of the medical schools will be doing this
in the next decade, unless there is support
for it that is equivalent to the strong sup-
port that has been given for 15 years in
building up the more academically-
oriented research personnel.
Nobody has mentioned the fact that
some of the best postgraduate education
comes from full exploitation of the re.
ferred patient. When a consulting group
makes full use of the opportunity that is
presented by a referred patient, they are
helping the physician give excellent care to
the patient that he has referred for consul-
tation, and this is a most effective means
of educating physicians.

DR. AMOS JOHNSON: Dr. Polley did
a most excellent job of reporting the ideas
and problems that were discussed in our
section. I am in accord with everything
that was reported.

I do believe that those of us who are in
family practice would be very anxious to
see these proposed plans implemented in
some manner and would be most cooper-
ative with such an effort.

DR. WEDGWOOD: I was delighted to
hear your talk, particularly the emphasis
on flexibility. I would like, first, to em-
phasize more strongly the need for direct

support of educational programs, at the
undergraduate, graduate, and the con-
tinuing level, for physicians and for
paramedical personnel. We have had a
great deal of difficulty in supporting this
type of education over the past few years.

Next, medical schools and regional
centers have got to become involved in
providing the training for first line or
family physician care. Otherwise, we are
left in a situation comparable to that of
having departments of theoretical surgery,
in which no surgery is done.

Finally, we have to look very directly at
the need for funds for construction of
appropriate facilities within which to pro-
vide the type of teaching that is necessary,
in centers that are designed for the care
of ambulatory patients.

If funds are not made available to pro-
vide optimal teaching facilities, as wt41 as
to support teaching personnel and educa-
tional processes, we will find it very difIi.
cult to provide the manpower that will be
necessary to carry out the purposes of this
meeting.

DR. POLLEY: 1 want to thank all of the
discussants for their comments.

Clinical Investigation
  and Training

Chairman: John L. Decker, M.D.

The assigned task of our panel was
clinical investigation and training. This is
not an easy area to report on to an audi-
ence of this type. What we attempted to
do was to have a look at the clinical investi-
gation that is currently going on that is of
the type that we believe pertains to the
prevention of disability from arthritis. As
we went through this rather large mass of
material, we tried to spot areas in which
we believe deficiencies exist.  We ended
the discussion with a consideration of the
investigator himself. We did not formally
vote or spend too much time on formal
recommendations. with the exception that
the Chairman has attempted to bring a
consensus in that regard, which I will pre-
sent to you at the end.

  We defined clinical investigation of
arthritis as the study, in the broadest per-
spective, of the biology of disorders that
affect joints and related structures.  Sucsh
study  r'cluirrs an inlrrdisril)linary ap-
proach and must include. among its pur-
l


poses, the definition of disease, efforts to
discern their etiology and natural history,
and continuing analysis of their manage-
ment, with special references to the pre-
vention of disability.

The clinical investigator was described
as a physician who is committed to the
understanding of a disease or to the under-
standing of a group of diseases of man.
The tools that he uses, the training he may
bring to bear, and the level at which he
elects to work were all thought to be less
pertinent to his effectiveness as a clinical
investigator than is his commitment to a
disease area.

This approach to clinical investigation
has produced an abundant and diversified
body of knowledge in recent years. But
the emphasis has, for a variety of reasons,
been on fundamental studies of biochemi-
cal, immunologic, and morphologic aspects
of disease. Support for these studies has
been available and should continue to be
available. In the long run, they are of the
utmost significance.

Nevertheless, there has been some tend-
ency for these fundamental efforts to over-
shadow clinical studies, to preempt the
attention  of investigators, junior and
senior alike, and, thus, to inhibit work that

is more directly applicable to patient needs
and to the prevention of disability.

The Workshop felt that both spheres are
worthy of full attention.  However, the
charge to the Workshop was interpreted to
be a consideration of clinical investigation
that is directly pertinent to the patient.
And this was the area to which we con-
fined ourselves.

The inadequacy of clinical work and
planning, which is currently to be noted
at some of our better medical centers, was
said to be evident in the poor quality of
applrcations for support of outpatient, or
ambulatory, investigative efforts, in which
new techniques and new approaches are
greatly needed. It was felt that the ex-
cellence of current, short-term, inpatient,
acute problem studies had not been dupli-
cated, nor even approached, in outpatient
work with chronic disease, such as the
rheumatic diseases.

The Workshop turned to a discussion of
examples of problems that were suitable
for this type of study and of some of the
factors that make them difficult.
It was felt that the definition of the
rheumatic  diseases  would require the
recognition of specific disorders in their
earliest phases, prospective epidemiologi-

cal analysis of genetic and environmental
factors, and the setting up of diagnostic
criteria.  The American Rheumatism As-
sociation diagnostic criteria for rheuma-
toid arthritis were cited as a tremendous
advance; and it was noted, with approval,
that groups are now working on criteria for
gout, systemic lupus erythematosus, and
juvenile rheumatoid arthritis. The need
for constant revision and updating is ap-
parent and should be done systematically.
Efforts to evaluate the criteria, one-by-one,
should be fostered; and the results should
be incorporated in updated criteria.

The imperfection and imprecision of
some of our clinical methods were dis-
cussed.  And pleas for standardization
were heard. This is especially needed in
terms of standardizing serological testing
in rheumatoid arthritis. But there was
also noted to be diversity and disagree-
ment in regard to such mundane matters
as the measurement of joint motion or the
grading of joint damage by X-ray.

There was much interest in the role of
epidemiologic studies and in the definition
of these diseases; and the conclusions of
the National Foundation Center Confer-
ence of 1964 were cited in this regard.
Population studies have been of two types.

77


First, the one-time study of the popula-
tion, which is designed to obtain preva-
lence figures, as well as information about
geographic  or familial aggregation of
cases; and, secondly, the continuing study,
in which all the inhabitants of a carefully
selected area or community are repeatedly
studied; for example, biannually, over
many years.

Prevalence studies in some of the tem-
perate zones of the earth have not revealed
striking divergencies in the frequency of
rheumatoid arthritis. It was thought to be
desirable to apply the same survey tech-
niques to areas that represent greater ex-
tremes of climatic range. Some believed
the disease, rheumatoid arthritis, to be un-
common or, perhaps, absent in tropical
areas.

78

The continuing type of study that pro-
vides information on incidence, as well as
on prevalence, permits the earliest type of
casefinding, and, thus, the best information
on environmental factors that surround the
onset of the disease. And, later, it will
allow the correlation of early and minor
signs and symptoms with the eventual
progress and outcome of the disease.
Such studies do, of course, have their
problems and limitations. The rate of

attrition, that is, the rate of emigration
from the geographic area, constitutes a
problem that may be surmountable with
the use of some form of national registry.
There is some evidence that the mere sur-
veillance of chronically ill people may alter
the disease patterns to the extent that the
validity of the results is impaired. Finally,
such work is costly, perhaps too costly
when evaluated on the basis of the useful
facts that are obtained per dollar spent.

The Workshop group felt that there was
a place for the clinician in studies that are
designed to determine the cause of rheu-
matoid arthritis, although it was granted
that this is an area of strength for the fun-
damental or exclusively laboratory worker.
The observer who is concerned with eti-
ology of cause must always be aware that
his observations may bear only on a medi-
ating factor, important in itself, but, pos-
sibly, distinct from the ultimate cause or
causes.

The discussion, here, centered on the
study of events that surround the onset-
that is, the period of transition from health
to disease. Data are needed on such fac-
tors as time of year, physical activity,
presence of a deficiency state, intercurrent
infections, and the possibility of exposure

to toxic, environmental factors, such aa air-
water pollutants.

This kind of study is greatly improved
by the ability to study prospective patients
-people who will get the disease. This is
possible in continuing population studies,
but it involves the examination of a thou-
sand normal persons in order to have pro-
spective data on four or five future pa-
tients. The data, which can be practically
recorded on the one thousand, must, ob-
viously, be very limited.

We would be in a better position if such
studies could be carried out on suscep-
tibles-if there was a way to pick out, for
example, one hundred normal persons, with
the certain knowledge that even ten or five
percent of them would develop arthritis.

There is no way to do this. But it was
pointed out that the selection of suscep-
tibles and their subsequent study could be
based on a hypothesis under test. If the
hypothesis were genetic it would be well to
analyze mono- and dizygotic twin pairs.
The available evidence hints that con-
cordance is so low in identical twins.as to
cast substantial doubt on most genetic hy-
potheses. Blood relatives of families with
two or three victims of rheumatoid arthri-
tis might be studied, although it is possible


that such groupings should, at the outset,
be regarded as an atypical form of the
illness.

If the hypotheses involved infection, per-
haps the spouse of the rheumatoid arthri-
tic should be studied. If one's hypothesis
involved trauma, persons who are subject
to the form of trauma that is involved
should be evaluated prospectively.

The next point in this matter concerns
the problems of educating the public. It
is to be noted that all of the above work
requires a high degree of cooperation from
perfectly healthy people who, particularly
in a poorly-informed society, may flatly
refuse the pertinent examinations.

From etiology, the Workshop turned to
a consideration of the natural history of
the disease, rheumatoid arthritis. This in-
cludes the study of its long-term evolution,
with a view to achieving more reliable
prognosis and, thus, more reliable evalu-
ation of remedial measures that are di-
rected toward the prevention of disability.
It was believed that the medical world
is now, more than ever before, capable of
handling truly vast amounts of data with
machine methods. This means that correla-
tive patterns can be sought with incredible
speed among the several hundred variables

that might be recorded. Stated simply, it
may become possible to say, for example,
that if joints A and B are active in a 35-
year-old woman with an elevated sedimen-
tation rate and a positive rheumatoid fac-
tor test, there is a ninety percent chance
that joint C will be involved within the
next six months.

The example is crude, but some of the
Workshop felt that the possibilities thus
opened are infinite. Obviously this kind of
prediction is not possible until we have
stored in our machine's memory the perti-
nent data on a rather considerable number
of 35-year-old women with elevated sedi-
mentation rates. And there is the rub. We
need a massive, persistent, and painstak-
ingly  accurate data collection system.
Surely, such an effort should involve many
clinics and, thus, we again run into the
problem of standardization-of standard-
izing the data to its most trivial detail. No
amount of fancy computer technology can
give good answers from sloppy clinical
observations.

The maintenance of interest, the assur-
ance of accuracy, and the persistence of
the examiners are all problems. But the
Cooperating Clinics Committee of the
American Rheumatism Association  has

shown us that these ideas are not vision-
ary, that the work could be begun now.
There are objections. The individual in-
vestigator feels that he is giving up some
of his freedom and initiative, often pre-
cious to him. And that is true; he would
be. There are advantages. Many have
found that in conducting work of this kind
in their clinics, the result has been a sharp
upgrading toward clinical excellence for
all patients, not just for those under study.

One of the thorniest clinical problems in
the field is in reference to psychological
factors. These may play a role in produc-
ing the disease. Certainly, they modify the
degree of disability that results from it.
And they are, in turn, themselves greatly
influenced by the morbid process.

The control of this factor in clinical in-
vestigation has not been achieved. Several
studies were cited. It has been found im-
possible to predict, on the basis of an ex-
tensive series of pain perception and psy-
chological tests, which patients will do the
work that is required in recovering from
knee surgery and which will not. Efforts
are now being made, prospectively, on the
basis of monthly interviews, to determine
whether or not a patient's mood has an
effect on the flaring of disease activity in

79


systemic lupus erythematosus. Studies of
this type are very much needed.

It was pointed out that the kind of phy-
sician that is required (someone with
training in psychiatry and in rheumatic
disease) is in short supply. Until supply
more nearly reaches demand, it was the
feeling of the group that extended and
detailed evaluations of a few patients, with
attempts to understand the processes that
are involved, were more appropriate than
were the more superficial survey types of
analyses of many patients.

The final form of investigation that was
discussed was that which directly pertains
to the prevention of disability. It was
pointed out that disability usually has at
least three elements-psychological, con-
stitutional,  and that which is due to
changes in the muscular skeletal apparatus,
specifically, the joints or local damage.

Again, the work of the Cooperative
Clinic Committee of the American Rheuma-
tism Association was cited as having pro-
vided a standard of uncommon excellence
in trials of medications that are directed
toward reducing inflammation and consti-
tutional signs of activity.

80

The lack of controlled work in the use
of splints, heat, exercise, braces, and like

modalities was noted. Despite the regular
observation of short-term improvement
with such treatment, it seemed pertinent
to suggest that long-term results should be
evaluated critically.

The problem of suitable controls in
surgical therapy was touched upon. No
easy  answer is available; but it was
pointed out that detailed knowledge of the
stages of progressive disease of the knee,
for example, could be used to project a
probable outcome, and that the result of
surgery could be compared with this hypo-
thetical outcome.

One of the major factors that restricts
study of the effects of physical and surgical
modes of therapy is the lack of investiga-
tive bed space. Such studies require ex-
tended hospitalization, and this key factor
is simply unavailable in the amount that
is required.

Three types of important inpatient facili-
ties were discussed. It was considered
mandatory that all three be in or near the
center of investigative work. A few beds
providing maximum services for acute,
severe disease, are needed. These would be
the most expensive type of general hos-
pital beds. There is a need for more beds
that provide the level of services that are

required in chronically active rheumatoid
arthritis-a middle price range facility,
perhaps. The least costly beds would be
those in which there could be a consider-
able degree of self-service, but in which
physiotherapy and occupational therapy
would be available. It was estimated that
a group of four or five active investigators,
working together on problems in manage-
ment, could appropriately use between
fifteen and twenty beds for the investiga-
tive program, alone.

The final hours of the Workshop were
spent on a consideration of the man who
is to do all of this investigating. What
must he be?

It was felt, first, that he must be a well-
trained physician, that we can't take a
shortcut and drop out portions of current
curricula. He must be a complete physi-
cian, but his specialty interest or training
is not necessarily pertinent. He must have
interest in these problems. He must have
interest in patient care, in clinical investi-
gation. as we have talked about it, and in
teaching clinical methods.

Where are we to find such a person? In
this regard, it was felt that this field should
face the fact that we are in a rough re-
cruiting fight for the interest and capaci-


ties of these men. There are other pro-





this was to work out a program, a train-
ing program, a recruiting program, with
grams, other areas of interest, other areas






appeal to it.
of, perhaps, more excitement; and unless
we face this fact we are going to fall short.
We felt that one of the ways to approach

have completed two years of residency. It
that, under certain selected circumstances,






is very common for us to find able young
men who simply do not have the financial
money should be available for the support







wherewithal1 to manage two years of resi-
dency.
of residency training. Men do not ordi-







   Support for tho
narily enter a special investigative area,








              se individuals is
needed.
such as the rheumatic diseases, until they

Another point in the problem of re-
cruiting is what is the future, in terms of
jobs, for this individual? What does he
have to look forward to? It was felt that
if there were a clear picture of how and
where he was to apply his prospective
skills, the recruiting effort would be im-
proved.
Next, we turned to the matter of training
this individual. And here our ideas paral-
leled many of those that Dr. Polley has
brought out. It was felt that the training
would have to be largely preceptorial-
simply watching someone else do it or be-
ing closely associated with someone else
who is carrying on investigation. It was
felt to be wrong, however, to insist, exclu-
sively, on the preceptional method and,
thus, to disregard a more formalized ap-

preach to such problems as experimental
design and biometrics. It is crucial that
studies be designed with knowledge that
is not generally available to the average
physician. In this area, there are statis-
ticians and specialists in experimental de-
sign who have much to give. The provision
for such people, available to the trainees,
was felt to be crucial.

tism Section of The Arthritis Foundation
(formerly, ARA)  or with other national

We felt that it was worthwhile to estab-
lish and maintain contact with prospective
trainees, beginning early in their medical
career-the first and second year of medi-
cal school, for example. We felt it worth-
while to encourage summer research proj-
ects for medical students and to be able to
support them. All of us wanted to inject
excitement and challenge into the work
of our units. We wanted to keep the pro-
gram wide and flexible, so that a man
could find an area of interest that coin-
cided with his own within the overall work
of the program.
Money was considered. This is a tough
program. We don't simply want to buy
the man. Such a person is not what we
want. And yet these young men come along
at a time when their needs are great. In
many instances, they are deep in debt for
their medical education. And there were
some in our panel who felt, very strongly,

Th e possibility of rotations to other
services of the university was discussed.

If the training program is under the aegis
of the department of medicine, for ex-
ample, it seems quite obvious that the
trainees should have some time in connec-
tion with orthopedic surgery and in con-
nection with physical medication and re-
habilitation services. The possibility of
rotation to other units across the nation,
especially those providing special skills,
was also discussed.  Some felt that this

kind of move would have to be for at least
a year if it was to be worthwhile.
The possibility  of providing special

courses in connection with the Rheuma-

meetings for the young investigator in
training was discussed. In the last analy-
sis, however, we felt that the most impor-

81


82

could be brought to bear on clinical in-
vestigation; and (c) clear and forthright
support of clinicians of proven capacity
who are in a position to give and to teach
excellent patient care and to conduct clini-
cal investigation. Such support is deemed
appropriate for both medical schools and
for large voluntary hospitals.
The Workshop believes that support for
personnel in these three areas would
greatly enhance the quantity and quality
of investigation that is directed toward the
prevention of disability from arthritis.
It is also recommended that careful and
thorough consideration be given to the
great need for bed services in investiga-
tive programs in arthritis.
Finally, it is recommended that the
present law pertaining to research training
grants be redrawn to expand support to
include the training of teachers and physi-
cians who are concerned with patient care
as a research and teaching activity.

Discussion

HELEN ANDERSON: I would like to
say that I thought this was an excellent
report; and I am delighted to see emphasis
on clinical research. However, just as we
recognize that the patient needs many

workers other than the physician in order
to be treated for his arthritis and to meet
a11 the problems of the patient and the fam-
ily, I would like to say, for all of the asso-
ciated personnel, that I was a bit disap-
pointed to hear only physicians included
in the section on clinical investigation. I
suggest that there is much research that
those in the associated professions can do
to contribute to meeting the problems of
the arthritic patient.

DR. DECKER: I think that that is an
excellent suggestion, and I really do feel
rather apologetic about it. We have been,
as Dr. Wedgwood says, parochial; and I
apologize. I don't think that there was a
physician in the group who had considered
the possibility of attempting to carry out
a clinical investigative program without
the support of all associated personnel.
But I also feel that there is a great breadth
of opportunity for each of these groups,
social workers,  occupational therapists,
and so forth, to run their own studies, not
"managed" by a physician, in any sense.
There is a tremendous need for that kind
of investigation.

DR. SHULMAN: I would like to pursue
this really important feature. For those
of us who are in the medical situation, I

would say that I applaud everything that
you have said.

First, before getting to my point, I
would like to congratulate, from the bot-
tom of my heart, Dr. Decker, for just about
the most concise and thorough resume of
an eight-hour discussion that I have ever
heard. There is not one single point that
was brought up during our discussion that
was of any importance that was omitted
from his unusually competent summary.

But I would like to get to the point of
the associated personnel. The associated
personnel are concerned with names, to
some degree. And we who were on this
particular panel were trying to do the best
with the extremely difficult problems that
we knew something about.

I know nothing about the social service
aspects of arthritis. And the reason I
know nothing about the social service as-
pects of arthritis is that, in spite of re-
peated efforts to obtain such services, and
in spite of being in an optimal, from a
relative standpoint, situation with respect
to it, I don't feel true cooperation or in-
terest from the parent organization of some
of these paramedical personnel. And I
would like to support, in the most general
manner and, really, in the most construc-


tant element of the training is something
that we already have before us, the research
training grants program of the National
Institutes of Health. This program has
been modestly successful in turning out the
kind of clinical investigator in which we
are interested. However, its emphasis has
been overwhelmingly on fundamental,
basic investigation.

I have indicated, and others have, too,
that there is nothing wrong with this, but
that this is not all that is needed. The
group felt, very strongly, that so long as
the emphasis persisted to be confined to
this area, we would be failing in the train-
ing of clinicians, clinical teachers, and peo-
ple who are interested in clinical-by that
I mean bedside-investigative work. We
think that a better framework for the fu-
ture can be built by a modification of that
program.

Finally, we dealt with the question that
was originally raised in considering re-
cruitment, of where this investigator would
go. Where would he work? Here, it was
felt that the medical schools can, and
should, consume--I guess I can use that
word-can consume a number, a large
number, of these individuals. When we
face the fact that very few of our schools

are actually involved in any teaching in
reference to this area of disease, that is
particularly apparent.

The opinion was also expressed, how-
ever, that such people are needed by vol-
untary hospitals. Here, I am thinking of
some of the excellent, topflight, large vol-
untary  hospitals,  which are gradually
swinging, in many instances, to a more
full-time system. It was felt that these
were most suitable places for centers of
excellence in arthritis and that this type of
investigator could take a full-time position,
under those circumstances, if support was
available.

I come, finally, to the recommendations.
First, it is recommended that a research
committee be formed on a national basis.
This body would be envisaged as including
two or three full-time physicians who do
nothing but serve this unit. At least one
member of the full-time group should be
an epidemiologist.  Another might have
special interests in information and data
handling. The duties of this committee
would be to coordinate and assist the work
of those investigative units that were in-
terested in cooperative clinical work, of
any kind, in the rheumatic disease field.

Among the services that the committee

would direct would be the provision of
standardized sera to be used in controlling
laboratories across the Nation, the mainte-
nance of such national registries of arthri-
tic patients as were deemed appropriate,
the maintenance of a drug information
service, which would be kept instantly up
to date by a standardized reporting sys-
tem, and the maintenance of epidmiologi-
cal data that would be in parallel with in-
formation that was available on regional
facilities. The latter function would pre-
pare the committee to advise regional uni-
versity and local medical groups of un-
filled needs and opportunities.
Next, it is recommended that the fund-
ing of the type of investigation that has
been surveyed here be on a competitive
basis with like, clinical studies, but not in
competition with fundamental or labora-
tory studies.

It is further recommended that support
for personnel be given in the following
three areas: (a) Relatively small amounts
for support of promising house staff physi-
cians who would, otherwise, be financially
unable to complete the required training
for investigation; (b) provision for suit-
able biometrical staff in those institutions
in which the skills of such individuals

83


tive manner, the notion that much needs
to be done at the home office. And much
really does need to be done. You should
plan to return from this meeting and go to
your national organization, as we will be
going to our national organization, with
these recommendations-and I mean your
national professional organization-to try
to help stimulate the provision of the as-
sistants that we sorely need to carry out
our job.

DR. REDFORD: I would like to men-
tion a point that was brought up in the
discussion, particularly since it was a
thought of mine: A physical therapist
should participate in studies of arthritis
and of some of the therapeutic modalities
that are used in the area. I think that this
is very important, because the motivation
of physical therapists who have interest in
areas other than just patient care can, per-
haps, be greatly enhanced if they are used
in programs in which investigative work is
being done. They will go on even further,
perhaps, into other fields, such as physi-
ology and so forth.

      I would like to state, for the record, that
    we are most interested in stimulating this
    kind of activity among paramedical per-
%      sonnel.

DR. STILLMAN: I think that Dr. Shul-
man made a very good point about the
encouragement from the home office. But
I think that even more important is encour-
agement in the individual unit in which the
paramedical personnel are working.
Our social worker, in the unit that is
associated with the study of. children, is
coming out, shortly, with a paper that was
the result of her own endeavors. She was
helped out by the other members of the
group, just as every member of the group
who comes out with a study is helped by
the other members. But 1 think that they
need encouragement to do this.
DR. TOONE: I would like to speak to
one point in your report, and that is the
part that deals with altering the training
grants that are now offered by the National
Institutes of Health. I think that this is a
very important point, a very strong point,
and I think that this should include the
words "clinical traineeship." I think that,
in many ways, this already is being done.
1 think that this would rectify the situation
that is already in existence.
Furthermore, I think that this would aid
us in our recruitment of new men. Some
of these people are frightened by the term
"research"; they feel as if they have to

take an entire laboratory training.
DR. DECKER: This is exactly the view
of the group that discussed the matter, Dr.
Toone, especially that point about being
frightened. There is some feeling abroad
that, unless you know about messenger
RNA, you are just not there. And that, we
would like to discourage.

DR. WHEDON: I would like to know
where to begin. But I think it is important
for me to try to tell you that not only do
we have the authority, within the laws and
regulations that govern our training grant
procedures and activities, to do the things
that you recommend, but we, in fact,
heartily support, the fact that, and try to
make that support as clear as we can,
training grants for research, which does,
most definitely, include clinical investiga-
tion. And there is no regulation against
the inclusion of careful and detailed clini-
cal care and clinical management as an
integral part of a training grant for re-
search.

Now, I am really disturbed about this
because, obviously, we have not gotten this
point across clearly. And we must go back,
and we  must apparently rewrite our
pamphlets and our handouts and revise
our telephone messages to make this per-


fectly clear.

Investigation at the bedside of indices
of variation and change in clinical disease
is clearly within the realm of what can be
supported and is actively being supported,
certainly in other fields of clinical medicine
and, I believe, in some of the training
grants within this area.

But please do not go away with the idea
that there is some rigid barbed wire fence
around the training grant programs of the
National Institutes of Health or of the
National Institute of Arthritis and Meta-
bolic Diseases that excludes active investi-
gation of the patient, as supported by our
training grant programs.

DR. DECKER: Thank you, Dr. Whedon.
I think this is very well and very fairly
said.

The  recommendations  are probably
written too much in terms of legalisms.
To some extent, this is a matter of the
mind, a state of mind, or a frame of mind
for which no particular person or body is
responsible.

DR. GLENN CLARK: I realize that
everything that Dr. Whedon says is true,
and I am not sure that it is the fault of the
law or of our attitudes that programs for
clinical investigation don't become better

funded. I think that the reason is prob-
ably, as was mentioned, that of having
clinical programs compete with basic sci-
ence programs. It is very, very difficult, in
this newer field, to design a clinical pro-
gram that looks as nice on paper, that has
as good controls. In rheumatoid arthritis,
for instance, they ask, "Where are your
controls? How are you ,going to get a
patient with rheumatoid arthritis who
doesn't go down to the drug store and get
aspirin?"

I would like to have the study commit.
tees look a little bit more into some of the
new and, perhaps, less stereotyped ideas
for clinical research. I would like to see
them put a little seed money into, perhaps,
a different and less well-organized, at first,
approach to clinical investigation. Above
all, as you mentioned, these grants should
not have to compete with basic science
grants in the study committees. That is
extremely important.

DR. FENNINGER: It seems to me that

through all of the presentations and discus-
sion, one recurrent theme has come up:
advice, education, and recruitment. And I
think that part of the dilemma that we all
face has to do with the piecemeal way in
which we have approached the whole ques-

tion of health care, of rendering health
services, of research in the various fields
that are related to health, and of the sup.
port of education and the support of
residency programs  and postdoctoral
traineeships. It seems to me that the time
has come to decide what the fundamental
issues are.

The first issue, I think, is the general
support at the undergraduate level of edu-
cation in the health professions.  I was
very glad to hear Dr. Polley mention this
in his report; and Dr. McEwen, I think,
mentioned it in his report.

Second, the exploration of the range of
investigation in the clinical field, which, I
believe, is as fundamental as is dealing
with molecules or portions thereof, re-
quires, in our present cultural setting, some
kind of general support of research within
institutions that are designated by the
members of the institution.

So, it would seem to me that there should
be fundamental support of education at
the undergraduate level. And there should
be fundamental general support of re-
search at the institutional level, in addition
to the other mechanisms that we now have,
such as the programs and projects that are
supported on a national basis in national

85


86

competition. But while I think that it is
extremely important that we retain present
programs and projects, I think that they
need a much broader foundation in the
support of education and in the support of
research at an institutional level than is
now provided.

I think both science and society demand
that we reexamine the bases of support and
put them in their proper perspective.

DR. WILLIAM CLARK: I will make it
brief.

There is a very fundamental problem
here. You stressed in your report, Dr.
Decker, that it will be necessary to collate
or integrate a vast amount of clinical
observation, that the basic problem we
have is in collecting reproducible observa-
tions by standardized criteria.

Now, we know that it is a fact that these
observations on the patient are going to
have to be made by a clinical observer who
will not be supported as a fellow, com-
mitted to clinical investigation. In practice,
in most instances, these men go off into a
clinically-oriented career that is devoid of
investigational opportunities.  This is a
basic deficiency and many of us know the
policy of the National Institutes of Health
very well; and we know that these fellows

will not qualify for fellowships, nor will
their projects qualify for research grants
in clinical investigation. It is a deficiency
that we must make up, or the observations
that we are making on rheumatoid disease
will always be garbage.

DR. BLAND: It seems to me that, be-
cause so very much has been brought to.
gether at this meeting, we are about to get
off the ground. Since the gears of govern-
ment shift slowly, I suggest that all of us
make known to our Senators and Represen-
tatives the conclusions of this meeting, in
the next few weeks, rather than at a later
time.

DR. SHULMAN: Just one plea. After
hearing the comments of Dr. Whedon and,
then, of Dr. Glenn Clark, I would only
make a plea. Tremendous gains have re-
sulted from the quality of the efforts that
have been engendered largely through the
support of the National Institutes of Health
and The Arthritis Foundation, and we, in
extending our efforts to clinical training and
recruitment, must insist on the same qual-
ity. I don't think this has been emphasized.

The danger exists that because of the
demands of the public for increased efforts
in this area, we may risk the irreparable
damage of impeding our actual goals by

not insisting on the type of quality control
that should be exerted.

DR. LAMONT-HAVERS: Dr. Decker,
I should like to second that. There is no
sense in just training or in just giving
grants in clinical investigation or in sup-
porting people for clinical medicine. You
have to look at the product. You have to
look at the trainer. And I think that much
of the lack of support or the suppression or
taking away of support at the present time
is not due to the fact that this type of in.
vestigation cannot be supported; it is the
product that is being turned out that is not
worth the support.

DR. DECKER: I think that is pertinent.
MRS. KINOY: I just wanted to speak

briefly on what some of the other people,
earlier in the discussion, talked about, and
that is this question of the team approach
to basic investigation. I think that we have
come a long way toward the use of many
different kinds of paramedical personnel,
or whatever we wish to call them, in work-
ing out followup and long-term care of
patients with arthritis. But I don't think
we will be able to attract people from many
other disciplines to work in this whole area
of arthritis unless they feel that they are in
on the ground floor of planning the basic


kinds of community research. And for this
reason I think we have to make a special
plea to include them in this whole area of
research.

DR. CLEVELAND: I want to wish you
God Speed in your search for this super-
man in research that you outlined in your
background paper. If you don't find him,
there may be some models that are already
available that will be of help, especially in
the area of investigating psychological re-
search and of investigating psychological
factors in arthritis in various parts of the
country, where psychologists are already
collaborating with rheumatologists and pe-
diatricians in this area with some degree
of success.

In California, I think, there is a psy-
chologist by the name of Rudy Moos who
has done some work recently with Dr.
Engleman. In Boston, Dr. Stillman's group
is working in this area; and in Houston
we have something going. We do have
some communication among the psycholo-
gists who are involved in this area, and I
think we might be able to offer something,
here, in terms of a group that is already
working in this area who have some com-
munication among themselves.

But I think, in terms of responding to

Dr. Shulman's earlier remarks about this,
that the psychologist will need an invita-
tion from the medical people who are in
the field who are administratively respon-
sible for these positions. The psychologists
are very busy people, too, and I don't think
that they will spontaneously become in-
volved unless they are invited.
DR. DECKER: None of my remarks
should be interpreted to mean that we are
trying to exclude anybody by training one
person to do everything. That is obviously
ridiculous.

DR. BLAND: I am concerned that we
are creating the impression that a clinical
or a patient-oriented investigator is very
different than a basic investigator in medi-
cal sciences. They are all the same people.
And I wager that there is no one in this
room who doesn't have a basic program,
meaning one that is wholly non-patient ori-
ented. I work with a colonizing amoeba,
and I relate it to the bedside physician.

I certainly wouldn't want to come off
with the notion that the bedside doctor
is a very different person than is the pre-
cipitator of proteins, because he really
isn't.

Voluntary and Public
Agency Activities
  and Programs

Chairman: William D. Robinson, M.D.

Our Workshop, which is concerned with
voluntary and public agency activities and
programs, had representatives from agen-
cies that perhaps were not as well repre-
sented on other panels. Not only did we
have the formal health departments repre-
sented at the national, regional, state, and
county levels, but we had representatives
from the Council on Voluntary Health
.4gencies of the American Medical Asso-
ciation, one individual who was concerned
with professional relationships in the
Blue Cross Association, and representa-
tives of the Visiting Nurses Association
and the physical therapy fields.

Our Workshop started off with the fol-
lowing premises: That we could regard
rheumatoid arthritis as the prototype for
the development of a program that would
automatically include other crippling dis-
eases, and that prevention of disability in
rheumatoid arthritis could, quite clearly,
he related to the institution of care early

87


in the course of the disease and to the
provision of continuing medical and social
support.

We started by visualizing the course of
a hypothetical patient with rheumatoid
arthritis, with an attempt to project the
stage in the evolution of the disease that
brought the patient into meaningful con-
tact with the programs of the various vol-
untary and public agencies. Intertwined
with the review of the current status of
such activities was emphasis on what can
be done to bring these efforts to bear more
effectively on the patient in the prevention
of disability.

Much attention focused on the mobiliza-
tion of present and potential activities, so
that they can be brought to bear on the
patient earlier in the course of his disease.
This broke down into several components,
the first of which covered efforts to de-
crease the interva1 between initial symp
toms and the first medical contact.

88

We have chosen to use the term "first
contact physician," or "first medical con-
tact," rather than "general practitioner"
or "family practitioner," because, in realis-
tic terms, the first medical contact and the
personal physician may frequently be an
internist, a pediatrician, an obstetrician, a

surgeon, or a man in any other field of
medical practice. Decreasing this interval
is, quite clearly, a matter of public infor-
mation and interest-an area in which the
recommendations of the first panel become
particularly important.

The second point centers on efforts to
make this first medical contact more effec-
tive in leading the arthritis patient to
prompt and adequate care. This involves
the basic training of the physician, which
has been discussed eloquently in previous
panels. It also involves the post-graduate
educational effort that must be made if
the practicing physician is to be kept up-to-
date in the field of arthritis. It implies the
availability of resources for early and accu-
rate diagnosis and the availability of facili-
ties for the provision of total, or compre-
hensive, medical care that is adapted to the
needs of the individual patients.

Some patients may require referral to
an arthritis center, in order that special
skills and resources can be brought into
operation. Others can be adequately cared
for in the local community. But it is im-
portant, here, that the community resources
be brought to bear early in the course of
the disease, rather than later, as is too
often the case at the present time.

A third point dealt with the problems
of providing early and adequate hospitali-
zation for the arthritic patient and with the
adequacy of hospitalization, in terms of
both duration and quality of care. Often,
an initial period of hospitalization can be
provided in a community or general hos-
pital. Such hospitalization provides an op-
portunity to bring to bear on the particular
patient the following principles of treat-
ment: Rest; adjustment of medication to
the needs of the particular patient; appli-
cation of mechanical principles and devices
to prevent deformity; indoctrination of the
patient in the use of physical therapy to
maintain function;  and careful attention
to all the factors which can exert a dele-
terious effect on either the physical or
psychological health of the individual. We
were not particularly enthusiastic about the
so-called "halfway house," as the facility
in which the initial activities in manage-
ment of the patient with rheumatoid ar-
thritis should be carried out.

A period of hospitalization also serves
most effectively to educate the patient about
the nature of his disease and to introduce
him to the essential features of his Iong-
term care program.

The fourth component dealt with the


provision of continuing medical and social
support for the patient. This is the area
in long-range care that brings the physician
who is concerned with prevention of disa-
bility into contact with many agencies that
have a responsibility in the area of chronic
illness-a responsibility that is not focused
exclusively on the patient with arthritis.
At the present time, such continuing sup-
port is seldom brought to bear until rela-
tively late in the course of the disease.
The groundwork for such support can often
be laid during the initial period of hos-
pitalization. But such support can, and
should, be applied when appropriate, soon
after the first medical contact.
The principal ingredients of this pro-
gram of long-term care are continued sur-
veillance by the physician, aided by the
home care program, as implemented by
visiting nurses or public health nurses, SU-
pervision of the physical therapy program,
and utilization of the aid of social service
workers, dietitians, and vocational, occu-
pational, and recreational therapists, when
appropriate.

In the course of reviewing the current
activities of public and voluntary agencies,
it was apparent that several are concerned
with public information. This is a major

activity of The Arthritis Foundation, both
at the national and chapter levels; and
the Foundation has been active in the
preparation and dissemination of authori-
tative information on arthritis. It has also
been a concern of the Public Information
Service of the American Medical Asso-
ciation, the Division of Chronic Diseases
of the U.S. Public Health Service, and their
counterparts in the State and local health
departments.

  Patient education, as distinct from pub-
lic information, is also a major function
of The Arthritis Foundation, which not
only provides pamphlets for patients with
various types of arthritis, but, particularly
at the chapter level, functions as an "in-
formation, counseling, and referral serv-
ice." Patient education is also an objective
of the Patient Information Service of the
American Medical Association.
  In considering professional education,
members of our panel also pointed out
deficiencies in the opportunities for medi-
'  cal students to experience exposure to the
problems of chronic diseases, including
arthritis, to participate in long-term care
of patients, and to become familiar with
the community agencies whose resources
must be brought to bear in the management

of such patients.

In postgraduate education, several or-
ganizations are concerned with the effort
to keep the medical practitioner up-to-date
with respect to advances in diagnosis and
management of rheumatic diseases. This
is a place where the Rheumatism Section
of The Arthritis Foundation (formerly,
American Rheumatism Association) cer-
tainly takes a major role. It is also the con-
cern of the Committee on Continuing
Education of the American Medical Asso-
ciation's Council of Voluntary Health
Agencies, which is particularly concerned
with improving the effectiveness of the
"first contact physician."

With respect to the training programs
of the National Institutes of Health, it is
correct to say that they are not in a posi-
tion to support training for the develop-
ment of clinical proficiency. They are in
a position to support training in clinical
investigation and, of course, training in
other aspects of research.

The problem of training the allied med-
ical and health professions also came up
for consideration.  We appreciated the
problems of recruitment and of support.
We did feel that a very worthwhile func-
tion was served by symposia, frequently

89


90

sponsored jointly by chapters of The Ar-
thritis Foundation and by public health
agencies, to provide public health nurses,
visiting nurses, nutritionists, physical ther-
apists, social service workers, and voca-
tional,  recreational,  and rehabilitation
workers with information regarding the
particular needs of the arthritic patient;
and we felt that some arrangement for
short-term training programs of a few
weeks or more for such individuals, with
attention placed on the needs of the ar-
thritic patient, would definitely be worth-
while.

New to many of us was the matter of
therapeutic recreation, with the objective
of maintaining the handicapped individual
as an active participant in society. This
addition to the community agencies that
can be brought to bear on the long-term
management of arthritic patients was ex-
plained to us by the representative of the
National Recreation Association. It has
been demonstrated that: in cooperation
with the responsible physician, arthritic
patients can be included in regular recrea-
tional programs, that recreational programs
can aid in getting the homebound arthritic
back into community activities, and that
such recreational activities can be success-

fully coordinated with nursing home pro-
grams.

There are two or three somewhat dis-
jointed points that came out in our panel
discussion that may be of interest to all
members of the Workshop.

It was the public health officers in our
panel who pointed out that, although the
magnitude of the problem of.arthritis made
it a public health problem, it could not
be realistically approached by "mass meth-
ods," in either diagnosis or treatment. The
diagnosis of arthritis rests on evaluation of
the history and physical findings that are
obtained by the physician who is aided by
X-rays and selected laboratory tests, rather
than by any single criteria. Similarly, man-
agement depends not upon a single mo-
dality, but on a program that is carefully
individualized to the needs of the par-
ticular patient. This is a process that ob-
viously has to be done by the physician
and can not be accomplished by mass
methods. Therefore, the role of a State
or local health department was visualized
as a supportive one for the practicing phy-
sician, providing the resources when, and
where, they are lacking in the community,
for the physician to carry out diagnosis
and treatment. The health departments are

also able to contribute to the coordination
and development of community resources
that are needed for long-term care.

Another point that is worthy of report-
ing is the fact that, in considering the
special problems of the arthritic related
to hospitalization, it appeared that agen-
cies that are concerned with hospital in-
surance and medical care insurance can
be expected to be responsive to the needs,
both for hospitalization and for certain
aspects of home care, as they are defined
and requested by the practitioners in the
particular community or region that is
served by such insurance plans. As a mat-
ter of fact, whether we were discussing
the activities of a community health de-
partment, the activities of the visiting
nurses or public health nurses, or the pro-
grams of various other supportive agencies,
it was brought out, repeatedly, that the
most effective way to bring these agencies
into meaningful activity in the arthritis
field is to develop the demand for such
services at the community level, by the
physician that these agencies have been
designated to assist and with whom they
are accustomed to work.

It was interesting to note that the incor-
poration of arthritis as a categorical pro-


gram, a special interest program, into    does recommend that existing programs be
already existing programs presented the   supported, strengthened, coordinated, and
same types of problems in all areas---from    expanded to the geographic areas in which
medical school curricula to the activities    they are lacking.  In contrast to the devel-
of a county health department. The prob-    opment of a new structure, we believe that
lem of introducing a categorical interest    building along the strengths and bolster-
into a program that was already under way   ing the weaknesses of what we now have
and integrated consisted of the usual basic    is not only a more practical approach, but,
difficulties-limitations of time and money,    in the long run, will be more effective.
shortage of trained personnel, and come     Because, at every turn, we came up with
petition of a new program with ongoing    the fact that the educational program, at
responsibilities, which were already over-    all levels, would be instrumental in provid-
taxing the available resources. In each in-    ing the resources that are necessary for the
stance, it appeared that the integration of   adequate care of patients with rheumatoid
activities that were directed toward the    arthritis, we recommend that voluntary
arthritic into programs that were concerned    agencies, in cooperation with public health
with chronic illness was the most feasible    agencies that are interested in arthritis,
and practical solution. I, personally, do    spearhead a more extensive public, patient,
not fear that arthritis will lose its identity    and professional information and educa-
by following such a course. It is quite    tion program that will utilize imaginative
clear that arthritis can serve as the proto-    and creative techniques. All channels of
type for the development and focusing of    health education should be used. The Ar-
resources that are needed in many other    thritis Foundation may well play a leading
types of chronic illness.               role in this effort.

We do not have a series of carefully
enumerated recommendations. However, I
find that, in some way or other, most of
them have been covered in reports of previ-
ous panels.

After careful consideration, this panel

It is our impression that the preparation
and formulation of authoritative informa-
tion in the field of arthritis has been well
accomplished. The channels of dissemina-
tion of this information, in the form of
pamphlets, brochures, and so forth, have

been well developed. But the primary prob-
lem is one of really getting this informa-
tion across to the public, to the first con-
tact physician, and to the medical student.
The real problem is getting this information
across in such a way that it has a mean-
ingful impact.

The need for a recruitment program in
the paramedical professions has already
been mentioned. It was felt that recruiting
in this field might well be the primary
responsibility of the voluntary agencies,
who are in a key position to have an im-
pact at the time of career choices. Financ-
ing may well be an area for consideration
of governmental support.

There are, essentially, two ways in which
interests in arthritis can be stimulated in
State health departments. One would be
the addition of arthritis to the categories
in which formula grants can be made to
State health departments; at the present
time, such grants are restricted to heart
disease and cancer. The other is stimula-
tion by chapters of The Arthritis Founda-
tion of activities in the State health depart-
ment that are appropriate to the field.

Again, as far as activities in local health
departments are concerned, the stimulation
by chapters of The Arthritis Foundation

91


would appear to be a logical recommenda-
tion.

There are grants available in the Public
Health Service for planning and survey
of community resources under the Com-
munity Health Service and Facilities Act.
These are short-term grants that are usu-
ally concerned with efforts to decrease the
need for hospital beds and hospitalization
and with utilization of home care plans and
nursing homes. It appears that such grants,
for purposes of surveying and planning a
community's resources for the chronically
ill patient, could well be recommended.

92

I hope that other members of the panel
will not hesitate to add to or modify the
report as I have presented it. Thank you.
DR. MCDONALD: Dr. Robinson, I want
to express my appreciation to your group
for defining, so well, the appropriate rela-
tionship of the public health agencies to
the practicing physicians. The people whom
I think are smart are those who agree with
me, but can express it better. So, there-
fore, I think you are a very smart man.
DR. ROBINSON: Frankly, it was an
education to me to learn what the divisions
of authority and responsibility at the vari-
ous levels of the public health activities
in this country actually are. I am impressed

with my ignorance on the subject. Per-
haps this should go into medical school
curricula, too.

FROM THE FLOOR: Hear !

DR. BLAND: There has been so much
discussion in New York about the need
for professional education that I think it
may pay to emphasize, again, some of the
opinion that was expressed, both here and
in our panel. Frequently, what happens is
that the best treatment goes to the sophisti-
cated, aggressive, and educated patient. Cer-
tainly, one of the functions of the voluntary
agencies in the field is to motivate, edu-
cate, and train patients to make maximum
use of existing community health facilities.
Frequently, it is not only a question of
the lack of availability of facilities, but also
the poor utilization, or misutilization. of
facilities.

I think, also, that. in light of the kind
of discussion that we have had through
most of the reports from these Workshops,
beginning with the very first one, with
recognition that financial support ir; a
major problem that faces the arthritis field
and that with the recommendation of Work-
shop One and the view that voluntary
agencies. in cooperation with the govern-
mental agencies. have a responsibility IO

advance the educational program on all
levels, that it seems to me that it is worth
thinking, for a moment, about the some-
what unique aspect of the voluntary agen-
cies in advancing the public's restlessness
with the present level of care.

The ultimate responsibility, I think, for
an increased flow of Federal, State, or local
money, from both public and private
sources, is going to depend very heavily
on an aroused public. And it seems to me
that a part of the community education
and public information and education func-
tion of the voluntary agencies is to arouse
the public, not only to knowledge about
the disease, but to a desire to see that
the necessary funds flow promptly to those
areas where they are needed.

MR. WARTOFSKY: In your rundown
of the information distribution points, you
omitted the National Institute of Arthritis
and Metabolic Diseases. I do know that
we have an active special education pro-
gram and exhibits. brochures, and so forth.
I do hope that you will include it in your
report.

DR. ROBINSOl\r: I spent a fair amount
of time on that point in the background
paper. and the role of the National Insti-
tute of Arthritis 8 Metabolic Diseases in


professional education was emphasized
there. In the report, today, I attempted
to bring out, primarily, those things that
had not been covered in the background
paper. I am sure that by proper adjustment
of the two sources we shall have a more
complete review of present activities.

Socioeconomic Aspects
  (Financial Resources)

Chairman: Ronald W. Lamont-Hauers, M.D.

One of the most effective means of judg-
ing the profound impact of arthritis on
the patient, his family, his community, and
the Nation is to examine its associated
socioeconomic problems.

Statistics

The extent of the socioeconomic factors
that are associated with the arthritis prob-
lem can be realized by a review of the
statistics that are obtained through the
National Health Survey and from other
sources.

Table I shows the latest estimates of the
number of people in the United States who
maintain, during lay interview, that they
or a member of their household have aches
and pains that are related to the muscular
skeletal system. This figure is now 12,668,-
000; but when it is compared to more
intensive community surveys, a total of
over 13 million people who suffer from
muscular skeletal complaints is obtained.
This means, in effect, that 13 million peo-
ple think they have, or think that members
of their family have, something that is
wrong with their joints or muscles.

A more meaningful figure is the one that
shows that some 3,300,OOO people in this
country maintain, on household interview,
that they have limitation of activity of
some sort.

Of interest is the fact that although the
number of arthritics who are over 65 years
of age is less than the number who are
under 65, the percentage of those with
limitation is greater in the age group over
65. Limitation, therefore, increases with
age. In fact, if we break down the statistic
that shows 3,300,OOO persons with limita-
tion, we see that there is a great increase
in the amount of limitation in the age group

over 65 and that this increase occurs par-
ticularly among the female population.
These data are in Table II.

Table III shows that the arthritis that
does cause limitation interferes with the
patient's major activity.

It should be emphasized that these statis-
tics from the National Health Survey do
not relate, in any way, to any of the diag
nostic categories of the rheumatic diseases.

This conference has pointed out, very
clearly, that one of the problems in the
rheumatic diseases is that of nomenclature.
At times, during the deliberations of the
past few days, arthritis has meant any
muscular skeletal ache or pain. At other
times, it has meant, specifically, the severe
rheumatic diseases, or again, it has been
equated particularly with rheumatoid ar-
thritis. The statistics and discussions that
relate to these three interpretations are not
really comparable.

  There has been a mention, today, of the
need to have a registry, or some central
gathering point, of all diagnoses of rheu-
matoid arthritis and followup information
on patients. The Canadian Arthritis and
Rheumatism Society has done something
like this. Information on all patients who
~ have received treatment through the So-

93


ciety is recorded in a central record file,
in Toronto. From this source, Dr. Rohin-
son, Medical Director of the Society's Med-
ical Centre, was able to collect data on
10,000 cases of rheumatoid arthritis, which
had been referred by physicians to the
Canadian Arthritis Society for therapy,
chiefly physical therapy.

94

The age of admission of these patients
increased by decades. It peaked at the SO-
60 decade. The increment of each decade
was added to that of the following decade.
An analysis of this shows that approxi-
mately 500 new cases are added a year.
Whether this means that the incidence
of rheumatic arthritis in Canada in this
group is 500 a year is another matter.
It may be. The d ropoff after the age
of 60 reflects that fact that people be-
gin to die at that time of life; it doesn't
mean that their disease is getting better.
Dr. Robinson was also able to show that
the amount of disability increased with
age in rheumatoid arthritis. This fits in
very well with the data for all persons
with arthritis from the National Survey.
In Dr. Robinson's study, there was a pre-
cipitous rise, by decades, so that by the
sixth decade, approximately 50 percent of
all patients with rheumatoid arthritis had

major disabling conditions when they were
referred to the Society.
Table IV confirms the statement that
arthritis is a condition of the lower eco-
nomic groups. As gross family income
goes down, the percentage of arthritis and,
also, the percentage of individuals in the
limited group goes up.

There was some question about whether
this increase was related to the age of the
patient or to the fact that as the patients
got older, particularly over age 65, their
income dropped off. Therefore, Table V
was computed. This table shows that while
it is true that persons who are over 45
do have more limiting arthritis, it is also
true that those over 45 years of age with
family incomes under $4,000 have even
more than do those with yearly incomes in
excess of $4,000. Thus, it can indeed be
said that limitation from arthritis is asso-
ciated with lower income, regardless of
age, although it is also associated with
increasing age.

   Table VI and Table VII are an estimate
of the costs for arthritis and rheumatism
in millions of dollars. They really repre-
sent the minimum figures, not the maxi-
mum. There is every indication that the
I  real cost is even greater than this. Again,

this is direct cost; and it does not include

The figure of $435 million for drugs and
the indirect costs.


other remedies was obtained from the re-
port of Ruth Walrad, which was made in
1961. Included in this amount is the sum
of $250 million, which was estimated to
have been spent for products that were
falsely and misleadingly advertised.

The National Health Survey has done
some experimental tabulation of data dn
arthritis as part of a multiple diagnosis. It
is well known that in the older age group,
particularly, arthritis is usually but one of
multiple conditions. To get the true socio-
economic impact of arthritis, therefore, one
must consider not just those cases in which
arthritis is the primary disease, but, also,
those in which it is associated with other
illnesses. These statistics are extremely
difficult to interpret, at the present time,
and discussion would not be profitable.
They do present a challenge for the future,
and the National Health Survey is trying
to work out techniques and means by which
the various multiple diagnoses on patients
can be evaluated.

  As far as the indications of indirect
costs are concerned, they must be tre-
1 mendous. The recommendation of our


Workshop with respect to a detailed study
of the indirect, or economic, costs of ar-
thritis is significant in this connection.
Data are not available at the moment for
estimating the indirect costs of this long-
term illness. To do so, correctly, would
necessitate taking into account losses in
output that would range from the time of
the onset of the illness. We would estimate
the present value of future losses and would

Table I  Persons with arthritis or rheumatism, by age,
sex, and activity limitation, United States, July 1961-
June 1963. (Civilian noninstiitional population)

      Number pwsons   With activity limitation
                     dus to arthritis
Age and sea  with arthritis
       or rfmumatism       or rheumatism
      (in thousands)   Number persons   percent of
               (in thousands)     total

Total     12,668      3,300      26.0
Under 65   7,661      1,641      21.4
65 and over  5,009      1,659       33.1

Males, total  4,400      1,202       27.3
                             .-__
Under 65   2,655       623       23.5
65 and over  1,744        579       33.2

Females,
total     8,268      2,098       25.4

Under 65   5,003      1,018       20.3
65 and over  3,265      1,080      33.1

Sourer: Unpublished data, and chronic conditions and activity     Source: Chronic conditions and activity limitation, United     Source: Chronic conditions and activity limitation, United
   limitation, United States, July 1961.June 1963. Es-         States. July 1961.June 1963. Estimated annual aver-        States. July 1961-June 1963. Estimated gnnugl aver-
   timated annual wwaga. U. S. Department of Haalth.         age. U. S. Dspaltmsnt of Health. Education. and         age. U. S. Department of Health, Education, and
   Education, and Welfare. Public Health Service Publi.        Welfare. Public Health Service Publication No. 1000.         Welfare. Public Health Smvice Publication No. 1000.
   cation No. lOOO.Series 10. No. 17. May 1965. Wash-         Sews 10. No. 17, May 1965. Washington: U. S.         Series 10. No. 17. May 1965. Washington: U. S.
   ington: If. S. Government Printing Dffice.               Government Printing Office.                      Government Printing Office.

compute the losses that are associated with
the person, or child, who contracts the
disease at an early age. We would also
take into account his future losses, in terms
of a spread over a period of time.

There is, however, one figure that should
be emphasized. This is the number of
work-loss days of patients who are usually
working-12 million. This figure does not
include the housewife.

Table II Percent distributiin of perxont with arthritis     Table Ill Persons with artfrrJtii or rfreumatism who
or rheumatism who are limitud in activity, by age and    are limited in a&i, by degree of limitation, United
sex, United Status, July 1961-June 1963. (Civilian    States, July 1961-June 1963. (Civilian noninstitutional
noninstitutional populatiin)                population)

Parsons with arthritis or
rheumatism who am

Degrw of limitation

Persons with arthritis or
rheumatism who an
limited in activity

Age and sex

limited in activity

Number
(thousands)

Penent
distribution

Total  _....._.._.._...       .._... 3,300        100

Under 45            327         10
4564             1.314         An

65 and over       11659     iii
Males, total         1,202        36

Under 45            120         4
45-64               503
65 and over          579    ::

Females, total        2,098        64
Under 45             206         6
45-65              811
65 and over        1,080    :z

In reality, these statistics can give but
an indication of the problems. A great
deal more information is needed if a better
delineation of areas for greater concen-
tration of efforts is to be obtained. What
can be done, and what needs to be done,
is shown very effectively by the background
studies in the economics of heart disease,
cancer, and stroke, which were prepared
prior to the DeBakey Report.

Number
(thousands)

Percent
distribution

All degrees

3,300        100

With limitation, but not
in major activity

714        22

Limited in amount or kind
of major activity    1,888         57

Unable to carry on
major activity

697        21

95


Recommendations
It is recommended that a much more
detailed study of economic costs be made,
a.s a concomitant activity to further plan-
ning of means of overcoming the effects of
arthritis.

The details of medical care could not
be discussed by our Workshop. It was
recognized, however, that the care of the
arthritic patient represented a continuum
of services that involve diagnosis, medica-
tion, and rehabilitation, with its physical,

Table IV Persons with arthritis or rheumatism who
are limited in a&My, by fumily inceme,.tJnJted States,
~~f~96LJune 1963. (Crvdian nonmstrtutronal popu-

Persons with arthritis or
rhsumatism who are
limited in activity

Family income (annual)

Number
(thousands)

Percent
distribution

Total

3,300        100

Under $2,000        1,269        38
$2,000-$3,999          764        23
$4,000.$6,999          605         18
$7,000 and over         478         15

Unknown             184         6

96

Source: Chronic conditions and activity limitation. United     Source: Chronic conditions and activity limitation, United
   States, July 1961.June 1963. Estimated annual aver-         States. July 1961.June 1963. Estimated annual aver-
   age. U. S. Department of Health. Education. and         age. U. S. Department of Health. Education. and
   Welfare. Public Health Service Publication No. 1000.         Welfare. Public Health Service Publication No. 1000.
   Series 10. No. 17, May 1965. Washington: U. S.         Series 10, No. 17. May 1965. Washington: U. S.
    Government Printing Office.                       Government Printing Office.

mental, and social aspects.
The increasing degree of disability with
the length of time of the disease gives rise
to the conviction that early diagnosis and
treatment,  with continued supervision,
could limit the effects of later disability.
This, of course, has been the dominant
theme of this conference. Even though
suc,h comprehensive care, given early in
the disease, would result in increased ini-
tial expenditures, it was our belief that
this would be more than offset by the de-

Table V Comparison of persons with limitation of ac.
tivity from arthritis or rheumatism with total popula-
tion, by family income and age, United States, July
1961-June 1963. (Civilian nonlnstiiutional population)

                 With activity limltation
                      duo to arthritis
            Total        or rheumatism
Annual family     population  -__. --_-
income and age   (in thousands)  Number persons Parcant of
                  (in thousands)   total
             -
  Total       ' 181,964    ' 3,300     1.8
Under $4,000     56,390    2,033     3.6
Under 45 years   34.897      114      .3
45 and
years
over         21,493    1,919     8.9
$4,000 and over  115,056    1,083      .9
                        - _--
Under 45  years   87,299      200      .2
45 years and
over     27.757     883     3.2

1 Includes unknown Incoms~.

creased need for more comprehensive and
expensive services later in the disease. It
should be emphasized that while this was
the deep conviction of the Workshop, no-
body knows whether this will, indeed, be
true.

It is recommended, therefore, that jtud-
ies should be undertaken to evaluate the
extent to which early diagnosis and treat-
ment would prevent, delay, or limit dis-
ability from arthritis.

Such studies should include the role of

Table VI Estimated expenditures for arthritis and
rheumatism (annual).

                Amount
Item              (millions)

$645

Hospital care (short-stay hospitals)      $ 60
Physicians' visits                  150
Drugs and other remedies (nonprescription)   435

Table VII Estimated work-productivity loss to national
economy because of arthritis or rheumatism (annual).

                            Amount
            Item              (millions)


       Total             $520
Among arthritics who work but lose time
because of arthritis               220

Among arthritics who are unable to work
because of arthritis and who receive
disability benefits                 300


early hospitalization, as one of the methods
of control, of management, and of patient
education.

This recommendation recognizes the need
for further studies to make more feasible
the early detection and diagnosis of those
patients who would become disabled.

An attempt was made to arrive at the
cost of disability, particularly with some
estimate of the direct cost that confronts
the patient with disabling arthritis. It was
recognized, immediately, that these data
were not available. And the advisability
of making it available was incorporated
into the first recommendation.

Nevertheless, some figures were arrived
at that are of interest. The initial medical
workup, for example, was estimated at be-
tween $35 and $150. This was obtained
from a practicing physician. The data
from the outpatient department at one
volunteer hospital in New York City indi-
cate that the average cost to the patient
for the initial workup is $100.

Continuing medical care, based on the
need for weekly visits for, say, gold injec-
tions, was estimated at from $20 to $50 per
month. Hospital costs for active beds was av-
eraged at around $40 a day, although there

is a wide variation in costs in this area.

There was discussion of those types of
minimum care units that would cost less.
This area needs a great deal more explora-
tion.

It was recognized, by the way, that the
shorter the hospitalization of the patient,
the greater the per diem rate to the hos-
pital. There was discussion as to how hos-
pital rates were set. The multiple factors
that are involved in this topic were so
complicated that no recommendations were
made.

Apparently, there are no reliable figures
that apply to the arthritis patient who is
treated in the outpatient clinic. One figure,
however,  was obtained from the Los
Angeles Welfare Department, which pays
six dollars a visit.

There was consideration of the role of
the nursing home and of its changing
status. With the increased services that
nursing homes are attempting to give, both
in diagnostic and rehabilitative measures
and in other functions, there is obviously
a change in rate schedules. At present, the
average nursing home cost is anywhere
from $200 to $250 a month, and this is
low. It should be mentioned, in this con-
nection, that the majority of such nursing

homes, as opposed to hospitals, are pro-
prietary. There is an attempt, at the pres-
ent time, to achieve a closer working
relationship between nursing homes and
hospitals, although there are many prob-
lems associated with this.

There was also discussion of home care
services. This type of service, with its
multiple functions, can phy an important
part in the care of the arthritic patient.
Fifty-five percent of the population of the
United States lives in areas that are sup-
plied by such services. But less than one
percent of this population actually receives
such services.

Even though the need for home care
services is probably much greater than
we think-how much greater, nobody
knows-it cannot be met because of the
gross inadequacies of staff and facilities
at the present time.  Certainly, a study
should be conducted in this area.

The average cost per visit for home care
services was four dollars in 1964. This
was an increase of over five percent from
the preceding year. So, here again, in-
creasing costs are associated with the care
of the patient.

Arthritic patients in a Philadelphia study
received, on the average, the largest num-

97


ber of visits of the various disease groups,
including hypertensive heart disease. On
the average, the arthritic patient needed
22 visits per year.

It is recommended, therefore, that means
of extending home care services should be
explored.

A particular problem, which should re-
quire greater recognition and further study,
is that of providing household assistance.
Also, of equal need are means to combat
isolation and the problems of the chron-
ically ill older person who lives alone.
Further experimentation should be done
with means of providing methods of con-
tact with community resources.

The problem with the very poor is the
fact that they are not sophisticated enough
to seek help. An added problem with the
aged is that they become withdrawn. They
have ambulation problems, to which their
arthritis contributes. The need for more
meaningful data on community resources
for these people is apparent.

The payment of medical care comes from
many sources. These include direct pay-
ment; insurance that is provided by the
sponsor, such as Blue Cross or Blue Shield;
insurance from commercial sponsors; in-
surance from independent or consumer

sponsors, such as HIP (Health Insurance
Plan of New York) ; governmental or tax
supported insurance, which includes wel-
fare,  veterans, vocational rehabilitation,
and crippled children programs; and, of
course, Medicare.

Approximately 129 million persons,
about 70 percent of our population, are
covered by some form of voluntary health
insurance. Sixty million persons have Blue
Cross and 50 million have Blue Shield. It
should be noted, however, that much of
this coverage is very limited and that of
those who are over the age of 65, only 50
percent are covered. In the lower income
groups, coverage is even less. And insur-
ance that is provided for these people is
grossly limited for services other than those
that are provided in the hospital.

The arthritic is particularly concerned
with problems that occur in areas that are
related to the chronicity of the disease
and to treatment that takes place outside
of the hospital. This applies, especially, to
such things as ambulatory care, home care,
rehabilitation,  nursing  homes,  chronic
beds, chronic bed care, and, in general,
diagnostic services and drugs.

It is recommended, therefore, that en-
couragement be given to the exploration

of means of achieving flexibility of insur-
ance  mechanisms.   These  mechanisms
should include an appropriate welding to-
gether uf both public and private financing
to cover the full range of care, including
the home, ambulatory, hospital, and reha-
bilitation needs of the arthritic patient and
of persons with chronic disease, generally.

It was mentioned that such a plan should
probably contain a deductible clause. It
could not be expected to cover everything,
however, primarily because of the in-
creased costs to the insured, in such cir-
cumstances.

Since a large proportion of all arthritic
patients have inadequate incomes, there is
a need for tax support to cover a full range
of care for many patients. Among plans
to provide this support is H.R. 6675, the
pending legislation  for health insurance
for the aged. If this legislation is enacted.
it may be helpful to the aged section of
the economy. But it will not solve all of
the needs of the chronically ill patient.
This brings up the question of how much
of the gross national income can be allo-
cated to health care. Of course, nobody
k nowe. At the present time, approximately
six percent of our gross national income
does go into some form of health care.


This is much higher, as a matter of fact,
than it is in such countries as England,
where, even under a socialized medicine
scheme, four percent is spent.

It is assumed that in a society as affluent
as our own more of the gross national
product could be spent on health care-
perhaps, up to 10 percent. This, of course,
would depend a great deal on other factors,
such as expenditures for defense. It was
believed that there should not be frag-
mentation of the provision of health and
welfare services by disease or patient pedi-
gree; rather, there should be collaboration
of a sort that would lead to coordination
of health services, where geographic loca-
tion is the determining factor.

It was pointed out that, at the present
time, a social worker really needs an ad-
vanced college degree to comprehend and
manipulate all of the many "ifs, ands, buts,
and maybes" that he encounters in the
various services that are offered. The pa-
tient must be either blind, but not lame,
deaf, but with no gastric ulcers, Presby-
terian, but not United Church, or one
thing, but not another, if he is to qualify
for care.

There is an obvious need for coordina-
tion, and there are many channels through

which it can be achieved. It may be
brought about by one of many organiza-
tions with a wide interest in the commu-
nity. These include the community health
welfare councils, hospitals, and local health
departments.

It is recommended that further study
and exploration be given to the matter of
making the extensive health and welfare
services of the core, or central, community
available to the satellite regions for pur-
poses of forming a coordinated and coop-
erative program.

It was pointed out that health services
are frequently stopped at city boundaries,
which, in the modern organization of urban
areas, have little real meaning.

Such available services should include
a wide range of treatment and care disci-
plines, including physicians and associated
professions-volunteer health and welfare
agencies, hospital and related institutions,
and governmental agencies, including pub.
lit health and welfare departments and
vocational rehabilitation services.

Health services should be included under
the present antipoverty campaign. At the
present time, health services frequently are
not even considered in this campaign.
The Workshop ranged over a wide va-

riety of topics. They did consider one final
recommendation :

It is recommended to the Surgeon Gen-
eral that arthritis be recognized as a major
health problem to the Nation that warrants
a concerted eflort to overcome it by all
available means.

Discussion

DR. REDFORD: I really appreciate this
report because I think it reveals a lot of
things that I may have had questions about
for a long time.

One point you made, though, that you
did not have any figures on the cost of
rehabilitation services, somewhat surprised
me, because there are such figures. I am
sure that the Vocational Rehabilitation
Administration can give them to you. I
think, for instance, that the cost of these
services is considerable.

One program that I know of in Minne-
apolis has what we might call a model
program, with very comprehensive services
for all disabilities, including arthritis. The
cost comes to about $55 a day. I think
we ought to think about this a little bit.
This is pretty high priced and it may be
rather significant.

DR. STILLMAN: During our Work-      99


100

shop sessions, all of us physicians were
concerning ourselves with the economics
of patient care and with the problem of
cutting down on costs by rehabilitating
people or by getting them out of the hos-
pital quickly and into a cheaper facility.
But one person said that we may actually
increase the cost of care-very likely in-
crease the cost of care to the whole com-
munity. He said, though, that the worth
of a program should not be measured by
its cost, alone, but by what it accomplishes
for the individual. This man was a lawyer
who is now directing a Blue Cross Plan,
which I thought was very interesting.
DR. LAMONT-HAVERS: Yes, I think
the emphasis was on the fact that we can-
not keep saying that because of our in-
creased technology we are going to decrease
the amount of money that is being spent for
health. We are going to have to face the
fact that we are going to have to increase
the amount of money that is spent for
health. But the population will be healthier,
yes.

Review of
Surgeon
General's
Workshop

By Cornelius Traeger, M.D.

I was asked to come to this meeting to
act as sort of an elder statesman, to review
the results of your labors, and to define
any gap areas that may have been over-
looked. My assignment was to cover all
the Workshops. I managed to spend about
two hours with each of the Workshops,
and I hope I was able to sense the trends
that were developed in each of them.
Before I get into details, there are a few
ideas that I would like to discuss with you.
About one-half century ago the problem
of arthritis was simple. If you had arthritis
and you had a lot of money, you went to
a spa. If you were poor, you went to a
clinic where you were given a large box of
salicylate tablets and a pint bottle of oil
of wintergreen and told to come back in


six months. Since then, we have come a
long way. But a wide gap area still exists;
and that is the distance between the labora-
tory and the bedside. I hope that, as a
result of this conference, this gap will be
narrowed.

You must remember that arthritis begins,
and is, in the patient. The disease falls
into four definite classes: the ambulatory
patient, the patient with walking aids, such
as the cane or crutch, the wheelchair pa-
tient, and the bedridden patient; and each
of these presents a special problem. These
cannot be dealt with en masse. In other
diseases, such as tuberculosis, diabetes, and
incipient glaucoma, it is easy to run mass
surveys. The same is true of cancer detec-
tion clinics. Early detection in these mass
programs has been most successful.

These techniques are not feasible in
dealing with chronic arthritis. This is an
individual business. Attempts to develop
arthritis registries or to devise means of
finding susceptibles are fraught with all
sorts of difficult and, perhaps, even insur-
mountable complications and would involve
an enormous effort, in terms of personnel,
criteria, storage, retrieval of information,
etc.

Because of the nature of the disease, the

first place where the patient seeks help is
not always the family doctor. It is quite
frequently the corner druggist. He is the
man to whom the patient goes for a bottle
of liniment or a box of pills, or for some
remedy that he has heard about on the radio
or television. Sometimes he goes to a spa
or to a chiropractor. Frequently the first
contact the arthritics have with their physi-
cian may come after the disease has been
present for a few years. The differential
diagnosis is not simple. There are 66 dif-
ferent diseases which have as their present-
ing symptoms pain, swelling, and limita-
tion of motion. They are not all arthritis;
and it is in this area of differential diag-
nosis that the romance of arthritis mani-
fests itself; it is here that the teacher can
make his first impact on the student.

I was surprised by the omission of quack-
ery in these deliberations. Quackery does
not exist in such diseases as diabetes and
pneumonia. Quackery thrives only in an
area where the etiology of the disease is
unknown and where there is no specific
therapy. Quackery thrives in cancer, in
many of the neurological diseases, and it
certainly thrives in arthritis. One would
suppose that quackery could be eliminated
by public education. Unfortunately, this

has not been true. "Information, such as
we have, is and has been reaching the pub-
lic for the past ten years in all media. The
preparation and formulation of authorita-
tive information in the field of arthritis has
been well accomplished. The channels of
this information have been well-developed."
Public apathy with respect to arthritis sim-
ply does not exist. That the public is moti-
vated and is interested in the problem of
arthritis is indicated by the fact that this
same public spends millions of dollars a
year in quackery and nostrums. Why?
Simply because the public is discouraged.
They see no progress in the scientific field.
They are frequently discouraged by the
lack of knowledge and the lack of interest
when they visit the doctor. The public
is confused by the lack of agreement among
doctors with respect to the various types
of therapy. Unfortunately, we all know
this to be true. There is still controversy
among rheumatologists with respect to
steroids, gold, phenylbutazone, splinting,
and even salicylates.

"What is really needed is to arrive, if
possible, at some agreement regarding early
diagnosis and specific therapy. Many of
our concepts of therapy need accurate eval-
uation. If and when such agreement is

101


102

achieved, the next order of business is an
educational program."

This program must begin in the clinical
years of the medical school.  Inspired
teachers can, at this level of medical edu-
cation, stimulate sufficient interest in young
medical students to arouse their curiosity
and to develop in them a desire to follow
through in this most important and fasci-
nating area of medicine. It is from these
young students that the Training Grant
Programs will best obtain their recruits.
The attempt to buy interest in arthritis by
subsidizing postgraduate students has not
been very successful. "The training of
doctors depends on the trainer. The prod-
uct that is turned out is worth support only
if the trainer and the trainee are motivated
by a scientific desire that cannot be equated
in terms of financial support." You can't
buy the man, and you really don't want
such a person. The need today is for teach-
ers who are knowledgeable and enthusiastic
and who can transfer the excitement of
rheumatology to their students.

As I have gone around the country to
visit medical schools, I have found that the
subject of rheumatic disease gets pretty
short shrift. When I was on service at the
Hospital for Special Surgery, we would

get two boys-a junior and a resident-
from Cornell Medical School to rotate on
our service. When they arrived on the
Rheumatic Diseases Service, they knew
only two things about rheumatoid arthritis:
that gold was no good and that phenyl-
butazone was worse. Most of them were
just ticking off the days until they could
get off our service. Now, Cornell is a good
medical school, and I consider Dr. Frey-
berg to be one of the best teachers of rheu-
matology. However, only rarely could we
light fires under these boys. The only way
we are ever going to get manpower is to
develop, in the medical school, teachers
at the third-year level with the ability to
inspire their students with the romance,
the importance, and the challenge that is
presented by the rheumatic diseases. At
one time? the Training Grant Programs of
the National Institute of Arthritis and
Metabolic Diseases included 49 Centers.
Today, there are only 38; and recruitment
remains the big problem. Why?

  Almost all of the doctors here present
were never recruited, were never subsi-
dized. Nobody proselytized them. They
came into this dreary field of rheumatic
disease because they wanted to.  If there
had not been such men as Ralph Pember-

ton, Walter Bauer, and Phil Hench, this
meeting might have been delayed 10 years
hence. You are not going to make rheuma-
tologists and you are not going to provide
personnel by running up and down the
highways and byways and bribing young
men to come into a Training Grant Pro-
gram, to come into a Research Grant Pro-
gram, or to get into this field at all, because
they are going to get paid. Unless they are
moved, unless they have a feel for this
dreary disease, there is no use getting them
in the first place. It is very easy for doc-
tors like Mike DeBakey to obtain recruits.
Their field of endeavor is spectacular. Their
patients are either dead or better in short
order. But in the rheumatic diseases, re-
sponses to therapy are frequently very slow,
and observation and progress reports may
extend over several years. Patience, dedi-
cation, and genuine interest are necessary
in this tedious field.

I remember being approached by one of
the pharmaceutical houses to carry out a
clinical trial of a new steroid. They asked
me how long it would take to get this work
done. When I replied, "Five years," they
were not much interested, and neither was
I. They finally settled for four years. The
rheumatic diseases are a dreary business;


and if you are not geared to thinking in
these long terms, it is best to stay out of
it entirely.

To my mind, there is no greater chal-
lenge to the medical student than the one
that is presented by these diseases. It is at
this point that one can light the spark. The
further along a medical student gets in his
career, the less interest he is apt to have
in the rheumatic diseases. The further
along he gets, the greener the pastures look
in the fields of cardiology, gastroenterol-
ogy, etc.  Our efforts as senior citizens (I
am talking about myself, now) should be
to look for the great teachers in the med-
ical schools and to get them to seek out
those students whom they think could be
inspired to go on to work in rheumatic
diseases.

With respect to training, Dr. Whedon
indicated that training grants for research
include clinical investigation. "Please do
not go away with the idea that there is
some rigid barbed wire fence around the
Training Grant Program of the National
Institute of Arthritis and Metabolic Dis-
eases against the investigation of patients
as supported by the Training Grant Pro-
grams."  This is true; but the Training
Grant Programs' directors are still loath

to take trainees who are primarily clin-
ically oriented. This is a real gap area that
needs further clarification and extension.

  Another gap area has to do with the
continuity of patient care. What so fre-
quently happens is that a patient comes to
a clinic, a history is obtained, and a phys-
ical examination is performed. (And I must
say that in most of the clinics I have visited
the history and physical are very well
done.1 Then there is the laboratory work
and the X-ray studies and, occasionally, in
a case of special interest, a clinical con-
ference is held. At this point, all too fre-
quently, the patient is seen on his return
visits by another physician who happens
to be on duty that day. This is especially
true if the patient is referred to either
physiotherapy, vocational therapy, psychia-
try, etc. The original doctor may not see
this patient for a long time. It is my firm
belief that it is the doctor's responsibility
to followup his patients until the relation-
ship is finished, either when the patient is
discharged, when he moves to another local-
ity, or when he succumbs to some inter-
  current disease. This is the only way for
the physician to learn about the natural
history of the disease and the efficacy of
~ his treatment.

It is only by these means that reliable
and authoritative knowledge can be pre-
sented to the physicians of this country.
"The physician is charged with the key
role in the management of his patients.
All plans for care center about the patient,
and his needs are the general responsi-
bility of the physician working with other
professional personnel who will meet the
needs as they arise."

In this connection, it is important that
the physician be thoroughly knowledgeable
regarding the availability of all community
resources. The physician must make real
efforts to find the ancillary resources that
are afforded by the community and to use
them to their fullest extent.

And now we come to statistics. I do not
believe that statistics in arthritis are at all
meaningful. We talk glibly about twelve
million arthritics. These are really only
people who think they have arthritis. A
little over three million would be a more
realistic figure, since this number includes
those who have definite limitation of ac-
tivity. In any event, statistics are not truly
important. If statistics were meaningful at
all, the common cold would occupy the sole
attention of medical science, and we would
have to stop building automobiles and good
roads.

103


The problem of establishing regional
centers and satellites was discussed in great
detail. The whole problem is fraught with
many complications and difficulties, which
were adequately discussed. I agree with
several of the Workshop Chairmen who
suggested that it might be easier and wiser
to examine all of the presently existing
facilities for the diagnosis and adequate
treatment of the arthritic-to evaluate their
strengths and their weaknesses. The strong
ones could be made stronger, and the
weaker and less efficient ones could very
easily be brought up to the level of the
first-rate clinics. This will do away with
committees, coordinators, etc. It will make
diagnosis and treatment accessible to all
patients in all localities. It will be much
cheaper and much more efficient in the
long run. "Existing programs need to be
supported, strengthened, and coordinated
and expanded to geographical areas where

104

they are lacking.  To build along the
strengths and bolster the weaknesses of
what we have now is important and prac-
tical."

In some of the other discussions, a sug-
gestion was made to attempt to curtail the
advertising claims of salicylate derivatives,
so commonly heard on radio and television.
This, of course, is not our province at all.
This is the job of the Federal Trade Com-
mission's Bureau of Deceptive Practices.

In closing, I want to make one other
remark, and that is that we talk a great
deal about cooperation between the rheu-
matologist, and physiatrist, the occupa-
tional therapist, the vocational counselor,
the social worker, etc. The truth is, how-
ever, that we don't cooperate with them.
How often do we discuss a problem case
with a social service worker? How often
do we discuss problem cases with the psy-
chologist or psychiatrist? How often do

we go to the plaster room and discuss the
problems of splinting to correct deformity?
The answer: We don't! But we keep talk-
ing about it. We come to meetings and
talk about team work and collaboration,
but, for the most part, that is all we do
about it. I think the only answer is that all
ancillary medical and paramedical person-
nel should make it a point to heckle the
clinician.

This conference was called "The Sur-
geon General's Workshop On Prevention
of Disability from Arthritis." We have
talked about everything else, but I suppose
that is only natural. But much more has,
and will, come out of this meeting. With
clear vision and an intelligent evaluation
of the facts and the suggestions that were
placed before our Group, I predict great
progress in the alleviation of the sufferings
of our arthritic fellow citizens.