communication between all who are in-
terested in the patient. This, in turn,
will increase the patient's confidence in
his care.  Ultimate arrangements for
continued care of the patient should be
integrated with his socioeconomic needs
and with the available health services
in the community.

g. Day hospital facilities for short-term
intensive group and/or individual edu-
cation and training should be provided
for patients whose diagnosis is estab-
lished and who do not require hos-
pitalization.

h. Approximately 10 hospital beds should
be available for patients who require
hospitalization for short periods.
i. Funds should be available for stipends
for professional personnel and for
transportation and temporary lodging
for out-of-town patients.
Recommendation 2. Certain existing ar-
thritis centers and service clinics should
receive continued support to enable them
to provide appropriate services.  These
should be identified as Diagnostic and
Treatment Clinics, and additional units of
this type should be created as fast as
trained personnel become available. Sug-
gested requirements for Diagnostic and

Treatment Clinics are:

a. They should be based in an accredited
hospital or other qualified medical
facility.

b. They should provide facilities for diag
nosis and comprehensive treatment of
outpatients.

c. Professional staffing should include the
part-time services of at least an intern-
ist, a pediatrician, an orthopedist, a
physiatrist or physical therapist, and a
coordinator of patient services. At least
one physician should have received
training in a Regional Arthritis Center.
d. Such clinics should meet at least one-
half day per week.

e. An adequate number of Diagnostic and
Treatment Clinics should be established
to provide good quality service within
an area of reasonable geographic di-
mensions and population density. (See
appendix).

f. Financial and patient admittance pol-
icies should be those of the parent
  institution.

g. Funds should be available for stipends
for professional personnel.
The shortage of physicians with skill or
interest in the care of the arthritic patient
and the wide gap between available knowl-

edge and its application to the patient are
well-known. How do we apply the available
knowledge, the experience of the arthritis
clinical centers, at the local level? How do
we bridge the gap between centers and the
local doctor in communities without ar-
thritis services?  Consultative  services,
laboratory, X-ray, and paramedical serv-
ices, which are so successfully applied at
the centers, should be made available to
the local doctor in such communities.

Recommendation 3. Roving Consulta-
tion Boards should be created. A Board
from the regional center, or clinic, will
visit local hospitals in communities in
which such consultation services are not
currently available.  Consultation Boards
will have the approval of local county med-
ical societies. They will meet on an "on
call" basis, approximately one-half day per
month. Each Board will be composed of
at least one medical specialist with training
in arthritis, a physiatrist and/or physical
therapist, and a community-oriented co-
ordinator of patient services, who does not
have to be from the center or clinic. Pa-
tients will be seen by the Board only on
referral by a local physician, who will re-
ceive a written report promptly. The con-
sultants will not treat the patients. Patients


will pay a nominal fee for consultation
services, when possible. Financial support
for these Consultation Boards will include
stipends for the services of the consultants.

Recommendation 4. Because of the lack
of uniformity and standardization in com-
monly used diagnostic tests, automated
multitest laboratories should be established
in each of the Regional Centers. The serv-
ices of these laboratories will be made
available to local physicians, Consultation
Boards, and Diagnostic and Treatment
Clinics in the region. Emphasis will be
placed not only on quality-controlled uni-
formity of laboratory techniques, but also
on data-processing capabilities. Although
the introduction of automated equipment
is costly, a savings will result from the
lower cost per test unit.

52

Local doctors must have easy access to
the many community facilities that are often
available, but not properly used. Examples
of such facilities are Public Assistance
Medical Care for Categorical Aid, which
provides aid for the aged, for the blind,
for those in need who are disabled, and
for families with needy children; Crippled
Children's Service; and Kerr-Mills aid for
patients who are over 6.5 who pass a means
test. Additional examples of local facilities

include home care programs, which may
be hospital-based or implemented by a
visiting nurse or by a local health depart-
ment ; homemaker programs, which are
sponsored by the Visiting Nurses' Associa-
tion or Family Service Agency; public
welfare programs; nursing home programs;
rehabilitation services;  information and
referral centers; shopping services; home
maintenance services; transportation serv-
ices ; and home dental services. A busy
local physician, who sees 30 or 40 or more
patients in a given day, is bewildered by
this endless list of facilities, which are, in
fact, available to him and to his patients.

Recommendation 5. The coordinator of
patient services in the Diagnostic and
Treatment Clinics should make readily
available to all doctors in the area iu-
formation regarding the easily accessible
local facilities for patients with arthritis.
Communication of such information may
be expedited by telephone calls, as well as
by frequently revised directories.

Recommendation 6. An Arthritis Ad-
visory Committee should be created. This
Committee will be responsible for recom-
mending standards of quality and proce-
dures for quality control of the Regional
Centers, the automated multitest labora-

tories,  the Diagnostic  and Treatment
Clinics and the local Consultation Boards.
This Committee will have close liaison
with The Arthritis Foundation,  public
health agencies, and with the American
Medical Association. Its  membership
should represent a cross section of phy-
sicians who are interested in arthritis and
should include representatives  of the
Rheumatism Section of The Arthritis
Foundation, the American College of Phy-
sicians, and orthopedic, physiatric, radi-
ologic, pediatric, and other professional
societies.

Recommendation 7. Physicians in Re-
gional Centers, Diagnostic and Treatment
Clinics, and on Consultation Boards should
maintain a registry of patients with rheu-
matoid  arthritis,  juvenile  rheumatoid
arthritis,  systemic  lupus  erythematosus,
gout, and hyperuricemia. Data for pro-
spective study are needed for better under-
standing of the clinical course of arthritic
diseases, of the value of early diagnosis, of
early treatment, and of comprehensive
treatment. Such a registry should include
the patient's name. parents' names, social
security number, sex, date of birth, date
of registry, and vital clinical data. Data
collection and processing should be stand-


ardized by the Arthritis Advisory Com-
mittee.  Periodic reports of the results
should be made to local medical com-
munities.

Recommendation 8. Clinical assessment
of the modalities of treatment and of drugs
in large numbers of patients in widely
distributed geographic areas, currently
performed by the Cooperative Clinics and
sponsored by the Rheumatism Section of
The Arthritis Foundation, should be ex-
tended to include participation by Regional
Centers and by Diagnostic and Treatment
Clinics.

Recommendation 9. The Arthritis Ad-
visory Committee should explore and make
recommendations regarding methods of
early casefinding in arthritis. A health
education program should be designed to
improve public awareness of the advan-
tages of early diagnosis and treatment.
Serious consideration should be given to
the suspension of drug advertising that
may discourage early medical attention.
Regional Centers, Diagnostic and Treat-
ment Clinics,  and Consultation Boards
should have available to them the person-
nel, equipment,  and facilities that are
necessary to achieve early diagnosis and
to evaluate the extent of disability. In this

way, early treatment can be directed to
prevent or to minimize such disability.

Recommendation 10. Financial support
of the programs that have been outlined
should come from public health agencies
at all levels and, whenever possible, from
voluntary health agencies.  Voluntary
agencies usually have greater opportunities
for experimentation than do those that are
tax supported. They often demonstrate
new methods that, if successful, may be
desirable for adoption by tax-supported
health agencies. It is hoped that voluntary
support will be available, perhaps, initially,
on a pilot basis, for new and untried facil-
ities, such as the roving Consultation
Boards, automated multitest laboratories,
or the arthritis registry. Funds for other
recommended facilities and, especially, for
maintenance of established facilities might
come chiefly from public sources.

Comment

Fulfillment of these recommendations
will provide the facilities that are required
in the United States for widespread early
diagnosis and treatment of arthritis. New
construction is not required. The proposals
include the sustained support and utiliza-
tion of currently available, effective facil-

ities, which may be lost if funds are not
made available immediately. These pro-
posals give local physicians easy access to
the practical application of information
that has been gained in recent years in
exemplary arthritis centers. They provide
a mechanism for early diagnosis and treat-
ment at grass roots levels, without inter-
fering with the traditional, American
doctor-patient relationship. Responsibility
for high professional quality of diagnosis
and treatment will rest with qualified phy-
sicians. Provisions are made for a national
registry of arthritic patients, for stand-
ardization of laboratory criteria for diag-
nosis, and for expanded opportunities for
cooperative assessment of new drugs and
other therapeutic modalities. An approach
to a study of methods in early casefinding
is also suggested.

Implementation of these recommenda-
tions can be accomplished in phases over
a period of several years.  The first and
immediate phase, however. is the provision
of funds for maintenance of those quali-
fied arthritis centers and clinics whose
voluntary support may terminate on July
1, 1966. The speed of evolution of remain-
ing proposals will depend on the avail-
ability of funds and trained personnel.

53


54

And it will differ in various parts of the
country. Professional training can he ex-

   APPENDIX TO WORKSHOP REPORT
Suggested Mechanism for Implementation of Proposals
  of Workshop on Diagnostic and Traatment
        Facilities for Arthritis.

I

I I









abgmstkmd -
abgmstkmd -
Tnlhnill clinks (2) _
Tnlhnill clinks (2) _







cmmdtatbn momd_
cmmdtatbn momd_

.J

(1) Su99osbd numbr: 9-12.

(2) Ultlmato goal: 1 clinic per 100,000 poplo In mdlus Or
30 mllr or, approximately, 15OU clinks. (On* cllnlc for
way 52 accmdltad hospitals.) In hlghr populrtlan amas
  mom thhm on. clinic should be ostabllshod In order to
maintain thm pmt-Urn0 status of those cllnlcs. The numba
ot clinics In ml&Ion to the Regional Cwtw should depend
on tJm volume of wmb dono In tbr cllnks and gagnphlc
  factors and thus must br flrlble In ordu to Insure tha
hlfiast pouibla quality.

pedited enormously within the framework
of these proposals, which are designed for
undergraduate and postgraduate education
in the Regional Centers and for con-
tinuing education of the practicing phy-
sician in his own community, with his own
patients. It is emphasized that many of the
proposed services should be shared with
those of other chronic diseases, whenever
possible.

In summary, the Workshop on Diagnostic
and Treatment Facilities recommends the
creation and/or preservation and the finan-
cial support of the following facilities:
1. Regional Arthritis Centers
2. Diagnostic and Treatment Clinics
3. Roving Consultation Boards
4. Automated multitest laboratories
5. Information regarding locally avail-
  able community facilities
6. An Arthritis Advisory Committee
7. An arthritis registry
8. Cooperative clinical trials of methods
   of treatment

9. Early casefinding
Financial support should come from volun-
tary and public health agencies.
These recommendations represent the
consensus of the participants in the Work-
shop.

Discussion

DR. FREYBERG: This is a very corn.
prehensive report. It is based on a lot of
study by people who gave a lot of time on
the panel.

I hope that what I am going to say will
not be misunderstood. It is more of a
reference to a historical event.  I hope
that the report that goes to the Surgeon
General does not imply that the best place
to get diagnosis and early treatment is in
the exemplary clinics and centers that have
been funded by The Arthritis Foundation.

To pay homage to some pioneers, who
are, unfortunately, no longer with us, some
very excellent centers existed before this
time. I hope that the report will not simply
single out the regional centers for support,
but will include others. of comparable
standards, some of which have been in
existence and have continued to function
with the same degree of excellence with-
out such support. I think we ought to in-
clude these centers in our planning, too.

DR. ENGLEMAN: I am sorry. You are
quite right, Dr. Freyberg. As a matter of
fact, this point was, indeed, brought out
in our historical discussions. I wasn't able
to inc-lude everything in our verbal report.
DR. GLENN CLARK: I think that this


was a beautifully organized report and
that many of the things are crucial to our
handling of the problem of arthritis. But
I would not like to see us go completely for
a categorical approach to the disease,
arthritis, before we seriously consider the
benefits of developing our program on a
broad chronic disease basis, with develop-
ing physiotherapy units, social service
units, and all the other things that are
needed in so many chronic diseases on a
regional basis.  I would like to see a com-
bined effort, with no separating out of
arthritis as a disease entity of its own.
DR. ENGLEMAN: I probably didn't
emphasize this sufficiently, Dr. Clark. We
agreed, in our discussions, that services
should be shared, whenever possible, with
those of other chronic diseases.
DR. CALKINS: This is certainly a very
interesting report. I am sorry that I had
to take a telephone call toward the latter
part; perhaps you raised points that were
applicable to what I am about to say.
As we consider this type of regional
center, which is something that the Heart
Disease, Cancer and Stroke people are pro-
posing, although perhaps along a some-
what different pattern, a question comes up
that is of great importance: HOW can we

best develop this approach, while still sup-
porting the private physicians, family phy.
sicians, private consultants, and others,
who, through the accepted pattern of
American practice, perform exemplary
care in their private offices and in the
homes?

At a time when there are groups of ex-
tremely low-income patients, it obviously
is not appropriate to consider only low-
income patients in this type of framework.
Yet, if we extend this program to cover
middle- and upper-income patients, how
can we develop it without basically and
seriously weakening the present fabric of
care?

  DR. ENGLEMAN: Dr. Calkins, 1 think
you probably did miss a critical portion of
the presentation-a portion in which em-
phasis was placed on preserving the
relationship between the local physician
and his patient. This, as a matter of fact,
has been a vital consideration in the plan
that has been evolved by the American
College of Surgeons, American Cancer
Society, and their 1,000 Tumor Boards.
They have had some 25 or 30 years experi-
ence with this kind of setup, and I know
that, in their experience, the rapport be-
i tween private patient and local physician

has not been disrupted.

On our panel, we have a gentleman who
is here because of his experience and back.
ground in facilities for the diagnosis and
treatment of cancer. I would like him to
speak to this crucial point, on which he
spent a great deal of time in our discus-
sions. Dr. Robbins?

DR. ROBBINS: I am Dr. .Robbins of the
Memorial Center in New York. That point
came up very clearly and, in short, if you
will look at the chart over here (indicating
Appendix to Workshop Report) you will
see that the "Local Physician and Patient"
box is the guts of the care of the patient.

If the patient is not satisfied with the
local physician and wants to go to a diag-
nostic and treatment clinic, he has to fol-
low the rules that have been laid down by
the community. In some local communities,
the Tumor Boards will not see a patient
unless there is a referral. Frequently, our
sector coordinator at the Tumor Board
will get a call from a patient. If he has no
doctor, the coordinator will ask: "To whom
would you like us to send the report if
you see us?"  And the matter is handled
that way.

If the patient has a doctor, the coordi.
nator will say: "We shall get in touch with

55


56

your doctor, or you tell him to call us."
If the consultants who work on the
Tumor Board or in the diagnostic clinics
are any good, or have any moxie at all,
they will set up this sort of system. The
people who fill the diagnostic clinics are
specialized in their field. They may be
from the regional centers or from their
community; but they are picked to meet
standards that are set up by a Surgical
Advisory Committee. And they are prac-
ticing. Some have salaries. You can call
us watch dogs, or friends, or whatever you
want; but we, in our program, are very
careful. And we have been relatively suc-
cessful, in that we haven't allowed a bunch
of thieves, who might clip the local phy-
sicians, to get into the diagnostic clinics.
This program is merchandised in such a
way, and with such economy of facilities
at the laboratory level, that patients pay
their way. If patients are indigent, the
local community takes care of their costs.
One more thing: State and county mttli-
cal societies and health agencies act as
another watch dog, to make sure that the
thieves do not cause trouble.
DR. CALKINS: It seems to me that you
may be developing a situation in which
the family physician as a referral source,

is coming along well. The private con-
sultant, however, is still the backbone of
most medical centers at the present time.
How is this system, with its supported,
endowed, and automated laboratories, and





DR. ENGLEMAN: No, no, Evan. Let
all the rest of it, going to enable the




me answer that question, because I happen
to be one of those consultants, myself; and
private consultant to exist, except by a





I would never support a program like that.
merchandised program, which he isn't
going to want?

I think you are talking about the level
of the Consultation Board. It is stated in
the report that no Consultation Board will
exist in an area in which such consultation
services are otherwise available. This is
primarily for the rural districts and for
those communities in which such services
are not currently available. Furthermore,
the Consultation Boards must have the
approval of the local county medical
society.

DR. ROBBINS: Now, if the local phy-
sician wants to send his patient to the Con-
sultation Board, to a previously established
consultant, to me. or, perhaps, to you, he
can do it. As a matter of fact, he can use
the automated multitest laboratory with-

out utilizing any of the other facilities of
the Regional Arthritis Center. To be able
to get these services, the local physician
doesn't have to promise to send his patient
to see anyone. This is a very flexible sort




DR. CALKINS: I am asking about a
constructive way out, here. How are we
of thing; and, certainly, in our committee,





going to do it to satisfy our physicians?
We are not changing the basic philosophy.
none of us had any preconceived ideas
about changing the practice of medicine in
America.

DR. ROBBINS: We do it just as we are
doing it now. Th is is one of the few cases
of which I am aware in which a surgeon
and his syndicate can come to the intellec-
tuals of the medical profession and say,
"Look, we have been doing this for 30
years."

DR. JOHNSON: I am Amos Johnson. I
represent  some twenty-eight or thirty
thousand family physicians in the Ameri-
can Academy of General Practice. These
physicians are immensely interested in this
program at the community level. They are
interested in it from the standpoint of their
knowledge of the patient in his own per-
spective in the community and of their
knowledge of him from the standpoint of


ecology and of other areas of interest.
I am really very impressed with the way
you have this all worked out. I assume
that there is no doubt in the minds of those
who erected this chart that this is a work-
able condition. If I thought that that were
so, however, I would be sitting down over
here and not standing up talking now.
Today, I happened to be in Workshop 4,
which was concerned with professional
education. There was some question, in
this group, as to whether or not we did,
indeed, have the answers to the treatment
of people who have the various arthritic
manifestations of the disease process of
joints. I have heard it expressed, here,
that all you have to do is identify arthritis
at a local level-that the arthritis panacea
will be effected by so many institutions per
one hundred thousand persons. Is 1,500
the figure?

DR. ENGLEMAN : Correct.

DR. JOHNSON: And all of this must be
funded--check me if I am wrong-by
public funds. I just get the impression that
we have built up something, here, that is
impractical. I think that when those of
you who are referred to as specialists in
this disease-the internists, the ortho-
pedists, and the rheumatologists-to whom

all of these cases will be referred, finally
see these patients, they will have been one,
two, three, or four years in their disease
process. And when the patient has the type
of personality that does not motivate him
to seek aid early in his disease process,
those of us who have attempted to provide
him with aid-and I am including not
only the family physician, but the internist,
the surgeon, and others in that area who
do general practice-we will have told the
patient that nothing can be done.

Your chart is really beautiful. I can
read it from the bottom up, from the top
down, and from inside out. But, to me,
from where I sit in the actual treating of
people, in  the community of captive
patients that I know well, this is not the
practical approach. I may be the only one,
but I would like to be recorded as taking
exception to the idea that this is a program
that can be handled by an outlay of public
funds. Would you record me as being
opposed to this concept.

DR. ENGLEMAN: Yes, sir.
DR. WEDGWOOD: I was wondering if
I could make a comment from the pedia-
trican's point of view?
DR. ENGLEMAN: By all means.
DR. WEDGWOOD: Unfortunately, this

Workshop  was scheduled concurrently
with the national pediatric meetings, which
somewhat precluded pediatric representa-
tion on some of the Workshop panels. I
would like, however, to make some points
about the child population of arthritics.

The number of children who have arthri-
tis is a little difficult to determine. It prob-
ably runs between five and ten percent of
the arthritic population. This sounds like
a small figure, but from the point of view
of man-years of potential disability, from
the point of view of potential manpower
lost, and, particularly, from the point of
view of crippling diseases that occur and
create their crippling in the early child-
bearing years-that destroy families, as
well as productivity-the pediatric age
group represents a severe problem.

One could calculate that, from the
point of view of possible man-years, the
figure of disability would represent at
least 25 to 35 percent of the potential dis-
ability for man-years lost for arthritis in
all age groups.

Now, there are certain problems that are
related to the child with arthritis that I
believe need the types of attention that are,
perhaps, best given by either the pediatri-
cian or the family physician who has a


clear understanding of the interaction of a
child and his family and who has some
fundamental knowledge of the process of
child development.

The impact of arthritis, when it starts
at, let's say, the age of one year, or one-
and-one-half years, is extraordinary; and
the problems that the acute phases of the
disease present are manifestly different
than those problems that occur in the
majority of adults. The projective prob-
lems of understanding the appropriate
therapy for the child, not only as they
apply to dose schedules, but also with re-
spect to activity and the difficulties that are
imposed on the child, who has to relate
not only to family, but, eventually, to
school, are very real.

58

I am delighted to see the report that Dr.
Engleman presented. From my experience,
this type of approach is necessary if we are
going to be able to provide the type of
health care, to a mass population, that is
needed so badly.  However, I think it
would be appropriate to suggest that we
not be parochial in our definition of the
persons who are involved in providing this
type of health care. And I would specifi-
cally suggest that we should not be denomi-
national in assigning the title of a program

director, for example, to an internist. It
seems to me that, in many communities
and in many areas, this person might well
be an entirely different subspecies group
and quite appropriate, himself.

1 believe that if we fix ourselves too
firmly to defining, designing, and designat.
ing the specialty guidelines for the care of
arthritic children, we may miss a flexibil-
ity that may be more appropriate in a few
years. Quite specifically, I would suggest
that the appropriate care of the arthritic,
be he child or adult, requires a variety of
personnel, all of whom have to work func-
tionally, as a team. The team director may
be a primary physician of any designation ;
and the person who follows the child or
adult might be a physician of distinctly
different designations in different areas.
But it is the team approach that is im-
portant.

I think, then, that it is inappropriate to
designate the pediatrician a consultant. He
is part of the working team, and I hope
that he will not be relegated to the side-
lines as a consultant, but will be included
more clearly. For certain patients, he is
going to have to be the primary physician.

To return to my original statement,
from the point of view of man-years of

productivity that are potentially lost, the
pediatric group supplies perhaps one-
quarter or even as much as one-third of
the potential tripping disability that may
occur from arthritis. I would, therefore,
file a mild minority report, Dr. Engleman,
concerning the designation. I think it is
important that we not be parochial or
denominational.

1 would like to add one other thing: I
believe that it is crucial to the provision
of optimal health care, particularly on a
mass basis, to be able to include the first
contact physician within the team, if at all
possible. And I hope that some means can
be designed by which the local physician
can have direct and continued contact, not
only with the Diagnostic Clinics, but with
the Regional Arthritis Centers. In this
way, he will be included in their functions.
In this way, too, the functional matter of
the continuing education of the physician
is best achieved.

DR. WILLIAM CLARK: Dr. Engleman,
while I may or may not agree with what
Ralph I Dr. Wedgwood) said so eloquently,
I do hope that the statistics that are pub.
lished in the final transcript are more in
line with the actuality.

First of all, Dr. Wedgwood is probably


quoting from Dr. Edstrom's article, which
states that five to seven percent of adult
rheumatoid arthritis starts in childhood. I



DR. WEDGWOOD: That doesn't mean,
doubt if there are any other statistics that


necessarily, that they are right.
could negate what he said.

DR. WILLIAM CLARK: Well, you pro-
vide correct statistics to the contrary.

I have mixed feelings about the report
of this Workshop. First of all, I, as a par-
ticipant in  this conference,  question
whether we, as a group, should make such
a structurally specific recommendation for
the care of the arthritic to the Surgeon
General. I think that those of us who have
been involved in the development of cen-
ters and in the administration of center
programs would say, with conviction, that,
as neat and symmetrical as this plan is, it
probably will not be a practical and feasible
solution to the problem of preventing crip-
pling arthritis in the foreseeable future.
The reasons for that are obvious, apart
from the cost, which would be in excess of
$30 million per year.

The point that Dr. Johnson raised is,
we know, reality. We do not now have the
personnel to properly man quality arthritis

centers in half the Nation's medical schools.
We will not have the personnel in the next
five years. If we do achieve that goal in


Now, let me give you a quick history
of the center program. Dr. Freyberg is
five years, we will be accomplishing a great




correct. Prior to World War II, there were
about five or six arthritis centers that were
deal.





responsible for establishing standards of
treatment and for training young men-
medical personnel-in the care of the
arthritis patient and in the techniques of
teaching and giving clinical service.

Following World War II, because of The
Arthritis Foundation, particularly those
chapters that encouraged interest in medi-
cal schools in their areas, the number of
centers proliferated. Also, because of the
fellowship program, provided first by the
Arthritis and Rheumatism Foundation and,
subsequently, by the National Institutes of
Health (PHS) , the number of young men
who were available for such programs did
increase. But, at this time, we do not have
programs that could be considered of top
quality in one-third of our medical schools.

Today, there is a dropoff in the avail-
ability of men. We are robbing Peter to
pay Paul. For example, several years ago,

the National Institutes of Health had train-
ing grant programs in 47 medical schools.
Since that time, the number has dropped
to 43.

We have a serious situation that we must

meet now.  Having been through many
workshops, I consider this sort of thing to
be a form of therapy for our own frustra-
tions. It looks good, but those who are
actively involved in the development of such
programs know that it is not attainable in
the immediate future.

The weakness in this approach is that
we are starting from the top and working
down. It is based on the assumption that
if you can have an administrative super-
structure, you can coordinate services, per-
sonal skills, and knowledge, which, in fact,
do not exist. But from a practical stand-
point, it is traditional in American medi-
cine that the motivation that increases the
number of troops that must be coordinated
begins from the bottom.

That might have been the essence of the
message in the public education and in-
formation program. Regardless of the po-
litical implications that might have been
brought out, or that must be running
through at least a few people's minds, I do
not think, as one who has had practical ex-

59


perience, that we can offer this structurally
specific program as an immediate and
practical solution to the prevention of
crippling arthritis.

DR. ROBINSON: I have one question
and one minor speech. First, how do you
arrive at the number of from 9 to 12 Re-
gional Arthritis Centers?

DR. ENGLEMAN: The number of re-
gions was based on two or three considera-
tions. One was the number of regions in
The Arthritis Foundation, which is nine.
There are also nine Federal regions. And
the cancer groups are divided into 12
regions. So, we decided that the number
should be somewhere between 9 and 12.

DR. ROBINSON: Well, I think that the
statement that Dr. Clark made with respect
to training programs, with full apprecia-
tion of training programs, does not mean
that we necessarily have the personnel,
manpower, and structure for an effective,
comprehensive care program in each of
those places. I think we already have more
than 9 or 12 centers where, with proper
support and development, exemplary stand-
ards of consultation and care for the
arthritis patient can be developed.

60

I would like to state that our panel, which
was concerned with voluntary and public

programs, considered this problem, as, I
am sure, other panels did; and we felt
that it would be much wiser to include into
existing programs, rather than to develop
a formalized structure, such as this. I hope
to be able to present the reasons for this
tomorrow morning, although the over-
whelming conviction and the underlying
reason for it can be stated now.

The problem of arthritis is not going to
be solved by the Advisory Committee or
by the various centers. The problem of
arthritis is a community problem, and it
is going to be solved by mobilizing com-
munity resources. I would agree with Dr.
Clark that, from the point of view of our
panel discussion, the place to start is down
at the bottom, rather than up at the top.
We must build up, not down.

DR. HILL: May I come up front? I
can't sit still any longer. I'm Donald Hill,
from Tucson, Arizona. I have been prac-
ticing in rheumatology and internal medi-
cine for over 30 years. There are several
points that I would like to make.

I have great respect for general practi-
tioners. In trying to educate more doctors
in arthritis-to understand it, to recognize
it, and to know what to do about it-1
have had occasion to talk with all kinds

of doctors. Of all of them, the members of
the Academy of General Practice are full
of interest, eager to learn. They are totally
different from the general practitioners of
fifty years ago.  These young men are
learning the different diseases. They are
learning to identify them. If they are too
busy to treat them, they are learning what
to do about them, where to refer them.
Already, this is taking place. It is very
refreshing.

Dr. Clark is, I think, quite right. This
chart is an example of beautiful diagram-
ming; but it is upside down. This (indi-
cating "Local Physician and Patient" box)
belongs on top, if we are going to make
progress; and we are making progress. I
am amazed and pleased when I see the
intelligence about arthritis, the keen inter-
est, the enthusiasm, and the motivation in
all of you people. We are making excel-
lent progress in this disease.

I am not an old man, but I have been
at this long enough to realize that you
don't change things overnight. We are
making good progress in arthritis, even
though we have a lot of problems that are
unsolved, a lot of people who are un-
treated, and lots of goals to accomplish.
We have come a long way in recent years,


if you will just stop and think a minute.
Turn this chart upside down and start
with the local physician, who is learning,
now, about arthritis, and with the patient,
who is learning more from public sources.
Incidentally, I would like to add one thing,
here, and that is that we doctors, these
days, have to read Newsweek, Time, and
the Reader's Digest, to be sure we keep up
with our patients. 1 do this every noon,
or most noons, when 1 drink my milkshake
at the drugstore. 1 grab a magazine to be
sure 1 have kept up. Too often, our pa-
tients are getting advised about new treat-
ments in the lay papers before our doctors
are advised; and this, 1 am sure, you are
all aware of.

To return to the subject, the local phy-
sician is catching up; the general practi-
tioner is learning;  and the patient is
certainly learning.  And there are good
centers available. We have a number of
them. Dr. Robinson has a good one. There
is a good one in New York, one in Boston,
and one around Philadelphia. There are
others in other places around the country,
too, and local physicians are learning
where these centers are and are referring
patients there.

Actually, we already have many of the

institutions that are shown on the chart.
And we have test laboratories to which we
can send materials. But if the local physi-
cian had to send everything to his auto-
mated test laboratory, then wait three days,
or a week, to get a report back, 1 am not
sure that the procedure would be practi-
cal. There are simple tests; and, after all,
1 think that those of us who practice are
not really convinced of the value to clini-
cal practice of laboratory procedures, any-
way. Some of them, of course, are good
guides; and we all use them as aids. But
I don't think that we are going to change
things overnight.

I would go back to one thing that 1 have
been insisting on in my time: that is that
we concentrate on spreading more infor-
mation-on trying to teach doctors to
understand the problem before the patient
understands it, if this is possible. We must
also emphasize the importance of provid-
ing more paramedical services and of
stimulating the comprehensive team ap
preach.

Finally, Dr. Johnson spoke, a few min-
utes ago, about the patient who rightfully
reveres his family doctor because he is a
good doctor. Unfortunately, a family doc-
tor is aIso a busy doctor. And, many times,

he has not had time to study arthritis
before he sees the arthritic patient. All
he has heard is that there is nothing he
can do but prescribe aspirin. The patient,
believing this, goes home and doesn't see
another doctor for a year. This chart
won't work until the local doctor realizes
that there is something else that can be
done for arthritis. It won't work until the
-local doctor either knows how to do it,
himself, or knows where to go to get as-
sistance.

1 will end by making a plea for contin-
ued effort from each of us. Thank you very
much, Dr. Engleman, for starting this
stimulating discussion.

DR. SHULMAN: 1 think we all agree
that some things have been accomplished.
But 1 think it is much more fruitful to
indicate that much needs to be done. And
1 am sure that we will be hearing from
the other groups with respect to what the
needs actually are.

1 would ask Dr. Engleman the following
brief questions: (1) Do you and your group
think that what applies to cancer applies,
also, to arthritis? Or do you think that
there might be some differences between
the approaches to the two sets of diaor-
ders? 1 wondered, in effect, whether or

61


not you have given thought to a further
explanation of this, and whether you think
that the figures, which have been elabo-
rate, have been worked out to a sufficient
degree; and (2) what thought have you
and your group given to the question of
timing? I ask because I think that this is
what seems to be bothering so many of the
people here. It is that the final plan has
been arrived at, perhaps, with a little
haste. I sincerely submit this to you.

DR. JOHNSON: One last word, Dr.
Engleman :  I want to thank Dr. Hill for
expressing, in such fine phraseology, the
thoughts that 1 did not, perhaps, bring out
in my earlier discussion. I want to empha-
size one point, one aspect of this total
question, that I think is of the essence. I
will do it by asking a question.

62

If we don't have the answer to the ques-
tion, then we had better be careful about
using certain areas of available patient-
physician interrelationships for learning
Is there anyone among us who, at this
time, would like to stand up and tell us
what the treatment of arthritis is? If there
is, I stand willing to listen. And if you
don't have an answer, does anyone choose
to give a learned discussion on this topic?
I would love to hear it.

more about the disease, before we assume
the posture, nationally, of saying that we
have a plan that will remedy all that besets
everyone.

Now, in all sincerity, if there is one per-
son here who is satisfied, in his own mind,
about the complete diagnosis and the com-
plete treatment of the various forms of
joint manifestations that beset mankind, I
am willing to listen to him. I stand avail-
able.

There is a disease, gout, that can be
treated very successfully in a variety of
different ways. There are other diseases,
such as osteoarthritis and rheumatoid
DR. STILLMAN: Mr. Chairman, I
would like to answer that loaded question,
not because I think I know all the an-
swers to the treatment of the rheumatic
diseases, because I have learned a lot of
questions in 30 years and not too many
answers. However, it can be said unequi-
vocally, that there are certain rheumatic
diseases that can be cured, such as infec-
tious arthritis. Now, this is cured when
you suspect the diagnosis, when you do a
joint tap, culture the fluid, and apply the
appropriate antibiotic to the patient. Un-
fortunately, this is not done too frequently,
and great destruction of the joint results.

arthritis, that cannot be cured. And they
are not being controlled in a way that is
satisfying to any of us. But, certainly, we
can stem the development of these crippling
diseases when we treat with all of the
skills that are available to us today. And
I hope that the education program will
make these skills available to everyone.

  DR. ROBBINS: In cancer-and it is
different-we have been using the facilities
that are available, including all of these
on the chart, and we have come a long way
in 30 years, just as you have. I was in
this Workshop group; and I can't remem-
ber that we advocated any kind of a final
word that was to go down as law. We
were given a job to do; and how we ever
stood all of this, I don't know.
  But we did come up with some sugges-
tions to tear apart. And for Heaven's sake,
I don't think that anyone on the committee
would say that this is a final thing at all.
  There are two ways to build a house.
You can build it with a big foundation,
like this one down here (indicating "Local
Physician and Patient" box). You can
1  also turn it upside down. Now, we con-
sidered the physician and the patient to be
the foundation; and we sort of like our
foundation on the bottom.


DR. ENGLEMAN: Dr. Shulman, the
current inadequacy of community facilities
for early diagnosis and treatment of ar-
thritis is reminiscent of the situation in
cancer 20 years ago. Since then, the cancer
people have come a long way. We should
profit by their experience.

I simply want to say, again, that we
were charged with the responsibility of
coming up with some suggestions about
how we might eventually improve, through
development of facilities, early diagnosis
and early treatment. We were given eight
hours for discussion; this is what we came
up with.

Certainly, this was not intended to be
the last word; nor was it intended, Dr.
Shulman, that all of this would go into
effect tomorrow, next year, or even in the
next two or three years. This is a long-
term, projected consideration which should
be implemented in phases over a period
of several years. However, we did empha-
size that the first and immediate phase is
the provision of funds for maintenance of
those qualified centers whose voluntary
support may terminate on July 1, 1966.
The speed of evolution of the other pro-
posals will of course depend on the avail-
ability of trained personnel; but it is

noted that professional training will be ex-
pedited within the framework of these

I think that, if nothing else, we have
provoked discussion.
proposals.


We are grateful to you for it.

Long-Term Control and
   Management

Chairman: Currier McEwen, M.D.

The long-term management of the pa-
tient with arthritis is a natural extension
of a program that begins during the acute
and subacute phases of these diseases. It
must be considered in relation to the over-
all problem of the management of chronic
diseases.

Nevertheless, there are special features
that are particularly important and perti-
nent to it. In the following statement, these
features will be emphasized; areas that
require further study will be noted, and
recommendations will be made.
I. OBJECTIVES

The objectives of long-term care are:
a. to prevent recurrences of attacks of

those diseases, such as rheumatic



b. to prevent disability.
fever and gout, where this is pos-


c. to restore function in patients who
  sible.


are already handicapped.
d. to maintain function that has been
gained.

The prevention and correction of dis-
ability must encompass not only the func-
tion of joints, but also the patient's total
physical and psychological status, capacity,
and well-being.
Il. RESOURCES

The resources that are required include
skilled personnel, facilities, and programs
of care.
A. Personnel:

The patient's personal physician is
the key figure, since he is the one
who has primary responsibility for
the patient; he is the first to see
him. In addition, various person-
nel with special skills are essential.
Required on an intensive basis are
rheumatologists, physiatrists, ortho-
pedic surgeons, physical therapists,
occupational therapists, hospital and
public health nurses, social workers,
and vocational counselors. For op

63


64

timal benefit, these skilled person-
nel must function not merely as in-
dividuals, but as a coordinated
team. In addition, supporting skills,
such as those of pediatricians, derm-
atologists,  opthalmologists, urolo-
gists, dentists, psychologists, radi-
ologists,  dietitians,  podiatrists,
laboratory personnel, and others
must be readily available.
B. Facilities:

These include general hospital beds,
long-term care and rehabilitation
facilities, facilities for the super-
vision of the ambulatory patient,
and the patient's own home.
1. Whereas the acutely and sub-
acutely ill arthritic patient often
needs the facilities of a general
hospital, the latter are neither
necessary nor most advantage-
ous for long-term management.
Nevertheless, general hospital
care must be readily available
to the chronic arthritic patient,
who may suffer a severe exacer-
bation of his disease, or who
may require an orthopedic op-
eration or other major diag
nostic or therapeutic measure.

2. The facility that is particularly
needed in the arthritis program
is the intermediate care facility.
These are necessary for the pa-
tient who no longer requires the
complex and expensive facilities
of the general hospital, but who
still needs a more intensive pro-
gram of therapeutic exercises
  and other measures that can be
  carried out at home. There is
need for exploration of the opti-
mal roles of the chronic disease
hospital, the rehabilitation cen-
ter, the "midway house" type of
facility, and the nursing home in
this program.

3. The ultimate aim of the treat-
ment of the arthritic patient, at
all stages of his disease, is to
enable him to engage in produc-
tive activity in his home and in
the community. The chronic
  nature  of arthritis  requires,
however, that a program of
supervision and care be contin-
ued for years after the patient
returns home. Two types of
supervision  are required: a.
home care programs, for the pa-

tient who is still homebound;
and b. outpatient care, for the
patient who can leave the home.
The principles of both types of
supervision   are  the   same,
whether they are provided on a
private basis or through prop-
erly organized clinics. In either
instance, it is essential that all
the necessary skills be available.
Also essential to ambulatory
care is suitable transportation
between home and place of care.
4. For the patient who does not
have a suitable home of his own,
boarding and foster homes and
nursing homes and homes for
the aged may serve as a substi-
tute. There is need for explora-
tion of the roles of these facili-
ties and of means of developing
constructive programs for ar-
thritic patients in them.

5. Although not specifically a fa-
cility for long-term manage-
ment, mention should also be
made of the need for units to
which the family physician can
refer his arthritic patient for in-
tensive evaluation and treat-


C.

   ment by the full team of skilled
  personnel that was referred to
   above. Such units can be devel-
  oped in the general hospital, re-
   habilitation center, or in the
   midway house type of facility.
Programs of Management:
1. Utilization of professional person-
  nel

Proper management of patients
with long-term illness depends pri-
marily on persons who have profes-
sional knowledge, technical skills,
and a commitment to the provision
of optimal patient care and to the
development and dissemination of
knowledge. The  physician is
charged with the key role in man-
agement. All plans for care center
on the patient and are the general
responsibility of the physician, who
must work with other professional
persons.

Organization of personnel from
the many disciplines that are needed
to give the broad spectrum of pa-
tient care that chronic disease re-
quires will vary from one region to
another and from urban to rural
localities. Groups of physicians and

representatives of other health pro-
fessions should join together in
such a way that they can provide
care within the home, nursing home,
midway and rehabilitation facili-
ties, clinics, and acute general hos-






  Such a group should be based in
* a general hospital, and the concept
pitals for patients who are acutely






of the general hospital should be
expanded to include facilities and
and chronically ill. In this way,









services for all levels of care, either
they can provide the essential con-








within itself or through affiliated
units. The members of the team
tinuity of patient management that









should go into local communities
for workshops, demonstrations, and
is so essential in arthritis.









consultation, and physicians and
other health workers from those
communities should participate in
patient care and educational pro-
grams in the centers. The physician
with the primary responsibility for
the patient might be a member of
the group or might use the group
for consultation and special ther-
apy. Good function of any pattern

of care depends on the understand-
ing by physicians, patients, their
families, and the community of the
advantages that are offered by the
particular organization that is ren-









2. Education of Professional Person-
dering service. It is evident that









  nel
the patient's physician is a most
important member of the team and
should be involved at every stage
in the planning and management of
the patient's care,

Meeting the needs of patients
with arthritis begins with the edu-
cation of those who will provide the
care and manage the patient in his
illness.  Professional people who
can meet the ever-increasing de-
mands for patient care, education,
and research in all health profes-
sions are in extremely short supply.
Their education must be supported
in colleges and professional schools
if needs are to be met and if the
future of health services is to be
assured.

Education of people in health
professions includes: (1) The gen-
eral preparation that is needed to

65


66

understand the needs of patients
and the settings in which they live;
(2) the acquisition of knowledge in
the particular field of specializa-
tion; (3) practice in the techniques
that are essential in the specialty;
and (41 the development of capaci-
ties to work with others to produce
effective teams that will give care,
teach others, and explore new areas.

  Experience and education in col-
laborative efforts in health care and
research have been inadequately
developed. They are applicable in
principle to all aspects of health,
hut are of singular importance in
the care of people with long-term
illnesses.  Programs of education
and training with broad financial
support and active recruitment pro-
grams, should he designed to meet
both current needs and those of the
future. They should prepare people
to adapt to changing social demands
and emerging medical knowledge.
3. Community Planning and Design
  The complexities of the disabili-
ties that result from arthritis de-
mand extensive community planning
if resources are to be used most

effectively. Health care has evolved
from the status of a privilege to a
right. This change requires the de-
velopment of a sense of community
trusteeship on the part of physi-
cians, other health personnel, com-
munity leaders, and the agencies
that are concerned with the provi-
sion of patient care. Only through
planning can the sick person be
assured continuity of care, from the
most highly specialized technical
and intensive levels to the home.

Community planning, in  the
broad sense, should include provi-
sion of facilities for all types of
care, the development of appliances
and equipment, the training of the
patient and his family to use them,
and the means of bringing the pa-
tient, personnel, and facilities to-
gether most effectively.  Further-
more, greater attention should be
given to architectural design in
community planning and building,
so that disabled citizens may enjoy
social and cultural advantages that
are available to the well.

Before planning for facilities and
resources for patient care, it is most

4.

important to determine resources
that are already available in the
community and to make them known
to those who will use them. Addi-
tional resources will then be de-
veloped in an orderly and economi-
cal fashion to supplement those that
are available. Programs that are
established should include means of
evaluating their strengths and limi-
tations, so that they can be modified
and improved on the basis of ex-
perience.  The results should be
published.  Educators and social
scientists can be of great assistance
in developing means of evaluation.
Financing of Care

Although the financing of care is
not the specific assignment of this
committee,  methods of financing
have profound implications for any
program. This is of particular im-
portance in chronic, disabling dis-
eases, such as the arthritides, in
which family resources are usually
insufficient to meet the costs of long-
term care. Planning and financing
are most important at the local
level. Private, voluntary agencies,
as well as public agencies, are in-


   volved; and the planning and fi-
  nancing of facilities and resources
  of care should also include regional
   and federal participation.
III. RECOMMENDATIONS

1. Because the most serious obstacle
to the provision of optimal long-
term management of arthritis is the
lack of sufficient numbers of person-
nel in the essential health profes-
sions, there is urgent need for sup-
port of education in these fields,
coupled with intensive recruitment
efforts. This should include direct
support of education in medicine,
physical and occupational therapy,
nursing, social work, and other spe-
cial skills. In addition, there is need
for the development and support of
special programs of postgraduate
instruction of these personnel in
the application of their skills to the
patient with arthritis.

2. Studies are needed of the numbers
and. types of arthritic patients that
require long-term care in rural, as
well as urban, communities and of
where and how they now receive
  care. Such studies should he made
in the context of the total health

needs and the social, economic, edu-
cational, and health resources of
the community.

3. Studies are needed of various pro-
grams of coordinated health serv-
ices for providing long-term care
for arthritic patients.  Support
should be given for research and
demonstration projects of this type.
Such projects should be undertaken
on both local and regional bases.

There is particular need for ex-
ploration of various types of facili-
ties and programs for providing
optimal, long-term care at low cost.
The role of voluntary health agen-
cies and of volunteers should be in-
cluded in such studies.

4. An important need in the long-term
management of arthritis is that of
educating physicians in the value of
physiatric and orthopedic measures.
5. The optimal care of chronic arthri-
tic patients requires the combined
  skills of the various essential health
professions, on a team basis. The
patient's family physician, the pa-
tient himself, and his family are
  essential members of this team.
Studies should he made of ways in

which the team can best cooperate
in improving the total care of the
patient and of factors that militate
against effective functioning of the
team.

6. In planning for improved means of
providing long-term management
of arthritis, consideration should be
given to the desirability of combin-
ing such programs with those that
  are  designed to combat other
chronic diseases.  In rural areas,
such combined efforts may be more
effective and feasible than attack-
ing diseases separately. They may,
therefore, enhance the management
of the arthritic patient without un-
duly increasing the economic bur-
den on the small community.

7. There is a need for rheumatologists,
orthopedists,  and physiatrists to
work together, through interdis-
ciplinary study, to define means of
evaluating various measures of care
of arthritic patients, as outlined in
the recommendations of the Confer-
ence on Surgical Criteria and Rheu.
matoid Arthritis, which was held in
December 1963, under the joint
auspices of the National Institute

67


68

of Arthritis and Metabolic Diseases,
the American Rheumatism Associ-
ation, and The Arthritis Founda-
  tion.
8.  Studies should he made to determine
which members of the professional
team can most efficiently provide
the various types of patient care
that are needed in diverse stages of
disability and improvement.  For
example, an evaluation should be
made of the current use and effec-
tiveness of therapeutic exercises, as
supervised by personnel with vari-
ous degrees of training, such as
physical therapists, physical ther-
apist aides, visiting nurses, and the
patient's relatives. Such studies will
not only permit the most effective
use of skills that are in short sup-
ply, but they will provide yardsticks
for determining staffing needs for
various types of facilities.
9. There is a need for programs that
are designed to enable the disabled
arthritic patient to lead the most
productive and meaningful life pos-
sible. Among these programs, for
example, should be ones that will
enable patients to be gainfully em-

ployed in their homes, in sheltered
workshops, and in competitive situ-
ations.  Recreational and social
opportunities should be developed
in conjunction with those that are
needed for other members of the
community. In addition to develop-
ing such programs, there is a need
for continuing studies of better
means of achieving these aims.

Discussion

DR. JOHNSON: I have been practicing
as a personal physician for 31 years, and
the thing that is important to me is that I
know that the man of first contact is the
one who sees the patient when he has the
little joint involvement, the first episode.
I know that when the patient gets around
to going to the clinic and seeing the per-
son who is specifically concerned with the
joint diseases, he is already far along the
course toward disability; and I think it is
of immense importance that those of us
who see all of these patients every day for
their  minor  illnees-be it  seborrheic
dermatitis of the scalp, the plantar wart of
the foot. or anything that intervenes be-
tween-that we look for these things and
hegin to do something about them. I wish
to emphasize that.

DR. CALKINS: I feel this has been a
very well brought out and balanced presen-
tation, and I would like to give it my fullest
endorsement.

DR. MASI: Your third recommenda-
tion, which I would like to compliment
you on, was very pertinent. It had to do
with demonstration. I think this is some-
thing we should try to emphasize.

Any program that we recommend at this
time is only something we can conceive of
in our present understanding of the prob-
lem. As time goes on, we will understand
better. I think that we should have an
open mind and be constantly trying to
demonstrate new and better ways of doing
what we are doing, or evaluating how we
are doing it. and of comparing one method
with another.

DR. MCDONALD: I would like to ron-
tribute one thought with regard to general
practitioners: They are our hope for pre-
vention, inasmuch as they are the first to
see the patients. We have stressed, in all
of these deliberations, the importance of
early identification, early diagnosis, and
early care in the prevention of later dis-
ability.  We must continue to stress that
general practitioners are in the front lines;
they give us the greatest core for preven-
tion.


Professional Education

Chairman: Howard F. Polley, M.D.

Our Workshop was concerned with pro-
fessional education. We had a very com-
petent group of participants and a very
good discussion. I am pleased to be able
to report it to you.

Arthritis and related rheumatic diseases
are a domestic problem with a high degree
of public health significance. The possi-
bilities of their prevention, or, at least, the
prevention of disability that is related
thereto,  warrant intensive consideration.
Because of this, better educational efforts
that are referable to arthritis are regarded
as a current major obligation of our so-
ciety. These efforts should be directed
towards medical, as well as associated pro-
fessional, personnel and, also: to the public.

Our Workship first considered the sub-
ject of professional education, from the
viewpoint of available resources and of
apparent deficiencies.

Some of the currently available educa-
tional resources are;
(a) Training centers, which are sup-
ported by the Public Health Service,

through the National Institutes of Health.
(1 understand that there are 43 of these.)
To date, they have been supported for re-
search training. Although they do provide
some patient care, they have not been
established to provide training for patient
care.

(b) Existing clinical study centers, of
which there are seven, and special treat-
ment centers, of which there are 18, are
presently  supported by The Arthritis
Foundation.

An indeterminate, but small, number of
centers, perhaps 10 to 15, are supported
by other agencies.

(c) Assorted graduate educational pro-
grams for both medical and associated
professional personnel.
(d) Currently existing training in the
field of rheumatology in medical school
curricula.
(e 1 Existing schools for education of
assoc,iated professional personnel, includ-
ing physical therapists, occupational ther-
apists, nurses, nutritionists, social workers,
and scientists in other fields.
Deficiencies that were noted were:
t a) An insufficient number of arthritis
stud!, 6r treatment centers to cope with the
magnitude of the public health arthritis

problem, and the limitations of the clinical
teaching or educational aspects of the func-
tion of these centers.

(b) Insufficient comprehensive care pro-
grams, which could serve as models of edu-
cational training  of medical students,
graduate physicians, and of other profes-
sional personnel. (We do not know of any
medical center that provides the full spec-
trum of optimal comprehensive care, from
prevention, on the one hand, to care of the
chronically-disabled patient, on the other).

(c) The wide variability of instruction
in rheumatology that now exists in various
medical school curricula.

(d) The orientation of medical under-
graduate educational experiences toward
acute illness.  (The recognition that such
episodes often are hut phases of chronic
illness is overlooked or neglected in train-
ing programs.)

(e) Limitations in the availability of,
and in the selection of, attendants at post-
graduate courses.

of) The quite limited or nonexistent
training in rheumatic diseases in the cur-
ricula of schools for associated professional
personnel and in the post-graduate edu-
cation that is offered to these personnel.
`gi A desperate shortage of physical

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70

therapists and a scarcity of other associated
professional personnel who are needed for
optimal care and education for arthritis.
(h) Deficiencies in support of faculty
who are interested in teaching clinical care.
(i) The lack of reliable information
on, (1) what to teach; (2) how to prevent
disability; (3) what particular disabilities
of arthritis are preventable; (4) the role
of various preventive measures; and (5)
psychological aspects of physical disability.
Other deficiencies could be listed since
deficiencies were obvious and critical in all
areas of our deliberations.
The recognition of resources quickly
pointed up deficiencies, and discussion of
one was usually intertwined with the other.
Our Workshop was .of the opinion that
education in arthritis requires broad con-
cepts of the diseases that are included in
this category and the avoidance of exces-
sive sophistication and fragmentation. The
objectives are the best care for all patients
who are properly motivated to receive it
and the prevention of disability.
The necessary balance between research
and clinical orientations seems, now, to be
lacking, because of the emphasis on re-
search in the post-World War 11 era. This
research emphasis has obviously been pro-

ductive.  Now, a similar resurgence of
training in clinical skills is needed to reach
a balance between the two.

Improved clinical skills would improve
clinical research and bring both teacher
and student closer to the patient. This is
important because an adequate educational
program should be centered around the
patient. And it requires a teacher who is
able to provide exemplary care. Clinical
skills are not easily acquired, and their
adequacy may be even harder to measure;
but they do need to be used continually to
be most effective.

In teaching,  individualized contact is
probably most effective. But it is woefully
inadequate to meet current public health
requirements. The essence. in any effective
medical teaching program, includes good
communications, teaching by example, the
ability to inspire a student to strive to meet
his best potential, and adequate time for
contact with patients.

Student interest is signally influenced
by the quality and excellence of a faculty
that can be readily recognized for its out-
standing care of patients and for the oppor-
tunity it provides to the student to practice
what he has learned under quality super-
vision. There is no recognized substitute

for training by example and for the care
of patients.

The establishment of a family practice
section or academic chair that would teach
care of patients at all socioeconomic levels
was suggested as a means of providing
future family physicians with the skills
that are useful for improved care of
arthritic patients. As has already been
stated, it is the family physician, in general
practice, who is often the most deficient in
this area. But it is also the family phy-
sician who has the earliest contact with
arthritic patients and, thus, the earliest
opportunity to apply preventive measures
against disability.

Postgraduate education is considered to
he an integral part of an effective educa-
tional program. It is most effective when
it is produced in a teaching center, when
the attendees have the opportunity to par-
ticipate actively in its planning. Existing
courses nerd to be strengthened and new
courses offered. The effectiveness of post-
graduate courses is dependent upon the up-
grading of clinical skills and levels of
patient care. Support of local chapters of
The Arthritis Foundation was also recog-
nized as a stimulating influence.

Postgraduate education has been offered


to the professions and to the public in
various forms. These have included lec-
ture courses, printed literature, films, teach.
ing machines and other types of pro-
gramed instruction, and teaching visits to
local community hospitals by specialists.
Physicians express strong preference for
workshops and seminars, rather than for
lectures. Associated personnel prefer short-
term lecture-type courses, although they
also have a need for long-term training
programs with rheumatologic orientation.
All agree that postgraduate education, in
any  form,  should be self-sustaining,
through tuition or other support.
Associated professional personnel are
considered to be an integral and essential
part of an ideal team approach to both edu-
cational programs and to patient care in
prevention of disability. Associated pro-
fessional personnel are especially helpful
in patient and public education, because
of their close and repeated contacts with
patients.

There is a great need for expanded edu-
cational efforts and for financial support to
overcome serious shortages of all asso-
ciated professional personnel.  Physical
therapy, especially, needs wider support
than it has received to overcome critical

shortages and to develop teachers in the
field.

Comprehensive care has three recog-
nized levels, including depth or expertness,
scope or breadth, and duration or con-
tinuity.  None have received adequate
emphasis. Some of the best comprehensive
care is given in arthritis clinics. In gen-
eral, however, it is very limited. It is a
neglected area because of the lack of
people to teach it. A stimulating teacher
could make comprehensive care attractive
to students by teaching the rewards to be
derived from rehabilitation of arthritic
patients. This would avoid the fragmenta-
tion that comes from teaching by separate
specialists from various fields.
Center-type programs stimulate more
interest and attract more people to the care
of the arthritic. They also appear to be
the ideal arrangement for improvement in
both management and educational train-
ing, at all levels of teaching and in all
aspects of the long-term care of chronic
disease.

Such programs also need to incorporate
the functions of all associated professional
personnel. The teaching aspects would be
strengthened by more emphasis on clini-
cians and by investigations of, and teach-

ing that is related to, patient care, train-
ing, and research, rather than emphasis on
service functions.

Comprehensive care in center-type pro-
grams readily offers the advantages of a
continuing postgraduate education pro-
gram and consultative guidance for phy-
sicians in regions that are adjacent to the
center. However, medical schools do not
have the financial resources for the estab-
lishment of such centers at this time.

Research that is related to all aspects of
disability in arthritis is an integral part
of the program of education. Vast areas of
scientific ignorance currently exist in diag.
nosis, treatment, and rehabilitation. Evalu-
ation of therapy seems to have ignored
important factors such as socioeconomic
stratification, geography, sex, age, how to
get patients motivated for early therapy,
and the exploration of the relevance of
psychological aspects of disability. Evalu-
ation is needed on a long-term basis, with
a free association of all philosophies and
skills, preferably in a center-type setting.
This may require that some beds be made
available for long-term studies. It is pre-
ferable that evaluation be conducted as
collaborative or cooperative studies.

Large-scale public health surveys to find

71


72

patients who may not be seeking medical
care are also needed. They would be most
helpful in the overall evaluation studies.

Better teaching for the 8,000 annual
graduates from medical schools would sig
nificantly and, probably, quickly improve
medical efforts against arthritis. But the
question of bow best to accomplish this
teaching requires data of a sort that is not
now available.

Our recommendations emphasize edu-
cational, rather than service, functions.

We recommend that current training
programs in rheumatic diseases be broad-
ened, within the framework of the Public
Health Service, to include support of
faculty to train both professional and
associated professional personnel at the
undergraduate and graduate levels, not
only for academic positions, but also for
treatment and clinical research of arthritis.
This recommendation favors support for
those persons whose graduate training has
not already been completed.

We recommend comprehensive care
centers, multicategorically oriented, that
focus on  arthritis as  a prototype of
chronic disease and serve as educational
facilities in which physicians work in con-
cert with well-trained associated profes-

sional personnel and provide graduate edu-
cation for all fields. Such centers should
be part of existing teaching centers. They
should make studies of management tech-
niques and teach by conducting exemplary
patient care. All teaching centers that are
presently in existence and those whose
development is proposed in the foreseeable
future will need to be included, if there is
any expectation of coping with the magni-
tude of the problem of arthritis in the ex-
panding American population.

We recommend that the Division of
Chronic Diseases, Public Health Service,
develop plans to help medical schools in
their formative stages to plan facilities and
curricula that are based on the foreseeable
future needs of the public health approach
to the major medical problems of chronic
disease and to the prevention of disability.
The Service should incorporate multidis-
ripline participation in the study of all
stages of disease and plan for long-term
teaching experiences in both outpatient
and inpatient needs. Arthritis represents
an ideal example of such a forward-looking
need.

We recommend that increased emphasis
he placed on training programs lor asso-
ciated professional personnel and on re-

education, when needed, for previously
trained personnel who are ready to reenter
employment.

We recommend the undertaking of
large-scale,  cooperative  studies  among
arthritis training and study units, involv-
ing all or most teaching centers in the
LJnited States.  This would constitute a
major contribution to the development of
more successful programs for care of
patients with arthritis.

Finally, we recommend that adequate
financial support be provided for the abbve.
Allocation of special project funds for
arthritis is one method of achieving such
support. In any event. Federal financial
support. where needed, is in the public
interest. because it will significantly ron-
trihute to the solution of a public health
problem about which the public. as well
as the professions.  have become more
aroused.

In conrlusion. on behalf of my asso-
ciates in this Workshop, I wish to thank
the SurgeoIl Crneral and Dr. McDonald
and his staff for the opportunity to `par-
tic.ipate in what clearly is an exciting
public health development of great im-
portance to us all. Thank you.


Discussion

DR. MANNING: First of all, I would
like to congratulate Dr. Polley for a very
spectacular summary of what went on. I
would also like to emphasize the point that
no one, I think, would like to establish a
center that would isolate arthritis from the
rest of medicine. I think that this is always
a danger and that we must remember that
arthritis doesn't exist in a vacuum. We
must keep it with the rest of medicine.

I have heard centers mentioned several
times. I trust and hope that the integrative
processes will be utilized to the fullest, so
that arthritis will not be isolated.

DR. GLENN CLARK: I hate to pick on
just one phrase of such a magnificent
report, but in each of the conferences 1
have heard the statement that properly
motivated patients should get good treat-
ment. It is a practical point, I guess, to
evaluate a patient's motivation  before
doing extensive orthopedic surgery. But I
would like to express what may be a
minority opinion: If treatment is restricted
to patients who have good motivation, this
merely provides an "easy out" for not tak-
ing care of the more difficult, less moti-
vated patients. I feel that we have a re-
sponsibility to teach the medical student

not to look for some flaw in the patient's
motivation. I feel, also, that we have to
take care of all arthritics and that we have
no right to sit in judgment of a patient's
motivation. If they aren't well motivated,
it may be because of their disease, because
of their economic environment, because of
the warmth of our clinic atmosphere, or
because of many other things. I think we
have the job of motivating them, as well
as of getting them well.

DR. CALKINS: This was a wonderful
report, Howard, and I am sure it will be
carefully studied by all of us.

We have heard a wonderfully strong
statement pertaining to the need for edu-
cation in the rheumatic disease field: per-
haps in unfortunate sequence. We heard
about facilities from Dr. Engleman and his
group before we heard about education
from Dr. Polley's committee. I would hope
we could perhaps reconsider these reports
before we go on to the next area of discus-

sion.

Let's think, first, of the centers with
which we are all familiar. Dr. Polley em-
phasized small group instruction in pre-
ceptorial fashion. He emphasized a close
relationship between the personal physician
and those with a little deeper experience

in the broader range of techniques and
available approaches. We should consider
making well-supported clinical traineeships
available to personal physicians who might
come to graduate medical centers for a
three-month or a six-month period to work
with the specialists in the various clinics.
These physicians would work in rehabilita.
tion, in physical medicine, and in the
laboratory and learn some of the things
that can be done.  We might consider
establishing, on a national basis, the sort
of program that has been going on for a
number of years in New England. I am
sure that there are a number of other areas
in which this type of graduate traineeship
for practicing physicians is receiving sup-
port. Through this approach, we might
take the initial step in improving communi-
cation and in getting the motivation of
physicians more clearly defined.

Then, perhaps, there should be support
for something that might be termed "com-
munity education plus consultation clinics,"
in which teams of specialists would go to
communities  and  conduct  exemplary
clinics, on the spot, in various hospitals.
The physicians could come with their
patients so that the educational program
would be reinforced in the community set-

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74

ting. These principles, and analogous ones,
might also be utilized for associated profes-
sional personnel, at least on a trial basis.
This approach might avert some of the
hazards that all of us fear when we think
of the grand scale, single disciplinary
center.

DR. POLLEY: The regional medical
center, however it's described, is certainly
most likely to be located in a teaching
center and have facilities that are available
at both undergraduate and graduate levels
for communication and teaching between
physicians in the adjacent areas and the
comprehensive care center.
DR. HILL: I would like to second this
very emphatically.  I congratulate you,
Dr. Polley, on your presentation.
DR. ROBBINS: I don't know how many
family physicians or surgeons or anybody
else can get away for three months. We
have had quite an educational program
along these lines in cancer, and to try to
do something for more than a month, we
found, is quite impractical.
DR. WILLIAM CLARK: First of all, I
want to add my word of compliment to
you and your group for what I think is an
outstanding report. I think it's something
we will want to read and weigh carefully,

because, obviously, each comment repre-
sented a great deal of thought. I also want
to compliment Dr. Robbins on his com-
ments.

Also, it would seem to me that any differ.
ences between the recommendations of
your panel and Dr. Engleman's panel may
be due, entirely, to semantics. First of all,
the definition of a center does not require
a rigidly structured physical or personnel
organization table. It is, rather, an island,
or focal point, of concentrated interest,
and, as such, will always be the leading
edge of progress against any disease. Dr.
Polley appropriately and carefully used the
word "prototype."  If we can solve the
problems of the disease, as well as of the
approach to the disease, there will be
similar emphasis in other areas.

Secondly, the idea of a regional medical
center sometimes frightens people because
"regional" often seems to suggest a num-
ber of quite different things: Federal re-
search regions, judicial regions, and Army
or military regions, for example. What we
want is to relate these programs to popu-
lation concentration. It is a fact that
medical schools also relate to population
concentrations. We  are really talking
about a region or an area around those

concentrations that will make these facil-
ities available and accessible to the largest
possible number of victims of arthritis and
to the physicians who care for them.

Finally I think that Dr. Engleman's
group should give some consideration to
deemphasizing the concept of a commis-
sion. I question, very much, if we need
another organizational structure at the top
to bring this about. I think that the func-
tion of such a structure can he brought
about by an assumption of responsibility,
on a broad base, by individuals who work
in the communities and in the medical
schools. Thus, the two reports can be
reconciled, and I think that we would all
agree that a strong recommendation should
come out of it for the support of this kind
of program.

DR. GLENN CLARK: I was a critic of
Dr. Engleman's report, as I listened to it,
but the more I look at it, the more I think
it is a good idea. It is what we need now,
and I don't think Dr. Engleman's report,
other than the few disturbing words that
have been mentioned, does anything but
exhibit the feeling of our group-that we
need to incorporate what we already have
into an expanded and well-supported pro-

gram.


DR. COLLEN: I would like to strike
while the iron is hot. Dr. Polley's report
was excellent; the similarities between it
and Dr. Engleman's report are really, now,
quite apparent to all of us. There is no
question that everyone at this conference
came for the purpose of improving the
care of the arthritis patient. We have, per-
haps, approached this important objective
from different viewpoints and, perhaps,
used different words. Some people are
more visually-minded than others, while
others, perhaps, prefer to express things in
less rigid manners. But let us not jeop-
ardize our objectives by semantics and
symbols and so forth.

To summarize, we are all interested in
the care of the patient; and we recognize
that the physician who takes care of the
patient is the key figure in getting the care
to the patient. Furthermore, we are agreed
that the assistance he needs should come
from the established areas that are close to
him. Local centers, or local hospitals, in
turn, need assistance from a regional area.
Some persons place a dreadful connotation
on regional medioal centers. But they are,
in fact, in existence; and we all work with
them. Nowhere in his report did Dr.
Engleman recommend the establishment of,

construction of, or expenditures of monies
for new facilities. He very carefully spoke
of utilizing existing centers to develop
additional support for the assistance of
physicians in giving care to their patients.

We wanted to assist the progress that is
being made in this difficult field by trying
to standardize terminology.  For this

reason, we recommended registries that
would gather information together and, in
so doing, utilize recent advances in auto-
mation for the benefit of physician and
patient, alike.

Dr. Polley's presentation helps to sup-
port Dr. Engleman's report; they are, in-
deed, very similar. It would be unfortunate
if positive recommendations were lost or
discarded because the chosen symbols and
signs were improperly understood.

DR. BRINKLEY: The Vocational Re.
habilitation Administration has teaching
grants and traineeships in physical ther-
apy and occupational therapy and in most
of the paramedical fields. One of the
problems we find among college students
and high school students is a lack of suffi-
cient interest in going into these fields. I
feel that our recommendations should in-
clude programs to encourage students to
go into these fields for their careers.

DR. POLLEY: We did discuss that, too.
DR. TRAEGER: I just want to empha-
size one point that you made, Howard, and
that is that the distance from the labo-
ratory to the bedside is increasing.
DR. POLLEY: Thank you.
DR. CAIJGHEY: I am very much inter-
ested in the fact that there has been so
much emphasis placed on the importance
of the personal or family physician in the
management of the arthritic patient to
prevent disabilities; but I hope that this
group recognizes that, unless something is
done about the education of our physi-
cians, we are talking about a disappearing
group. Furthermore, most of us are help-
ing the disappearance by the way we plan
the educational program. You all know the
statistics; there are steadily declining num-
bers of people who are fulfilling this role
in the care of patients.

  I hope that this conference will put
appropriate emphasis on the fact that,
today, most medical schools do not have
the resources or the personnel to set up
excellent models of comprehensive patient
care-units in which the students and
house staff have a chance to observe and
to participate in excellent comprehensive
care. Furthermore, as far as I know, none

75