Dr. Stuart Schneller: Bringing Scientific Advances to Arthritis Care
June 26, 2006
Dr. Schneller is a long-time resident of the Boston area where he has held a rheumatology practice specializing in the treatment of arthritis for more than 25 years. Schneller earned his undergraduate degree in Mathematics from Boston University and went on to complete his medical degree in 1975 from the Medical College of Wisconsin in Milwaukee. In addition to his private practice, Schneller has held academic positions at Boston University and is currently an assistant clinical professor of medicine at Tufts University School of Medicine. He is a member of the Alpha Omega Alpha Honor Medical Society and has authored several articles in medical journals, including Arthritis & Rheumatism and Clinical Genetics. Throughout his career Schneller's focus has been primarily on patient care and clinical practice. He hopes to continue to see scientific research breakthroughs drastically improve arthritis treatment.
Knee1: What drew you to rheumatology?
Dr. Schneller: I was in internal medicine first, which is a prerequisite for going into a sub-specialty, and I found the illnesses interesting; I found there were new treatments coming along and also it had an emerging scientific base. The immunology was just being explored and identified and these diseases seemed to have an immunologic origin to it, which intrigued me.
Knee1: Since you started in the field, there have been a lot of changes. What have you found to be some of the best innovations that you've seen move forward?
Dr. Schneller: I think the focus has been in the past five years in the treatment of rheumatoid arthritis, which is one of the most severe and the most disabling forms of arthritis and also one of the most common other than osteoarthritis. The changes have been, finally, the implementation of treatment based on all that immunologic research. We've seen the biotech promise finally be truly realized. What we do today hardly resembles what we did when I first went into practice.
Knee1: With the high expectations, do you find patients coming in and expecting better outcomes? Also, do you sometimes find that the outcome they expect is not realistically possible to deliver based on their condition?
Dr. Schneller: I think it's fully understandable that patients have high expectations. They want to feel better; they want their conditions to be under control; they want their conditions to go away. I think that's the starting place. Sometimes that's not achievable and they have to be educated about what is a realistic expectation nowadays. But if they come in expecting their condition to be treated quickly and completely, then that's the goal we're looking for as well.
Knee1: Do you find that patients coming in are more educated, and if they are more educated, how much does that help with them getting better treatment outcomes?
Dr. Schneller: I think it's been enormously helpful. The access to information has just exploded in the past few years. There are times when the vocabulary is not available to patients to understand this or put this into the right context, but I think they're far better off having access to this information than having that information shaped for them, or modified so it's understandable for their particular problem or their particular issue. It also, I think, allows them to appreciate what it is you're trying to accomplish. Also, there are a lot of instances where they have to make a decision about what gets done. If a patient is informed about not only what good can come from a treatment, but also side effects can come from a treatment, then they are better able to make a decision that fits with their concerns, their family's expectations and what it is they are trying to get out of their own life.
Knee1: Are there common mistakes, or things that people do in their life that will result in them having to see a rheumatologist? Dr. Schneller: Not really, these conditions are sometimes degenerative conditions. If you want to call it a mistake, I wouldn't call it a mistake, but some of these conditions like knee osteoarthritis may be a result of sports injuries or being overweight for a long period of time, so in that sense they do things or make choices along the way that lead them to have a problem. But that's the minority of cases, so it's very hard to be certain that that one act or that one lifestyle led to this problem. With the more serious conditions we deal with, like rheumatoid arthritis or lupus, we simply do not know the cause. Unfortunately people search for an explanation of why it happened but the reason behind why it happened is still unknown. Their focus should be more on what it is that they now need to do to feel better and get better that may be a change in their expectations about sports, a change in their expectations about family, a change in their expectations about work responsibilities but if they then get past the fact that they led themselves to get there and instead think about what do I do now that this has happened to lead a productive life? that's a lot better for them.
Knee1: What are the most common complaints that people bring when they come in to see you?
Dr. Schneller: The complaint, almost universally, is pain in some location. And, where that pain is and how long it's been present and how it responds to different activities is the clue we need to figure out what it is that's causing the problem.
Knee1: If you are a person sitting at home with pain, is there any way for you to determine if you should be going to a primary care doctor or if you should be seeing a rheumatologist?
Dr. Schneller: I think it's best to start at the primary care physician's office. I think they have, first of all, a knowledge of your background and other conditions you may have. Secondly, they can take a broader view of what this particular condition is: Is it acute? Is it related to trauma? Should it be taken care of by someone more skilled at taking care of traumatic injuries like an orthopedist? Maybe it's neurological and the focus should be on a neurologist. I think the starting place is with a capable primary care physician whom you have an ongoing relationship with and let that person also select the specialists that they think best fit your needs both in terms of capability of treating your disease and also sensitivity to your issues and the personality that you would mesh with best to solve the problem.
Knee1: It sounds like you have to ask some tough questions about lifestyle and the type of treatment, and if you don't get along with the doctor personally you could come up against some barriers that would impede your healthcare.
Dr. Schneller: I don't think so. I think that most physicians are very capable to address the needs of patients even though those patients may be very varied. I don't think it's a contentious relationship. There are many, many different personalities in the world both physicians and patients but it doesn't mean that you have to seek out the one type of person that's for you. I think a lot of physicians can modify their approach to patients depending on how that patient feels about their conditions.
Knee1: In terms of alternative therapies, what's your position, or really does it depend on the people coming in and their specific cases?
Dr. Schneller: In a manner of profession I was trained in Western medicine: that's what I know, that's my base knowledge and that's what I look to for treatments. [Western medicine] was all derived in the scientific method I'm accustomed to, but at the same time there are other things about alternative therapies; sometimes genuinely therapeutic and also an adjunct to what we do. It's not an either-or decision. Someone came yesterday and said in addition to what you're going to do, do you think it's OK if I seek treatment by an acupuncturist?' That's perfectly fine. I think if they were walking away from therapy that was effective they were making a bad decision and they should alerted to that bad decision.
Knee1: What do you see as challenges for the future of rheumatology?
Dr. Schneller: I think that we've really made a change in the past five years and our expectations are now much higher than they were before. We have to follow that dream to make people better. Everyone would like their disease to be cured. It doesn't happen very often in medicine, where we actually take a disease and knock it out never to be seen again. So far we haven't come close to that, so one of the objectives would be to find treatments that are easier to tolerate, less costly and short-term. We're not there yet. The other big area that so far hasn't had the breakthrough is osteoarthritis. In fact, more people have osteoarthritis than have rheumatoid arthritis far more people do and the treatments there haven't changed as quickly as in other areas. Mostly because it doesn't appear to be an immunologic disease, it appears to be a degenerative disease so all of the biotech payoffs or breakthroughs that have come in the past few years haven't really helped osteoarthritis as much. That's coming. Now osteoarthritis though is more prevalent, probably it's a less severe disease for most patients, but, osteoarthritis I think is the next large area that needs to be attacked and so far we're not much above where we were in about 1985 in that condition. There are some newer things, but they're short-term treatments. Joint replacement has been enormously helpful. It's odd that when rheumatologists were polled a few years ago: (now this is before the advent of new treatments for rheumatoid arthritis) what's the biggest, most important breakthrough in the treatment of arthritis in the past 25 years?' they picked joint replacement surgery, oddly enough something they don't even do. That's [joint replacement surgery] been fairly well perfected. The treatments nowadays are really refinements on an already successful group of surgical procedures. It would be nice if we could identify it early and not get to the point of needing joint replacement surgery, but so far that hasn't come.
Knee1: So normally you'll see a person and then the course of action would be joint replacement?
Dr. Schneller: It depends on the condition. In the situation where it progresses or it's beginning to affect their ability to function and their lifestyle, then coordinating care with an orthopedist is done commonly. I'm in a fortunate situation where I work very closely with an orthopedist we basically work in the same office so I see them every minute of the day. It's common for us to see patients almost simultaneously or for me to walk one of my patients down to their room (hopefully walk one of my patients down to their room) and try to introduce them to the next therapy that they'll need namely surgical therapy and make that transition easy for them. Then I step to the background for a while until that procedure gets done.
Knee1: Do you tend to go to the surgical route more quickly with people who are younger?
Dr. Schneller: In fact not, because these prostheses, particularly knee and hip, do not last forever. Especially in a younger person, they may need at some point in the future to be redone. Now, redoing the procedure a second time, from what I know from the orthopedist colleagues I work with, is more difficult, more challenging technically so that they try their best to delay the procedure if they can until they get to an age where their life expectancy would maybe predict that they'd only need the procedure to be done once rather than twice. And if they needed a second one they'd be older at that point so rather operating on a 50 year old to have a knee replacement who may need it again at the age of 75 or 70, they'd rather wait until perhaps they are 60 years old and may not need it again. Having said that though, there are some instances where the patients' knee problem or hip problem is so severe that it's limited what they can do. Sometimes it's limited even their ability to work or their ability to enjoy or do things around the house. So you say despite the fact I'd like to wait, waiting is no longer permissible and we'll hope this lasts for a long time and in 10 or 15, or maybe 20 or 25 years, address the question again. Maybe our options 25 years from now will be much better than they are now.'
Knee1: When should a patient and their doctor discuss seeing a rheumatologist?
Dr. Schneller: I think when the problem is persistent and when it's progressive, and that means when the symptoms are getting more severe. So, let's say your hands have been painful for two days, I don't think that warrants a referral to a rheumatologist. If your hands have been swollen for two weeks, and painful during that time and are stiff, that's a clue it might be rheumatoid arthritis that would warrant a referral after a few weeks. Sometimes it may take a long time, say a knee has been painful for a long period of time two years, three years and certain things have been tried and worked but they only work for awhile and the treatment options are really no longer successful, or they're successful for too short a period of time that might be a justification to have the patient's case reviewed by a rheumatologist. There's no one time, and part of that's because we deal with so many different conditions that to make a specific guideline or rule about it simply can't be applied.
Knee1: Do you have any final thoughts that you would like to share with the Body1 community?
Dr. Schneller: I think that rheumatology is changing very quickly. It's changed right before my eyes in the past few years, and even in the past three months it has changed. It's really remarkable how many different treatments that are coming along. Some of them are very expensive, some of them are potentially toxic, but it's very encouraging to see that the fruits of all of that research are finally coming to the point that they can be administered to patients and see an effective outcome.
Last updated: 26-Jun-06