Rheumatology Firefighters — The Ground Is Shifting Beneath Us

A Letter From the Front

Issue 01 | Nisha J. Manek, MD, FACR, FACP, FRCP | ACR Convergence Dispatch

“Before you enter a burning building, you must know what’s inside it.”

Dear Friend,

Rheumatology is, in a nutshell, a specialty of fighting inflammation. Daily, we assess how much inflammation say, swollen joints have and thereby, the whole body. We are firefighters.

This past October, I had the privilege of standing on the stage at the American College of Rheumatology Convergence in Chicago. The room was full of firefighters. That is what we are: the rheumatology brigade. Physicians, nurses, rheumatology fellows, physician assistants, nurse practitioners, pharmacists, physical and occupational therapists, all of us fighting the same fire: inflammation. It is the common factor underlying all immune disease, heart disease, cancer, and, ultimately, death.

One golden rule of firefighting is this:

Every firefighter knows that a house fire and a brush fire are entirely different battles.

Similarly, knowing your terrain means knowing the difference between a house in flames and a smoldering heap, knowing the difference to containing the inflammation before new fires break out and certainly, taking out all smoking embers.

In rheumatology we are somewhat better with more drugs called biologics. We have spent decades understanding the molecular terrain of inflammation: the cytokines, what happens to the joint synovium, and autoantibodies. We are good at this. However, it’s still a trial-and-error method. We try putting out the inflammation with a biologic drug, then ask, did it work? Often, the joints are still swollen, the patient complains of pain and stiffness, and we prescribe the next drug.

Now the very ground we are standing on is shifting.

There is another terrain emerging, one that is reshaping every patient encounter we have, and yet we rarely name it plainly. The brigade is exhausted, and the fires are not getting smaller.

In fact, rheumatology doctor uses the same water, the same hose, the same training and yet strategy must change completely depending on what you are walking into.

In medicine, we call this the patient’s inner landscape. Their biology. Their habits. Their history. Their terrain.

Our House Is On Fire

We cannot fight a fire we do not understand. And right now, there is a fire we have never faced before. A fire that is reshaping the internal terrain of every patient we see.

In truth, our house is on fire!

1 in 2

U.S. Adults Projected Overweight by 2030

42%

Of Americans Currently Living With Obesity

#1

Modifiable Driver of Systemic Inflammation

By 2030, an estimated one in two American adults will be overweight or obese. This is not a footnote in a public health report. This is an emergency of epic proportions.

And for rheumatologists, it is terrain we have never fully reckoned with.

Obesity is profoundly pro-inflammatory. It alters drug pharmacokinetics. It changes outcomes. It is, in many of our patients, fuel on the fire we are trying to extinguish.

From the stage in Chicago, I said something I want to repeat here, plainly and without hedging:

Our patients already hold the answers to losing weight. The question is whether we are asking the right questions to help them find those answers.

We are at an inflection point.

A new class of drugs called the GLP-1 receptor agonists has swept into medicine with extraordinary promise and, I believe, an extraordinary risk of becoming a medical prescription crutch.

The risk is not only physiological. It is cultural.

It is the risk of bypassing the conversation entirely and of reaching for a prescription before we have truly understood what is happening in the life of the person sitting across from us.

That conversation about food, about movement, about sleep, about stress is harder than writing a prescription. It takes longer. It requires skill.

But it is the conversation that can change the terrain permanently, not just while a biologic drug is on board.

A Moment of Reflection

Questions Worth Sitting With This Week

• When did you last feel genuinely well and what were you eating, doing, sleeping like at that time?
• Is there a habit or craving you’ve tried to change more than once, and found yourself returning to? What does that pattern tell you?
• If a trusted doctor asked you—not as a clinical checklist but as a real conversation—how would you honestly describe your relationship with food right now?
• What would it feel like to address the root, rather than manage the result?

These are not trick questions.

They are the questions that open doors and perspectives for patients and, honestly, for the Brigade (the whole medical team) too.

We are not exempt from this terrain.

In the newsletters ahead, we will go deeper. We will look honestly at what the rise of GLP-1 drugs means for our patients, for our practice, and for the culture of medicine we are building together.

We will examine the terrain, honestly, critically, and I hope, usefully.

You are part of that Brigade!

For now, I simply ask you to sit with one thought:

The fire is changing. Are we changing with it?

Coming in Issue 02

Chipotle now has an Ozempic-friendly menu.

What does it mean when fast food starts selling us our own medicine?

Until next time, stay in the fight, know your terrain, and remember:

The best firefighter is the one who never stops learning.