Summer 2021 (Volume 31, Number 2)

The CRA's 2021 Distinguished Rheumatologist:
Dr. Rachel Shupak

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Why did you become a rheumatologist? What or who influenced you along the way to do so?
My decision to become a rheumatologist occurred in my PGY2 year when I looked after a young woman who presented with an acute and severe polyarticular inflammatory arthritis that totally disabled her. Under the supervision of Drs. Gladman and Lynn Russell, we were able to treat her effectively and she walked out of the hospital. The ability to treat and control inflammation both articular and systemic and at the same time minimize or prevent damage was a powerful influence on my decision. As a rheumatologist, I believe that we make a big difference in the quality of our patients’ lives.

Since 1995, you’ve been Associate Professor in the Department of Medicine at the University of Toronto (UofT). Over the past 40 years, you’ve taught and mentored many undergraduate students, postgraduate residents and rheumatology residents. In your role as Clinician Educator, you’ve had the opportunity to develop, operationalize and evaluate innovative educational programs for primary care clinicians, patients and allied health professionals.

(a) From where do you think your passion for education stemmed?
At an early stage in my career, I recognized the importance of training our young students, both undergraduate and postgraduate, to recognize, diagnose and manage patients with rheumatic diseases. For my first five years on staff at St. Michael’s Hospital (SMH), I ran a general internal medicine team for three months a year, which gave me the opportunity to interact with many students and residents on a regular basis. I was rewarded with a number of teaching awards at the postgraduate and undergraduate level which made me recognize that I was probably doing a good job. Over many years, I strengthened my teaching skills and eventually cultivated the ability to develop educational programs and thus evolved into the clinician-educator role.

(b) As a respected clinician-educator, what would your advice be to a prospective rheumatologist?
I would advise them that to be a good rheumatologist, you have to first be a good internist. Rheumatology deals with systemic diseases in patients who are often quite ill and requiring extensive treatment and monitoring. A detailed comprehensive history and physical exam is the foundation of our specialty which remains very much hands-on. The breadth and depth of knowledge in this specialty is growing at a rapid rate and ongoing learning is an essential part of training and clinical practice.

I was grand-mothered as a clinician-educator but today formal training and a Master’s degree is required to assume this role in academic practice. All academic rheumatologists are required to teach, whereas clinician-educators’ role is to develop innovative programs, evaluate these programs and publish the results.

The “jewel in your crown” is the Advanced Clinician Practitioner in Arthritis Care or ACPAC program, which you co-developed with your esteemed colleague, Dr. Katie Lundon. This academic/residency program has created a new cadre of clinician practitioners to address the current and growing gap in access to care for patients with arthritis and musculoskeletal (MSK) conditions. One hundred highly knowledgeable and skilled practitioners, graduates of this rigorous program, are poised to work in a model of shared care delivery. Why did you create this program and how has it impacted the Canadian rheumatology landscape?
Recognizing that there will never be enough rheumatologists to provide equitable access to care, Katie and I hoped to change the way care is delivered for patients with arthritis and MSK diseases. We developed a formal rigorous program for existing allied health care professionals that was competency based and which we prospectively evaluated at the program and trainee level. The gap in access to and quality of care for patients with arthritis and MSK conditions is in large part due to a well-documented inadequate number and unequal distribution of rheumatologists practicing in Canada. Our goal was to increase knowledge (academic program) and hands-on training (residency program) for existing heath care providers to enable them to work in a model of shared care, thus improving access to and continuity of arthritis and MSK care in rural/remote, community and urban centers. Last year, Amanda Steiman kindly took over my role as the medical director of the ACPAC program.

Can you tell us about your involvement with The Annual Arthritis Day for Primary Care Clinicians, which has continued into its 14th year and addresses relevant MSK gaps in the knowledge of family doctors and ACPAC practitioners?
I started this program approximately 15 years ago to provide continuing medical education to primary care physicians and practitioners. Although MSK/arthritis represents about 15% of all patients seen in primary care, it is well recognized that knowledge and skills in assessment, diagnosis and management of these conditions needs to be enhanced at the primary care level. My colleague Dr. Ophir Vinik took over the role of Medical Director of this continuing professional development (CPD) program about five years ago and continues to provide an outstanding annual CPD course.

What is the greatest professional and organizational challenge you have faced, and how did you address/overcome this challenge?
We embarked on ACPAC, a very ambitious project and were determined to create a rigorous program, episodically delivered and competency based. We had a large faculty (>90), largely volunteers, that made the program the success it has become. However, finding a sustainable home and funding for the ACPAC program proved to be a huge challenge, despite our heroic efforts. We were making substantial gains with the Ministry of Health (MOH) prior to the change in government, which unfortunately then never moved forward. This is an ongoing bureaucratic process that continues and will in my opinion be successful, due to the recognized incredible added value of the ACPAC graduates on the delivery of care to our patients.

What major changes to the landscape of rheumatology have you witnessed over the course of your career?
Mostly, we have all seen an explosion in biologic therapies for rheumatic diseases, benefitting our patients tremendously.

What do you foresee as challenges to Canadian rheumatologists in the future and what can individual rheumatologists and the CRA do to meet these challenges?
I believe that we need to remain patient-focused in all we do. The challenge is to provide equitable (newer models of care), affordable (provincially supported) care. We need to double down on our effort to develop one of the Chronic Disease Management Portfolios that will provide the resources required to effectively manage our patients’ care. Recruitment and retention of rheumatologists has been an issue dating back to when I first started in practice. This has been a priority for the CRA and needs to continue. However, attention is also needed to foster the development of newer models of care, utilizing knowledgeable, well-trained and highly skilled allied health professionals to decrease the gap in access to and quality of care. This would require new provincial funding models, referral patterns and adoption of medical directives recently provided to nurse practitioners in Ontario. Cancer and diabetes are examples where this can work effectively to the satisfaction of the physicians, allied health care providers and patients.

What is your favourite book of all time?
I like historical fiction best as it takes me to different places and times in history. I thoroughly enjoyed “A Gentleman in Moscow” by Amor Towles.

If you had an extra hour in the day, how would you spend it?

If you could eat one food for the rest of your life, what would it be?

If you had a “theme song” that played whenever you enter a room full of people, what song would it be?
“What the world needs now is love sweet love.” There is too much anger and hatred in the world today.

How many cups of coffee does it take to make a productive day?
Two at breakfast (to get me going in the morning) and one at 4 pm (to allow me to finish my day).

Dr. Shupak receiving the CRA Distinguished Rheumatologist Award during the virtual gala in February.

Rachel Shupak, MD, FRCPC
Associate Professor,
Department of Medicine
University of Toronto
St. Michael’s Hospital,
Toronto, Ontario

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