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Some requirements for the successful future of american rheumatology presidential address.

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Some Requirements for the Successful Future
of American Rheumatology
(Presidential Address)
T
HE AMERICAN KHEUMATISM ASSOCIATION (ARA) is the only
national medical society dedicated to all phases of arthritic and rheumatic
diseases. Members of ARA thus have a great responsibility as medical leaders
and spokesmen for about 6 per cent of the population of the United States
who are directly aflected by rheumatic diseases and for as much as a fourth
to a third of the population affected indirectly; and we are medical advisors
to our fellow men and women outside the medical profession who also support mutual objectkes for better control of rheumatic diseases. Hence, a
mccessful future for ARA and American rhcumatology can have considerable
consequence, and all of the elements necessary to achieve this success are
important.
Walter Bailer said to us 18 years ago that a successful maturity of rheumatology was predicated on its succectful adolescence. Perusal ol AKA’S achicvements in its adolescence and the succeeding years certainly shows siibstantial
growth in many areas. If Dr. Rauer were with us now, I think he would
agree there is every promise of a future with broad and exciting potential
for turther significant accomplishments.
Most, hut not all, of the requirements for the future success of American
I heiimatology which now can be rccognized are medical in nature.
One of the medical requirements-which
currently may be the most
essential onc-is greater dissemination of rheumatologic education. This can
anc1 probably will be accomplished in several ways, since such educational
programs nccd to include training for either part-time or full-time interest in
1)otli clinical and research aspects of rheumatology. In any event, the broader
emphasis now needs to be clinically oriented. Short-term postgraduate course5
liave proved an expedient and acceptable method for reaching many physicians whose more formal medical training had been completed, usually without
including in5triiction in rheumatology.
Graduate training programs, of which there are now about 75 supported
by Irarious agencies, provide an intensive experience for the approximately 80
phycicians wlio annually clect a rheumatologic career. In the internship years,
iu contract, rheumatologic education is almost certainly quite limited, if not
nonexistent, in most instances.
Idcally, however, medical education in rheiimlatology should begin with
imdergraduate medical students. Though yet to be proved, it seemr generally
Read at the mcctiiig of the American Rheumatism Association, Philadelphia, June 17
and 18, 1965.
58 1
ARTIIIUTIS
AND RHEIWATISM, VOL.8, No. 4 (AUGUST),
1965
582
thought that early educational encounters with rheumatic diseases would
produce more sustained interest in rheumatology. Traditionally, clinical subjeats have not received much specific attention in the undergraduate, basicscience years. However, in a recent questionnaire asking each medical school
to indicate the academic year or years in which rheumatic diseases were
taught, it was encouraging to find that 9 of SO schools replying specified
the first year and 53 of the SO specified the second year. If-as
has been
predicted by a few medical educators-future
revisions of curricula will
orient instruction more toward disease than heretcfore, then without increasing curriculum hours, material already taught in basic-science courses such
as anatomy, histology, biochemistry, and pathology can be given its rheumatclogic significance.
Education in rheumatic diseases is greatest in the third and fourth undergraduate years, but it still varies widely from one school to another. When
supervised by units, sections, or departments of rheumatology, teaching programs are more effective and aflord a greater opportunity for students to
see the spectrum of particular rheumatic diseases rather than perhaps just a
case or only a single phase of some of the various diseases. This valuable organizational stimulus to undergraduate education in our field exists in two
thirds of the medical schools in the United States. The leaders who have
labored so successfully in developing these units deserve our commendation.
What they have accomplished benefits us all and should, with our cooperative
efforts and enthusiastic support, now be extended to include all medical schools
and other teaching centers. There can be no place at any time for complacency over progress already achieved.
W e especially need to strive now to overcome the great diversity in both
the quantity and quality of rheumatologic education at all levels of medical
education. The effectiveness of a teacher who is intellectually stimulating,
erudite, and competent is another factor not to be underestimated. In this
respect, too, our forebears in ARA have been admirable examples. This
heritage should be perpetuated by each member of A M . We all are doctors,
and the word “doctor” is but the Anglicized version of the Latin word docere,
meaning simply “to teach.” Clinically talented students should be directed to
clinical careers just as those students who show special capabilities for basic
research should be chosen for academic, basic-science careers.
A second and closely related medical requirement for our future success
is fortifying the function of the clinical rheumatologist in the inlrestigation
and teaching of rheumatic diseases. Though both the clinician and the basicscience investigator have contributed creditably to rheumatology without the
close cooperation of the other, they should be medical partners in a broadly
based team approach. The necessary balance between research and clinical
orientation has been lacking in the past 10 to 12 years because of increased
emphasis on training for research and academic careers in rheumatology.
This emphasis has been demonstrably productive and important, but now a
similar resurgence of training in clinical skills is needed to reach a balance
at the highest possible level. Clinical training programs should include enough
583
experience in research laboratories so that the clinician and the researcher
can communicate and cooperate with each other. Also, it should enable the
clinirian to apply the principles, disciplines, and techniques of laboratory
rrsearch to clinical investigation, and to assess critically and thus interpret
better the reports of both the clinical and basic-science research of his peers.
An immediately apparent complement of this requirement is the need to
clarify the desirable standards of competence in rheumatology and the various
types of training and other qualifications related thereto. Whether this should
or would eventuate in any type of certification is a complex matter with many
ramifications, and still the center of widely divergent opinions. However, legal
agencies and health agencies, both private and governmental, increasingly
want such criteria now; and the Association of American Medical Colleges
has expressed a desire for our guidance toward better definitions of suitable
h euniatologic training in undergrad1late m t di cal education.
The ARA already has demonstrated its leadership in developing classifications of rheumatic diseases, criteria for diagnosiq, and categories of rcsponse
to treatment; and it should now accept this opportunity, if not obligation, to
help ensure the futiire succe5.s of American rheumatology.
’4 third undertaking which would help to enwre a suocessfiil future is a
strong, broadly based effort to increase our membership. The wisdom of
ARA’s initial and sustained p l i c y of encouraging the membership of all
physician5 interested in rheumatic diseases has been firmly established, and
(inr nnmerical growth has produced a respectable doubling of our member?hip in the past 12 years; but there is now a need to expand further. It is
estimated that there are about 1,OOO to 1,500 physicians in the United States
who have enough interest in rheumatology to- be members of local rheumati\m societies but do not belong to our national association. We must find
the means to make AR,4 membership attractive to them and thus increase the
opportunity for more effective scientific and educational activities. We should
strive to double our ranks again, but this time in the next 3 to 6 years. Surely
that would more than double the impact of the rheumatologists’ efforts to
enhance the welfare of patients and the science of rheumatology.
Fourth, we can also contribute medically to our future succes by encsouraging and supporting continued expansion cf research programs, including both those with basic-science and those with clinical orientations. The
emphasis of this undertaking must be on quality (rather than quantity) in
scientifically disciplined applications of curiosity within an environment of
intellectual freedom. &lore specifically. greater attention should b e directed
to degenerative joint disease, gout, and psychiatric factors associated with
connective-tissue diseases. Degenerati1.e joint disease has been relatively
neglected because it is ordinary, gout because it is uncommon, and both became thev often are not disabling; but already it is evident that these diseases
dre aveniies for significant exploration of genetic and enzymatic factors of
wide significance not only to rlieumatology but to medicine in general. It
becomes increasingly conspicuous that connective-tissue diseases-which
ha1.e remained unsolved etiologically-are
especially human disorders in
584
which the effects of emotional upsets are as great as, Or greater than, the
effects of other more commonly suspected environmental or genetic factors.
Between psychiatrists and rheumatologists there is a lack of knowledge of
each other’s fields which is reminiscent of a similar obstacle to our progress
that existed a generation ago between rheumatologists and orthopedists. The
earlier handicap has been largely eliminated; and more recently the special
knowledge and skills of statisticians, geneticists, biophysicists, chemists, and
other scientists, which once seemed unrelated to rheumatology, have indeed
contributed to advances in the science of our specialty. Similar assistance
from psychiatrists and psychologists should be encouraged, because there is
an obvious need for more objective and research-oriented studies of emotional
factors in rheumatic diseases.
Finally, in addition to these four medical requirements, there are nonmedical or sociological factors to be considered. Much progress in the treatment of specific diseases has developed from widespread recognition of the
need, established in its turn by effective public education. And thus, although
belatedly, greater attention to unsolved problems of rheumatic diseases has
become inevitable and now appears imminent. Privately supported voluntary
health agencies can effectively activate such social responsibilities for the
health and welfare of individuals and communities, and are useful also to
counterbalance and supplement tax-supported health programs.
The voluntary health agency in which we are particularly interested is, of
course, the Arthritis Foundation (AF). We have had both paternal and
fraternal attachments to the AF through the creation of its predecessor, the
Arthritis and Rheumatism Foundation (ARF), over 17 years ago. In the
period since, the best separate efforts of ARF and ARA have left much to be
desired. This became more evident in the 7 years ending last year, when the
National Foundation was a third separate rheumatologically oriented organization. ARA was privileged to have a leading part in bringing the simultaneously divergent and overlapping activities into a more unified effort shared
by ARA and AF. Now that AF is passing i t s age of adolescence and stands
ready to be an effective instrument of growing public concern for better control of rheumatic diseases, there is much wisdom in further unification. Neither
ARA nor AF will lose its identity and purposes, and our combined efforts could
well become the prototype for control of other chronic diseases. Our very
best efforts will be required, but we must not lose this opportunity to improve
both the medical and social environment of the future!
In conclusion, I am tempted to paraphrase Charles E. Wilson’s famous
“what’s good for . . .” remark and state that what is good for American
rheumatology will be good for us as individual physicians and for our patients, their families, and communities, and may even be beneficial to rheumatology throughout the world. For us in particular the requirements for continued success are (1) strengthening and expansion of educational efforts;
( 2 ) encouragement and enlargement of training programs for clinical rheumatologists and better definitions of desirable standards for all phases of
rheumatologic training; ( 3 ) increased support and development of research,
585
both clinical and laboratory, into unsolved problems of rheumatic diseases;
(4)a significant growth of our membership; and (5) dedicated support of
our objectives, in unison with our alter ego, the Arthritis Foundation, and
coopcrative support of the beneficial social principles of voluntary health
programs which they espouse.
Howard F. Polley, M .D., M.S. (hied.), Sc.D., Consultant, Section uf Medicine, hluyo Clinic; Professor of Medicine, Mayo
Graduate School of Medicine (Uniuersity of Minnesotu);
Rochester, Minnesota.
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