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