about puzzling patients, mega-meetings and Moneyball medicine

Medicine was an obvious choice for a young man who was good at science and wanted to help people.

But as a resident, the young Jack Cush noticed that rheumatologists were like the Sherlock Holmes of medicine, effortlessly solving problems other doctors couldn’t. That, as well as the unique way rheumatology combines problem-solving with highly personal patient care, made it the obvious choice of speciality.

Dr John “Jack” Cush, founder and executive editor of the website and podcast, has been based in Texas since the early 80s but grew up in Long Island, New York, the son of a school teacher and a secretary. After a science degree he studied medicine at St George’s University in Grenada in the West Indies, did his internship and residency at Coney Island Hospital, New York, then did his rheumatology fellowship at the University of Texas Southwestern.

Why rheumatology?

“I think it was the patients I saw at the end of my internal medicine residency,” he says, “and the fact that a lot of the patients were hard to understand, and we were often left saying things like: ‘Let’s get the rheumatologists involved. They’ll know what to do.’

“I was always a little perplexed. Why are these things easy for them but hard for the rest of us? I did a rotation or two and found out that rheumatology is about problem solving. It’s about inquisitiveness. It’s about science where science intersects with very personalised patient care, a lot of handholding. I mean, I’ll hold more hands in one day than a surgeon would in a year.”

He says rheumatology is still “voodoo” to most other practitioners.

“They don’t get immune diseases at all, whereas rheumatologists get it easily. We have to understand what’s under the surface. How do you make this complaint or this physical finding into something that’s immunologic or structural and understandable? That’s the challenge of rheumatology.”

Dr Cush recently rejoined the faculty full-time at UT Southwestern as professor of internal medicine in the rheumatic disease division after some time spent running clinical trials, teaching and in private practice. He has written two textbooks, published more than 140 papers and book chapters, and edits the free online textbook RheumaKnowledgy.

But most readers will know him from RheumNow, only five years old but already an indispensable resource for practitioners, which evolved from his habit of tweeting problems out to students. “People I didn’t know would come up and say, thank you, you helped me pass the boards,” Dr Cush says. “So I got more serious about that.”

Distaste for Twitter, and the fact others were putting out daily rheumatology information but doing it badly, prompted him to start a blog, which grew. Now he puts out five items a day, structured in a way that is useful whether you read only the headline or go all the way to the source material.

“It’s designed to meet the need that rheumatologists have, which is: tell me what I need to know, give it to me in a digestible manner, spark my thinking on things that are going to help me and make me more confident about what I do,” Dr Cush says.

“Everything we put out has a title that is something immediately learnable. If you get my daily email, you can scan it and in about 16 seconds know everything that’s going on in the world of rheumatology. If something piques your interest, you click on it and now you’ll read the blurb to the tweet or the two-sentence paragraph opening to the news article. Or you can commit to reading the whole thing. It’ll take you five minutes to read the news for the day, and after that you can go read the original source.

“That’s why it meets the needs of many. We started out with a few hundred followers and now we have over 7000 people getting our daily email.”

It takes Dr Cush 10-12 hours of work a week to create these little gems. He works with an editor and web team, but still does most of the research and curating himself.

The reward is in the number of strangers who come up and thank him – especially at something like the ACR meeting in Atlanta, where Rheumatology Republic sat down with Dr Cush late last year.

The testimonials he gets are so appreciative they can get him through a bad day. It’s also pleasing to watch doctors taking up new media, such as podcasts.

“One of my greatest goals behind RheumNow was to turn a disconnected, ageing rheumatologist population into people who are going to be connected to newer forms of education and social media,” he says.

And ultimately Dr Cush learns from the work himself.

“It’s content that I generate for me. I’m very selfish, I want to learn. So if I have a need, I find it and I publish it, and it turns out to be somebody else’s need as well.”

Rheumatology is so complex and multifarious it tends to breed hyperspecialists, but Dr Cush is not one of them. RheumNow caters to every subgroup.

“I cover everything. That’s just a function of growing up in an academic environment and being a teacher for a long time, I never pigeonholed myself into one thing. So some people would say, Oh, he’s known for rheumatoid arthritis or biologics or drug safety, someone else will tell you I’m known for myositis or Still’s disease or JIA.

“I need to learn a lot because I’m a general rheumatologist, so when I’m not good at something I get experts, and I’m lucky enough to have a lot of experts at my disposal. RheumNow pretty much is a one-man show but we do have sometimes other people involved and teaching.”

Such is the barrage of information at a conference like ACR, he has a little international army – including RR’s clinical editor Dr Irwin Lim and editorial board member Dr David Liew – tweeting for him, on topics that interest them.

While the huge ACR meeting “can’t be beat” for its scope and impact, Dr Cush wishes there would be more discussion and fewer rooms. The emphasis is a little too much on the didactic and it’s hard to be everywhere at once – though it’s great for getting your daily steps in (Dr Cush says he’s been averaging 15,000-17,000).

“My opinion is if you’re overwhelmed by the ACR meeting or EULAR meeting you have to do your homework ahead of time and choose which big room you’re going to be in and stay in that room the whole meeting. Maybe twice during the day, go to some other room just to get a little walk in.

“Otherwise you’re running nonsensically from one gigantic room to another, not knowing what the payoff is.”

ACR 2020 is in November in Washington D.C., just days after a political event that will undoubtedly generate as much talk as the medicine itself.

“I’m sure it will spill over in rheumatology. I think it’ll be fun ¬– my best friends are evenly split between Republicans and Democrats, and we make great fun of each other. None of it’s mean-spirited, not like the current Democrats and Republicans who seem to hate each other genuinely.”

Dr Cush’s predictions for hot topics at that meeting include money and economics, including the price of drugs; personalised medicine; more on races and ethnicities; frailty; and “Moneyball” medicine, that is, machine learning to inform better prescribing.

He wants to see intuition replaced by data, “hunch-based prescribing” replaced by models that predict a particular patient’s likely benefit from a particular drug.

“Right now everybody guesses on every drug that they use. Everybody tends to use one, two, and mostly three TNF inhibitors in a row, regardless of whether they failed the first time, then they use their next drug based on their own preferences.

“What will happen in the future is that the data will show that if you never responded to a TNF inhibitor, or you lost response, you should move on to a second, a different class of drugs.

“I think we’re getting to the edge of smart use of existing data.”

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