A POINT OF VIEW The Future Training of a Rheumatologist By L. A. HEALEY 1965, a conference on the Igistseducation and training of rheumatolowas held by the International League N DECEMBER Against Rheumatism. The report of this conference,l which has recently been published, surveys the present state of rheumatologic training and suggests a model education program. There is much merit to the conference’s recommendations but I wish to question whether the proposed program is actually the best one for the rheumatologist of the next decade. The particular point of contention is the assumption that the rheumatologist need be an internist. The report calls for 2 years of residency in internal medicine, followed by 2 years of special training in rheumatic diseases. During this time, the trainee would become familiar with the techniques of physical medicine and rehabilitation and nonoperative orthopedic procedures as they apply to the rheumatic patient. This is an accurate description of most of the present training programs, but there is no inherent reason why it must remain SO. Present training programs in arthritis are not the result of logical deliberation and a prescribed course of study to achieve a specific goal. Rheumatology as a special field of internal medicine evolved in response to the demands of the time, and rheumatologic training followed suit. The challenge presented by patients requiring long term nonoperative care, and the nosologic classification of a host of overlapping diseases naturally attracted t& internist. This attraction resulted from 2 major developments; the synthesis of cortisone, and the discovery of the rheumatoid factor. The former put a potent weapon in Id. A . HEALEY,M.D.: cine, Uriiveisity of Professor of MediWashington School of Assistant the internist’s hand, and Ragan has suggested that the main contribution of the latter is the number of good investigators it attracted to the field.2 By now, it is evident that neither of these discoveries has fulfilled its initial promise to rheumatology. Cortisone has not been the cure for arthritis, and the rheumatoid factor has not revealed its cause. Recent events have refocused attention on the joint as an area for investigation in arthritis. Crystals, phagocytic leukocytes, inclusion bodies, lysosomes and possibly Bedsonia have contributed to this synovial renaissance. Joint aspiration, intra-articular injection, and percutaneous synovial biopsy, for all of which the orthopedist was called not many years ago, are now every day pursuits of the rheumatologist. On the other side of the fence, the conference noted that “in recent years a rheumatologic subspecialty has been developing within the field of orthopedic surgery.”l The impact of orthopedic surgery is refledted in the programs of the annual meeting of the American Rheumatism Association and the contents of the Rheumatism Reviews. The 16th Rheumatism Review of 1964 contained a section headed “Orthopedic Aspects of Rheumatic Diseases.” Such developments are not unique to the field of rheumatic disease. They are paralleled in cardiology where cardiac catheterization and puncture, pacemaker implantation, and valve replacement have led to overlap of the roles of cardiologist and surgeon. Renal transplantation has hastened the amalgam of the urologist and nephrologist started by renal biopsy and dialysis. Medicine, Seattle. 256 ARTHRITISAND RHEUMATISM,VOL. 10, No. 3 (June 1967) 257 THE FUTURE TRAINING OF A RHEUMATOLOGIST Training Program in Rheumatology Present Years Medical School Proposed 2 3 4 5 Medical School 7 Arthritis Surgery Internship Medical Residency I Fellowship Fig. 1 The growing role of the orthopedic surgeon in rheumatic diseases is also evident. From fusing destroyed deformed joints, he has progressed to early prophylactic synovectom; and wider use of prostheses. On the horizon are the experimental joint transplantations. It is possible, if not likely, that doctors will not continue to separate along the traditional lines of medicine and surgery. The specialist of the future may combine both medical and surgical techniques to treat diseases of a single system. In the field of rheumatic disease, the present team of a -rheumatologist working with an orthopedic surgeon would be supplanted by a single physician trained in both rheumatology and orthopedic surgery-or more precisely in surgery of the joints. There are obvious advantages to this scheme. This physician would have a more complete understanding of the disease process; both anatomic and biochemical, for example. This could lead to better treatment and new investigative approaches. The patient would rely on a single doctor to provide all his care and answer all his questions. An obvious objection to this program concerns the time required for training. Would it take too long? Figure 1 compares the length of the present training with a proposal for the future. The blocks of medical school, internship, residency, and fellowship, which comprise a typical program today, total 9 years. The proposed program would take an equal length of time. As has been ~uggested,~ the fourth year of medical school and internship are combined. This may be either a straight medical internship or include 4 months of surgery. Next is a year of medical residency followed by a year of orthopedic residency, both similar to present programs. The seventh year is spent in surgery of the joints. During this time, the trainee begins clinical training in rheumatic diseases by working in an arthritis clinic. The last 2 years are similar to the arthritis fellowship as known at present. This would include clinical rheumatology, research training and experience, rehabilitation, physical medicine, and splinting. In addition, the trainee would continue with surgery by operating on patients with joint disease one day each week. The division of the last 3 years of training might vary in several ways; €or example, 18 months in rheumatologic surgery and 18 months in arthritis fellowship. Board recognition, hospital staff appointments and traditional departmental boundaries are not unsurmountable barriers. In the past, these, have responded to change, and they can in the future. The main difficulty may be to find an appropriate name for this rheumatologist of the future. 258 L. A. IIEALEY REFERENCES 1. Education and Training of Rheumatologists. Report on a Conference Convened by the International League Against Rheumatism. December 2-4, 1965. American Rheumatism Association, publishers, New York City, 1966. 2. Ragan, C. The history of the rheumatoid fac- tor. Arthritis Rheum. 4:571, 1961. 3. The Graduate Education of Physicians. Report of the Citizens Commission on Graduate Medical Education. (J. S. Millis, Chairman) American Medical Association; publishers, Chicago, August, 1966.