History of Rheumatology at WUMS and Barnes Hospital

Early History of Rheumatology: Two first-hand and delightful accounts of the beginnings of Rheumatology at WUMS and at Barnes Hospital are presented below. Note that at the outset the “division” had two branches. The research/academic side with a focus on immunology as outlined by C. Kirk Osterland and the practice/clinical side as discussed by Bob Karsh. Some of the most distinguished rheumatologists of the next generation had their first exposure or were young faculty members in this division which was originally set up as part of the Department of Preventive Medicine. In addition to Kirk Osterland who left in 1972 to become Chairman of the Department of Rheumatology, Clinical Immunology, and Allergy at McGill, Eng Tan and Bevra Hahn, who went on to become longstanding Rheumatology Chiefs at Scripps Clinic in LaJolla and at UCLA, respectively, were part of this group. All three of these remarkable individuals have been nationally and internationally recognized for their contributions to rheumatology. In addition, Gary Fathman, Chief of Rheumatology at Stanford and Luis Espinosa, Chief of Rheumatology at University of South Florida and then University of Louisiana (New Orleans) had their formative years here and then went on to exceptionally outstanding academic careers.

Edited Accounts of C. Kirk Osterland and Bob Karsh

C. Kirk Osterland – “Research and Academic Beginning in the 1960s.”

“After finishing extra training years at the Rockefeller and then going to the Institut Pasteur, I was recruited to Washington University by Richard Krause who was my immediate chief. I was to establish and develop a Rheumatology Division. The Department of Medicine in those days was quite unusual. We were located in an area some distance from the bulk of the department; the area being called a Department of Medicine and Preventive Medicine.
The Department of Medicine divisions were very strong and competitive, vying for the best trainees. We received some grants and got started. Krause busied himself with his work on Streptococci, some immunology and miscellaneous. He was a strong organizer and he believed (as did I that he should have been head of all Infectious Diseases – a hot area in those days). I was left largely on my own. There were some clinical Rheumatologists at Barnes/Jewish Hospital and they were very helpful and cooperative, but without any interest or skill in research. Bob Karsh was quite outstanding as a teacher and he was very well read giving him lots of ideas. We were good friends. Dave Lieberman, Bob Owen, Bernie Hulburt and Paul Hageman (an outstanding gentleman and statesman of the Department of Medicine) made up the rest.

It was greatly strengthened when Eng Tan joined the Division. About the same time Julian Fleischman joined us. Julian was a Ph.D. coming from a series of Nobel laboratories. He did his own Immunochemistry and was very much involved with the Microbiology Department. As things turned out, Eng was offered the job of Chief of Rheumatology at Colorado. He pursued a distinguished career there and at Scripps. Krause got itchy feet, wanting more, with administration – first at NIH, later Emory (Dean) later back to NIH where he is still active!! By this time (late 1960s) the Division had good financial support and a training grant. Chick Spilberg came from NYU, and Bevra Hahn joined me finishing off her training and then joining the staff (she also was to have a very strong career at UCLA).

Gary Fathman got his start with me spending a year plus in my lab. As we got him into medical school (he was a renegade, but needless to say, his career has been distinguished). Joe Davie started a PhD with Krause, but spent his last 2 plus years with me in medicine. He was a pathologist and he obviously became a superstar of Washington University (Chairman of Microbiology and Immunology). I received a very attractive offer to run a Dept. at McGill and took over there in 1972. This was done with reluctance as I was a Professor by then and because I loved Washington University and my colleagues there.”

Robert Karsh – “Clinical Beginnings”

“A PLEONASMIC PEIRASTIC APERCU ON W.U. RHEUMATOLOGY”
I finished as chief resident in medicine at Jewish Hospital in 1957, after one year of residency and two years as an Air Force internist. That left one more year of training to satisfy internal medicine boards. Internal medicine is my first love, but St. Louis boasted so many fine internists that I needed a gimmick. So I asked Carl Moore what the community lacked and he said a rheumatologist. “Get me a good job and I will be a rheumatologist.” The good job was at Mayo’s with Phil Hench, the cortisone Nobel laureate.

After one year of training, I returned to find that my serendipity was empyrean. Carl Vernon Moore put me on Barnes staff at once and rewarded me with consultant perks at City and Homer Phillips Hospitals. Mind you, this was a time when anyone could label himself a rheumatologist, since there were no boards and no training at WUSM or Barnes Hospital.

My earliest memory of a chief was Kirk Osterland who served well until he moved to Montreal, being a Canadian. Petie and I visited him and Jane and confirmed his success there in an antique house built of ancient ship rafters. These were also the days of Eng Tan and Bevra Hahn who went on to greater things out west.”

Leadership from 1976 to 2010: After Kirk Osterland left in 1972, the Division had no formal head but Bevra Hahn more than held things together and began to establish her reputation relative to the immunologic basis and treatment of SLE. John Atkinson, after a three-year stint at the NIH and two-year postdoctoral fellowship with Charles Parker in the Division of Allergy here at WUSM, was appointed Divisional Director in 1976. Within a year, Ben Schwartz, M.D., Ph.D. (Immunology), having just completed a two-year postdoctoral fellowship at the NIH, arrived to direct rheumatology at Jewish Hospital. They combined forces and then co-directed divisional activities until Ben departed for Monsanto in 1991 before founding the Camden Group in 1999.

In 1992, John Atkinson became Chairman of the Department of Medicine and Louis Simchowitz became Interim Division Chief. In 1995, Wayne Yokoyama was recruited from Mount Sinai School of Medicine to be the Division Chief. Wayne did a spectacular job of rebuilding including recruiting Rick Brasington to direct clinical activities. In 2007, Wayne stepped down to become Director of MSTP and John Atkinson has served as interim director since.

There has been a “subdivision” at the VA Medical Center since the early 1970s. It was initially directed by Isaias Spilberg who made contributions to our understanding of gout and related crystal deposition diseases. Seth Eisen became director at the VA in 1993. He developed a national reputation through his Vietnam twin study registry and ability to tap into the VA database so he could ask questions about the treatment of rheumatoid arthritis. Amy Joseph has headed this program since Seth left in 2006 to become the Director of Health Services Research and Development at Veterans Health Administration in Washington, D.C.

Overview of the Current Division: The Division is committed to the highest levels of excellence in its three academic missions of patient care, research and education. Established nearly fifty years ago in 1962, the Division is proud of its track record in these areas. It is particularly recognized for developing academic rheumatologists, training clinical rheumatologists, and carrying out cutting edge biomedical investigation relative to the immunologic basis of rheumatic diseases. Since 1976, the Division has trained over 60 individuals who are in academic investigative pursuits, 16 who are in biotechnology and governmental science and 27 who are in academic clinical activities. The Division is home to the newly developed “Center for Arthritis and Related Diseases” that integrates arthritis patient care, research, and education with the many different types of expertise at Washington University. The Division houses one of seven NIH awarded “Rheumatic Diseases Core Center” grants for the multidisciplinary study of arthritic diseases. The Division has had an NIH sponsored Training Grant since 1977. It ranks among the top few Rheumatology Divisions relative to funding received from the NIH.

The Division has a strong and continuous commitment to clinical and basic science training. The Division has trained many fellows who have matriculated to populate Rheumatology Divisions in other medical schools as well as to key positions in industry and at the NIH. Recent examples of division chiefs include David Karp (University of Texas Southwestern Medical Center), V. Michael Holers (University of Colorado), and James Jarvis (University of Oklahoma University College of Medicine). Andy Chan both trained with us and was on our faculty before becoming Vice-President for Immunology and Antibody Engineering at Genentech, Inc. Dan Littman (MSTP) did his Ph.D. thesis in the laboratory of Ben Schwartz and is currently an HHMI investigator at New York University and a member of the National Academy of Sciences. Two other former postdoctoral fellows who have matriculated to outstanding academic careers are Tsukasa Seya, M.D., Ph.D. who now holds the Professorship of Immunology at Hokkaido University School of Medicine, Sapporo, Japan, and Nalini Bora, Ph.D., who holds the Bernice Young Jones Chair in Ophthalmology at University of Arkansas for Medical Sciences.

Clinical Training and Education: Since the late 1960s, we have had a productive relationship with the Department of Pediatrics. For over two decades, the adult service provided inpatient consultative care and Owen Kantor directed the JRA clinic at Shriner’s Children’s Hospital. Although the clinics and consult services are now distinct, we continue to run a combined educational program. The weekly Rheumatology Grand Rounds and Translational Research Conference are conjoint activities. Pediatric fellows with an academic interest in the immunologic underpinnings of rheumatic disease usually do their research training in the adult rheumatology research laboratories.

Of note, Debi Parks, a former fellow, physician leader in the BJC system and distinguished rheumatology subspecialist in our community, joined the division as a Professor of Medicine this past year. She will 1) direct and expand our outpatient clinic operation, 2) set up focused clinics such as for early rheumatoid arthritis, and 3) oversee the point-of-care musculoskeletal ultrasound primarily for monitoring injections and evaluation of synovitis.

Research Training: A goal of our program has been to train postdoctoral fellows for careers as principal investigators in areas that are highly relevant to rheumatic diseases. Fellowship training is supported by an NIH grant, now in its 32^nd year of funding, as well as grants from the local and national Arthritis Foundation. Our training program supports young investigators in basic immunology and inflammation research.

The “Rheumatic Diseases Core Center” provides an environment to enhance multidisciplinary study of the rheumatic diseases. The Center has four primary goals: 1) Support genetic and protein production core facilities to enhance funded, ongoing research that is relevant to the rheumatic diseases; 2) Facilitate direct research on these diseases; 3) Enhance interest in the rheumatic diseases; and 4) Foster development of junior faculty.

Research Laboratories: The Division now has six independent research laboratories with an emphasis on basic immunology and inflammation centered on the complement system (John Atkinson), T regulatory cells (Chyi Hsieh), renal manifestations of rheumatic diseases (Al Kim), interferons (Debbie Lenschow), metalloproteinases (Christine Pham), natural killer cells (Wayne Yokoyama).

Clinical Research Activities: The Washington University Arthritis Research Network was established with the goal of collecting clinical information, along with serum samples, on a large cohort of rheumatoid arthritis and lupus patients.  Numerous clinical trials are also being conducted on novel therapeutic agents. These are led by Rick Brasington, Prabha Ranganathan, Hector Molina and Amy Joseph. Capitalizing on the advances from the Human Genome Project, faculty are characterizing the pharmacogenetics of medications used for rheumatic diseases.

Community Rheumatologists: A goal of the Division is to provide outstanding rheumatology consultants for the greater St. Louis community. In our region, there are currently 25 rheumatologists who underwent their clinical training in our Division. Also, an equal number practice throughout the United States. Several have formed successful enterprises including medically related companies. Further, David McLain founded in 1983 and continues to direct the Congress on Clinical Rheumatology, formerly Rheumatology on the Beach, in Destin, FL.

Teaching Activities: The Division has a remarkable record of achievement in this arena. Richard Brasington received the Clinical Teacher of the Year Award in 2008, Leslie Kahl the Distinguished Service Teaching Award 11 times and the Samuel L. Goldstein Leadership Award in Medical Student Education in 2008. John Atkinson has received multiple teaching awards including Teacher of the Year twice, Alpha Omega Alpha National Distinguished Teacher, Distinguished Service Teaching Award from the medical students (12 times), and the Distinguished Clinician Award from WUMS. Of note, Leslie Kahl served the medical school for 17 years as Associate Dean for Student Affairs and Wayne Yokoyama became MSTP Director in 2007.

Honors: In 2007, Wayne Yokoyama was elected to the National Academy of Sciences. In 2009, he was elected to the American Academy of Arts and Sciences. These are two of the most prestigious honorary organizations that a scientist can be elected to in the United States. John Atkinson was elected to Institute of Medicine of the National Academy of Sciences in 1996 and was made a Master of the American College of Rheumatology in 2008. Five Howard Hughes Medical Institute Investigators have been members of this Division [John Atkinson, Andrew Chan, V. Michael Holers, Benjamin Schwartz and Wayne Yokoyama (current)]. There are two endowed chairs in the Division -- the Samuel B. Grant (Atkinson) and Sam J. Levin and Audrey Loew Levin (Yokoyama). Several members of the Division have been named Best Doctors in America, including John Atkinson, Richard Brasington, Leslie Kahl, and Benjamin Schwartz. John Atkinson and Ben Schwartz were named Masters of the American College of Rheumatology in 2008 and 2009, respectively.

In addition, over the past year, Deborah Parks, Tara Adhikari, Linda Grismer, and Vladimir Despotovic joined our program and are primarily involved in teaching in the clinic and in directing an out-patient practice.