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The future training of a rheumatologist.

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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.
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