REPORT

+rgeon General's
   Workshop
  on Prevention
of Disability from
     Arthritis

U.S. DEPARTMENT OF
HEALTH, EDUCATION, AND WELFARE
Public Health Service
Division of Chronic Diseases
Diabetes and Arthritis Program
Washington, D.C. 20201


.---. BETHESDA 14, MD.

Background

The need for a national conference on
the prevention of disability from arthritis
was first described in a long-range plan-
ning document that was prepared in the
fall of 1963 by the staff of the Diabetes and
Arthritis Program, Division of Chronic
Diseases, U. S. Public Health Service
( PHS) . The document noted that, although
arthritis is a major public health problem,
the dimensions of the problem are not
widely recognized. And it stressed that, al-
though therapeutic measures for dealing
with the problem are far from ideal, pro-
cedures that diminish disability, particu-
larly when applied in a timely fashion,
have been devised and should be made
available to the millions of Americans who

of the Conference  suffer from disabling arthritis.

AA;riii;ne 19~ representatives of the
     and Rheumatism Foundation

(now, The Arthritis Foundation), the
National Foundation, the American Rheu-
matism Association, the National Insti-
tute of Arthritis and Metabolic Diseases
(PHS), and the Diabetes and Arthritis
Program (PHSI met in San Fran-
cisco to give further consideration to
the need for a national conference on arth-


ritis. At the conclusion of this meeting, it
was the consensus of the group that such a
conference was vitally needed. Participants
submitted a recommendation to this effect
to the Surgeon General and offered to serve
as a steering committee to plan the confer-
ence. On the basis of this recommendation,
the Surgeon General agreed that a confer-
ence should be held and accepted the par-
ticipants' offer to serve as a Steering Com-
mittee.  This Committee, later enlarged,
met several times during 1964.

In these subsequent meetings, the Steer-
ing Committee determined that the empha-
sis of the deliberations should be on com-
munity health services, as opposed to basic
research. Therefore, the title of the Con-
ference, THE SURGEON GENERAL'S
WORKSHOP ON PREVENTION OF DIS-
ABILITY FROM ARTHRITIS, reflected
this emphasis on prevention. The Steering
Committee also determined that the objec-
tives of the conference should be to:
1. Assess the problem
2. Assess the resources to meet the prob-
   lem

3. Determine gaps between needs and
  resources

4. Recommend action to close the gaps

The Workshop was held May 5-8, 1965,
at Airlie House, Warrenton, Virginia.
About 100 persons participated. Repre-
sented were every. health profession, medi-
cal economics, science writing, health and
medical insurance, and other specialties.
To accomplish intensive discussion, the
total group was divided into seven Work-
shops :

1. Public Education and Information
2. Diagnosis and Treatment Facilities
3. Long-Term Control and Management
4. Professional Education
5. Clinical Investigation and Training
6. Voluntary and Public Agency Activ-
ities and Programs

7. Socioeconomic Aspects (Financial
Resources 1

Each Workshop reported back to the total
group and each report was discussed by
the total group.

This report is a summary of the Work-
shop reports. Although it represents a con-

sensus of the total group, no individual
participant or agency is necessarily in

agreement with the total report; and it
should not be inferred that any individual
participant identifies himself with the
report.


Conference

Workhop 1

d Participants    PUBLIC EDUCATION AND
                       INFORMATION

William S. Clark, M.D., CHAIRMAN
President

The Arthritis Foundation

WORKSHOP 1
William S. Clark, M.D., Chairman

WORKSHOP 2
Ephraim P. Engleman, M.D., Chairman

WORKSHOP 3

1212 Avenue oj the Americas
New York, New York
Helen C. Anderson, R.N.
Associate Editor
American journal of Nursing

10 Columbus Circle
New York, New York
Theodore B. Bayles, M.D.

Currier McEwen, M.D., Chairman

WORKSHOP 4
Howard F. Polley, M.D., Chairman

WORKSHOP 5
John L. Decker, M.D., Chairman

Director oj Research
Robert B. Brigham Hospital
125 Parker Hill Avenue
Boston, Massachusetts
Adelia M. Beeuwkes
Projessor, Public Health Nutrition
School oj Public Health
The iiniversity oj Michigan
Ann Arhor, Michigan

" VIC
William D. Robinso

""RKSHOP 6                     James L. Curran
         n, M.D., Chairman     Director, Dept. oj Public Injormation
                              The Arthritis Foundation
                          1212 Avenue oj the Americas
WORKSHOP 7                  New York, New York

Ronald W. Lamont-Havers, M.D.,
Chairman

REVIEW

WORKSHOPS l-7
Cornelius Traeger, M.D.

Mr. Pierre C. Fraley
Chester Springs
Pennsylvflnia
Harold T. Furrst, M.D.
Assistant Commissioner jar Preventable
and Chronic Diseases
Department oj Health, City of New York
12.5 Worth Street
New York, New York

Mr. Charles E. Hovorka
Executive Director, The Arthritis Foundation
Southern Calijornia Chapter
8576 Wilshire Boulevard
Beverly Hills, Calijornia
J. Stewart Hunter
Assistant to the Surgeon General

jGr In formation
U.S. Public Health Service
Washington, D.C.
Ralph F. Jacox, M.D.
Department of Medicine
School of Medicine and Dentistry
The Ilnivrrsity of Rochester
2(i Crittenden Boulevard
Rochester, New York
Mr. David R. Preston
8 Washington Avenue
Westport, Connecticut
Elam C. Toone, Jr., M.D.
Department of Medicine
Medical College of Virginia
Richmond, Virginia
Ifiawatha B. Walker, Ph. D.
Associate Projessor, Department oj
Health Education
School oj Public Health
1 inivcrsity oj North Carolina
Chapel Hill, North Carolina
Mr. Victor Wartofsky
Injormation Oficer, National Institute
of Arthritis and Metabolic Diseases
National Institutes of Health (PHSI
Bethesda, Maryland
`Thomas E. Weiss, M.D.
Department oj Internal Medicine
Ochsner Clinic
1514 Jeflerson Highway
New Orleans, Louisiana

4


work4?hop 2
DIAGNOSIS AND TREATMENT
FACILITIES

Ephraim P. Engleman, M.D., CHAIRMAN
Head, Arthritis Clinical Study Center

and Rheumatic Disease Group
University of California Medical Center
San Francisco, California

Roy M. Acheson, D.M., Sc.D.
Professor of Epidemiology and Medicine
Dere;[yt of Epidemiology and Public
Yale University School of Medicine
New Haven, Connecticut

Mrs. H. Marie Callender (R.N.)
Associate Director, Division oj Chronic
Disease and Adult Health
County oj Westchester, Dept. of Health
County Ojlice Building
White Plains, New York

Morris F. Collen, M.D.
Director, Medical Methods Research
The Permanente Medical Group
1924 Broadway
Oakland, California

Miss Mary E. Davis
Staff Associate
American Public Welfare Association
131.3 East 60th Street
Chicago, Illinois

David J. Hamerman, M.D.
Department oj Medicine
Albert Einstein College oj Medicine
Yesh.iva University
Bronx, New York

Dr. lrvin E. Hendryson
1750 Race Street
Denver, Colorado

Miss Mary L. Hemmy
Executive Director
The Benjamin Rose Institute
Cleveland, Ohio

Charles Ragan, M.D.
First Medical Division
Bellevue Hospital
462 First Avenue
New York, New York

Guy F. Robbins, M.D.
Memorial Center for Cancer and

Allied Diseases
444 East 68th Street
New York, New York

Cecil G. Sheps, M.D.
General Director
Beth Israel Medical Center
10 Nathan D. Perlman Pkace
New York, New York

Ralph J. Wedgwood, M.D.
Projessor and Chairman, Department
o j Pediatrics
University of Washington
Seattle, Washington

Workshop 3

LONG-TERM CONTROL AND
MANAGEMENT

Currier IMcEwen, M.D., CHAIRMAN
Department oj Medicine
New York Univ. Medical Center
550 First Averme
New York, New York
Martin H. Acker, Ph. D.
Associate Projessor and Coordinator,
Counselor Training
School oj Education
University oj Oregon
Eugene, Oregon
Sterling B. Brinkley, M.D.
Program Services
Vocational Rehabilitation Administration
Dept. oj Health, Education, and Welfare
Washington, D. C.
Mrs. Louise Broderick
Regional Vice President
American Nursing Home Association
2445 Broadway
San Diego, Calijornia
Mrs. Joy C. Cordery
American Occupational Therapy Assoc.
Hospital of the Medical Research Center
Brookhaven National Laboratory
Upton, New York
Edward F. Delagi, M.D.
Associate Professor
Department of Rehabilitation Medicine
Albert Einstein College of Medicine
Yeshiva University
New York, New York

5'


Robert B. Duthie, M.D.
Professor of Orthopaedic Surgery and

Orchopaedic Surgeon-in-Chief
Strong Memorial Hospital
Univ. of Rochester School of Medicine
Rochester, New York
Leonard D. Fenninger, M.D.
Medical Director
Strong Memorial Hospital
Uniu. of Rochester School of Medicine
Rochester, New York
Miss Evelyn M. McNamera
Chief Social Work Consultant
The National Foundation
800 Second Avenue
New York, New York
Miss Catherine Nelson
Department of Nursing Education
Teachers College, Columbia University
121sc Street and Amsterdam Avenue
New York, New York
Mrs. Beth Loggins Roberts
1515 Redondo Drive
Killeen, Texas

Harold S. Robinson, M.D.
Medical Director, Medical Centre
Canadian Arthritis and Rheumatism Society
900 West 27th Avenue
Vancouver, British Columbia

Clarence A. Tinsman, M.D.
Chief. Heart and Metabolic Diseases Section
D&ion of Chronic Diseases
Bureau of Special Health Services
Pennsylvania Department of Health
Harrisburg, Pennsylvania
G. Donald Whedon, M.D.
Director, National lnstitute of Arthritis

and Metabolic Diseases

6     National Institutes of Health (PHSI
     Bethesda, Maryland

Workshop 4

PROFESSIONAL EDUCATION

Howard F. PoBey, M.D., CHAIRMAN
President, American Rheumatism Association
The Mayo Clinic
Rochester, Minnesota

John H. Bland, M.D.
Director, Rheumatism Research Unit
Department of fi4edicine
llniv. of Vermont College of Medicine
Burlington, Vermont

Alfred Jay Ballet, M.D.
Associate Professor, Department of

Preventive Medicine
llniv. of Virginia School of Medicine
Charlottesville, Virginia

Alfred A. Burr, Jr., R.P.T.
Departm.ent of Medicine
New York Ilniv. School of Medicine
New York, New York

Evan Calkins, M.D.
Buflalo General Hospital
100 High Street

Buflalo, New York

John L. Caughey. Jr., M.D.
Associate Dean, School of Medicine
Western Reserve flniversity
Cleveland, Ohio

Lillian E. Chabala, R.P.T.
Consultant, Division of Professional Service
American Physical Therapy Association
New York, New York

Sidnev Cleveland. Ph.D.

           /
Chief. Psychology Service
Veterans Administration Hospital
Housron. Terns

N. L. Gault, Jr., M.D.
Associate Dean, College of Medical Scic
University of Minnesota
Minneapolis, Minnesota
Amos N. Johnson, M.D.
President-elect
American Academy o/ General Practice
Garland, North Carolinn

Phil K. Manning, M.D.
Associate Dean, Postgraduate Medical
Education
University of Southern California
Los Angeles, California

Miss Martha E. Schnebly t0.T.R.)
Director of Occupational Therapy
Institute of Physical Medicine
and Rehabilitation
New York University Medical Center
New York, New York

Gladys E. Sorensen, Ed.D.
Professor of Nursing
College of Nursing
University of Arizona
Tucson, Arizonn

Mrs. Dorothea F. Turner
Editor, journal of the American
Dietetic Association
620 North Michigan Avenue
Chicago, Illinois

John Robert Ward, M.D.
Associate Professor of Medicine
Chief. Arthritis Division
Salt Lake County General Hospita)
Salt Lake City, Utah

hforris Ziff. M.D.
Department of Internal Medicine
Southwestern Medical School
The llniversity of Texas
Dnllns. Texas

wces


Workshop 5

CLINICAL INVESTIGATION
AND TRAINING

John L. Decker, M.D., CHAIRMAN
Chief, Arthritis & Rheumatism Branch
National Institute of Arthritis &

Metabolic Diseases
National Institutes of Health IPHSI
Bethesda, Maryland
Earl J. Brewer, Jr., M.D.
Assistant Professor of Pediatrics
Baylor llniversity College of Medicine
Director, Arthritis Clinic
Texas Children's Hospital
Texas Medical Center
Houston, Texas

Alan S. Cohen, M.D.
Associate Professor of Medicine
Director, Arthritis and Connective
Tissue Disease Section
Boston University Medical Center
Boston, Massachusetts

Alexander B. Gutman, M.D.
Director, Department of Medicine
The Mount Sinai Hospital
New York, New York

Donald Mainland, M.D.
Professor oj Medical Statistics
New York University College of Medicine
112 East 19th Street
New York, New York

Alfonse T. Masi, M.D.
Assistant Professor
Department of Epidemiology
The Johns Hopkins University School of
Hygiene and Public Health
Baltimore, Maryland

Sanford Meyerowitz, M.D.
Department of Psychiatry
University o/ Rochester School
of Medicine and Dentistry
260 Crittenden Boulevard
Rochester, New York

William M. Mikkelson, M.D.
Department o/ Internal Medicine
llniuersity of Michigan Medical Center
Ann Arbor, Michigan

Robert L. Preston, M.D.
Clinical Professor o/ Orthopedic Surgery
Rheumatic Discuses Study Group
New York University College of Medicine
New York, New York

Robert D. Ray, M.D.
Department of Orthopaedic Surgery
University of lllinois Medical Center
Chicago, Illinois

John B. Redford, M.D.
Chairman, Department of Physical
Medicine and Rehabilitation
Medical College of Virginia
Richmond, Virginia

Robert Rosengarten, M.D.
Department oj Medicine
New York Univ. College of Medicine

New York, New York

Lawrence E. Shulman, M.D.
Associate Professor of Medicine
The johns Hopkins Hospital
725 North Wolfe Street
Baltimore, Maryland

Gene H. Stollerman, M.D.
Professor and Chairman
Department of Medicine
University of Tennessee
Memphis, Tennessee

Workshop 6

VOLUNTARY AND PUBLIC AGENCY
ACTIVITIES AND PROGRAMS

William D. Robinson, M.D., CHAIRMAN
Prolessor and Chairman
Department of lnternal Medicine
University Hospital
University of Michigan Medical Center
Ann Arbor, Michigan
Paul J. Bilka, M.D.
500 Physicians and Surgeons Building
Minneapolis, Minnesota
Benjamin T. Burton, Ph. D
Associate Director for Program Analysis

and Scientific Communication
National Institute of Arthritis and

Metabolic Diseases
National Institutes of Health (PHS)
Bethesda, Maryland
Mr. James M. Ensign
Director of Professional Relations
Blue Cross Association
840 North Lake Shore Drive
Chicago, Illinois
Mr. Benjamin Fogel
The Arthritis Foundation
1212 Avenue of the Americas
New York, New York
Richard H. Freyberg, M.D.
Director, Department of Rheumatic Diseases
Hospital for Special Surgery
Cornell University Medical College
New York, New York
Mr. Thomas E. Hanrahan
Secretary, Council on Voluntary Health

Agencies
American Medical Association
535 North Dearborn
Chicago, Illinois

7


Robert F. Hansen, M.D.
Regional Chronic Disease Consultunt, IY
Public Health Service
50 Seventh Street, N. E.
Atlanta, Georgia
William S. Jordan, Jr., M.D.
Projessor and Chairman, Department of

Preventive Medicine
Univ. of Virginia School of Medicine
Charlottesville, Virginia
Mr. Alfred Moran
Executive Director
New York Chapter, Arthritis Foundation
432 Park Avenue South
New York, New York
John S. Neil& M.D.
Director, Hillsborough County

Health Department
Tampa, Florida

Mildred C. J. Pfeiffer, M.D.
Director, Division of Planning
Bureau of Planning, Evaluation and Research
Pennsylvaniu Department of Health
Harrisburg, Pennsylvania
Mack I. Shanholtz, M.D.
State Health Commissioner

Department of Health
Richmond, Virginia
Morton Thompson, Ed. D.
Director, Consulting Service on R

for the III and Handicapped
National Recreation Association
8 West Eighth Street
New York, New York
Miss Sarah Van Buskirk (R.N.)
Executive Director
Visiting Nurse Association of the

District of Columbia
Washington, D. C.

8

Workshop 7

SOCIOECONOMIC ASPECTS
( FINANCIAL RESOURCES)

Ronald W. Lament-Havers, M.D., CHAIRMAN
Associate Director, Extramural Programs
National Institute oj Arthritis and

Metabolic Diseases
National Institutes of Health (PHS)
Bethesda, Maryland

Mrs. Edith S. Air
Director, Division of Community Resources
Health Insurance Plan of Greater New York
625 Madison Avenue
New York, New York

Mrs. Dorothy P. Rice
Health Economics Branch
Division of Community Health Services
U.S. Public Health Service
Washington, D. C.

Glenn hf. Clark. M.D.
Dean of Hosoital A flairs
Univ. 01 Tennessee "Medical School
860 Madison Avenue
Memphis, Tennessee

Donald F. Ilill, M.D., F.A.C.P.
President, South Western Clinic
and Resrarch Institute, Inc.
Tucson. Arizonu

Mrs. Susan K. Kinoy
Project Director, Kingsbridge

Neighborhood Project on Aging
900 Grand Concourse, Suits 201
Bronx, New York

Robert H. Manheimer, M.D.
Medical Director, New York Chapter

Arthritis Foundation
432 Park Avenue, South
New York, New York

A. B. Price, M.D.
Head, Section of Health Facilities
Division o/ Health Services
State Department of Health
Olympia, Washington

-Milton I. Roemer, M.D.
Professor oj Public Health
School of Public Health
University of California at Los Angeles
Los Angeles, California

Jean Stair, Ed. D.
Professor of Public Health Nursing
Western Reserve University
2063 Adelbert Road
Cleveland, Ohio

J. Sydney Stillman, M.D.
Robert Breck Brigham Hospital
125 Parker Hill kvenue
Boston, Massachusetts

Mr. Thomas M. Tierney
Executive Vice-President
Colorado Blue Cross
244 University Boulevard
Denver, Colorado

XIr. Elijah L. White
Assistant Chiej, Division of Health

fnferoiew Statistics
National Center for Health Statistics
U.S. Public Health Service
Washington, D. C.


The Problem of
Preventing
Disability
f rom Arthritis

The crippling effect of arthritis on the
citizens of this country has created an eco-
nomic and sociologic problem that can no
longer be ignored. Arthritis is the number
one crippler in the United States. And the
National Center for Health Statistics
(PHSI  recently reported that arthritis
ranks second only to heart disease as the
leading cause of limitation of activity for
persons who suffer from chronic disability.

The physical ravages of arthritis impose
great economic and social burdens on all
members of society. Arthritis gradually
withdraws from productive activity large
numbers of otherwise capable people. The
latest estimate of the number of persons in
the United States who report that they have
arthritis or rheumatism is now 12,668,OOO.

A more dramatic indication of the physi-
cal waste from arthritis appears in data
that show that 3,300,OOO arthritics in this
country maintain, during home interview,
that they suffer limitation of activity be-
cause of arthritis. About 700,000 report
that they are unable to work, keep house,
go to school or engage in most recreational
activities (see Table A, page 10).

Economic Problem. The total cost of
arthritis to the public has not been deter-
mined. That it is substantial is indicated,
in part, by a 1962-63 survey of recipients
of public assistance under the program of
aid to the permanently and totally disabled.
Of the more than 500,000 persons who
were receiving aid under this program, an
estimated 33,000, or 6.6 percent, had ar-
thritis as their primary impairment. At least
17,000 additional recipients had arthritis
as their secondary impairment, for a total
of 50,000 recipients with primary or sec-
ondary impairment.  Since the average
payment in this program is approximately
i $78.00 per month, or $948 per year, a
total of $47 million was paid annually to
the 50,000 recipients.

To compound this economic tragedy,
arthritis accounts for over 12 million work-


10

loss days per year. In terms of productiv-
ity, the loss to the economy is estimated
to be $520 million a year.
Loss of earning power, coupled with the

Table A Number and percent distribution of persons
with mthritis or rheumatism, by type of usual activii
status, and by degree of activity limitation, United
States, July 196LJune 1963. (cfvilian noninstiinal
population)

Type of usual
activity end degrw
of activfty limitation

Number parsons
(in thousends)

Percant
distribution

Total

Usual activity status:
Preschool or school age
Working  
Keeping house .,
Retired
Other or unknown "

Degree of activity limitation
due to arthritis:
   Limited, total

Unable to carry
on major' activity
Limited in major activity
Not limited in major
activity, but other-
wise limited
None, total'

12,668      100.0

4.0:;        0.4
         32.2
5,926       46.8
1,991       15.7
615        4.9

3,300      26.0


697        5.5
1,888       14.9

714        5.6
9,368       74.0

1 Refers to ability to work. keep house, or engage in school

or pm-school activities. Note: Does not include persons in
nursing homes.

Source: Unpublished data. and

Chronic conditions and activity limitation, United States, July
1961.June 1963. Estimated annual avenge. U. S. Depart-
ment of Health. Education, and Welfere. Public Health Service
Publication No. 1000~Series 10. No. 17. Mey 1965. Wesh-
ington: U. S. Government Printing Office.

high costs of treatment and care, often
leads the victim of arthritis to economic
dependence upon other members of the
family or upon community agencies. This

Table B Estimated annual work productivity losses,
benefit payments, and expenditures due to arthritis.

              Total
Work productivity loss, total
Among arthritics
who work, but lose
time because of
the arthritis $220,000,000
Among arthritics
who are unable to
work and who re-
ceive disability bene-
fits    (minimal) $300,000,000
Benefit payments
to arthritics, total    (minimal)
From Old.Age, Sur-
vivors, and Disabil-
ity Insurance, Social
Security Adminis-
tration       $ 85,000,OOO
From Aid to the
Permanently and
Totally Disabled,
Welfare Administra-
tion       $ 47,000,000
Nonprescription drugs (except aspirin)
Physicians' visits
Hospitalization
Other:
Prescription drugs
Aspirin
Physical therapy
Certain services in doctors' offices
Nursing home care
Care in private homes
Private insurance benefits
Federal, State, and local income
taxes lost

$1,297,000,000
$ 520,000,000

$ 132,000,OOO

$ 435,000,000
$ 150,000,000
$ 60,000,OOO

?
?

?
?
?

?
?

?

costs the public money. Although the true
figure is not known, arthritis is estimated
to cost the U.S. economy over a billion
dollars a year. Not counted in this figure

Table C Number of persons per 1,000 civilian non-
instiiutional population with activity limitation due to
arthritis or rheumatism, by family income and age,
United States, July 196LJune 1963.

                  Persons with activity
                    limitation due to
              Total    arthritis or meumatism
Annual family      population    Number   Per 1.000
income end age    (in thousands) (in thousands) population


Total     3,300
          181964
               I             18.1

Under 45 years 128,658     327     2.5
45 years and
over        53,306    2,973     55.8

Under $4,000     56,390    2,033     36.1

Under 45 years  34,897     114     3.3
45 years and
over        21,493    1,919     89.3

$4,000 and over 115,056    1,083     9.4

Under 45 years  87,299     200     2.3
45 years and
over        27,757      883     31.8

Income unknown   10,518     184     17.5

Under 45 years   6,463      13     2.0
45 years and
over         4.055      171     42.2

Source: Chronic conditions and activity limitations, United
States. July 1961.June 1963. Estimated annual ewrego. U. S.
Department of Health. Education. end Welfare. Public Health
Service Publication No. 1000.Series 10. No. 17. May 1965.
Washington: Ll. S. Gowrnment Printing Office.


are the costs of prescription drugs, aspirin,
certain services in doctor's offices, nurs-
ing home oare, care in private homes, pri-
vate insurance benefits, and Federal, State,
and local income tax losses (see Table B,
page 10).

Of the $435 million that is spent annually
for medications for arthritis, $250 million
is wasted by arthritics on products that are
falsely advertised  or grossly misrepre-
sented.  Frequently, quackery flourishes
because the physician who first sees the
arthritis patient is not trained to cope
adequately with the problem. In addition,
public and private organizations do not
have the resources to counter the promo-
tion of fraudulent remedies. In lieu of con-
crete information about arthritis, the suf-
ferer, believing that nothing can be done,
wanders aimlessly into the pit of quackery.
When he does seek the aid of a knowledge-
able physician, his disease may have pro-
gressed beyond the point at which effective
measures might have been applied.

Growing Problem. Since arthritis lacks
the virulence to kill, prevalence rises with
age. Victims of arthritis may become
crippled, disabled, and wracked with pain,
hut they continue to live.

Arthritis has its greatest impact on the     The battle that the crippled arthritic
lower income groups. As family income    must wage to maintain his levels of reserve
goes down, the percentage of arthritis and,   and adaptability against the onslaught of
the percentage of arthritics in the disabled    his disease has profound meaning for all
group, goes up.               responsible members of society.

A comparison of persons with limitation
of activity by family income and age in-
dicates that arthritics who are over 45 years
of age with family incomes under $4,000
have even more limitation of activity than
those who are over 45 years of age with
incomes over $4,000 (see Table C, page
10). It can be said that arthritis is asso-
ciated with lower income, regardless of
age, although it is also associated with in-
creasing age.

Something Can Be Done. The princi-
pal problem in preventing disability from
arthritis is that of decreasing the interval
of time between the patient's first symp
toms and the initiation of comprehensive
treatment and care. Decreasing this inter-
val is, in part, a matter of patient and
public education. Delay in seeking proper
care speeds crippling; the informed patient
will not delay.

Of perhaps more significance, however,
is the related problem of making the pa-
tient's first medical contact more effective
in leading him to prompt and adequate
care. This involves the basic training of
the physician and the postgraduate efEorts
that must be made if the practicing physi-
cian is to be kept up-to-date in the field of
arthritis. Also, it implies the availability
of resources for early and accurate diag-
nosis and the adequacy of facilities that
will provide total or comprehensive medi-
cal care that is adapted to the needs of the
individual patient.

Psychological and Sociological lm-
pact. While our society manifests a strong
consciousness of responsibility for the
handicapped and disabled, it nevertheless
places emphasis on youth, activity, and
achievement-values that are hardly com-
patible with a long-term crippling disease.
When crippling arthritis strikes, the psy-
chological and sociological stresses that
twist and tear at the patient and at all who
must suffer with him are so great, both in
magnitude and in duration, that they defy
quantitative measurement.

11


Unfortunately, public education activ-
ities, professional training programs, diag
nostic  resources,  and  adequate   care
facilities are, at present, insufficient. This
must change. Something can be done for
the arthritic. It can be done now, if society
is willing to undertake the task.

In the prevention of disability from
arthritis, there is one fact that has been
repeatedly demonstrated; there is one point
on which virtually all workers in the field
agree: The early initiation of comprehen-
sive treatment and care activities, including
hospitalization, when necessary, and em-
bodying subsequent and continuing med-
ical and social support, is essential to the
prevention of disability from arthritis.

Severe crippling can be prevented. In
seven out of ten cases, victims of rheuma-
toid arthritis can be kept out of the bed
or wheelchair. They can be helped to lead
a useful and productive life. For this
reason, it is of vital importance that com-
munity resources be augmented substan-
tially and that they be brought to bear
early in the course of the disease, rather
than later, as is too often the case at the
present time.

12

Chronic Cripplers Excluded. For too
long, the public, professional health work-
ers, and statesmen have been concerned
with diseases that kill, to the exclusion of
the chronic crippling diseases. As a result,
much progress needs to be made. The ex-
cellence of current, short-term, inpatient,
acute-problem studies has not been dupli-
cated in outpatient work with chronic dis-
eases. Clinical work and planning, which
could include a comprehensive program
of patient education, is inadequate at many
of our better medical schools. Facilities
for early hospitalization for patients who
would benefit from such care are fre-
quently inadequate.  There are too few
comprehensive care programs, which could
serve as models of educational training of
medical students, physicians, and other
professional personnel, too few clinics, too
few general hospitals, nursing homes, and
home care programs, which are capable
of dealing with the specific needs of the
arthritic, and too few interested health
professionals.

With respect to professional education,
recruitment, support, and training of both
medical and allied health professionals is
inadequate. The sparse or nonexistent

training in rheumatic diseases in the cur-
ricula of schools for associated profes-
sional personnel or in the postgraduate
education that is offered to these personnel
contributes, substantially, to the present
desperate shortage of physical therapists
and to the scarcity of other health workers
-all of whom should be instrumental in
providing optimal care and education for
arthritics. In the training of physicians,
the orientation of medical undergraduate
experience is toward acute, rather than
chronic. illness.

Needs Are Great. The prevention of dis-
ability and the restoration and maintenance
of function require the long-term services
of an expensive team of specialists. The
facilities that such a team requires are pro-
portionately costly, and they range across
a broad spectrum-from acute care beds
in a hospital to special devices in a pa-
tient$s home.

There is much to be learned about this
complex and costly disease, arthritis. If
new knowledge is to be developed and dis-
seminated, postgraduate training for physi-
cians who are already in practice is
imperative. Associated professional per-
sonnel must be increased in number and


better trained to deal with the problem of
crippling arthritis.  And medical students
must be exposed to the challenge of this
provocative disease.

In addition, the victim of arthritis, his
family, and the general public must be set
free of the notion that nothing can be done
about this disease.

Fundamental research must be contin-
ued, but a comparable effort must be
mounted in the clinical area. Exemplary
care centers should be supported as the
focus of study, teaching, and consultation.

And, of particular importance, the com-
munity must be helped to organize and to
support facilities that will provide a full
range of services to the chronically ill, in-
cluding the arthritic. Everyone who is
concerned with health care must be im-
bued with the philosophy of a team effort,
of a persistent and concerted attack, which
will not falter in the face of discourage-
ment or disappointment. It must not be
forgotten that the needs of millions of
Americans will be met only if society de-
cides to redirect its investment, to mold
public and private resources into a force
that will halt the crippling of arthritis
and its impact on the Nation.

Recommendations

1. That the Surgeon General
designate arthritis a major
health threat that must be
surmounted.

Arthritis is the foremost crippler in the
United States. Its impact on the citizens
of this country is staggering. Though
rarely fatal, arthritis far exceeds the killer
diseases in terms of human suffering, mis-
ery, and privation. In addition, it imposes
on the economy the burden of providing
for citizens who have been permitted to
become crippled and unproductive. In our
society, this burden is accepted. However,
since the immense costs of arthritis to the
Nation can be prevented, further squander.
ing of these human resources is neither
economically nor morally justified. Ar-
thritis is a major threat to the health of
the citizens of the United States. As'such,
it warrants a concerted effort to overcome
it by all available means.

13


2. That facilities for the diag-
nosis and treatment of ar-
thritis be maintained, im-
proved,  and created ac-
cording to  geographic,
population,  and commu-
nity needs.

It has been shown that the early initia-
tion of comprehensive treatment and care
activities is essential to the prevention of
disability from arthritis. As was pointed
out earlier in this report, however, diag-
nostic and treatment facilities for arthritis
do not meet today's needs.

14

The optimal care of chronic arthritic
patients requires the combined capabilities
of a team of skilled health professionals.
The patient's family physician is a most
important member of this team, since it
is he who is charged with the key role in
management. If optimal care is to be
provided on an effective and widespread
basis, without interfering with the tradi-
tional doctor-patient relationship, facilities
and personnel for early diagnosis and com-
prehensive treatment should be established
and supported at four basic levels: Re-

gional Arthritis Centers; Diagnostic and   of outpatients from a defined geographic
Treatment Clinics;  Roving  Consultation   area. They would be staffed by part-time
Boards; and an Arthritis Advisory Com-   medical and associated personnel, and pol-
mittee of the Rheumatism Section of The   icies of financing and admitting would be
Arthritis Foundation ( formerly, American   identical to those of the parent institutions,
Rheumatism Association).          the Regional Arthritis Centers.

Regional Arthritis Centers should be uni-
versity-based or affiliated with large med-
ical centers. They should provide facilities
for the diagnosis and exemplary, compre-
hensive care of outpatients, by both full-
time and part-time medical and associated
professional personnel, and each Center
should contain a limited number of beds
for short-term inpatient care. In addition,
each Center should operate an automated
multi-test laboratory and make laboratory
services available to other diagnostic facil-
ities and to physicians in the area. Such
laboratories would provide for quality-
controlled uniformity and standardization
of diagnostic tests--services that are not
presently available.

Roving Consultation Boards would make
periodic visits to hospitals in communities
in which arthritis consultation services are
not available. These Boards would be com-
posed of professional personnel from the
region's Arthritis Center or nearby Diag-
nostic and Treatment Clinic.

Diagnostic and Treatment Clinics should
be established in existing arthritis centers
and service clinics and in accredited hos-
pitals or other qualified medical facilities.
These clinics would provide facilities for
the diagnosis and comprehensive treatment

An Arthritis Advisory Committee of the
Rheumatism Section  of The Arthritis
Foundation would be responsible for estab-
lishing standards of quality and of pro-
cedure for quality control of Regional
Arthritis Centers, their automated multi-
test laboratories, the Diagnostic and Treat-
ment Clinics, and the Roving Consultation
Boards. The Committee would work closely
with the U. S. Public Health Service, all
other public and voluntary health agencies,
and with the American Medical Associa-
tion.

The philosophy of providing these facil-
ities for early diagnosis and comprehensive
treatment should be one of building on
the strengths and eliminating the weak-


nesses of present resources, rather than of
creating a new structure. Maximum util-
ization of and sustained support for cur-
rently available facilities, together with the
creation of new facilities, where needed,
will give local physicians easy access to
new information, as it becomes available;
provide a mechanism for early diagnosis
and treatment at the grass-roots level; and
provide for the standardization of labora-
tory criteria for diagnosis. Responsibility
for achieving and maintaining a high
standard of medical care will rest with the
patient's family physician, leading rheu-
matologists, and the Arthritis Advisory
Committee.

3.

That recruitment programs
and undergraduate, grad-
uate, and continuing edu-
cation programs for the
physician and for asso-
ciated health personnel be
improved and expanded in
the area of the rheumatic
diseases.

Meeting the needs of the patient with
arthritis begins with the recruitment and
education of those who will care for and
manage the patient. Proper management
of arthritis patients can be provided only
by persons who have professional knowl-
edge, technical skills, and a commitment
to the provision of optimal care and to the
development and dissemination of knowl-
edge. Professional people who fit this
description-who can meet the ever-in-
creasing demands for patient care, educa-
tion, and research in chronic illness-are
in extremely short supply.

It is precisely because special and sup-
porting skills are not available in quan-
tities sufficient to provide optimal care for
the arthritic that there is an urgent need
for support of education in these fields,
coupled with intensive and imaginative re-
cruiting programs. Because recruiting suc-
cess is, in the end, largely dependent upon
the excellence of educational and training

programs, the great need is for programs
with the kind of built-in appeal that attracts
medical students, well-trained physicians,
and associated professional personnel. For
this reason, exemplary, comprehensive care
centers should be established in conjunc-

tion with medical schools. These centers
would be multi-categorically oriented, but
would focus on arthritis as 9 prototype of
chronic disease. They would serve as edu-
cational facilities in which physicians would
work in concert with associated profes-
sional personnel and would provide grad-
uate education for all fields. Federal grants
to medical schools should be offered to
assist in planning facilities and curricula,
as well as for the support of faculty. As-
sistance is also required for the support of
large-scale, cooperative studies among all
or most of the arthritis teaching centers
and study units in the country.

4. That training for and sup
port of better clinical in-
vestigation be encouraged
by all available means.

The current approach to clinical investi-
gation has produced an abundant and di-
versified body of knowledge in recent
years. For a variety of reasons, however,
the emphasis has been on studies of bio-

15


chemical, immunologic, and morphologic
aspects of the disease. Support for these
studies has been, and should continue to
be, available. In the long run, they are
of the utmost significance. Nevertheless,
there has been a tendency for these efforts
to overshadow fundamental clinical stud-
ies, to preempt the attention of investi-
gators, and, thus, to inhibit work that is
more directly applicable to patient needs
and to the prevention of disability. The
detailed recommendations that follow serve
to identify means by which this imbalance
in attack may be corrected.

It is recommended that support for the
Research Training Grant Program be ex-
panded, thus accelerating the training of
teachers and clinicians who are primarily
concerned with patient care as a research
and teaching activity. Physicians who are
capable of asking the pertinent clinical
questions, of designing studies that are
capable of answering such questions, and
of carrying these studies through to com-
pletion are in short supply. There has been
too little emphasis on the kind of excellent
clinical judgment and critique that is' man-
datory in such work.

It is further recommended that clear and

forthright support be made available to
clinicians of proven capacity who are in
a position to give and to teach excellent
patient care and to conduct clinical investi-
gation. Support has been inadequate for
the physician whose area of major con-
tribution is in such clinical spheres as
defining natural history of disease and es-
tablishing the role of a given therapeutic
modality. It must be recognized that these
problem areas are of fundamental im-
portance, that they are distinctly worthy
parts of the total investigational effort,* and
that, as such, they are areas in which com-
petent, research-oriented clinicians should
be supported.

It is recommended that support for hos-
pital beds for clinical investigation be
provided within the framework of the ar.
thritis center concept. Hospitalization is
of major, yet poorly defined, significance
in the management of crippling arthritis.
Proper clinical studies cannot be performed
without an adequate supply of hospital .beds
that are available to the subjects. The cost
of providing such facilities is more than
justified by the fact that each bed serves
not one, but three interlocking purposes-
exemplary patient care, the teaching of

exemplary care to learners in all profes-
sional health fields, and clinical investiga-
tion.

It is recommended that research grant
appbcations that pertain, in large degree,
to clinical studies be evaluated on a com-
petitive basis with similar studies, rather
than with programs that are based primar-
ily in the experimental laboratory. Clinical
studies are generally considered to be much
more difficult to evaluate than experi-
mentally induced results because of the
extended observation programs that are
required. the many subjective factors that
impinge on the observer, and the slower
evolution of scientific truths from observed
data. Despite these problems, value judg-
ments can be made if clinical studies are
compared only to each other.

There is a great need for a central co-
ordinating agency that would be concerned
exclusively with the clinical and epidemio-
logical features of arthritis. Such an agency
would provide continuing consultation in
the areas of experimental design, biomet-
rics, and data processing. It would s&ve
as a focal point for drawing together
widely separated investigators, who might
then elect to join others in cooperative
studies. And it would be expected to origi-


nate investigative efforts of its Own.

Finally, it is .recommended that an ar-
thritis research coordinating agency be es-
tablished as a function of the U.S. Public
Health Service. This agency would, on a
voluntary basis, contribute to the design
and execution of cooperative clinical stud-
ies, provide technical consultation in ex-
perimental design and biometrics, and
assist in efforts to standardize criteria and
laboratory procedures. In general, it would
coordinate clinical research activities in
three major problem areas: 1) The natural
history of the diseases and the effect upon
them of therapy or lack of therapy, includ-
ing analysis of such areas as patient mo-
tivation and the useful patterns of various
agencies, such as centers, clinics, and hos-
pitals; 2) The study of diagnostic criteria,
therapeutic efficacy, and such patterns as
remission  and  exacerbation,  including
both laboratory and clinical features; and
3) Classical epidemiological work, both in
terms of measuring the extent of the prob-
lem in various areas and under various
circumstances and in terms of identifying
etiological factors.

5. That all agencies that are
concerned with crippling
arthritis dramatically im-
  prove  and expand pro-
grams of public education
and in formation.

Comprehensive programs of public ed-
ucation and information are essential to
the effective control of crippling arthritis.
An uninformed patient and general public
can neither intelligently seek good care nor
demand that health authorities provide
proper treatment and care facilities for
arthritis.' In lieu of professional help, the
victims of arthritis spend $250 million
annually on worthless and fraudulent treat-
ments for arthritis. Obviously, neglect of
this disease problem, on all fronts, has
created, and is, in turn, caused by, a com-
posite of apathy, ignorance, and misunder-
standing. B rea ing this frustrating chain
         k
of hopelessness will require intelligent and
aggressive action by a number of agencies,
at a variety of levels.

A public education and information
program on arthritis should work to achieve
the following goals: To motivate arthritics

to seek qualified care, to seek it sooner
than they might otherwise, and to stick
with it; to improve the attitude of the pub-
lic toward arthritis and the attitude of the
arthritic toward his disease; to motivate
those who produce and disseminate health
information to place more emphasis on
arthritis; to create in the public an aware-
ness of the size and seriousness of the ar-
thritis problem; and to stimulate wide-
spread interest in a major effort to meet the
challenge that the problem of crippling
arthritis poses.

If these objectives are to be accom-
plished, all agencies that are concerned with
arthritis must concentrate their efforts in
a continuing, nationwide program of in-
formation dissemination that will make
maximum use of all the tools of communica-
tion to inform and educate the general and
special publics about arthritis. In years
past, the role of the Federal Government
in focusing public attention on, and in pro-
viding support for, the amelioration of trip-
pling from arthritis has been small. It is
now time for the U.S. Public Health Serv-
ice to provide the resources and leadership
that will enable public, private, and vol-
untary agencies to work together to es-
tablish a program of arthritis education

17


and information that will deal system-
atically, thoroughly, and realistically with
the needs of the millions of arthritics in
this country.

6. That a substantial portion
of Federal grants for the
chronically ill and aged be
earmarked for comprehen-
  sive  community  service
programs for the arthritic.

18

The chronic nature of arthritis often re-
quires that programs of supervision and
care be continued for a prolonged period
of time after the patient returns from the
hospital to his home. Basically, two types
of supervision are required: Home care
programs, for the patient who is still home-
bound; and outpatient care programs, for
the patient who can leave home. Although
necessarily different, both approaches to
patient care depend for their success on
the availability of a variety of facilities and
skills. The availability of these skills and
facilities is, in turn, directly dependent
upon the support that is given to communi-

ties to plan and to operate comprehensive
service programs.

The ultimate aim of treatment of the
arthritic patient is to enable him to engage
in productive activity in his home and in
the community. Because of the tremendous
variations in the prevalence of illness and
in the resources that a community might
have to combat the social, emotional, and
economic, as well as the medical, problems
of chronic illness, each community must
develop the patterns by which it may use
its particular resources to the fullest.

It is while communities are developing
patterns of resources utilization that they
should give serious consideration to the
desirability of combining programs for the
long-term management of arthritic patients
with those that are designed to cope with
other chronic diseases. Combined efforts
are usually more effective and more feasible
than separate attacks on different disorders;
and they enhance the management of the
arthritic patient without unduly increasing
the economic burden on a small community.

Community planning should include pro-
vision of facilities for all types of care; the
development of appliances and equipment
and the training of the patient and his fam-
ily to use them; the means of bringing to-
gether, most effectively, the patient, per-

sonnel, and facilities; and the development
of recreational and social activities that
can be operated in conjunction with those
that are enjoyed by other members of the
community. Programs should also include
means of evaluating their strengths and
weaknesses, in order that they may be
modified and improved on the basis of ex-
perience.

The need is great for community serv-
ices that go beyond the hospital and the
clinic-that enable the arthritic patient to
lead a satisfying and productive life. Fed-
eral formula and project grants that are
earmarked for arthritis would, if provided,
stimulate States and communities to come
to grips with the problem of planning for
and providing the long-term care that is
needed to prevent crippling arthritis.


Background
Papers

Works hop 1

Public Education and
  Information

William S. Clark, M.D., Chairman

It is to be hoped that we have just about
reached that stage of civilization when we
can say: "Our society can no longer afford
the crippling diseases, the most notorious
of which is arthritis."

As distinct from the killer diseases, on
behalf of which a dramatic mobilization
of resources has enlisted overwhelming
public response and cooperation, the gen-
eral attitude toward this most familiar of
the crippling diseases has become one of
apathy. Perhaps because some form of
arthritis has been known as far back in the
history of man as we can go, and perhaps

because a habit of frustration has been
built up through the years (by the medical
profession and by the lay public), this at-
titude seems to be based on a belief not
dissimilar to that held until very recently
about poverty: that "rheumatism, like the
poor, has always been with us."  The
built-in implication, of course, is that it
always will be and that there's not much
point in doing anything about it.

But today, we are taking a new look at
poverty in the midst of abundance, and we
are attempting to apply intelligent and in-
tensive effort towards its elimination. It
would seem to be more than about time to
take a new look at the country's leading
crippler. This necessarily includes an ex-
amination of what can be done to clear
away the mists of apathy, now lying like
some vast primordial miasma between us
and the prospect of successful subjugation
of this crippler of mankind. Let us first
look at the facts.

Arthritis, the second most prevalent
chronic  disease,  affects an  estimated
13,000,000 persons in the United States-
one out of every 15 people-and adds
250,000 new victims each year. Over
3,300,OOO persons are limited in their ac-
tivities by arthritis, of which number 697,.


20

000 are unable to work, keep house, or go
to school. Of the 915,000 persons who are
confined to their homes by chronic dis.
eases, 17 percent attribute their problem to
arthritis and rheumatism. Sixteen percent
of over 16,000,0000 individuals who are
classified as having limitation of major ac-
tivity report arthritis as the responsible
cause.

Arthritis and rheumatism cause 1,223,.
000 persons to be confined to bed for one
or more days each year.

According to the National Health Survey,
arthritis caused the loss of 12,000,OOO days
from work in a recent single year. Arthri-
tis is estimated to cost the Nation approx-
imately $2,000,000,000 a year, including
$500,000,000 in productivity loss and
$130,000,000 in disability benefits.

When arthritis strikes, there is a double
loss: a worker ceases to produce at top
capacity, perhaps to produce at all, with
all that that means in loss of productivity
to the economy, as a whole, and in terms
of tax dollars for city, State, and Federal
governments. In fact, only too often the
wage earner is moved from the plus side
of the ledger to the debit side; he becomes
a consumer of tax monies.

Proportionately, the arthritides consti-
tute the most neglected group of diseases in
the modern approach to good health. The
general public has demonstrated no great
concern. Funds from private and tax-sup
ported resources that are allocated for re-
search support that is directly related to
arthritis are something less than $15,000,-
000. Facilities that are provided by the
public for diagnosis, treatment, and re-
habilitation are generally inadequate or
lacking. Of the Nation's medical schools
and teaching hospitals, less than one-third
have noteworthy programs and projects for
treatment, teaching, and research. Fewer
than 1,600 physicians in the United States
manifest an active interest in the arthritis
problem, and it is estimated that there are
fewer than 500 properly qualified medical
specialists in the field of rheumatology.

We have an ironic situation. On the
one hand, there are not enough adequate
facilities and not enough professional com-
petence to meet the need; on the other hand.
8250,000,000 a year is spent on worthless
and fraudulent treatments. We have a sit-
uation in which, even when adequate pro-
fessional help exists, large numbers of pa-

tients do not seek or avail themselves of
good care on the assumption that nothing
can be done about arthritis-that it's a
hair shirt they just have to live with. Re-
inforcement of this traditional point of
view, driven home by families, friends, and
even physicians. is probably deepened by

incessant, day-in-and-day-out TV commer-
cials: "Medical authorities state there is no
cure for arthritis; take aspirin to relieve
the pain." Yet, it is now true that, with
early diagnosis and comprehensive care, 75
percent of the crippling that is incident to
arthritis can be prevented.

It becomes obvious that the neglect of
the arthritis problem is due to an amalgam
of apathy, ignorance, and misunderstand-
ine. Any solution must include intelligent

and aggressive programs, by a number of
agencies, at a variety of levels.
Greater public awareness of the nature
and magnitude of the problems of arthritis
and rheumatism should have the following
purposes :
1. To motivate patients to seek qualified
medical services and to seek them
sooner. so that they will receive earlier
treatment and more effective prevention
of disability.


2. To improve attitudes toward those that
are aillicted, including those in the fam-
ily,  employees,  teachers,  neighbors,
schoolmates, and friends, by encourag-
ing them to replace a fatalistic attitude
of gloom with a constructive and hope-
ful outlook.

3. To motivate large numbers of prac-
ticing physicians  to become more
knowledgeable and more skillful in the
field of rheumatology.

8. To motivate more educators to provide,
at all levels, more effective and more
attractive programs for continuing edu-
  cation.

5. To motivate more hospitals and related
agencies to provide optional facilities
and resources, as required by knowl-
edgeable physicians.

6. To encourage paramedical personnel
to acquire increasing awareness and to
improve general skills, knowledge, and
  services.  Paramedical educators will,
of necessity, improve programs for un-
dergraduate and postgraduate educa-
  tion.

7. To provide for medical students, in-
terns, and residents greater exposure to
the diseases and to motivate them to
take greater interest, with the result

that more young persons will seek re-
search and clinical careers in rheuma-
tology.

6. To make more funds available for

clinical and basic research.

9. To stimulate the development of new
and more effective treatment methods.
Impressing the public with the nature

and importance of an insidious and undra-
matic chronic disease, such as arthritis, is
a challenge to physicians, health educators,
and specialists in  communication tech-
niques.

The successful methods that are appli-
cable to acute and .limited morbidity and
to the dreaded fatal diseases are not likely
to be as effective in public education pro-
grams that involve less dramatic, long-
term chronic diseases. The problem is
further complicated by the need for cor-
recting false and misleading concepts,
which are held by vast segments of the
public.

New and imaginative methods, involv-
ing the development of educational con-
tent and of communication, must be de-
vised. Crash programs must be launched.
Dedicated representatives from the fields
of medicine, health education, and the
communications professions must develop

and apply techniques that will get the mes-
sage across-that will compete favorably
with public information programs in other
fields.

A new attitude toward health informa-
tion must be cultivated in editois, news-
casters, and writers in the years ahead.
Moreover, the effort of government and
voluntary agencies must be stepped up to
achieve a greater impact. The combined
public education activities of agencies
should be focused on an immediate goal,
the amelioration of crippling.

A critical appraisal of public education
by all who play a responsible role is long
overdue. Such a review should take inven-
tory of the past and current efforts. On the
basis of current and future needs and
trends in health education and mass cdm-
munication, a program must be designed
that will deal systematically, thoroughly,
and realistically with the problem.

21


Workshop 2

Diagnosis and Treatment
     Facilities

Ephraim P. Engleman, M.D., Chairman

The objectives of our Workshop will be:
(a) To consider those community-oriented
facilities that are needed for the diagnosis
and short-term treatment of arthritis; and
(b) to explore the resources that are po-
tentially available for such facilities.

22

It is appropriate, at this time, to define
the term "arthritis," as it will be used in
our Workshop. For purposes of our dis-
cussion, the term "arthritis" will be used
in a general sense to refer to a group of
articular and para-articular diseases, often
chronic that cause painful disability, which
may be evanescent, episodic, static, or pro-
gressive.  Examples of such diseases are
gout and bursitis, in which t&e disability
may be evanescent or episodic, degenera-
tive joint disease (osteoarthritis), in which
disability may be static, and rheumatoid
arthritis, in which disability is often pro-
gressive.

There are certain problems that must be
recognized prior to our discussion of fa-
cilities for diagnosis and treatment of
arthritis. In the first place, we have little
or no information about the cause or pre.
vention of these diseases. Secondly, there
is no unequivocal diagnostic test. And of
those tests that are commonly used, there
are at least two sets of diagnostic tests for
which there is no uniformity or standardi-
zation. I refer, specifically, to the tests
for the rheumatoid and lupus factors and
to the criteria for radiologic diagnosis.
Thus, our methods for diagnosis are tra-
ditional. They include the time-consuming
history and physical exainination and the
performance of laboratory tests and X-ray
studies.

A third problem concerns the lack of a
cure. Thus, in most instances, we employ
several therapeutic modalities, which may
be used simultaneously. Examples of such
modalities are rest and exercise, in proper
balance, and drugs and simple orthopedid
supports or appliances. Often the treat-
ment is palliative. Nevertheless, the proper
management of early disease will usually
reduce pain, preserve function, and pre-
vent progressive deformity. Furthermore,
proper treatment will minimize the likeli-
hood of iatrogenic disease.

Some 13 million people in the United
States maintain that they have some form
of arthritis. This prevalence is so high that
responsibility for these patients must be
assumed by their local physicians, by doc-
tors with varying interests, including those
in general practice. This brings us to the
fourth problem, namely, the shortage of
physicians with at least a modest degree
of skill, or even interest, in the care of the
arthritic patient. The gap that exists be-
tween the knowledge that is available about
arthritis and its application to the patient
can only result in a critical delay in accu-
rate diagnosis and proper treatment.

At the community level, we are faced
with a fifth major problem: the shortage
of arthritis clinics. Although there are ap-
proximately seven thousand accredited hos-
pitals in the United States, there are only
300 arthritis clinics, many of which are
poorly staffed and equipped. And most of
these clinics are restricted to large popu-
lation centers.

Finally, it must be noted that there is an
almost complete absence of certain arthritis
facilities that are available in many other
parts of the world. Thus, we have, in the
United States, virtually no provision for
rural arthritis services, hospital beds for
arthritis, national registry of patients with


arthritis, a directory of diagnostic and
treatment facilities that are available,
and/or an assessment of screening tech-
niques, which might provide early diag-
nosis on a large-scale basis.

This, briefly, is the current status of the
diagnosis and treatment of arthritis in the
United States. That there are vital needs
is self-evident. Nearly one-half of the pa-
tients who have arthritis are receiving no
medical care. Thus, they are candidates
for crippling or disability, which might be
prevented or minimized. Our Workshop
will make practical  recommendations,
which, hopefully, will satisfy some of our
needs.

Workshop 3

The Long-Term Care of
Patients with Arthritic
    Disabilities

Currier McEwen, M.D., Chairman

A. Who are the patients with whom we are
concerned?

It is assumed that arthritic patients in
acute and severe subacute stages need gen-
eral hospital facilities and that this Work-
shop is concerned with those who have
progressed beyond those stages. These pa-
tients have need of less complex facilities,
but, nevertheless, specialized skills and
programs.

The patients who are in need of this
care include:
1. Those with inflammatory types of ar-
thritis, in mild subacute and chronic stages,
without deformities, but whose illnesses
can be expected to remain active for many
weeks or months;
2. Those with similar arthritis who have

developed deformities that probably can
be corrected with nonsurgical measures;
3. Similar patients with advanced deform-
ities, which require surgical measures for
correction;
4. Patients with advanced deformities and
disabilities, which have little promise for
more than very limited correction;
5. Patients with osteoarthritis of the dis-
abling type, who require intensive pro-
grams of physical therapy and therapeutic
exercises;
6. Similar patients who require surgical
measures ;
7. Patients with arthritic disabilities, who
have little potential for rehabilitation be-
cause of other handicaps, such as senility,
stroke, etc. ;
8. Patients who should be removed from
their home environments for short periods,
either for intensive supervision of correc-
tive measures or for psycho-social reasons;
9. Patients who are in need of learning
Aids to Daily Living;
10. Patients who require prevention of de-
formity, as well as correction.

These groups include patients of all fi-
nancial levels, but the needs are especially
important for those in low and moderate
income groups.

23


B. Where do these patients IWW receive
care?

Information that is currently available
permits only general answers to this ques-
tion.

The great majority of these patients now
receive very inadequate care, either in their
own homes, in general hospitals, in chronic
disease hospitals, or in nursing homes.

It is probably true that, in many in-
stances, even well-to-do patients, in their
own homes, receive inadequate care be-
cause of lack of (a) suitable programs,
(b) skilled personnel, (c) knowledge of
available community resources, and (d)
coordination of existing community re-
sources.
C. What are the special needs?

The special needs of the various types
of patients who are listed under section A
include:

24

1. Facilities of the simple hospital type
with which they can be effectively and
economically cared for;
2. Skilled consultant services, provided on
a team basis, to plan and periodically
assess each patient's program;
3. Ready access to general hospital beds
for those patients whose course of disease
demands that level of care, because of

intercurrent illness, exacerbation of dis-
ease, or suitability for a definitive surgical
or other therapeutic measure;

4. Financial arrangements that will permit
patients of all economic levels to receive
optimal care for whatever period is re-
quired;

5. Means of continuing supervision of the
program after the patient returns home;
and means of providing for his total needs,
including care of all illnesses other than
the arthritis;

6. Arrangements to facilitate the retrain-
ing of patients for jobs that are within
their capabilities and assistance in job
placement;

7. Development of arrangements to meet
the ultimate needs of those patients who
have no homes and whose potential for
rehabilitation is small.

D. What skills are needed?

The essential skills include those of the:

1. Rheumatologist; 2. Orthopedist; 3.
Physiatrist; 4. Physical Therapist; 5.
Occupational Therapist; 6. Psychologist;
7. Social Worker; 8. Vocational Coun-
selor; 9. Nurse and Aide; 10. Public
Health Nurse (including Visiting Nurses).
E. What facilities are needed?

These include:

1. Facilities of a simple physical type,
which provide a pleasant atmosphere, beds,
medical supervision, nursing care, space
and equipment for therapeutic exercises.
splinting and other unelaborate measures,
and facilities for recreation, where con-
structive rehabilitation programs can be
most effectively and economically carried
out for patients of the types that were noted
under section A ;

2. General hospital beds, to which patients
can be transferred readily if their medical
needs demand it;

3. Consideration must be given to the roles
of existing types of facilities, such as nurs-
ing homes, in the care of these patients;
4. The patient's own home should be the
most important facility of all in' the ulti-
mate care of the arthritic. Means must be
developed to make the home an effective
place for the continuation of constructive
programs;
5. Development of more shops with faeili-
ties for the employment of rehabilitated
arthritic patients.


Workshop 4

Professional Education

Howard F. Polley, M.D., Chairman

Increasing attention is being given to
arthritic diseases, not only because they
are conditions for which satisfactory scien-
tific answers have not yet been found, but
also because of the increasing awareness
of the associated public health and com-
munity problems. No doubt, both scien-
tific and public interests have been stimu-
lated by research efforts, especially those
of the last 15 years or so, that have been
directed toward the solution of both the
clinical and the basic science aspects of the
biochemical, cellular, and other abnor-
malities that occur in various arthritic dis-

eases.  Although interest in arthritis
prompted such investigations, the resulting
scientific and public health benefits may
extend to areas far beyond those of the
diseases toward which the efforts were
initially directed.

The increasing attention that arthritis

has received has also revealed major ob-
stacles to the solution of community health
problems that arthritic diseases present.
The recognition that there are such oh-
stacles and that they may not yet have been
defined well enough to facilitate their solu-
tion is the basis for this conference, which
has been called by the Surgeon General,
U.S. Public Health Service Our Work-
shop's attention is particularly directed to
-the professional education aspects of the
prevention of disability from arthritis.

Obstacles that are related to the pro-
fessional education aspects of better public
health management of arthritis may in-
clude: (1) shortages of skilled professional
personnel in various pertinent medical and
paramedical fields; (2) inadequate use of
presently available knowledge and public
health techniques to determine which per-
sons and which areas would be amenable
to preventive measures; (3) public and
professional indifference to the ever-in-
creasing magnitude of the social and eco-
nomic consequences of failure to prevent
disability; and (4) financial requirements
of the correction of recognized deficiencies.

In order to obtain a better approach to
the solution of these obstacles and of those
that are, possibly, less well recognized, it

seems necessary to define, more clearly,
the current resources, such as the number
of presently available medical and para-
medical specialists, whose skills could con-
tribute to the prevention of disahility in
areas in which they are now located. It
seems necessary, in addition, to determine
how they function in their medical and
social communities. A whole series of
corollary questions that are suggested are
listed below.

How can the talents of these specialists
best be used?

What are the optimal methods of teach-
ing and training medical and paramedi-
cal skills at the professional level?
How can professional education attract
the dedicated interest of knowledgeable
graduate physicians and scientists and
paramedical personnel, such as physical
and occupational therapists, social-serv-
ice workers, nurses, nutritionists, and
others, for prevention of disability?
What are the relationships, if any, be-
tween the undergraduate educational ex.
periences in either clinical or research
aspects of rheumatic diseases and gradu-
ate professional education?
Who can undertake professional educa-
tion most effectively, and where?

25


Will postgraduate training of established
medical  and paramedical personnel
reach those physicians, scientists, and
others who have the earliest opportunity
to apply preventive measures against
disability?

of arthritic patients for whom medical
could determine, accurately, the numbers

or paramedical care (or both) is needed
to prevent disability?
Where are such patients in relation to
the availability of the skills they are
thought to need?

Hopefully, such attention might also con-
tribute toward solution of those other
aspects of the prevention of disability that
are being considered in the other Work-
shops in this conference.

Will the experience of postgraduate edu-
cation in related public health endeavors
indicate whether postgraduate education
can hasten the solution of public health
problems that are presented by disa-
bility from arthritis?

Other related questions arise, such as:

When does the arthritic patient need the
attention of the specialist-medical or
paramedical-for the prevention of dis-
ability?

Is the current use of local hospital and
other medical facilities, university medi-
cal or other research centers, and public
health offices the best approach to the
prevention of disability from arthritis?
Can restorative measures or ordinary
domiciliary care be used to better ad-
vantage, or modified readily, for preven.
tion of disability?

26

Would it be pertinent to know whether
comprehensive public health surveys

How might patients be motivated to use
available preventive measures?
What is the significance of the socio-
economic aspect of disability from ar-
thritis on the patient, family, and com-
munity?
Certain of these and related questions
are more particularly the province of other
Workshops in this conference,  namely,
those that are concerned with public edu-
cation and information, diagnostic and
therapeutic facilities, long-term manage-
ment, clinical investigation and the train-
ing for it. voluntary and public agency
activities, and socioeconomic factors. Like-
wise, the questions that are pertinent to
postgraduate education may not all be
separable from their specific approaches.
However, in so far as it is practical to do
so, our attention will be directed, particu-
larly, to solution of the problems of pro-
fessional education,  as it is related to
prevention of disability from arthritis.

Workshop 5

Clinical Investigation and
    Training

John L. Decker, M.D., Chairman

"Clinical investigation" is, in the current
language of the medical scientist, com-
monly interpreted as encompassing a wide
field, from electron microscopy to the in-
dications for synovectomy, from the struc-
ture of peptides to population studies, and


from the problems of membrane potentials
to the psychologic impact of chronic in-
validism. While recognizing and rejoicing
in the breadth of this definition and in the
fundamental role of the more basic ap-
proaches to generating new avenues of
thought and investigation, the clinician,
and with him, our society, is confronted,
now, today, with the unfilled needs of the
rheumatic disease patient. A part of the
title of this conference, "prevention of dis-
ability," makes the point clearly. The way
to prevent disability is to prevent or cure
the disease. Despite some hopeful flicker-
ings on the horizon, flickerings that need
continued nourishment and hard work,
these routes are not now open. Another
way must be sought.

It is this effort-to address ourselves
directly to the individual patient, to under-
stand the framework in which his disease
develops, to diagnose and classify his ill-
ness, to predict its outcome accurately and
to manage it in such a way as to prevent
disability-which constitutes "clinical in-
vestigation" in a more restricted form and
is our subject, here.

There is no clear dividing line between
"basic" and "clinical" investigation; and
it is unwise to seek or to draw one, for

each flourishes best when enlightened by
the other. The emphasis on the patient and
on his problem that is expressed here is not
meant to denigrate more fundamental
studies, nor to imply that there is only one
way to do things.  Obviously, there are
many avenues; but it is our present pur-
pose to explore the possibilities and pitfalls
of one, only.

Within the health professions, "arthri-
tis" means inflammation of the joint. Thus.
this conference has great breadth, in terms
of specific diseases. In selecting a specific
area or disease for work, many considera-
tions, some appropriate and others dis-
tinctly inappropriate, assail this conference
(and the investigator). The choice might
be based upon quantity. Which disease is
most common? Degenerative joint dis-
ease? Which disease causes the greatest
economic loss and misery? Rheumatoid
arthritis? The choice might be based on
scientific considerations-that is, where the
leads look best. Which disease seems more
likely to be due to infection? Reiter's
syndrome? Which disease permits study
of the synovia before, during, and after
induced inflammation? Gouty arthritis?
The choice could be based upon its current
"popularity rating"; no granting commit-

tee can entirely divest itself of medical
fashion. In which disease do genetic fac-
tors seem most pertinent?  Ankylosing
spondylitis? Which disease is the proto-
type of "autoimmunity?" Systemic lupus
erythematosus? Or perhaps the considera-
tions should be more practical. What dis-
ease will be troubling the largest propor-
tion of the next one hundred patients to be
seen? Fibrositis?

In practical fact, all of these considera-
tions, and more besides, enter into the
choice. For our purposes, it is sufficient to
recognize that choice is difficult and that
it is foolish to restrict or to delimit, unduly,
the area of concern. The diseases that
cause crippling overlap in a myriad of
fascinating ways, and the study of the
exotic is no less (nor no more) to be pre-
ferred than the study of the common.

The prototype disease, and the major
public health problem, is rheumatoid ar-
thritis. While most of our thinking will be
concerned with rheumatoid arthritis, les-
sons that are learned in other diseases will
apply to rheumatoid arthritis; and, con.
versely, many of the conclusions that are
reached will have validity beyond rheuma-
toid arthritis, alone.

This essay will cite a few approaches to

27


knowledge that can be applied to prevent-
ing disability from rheumatoid arthritis.
It will discuss the difficulties which tend to
hinder these investigations. And it will
suggest means of eliminating some of these
obstacles. The nature of the professional
training that qualifies individuals for such
work will be considered.

28

1.  Problems for Clinical Investigation
The number of unanswered questions
that are concerned with rheumatoid arthri-
tis is unlimited. Much of the operating
knowledge that is now in general use has
not been "established," in the rigorous
scientific sense of the word. Consequently,
almost all of the thought and action pat.
terns of today's clinician might be consid-
ered to be in need of reevaluation.
In practical fact, the last 20 or 30 years
have provided a reasonable baseline of
knowledge, both in the literature and in
the abilities of physicians and others who
have been privileged to observe the disease
in large numbers of patients. A good ex-
ample of this baseline knowledge exists
in the criteria for the diagnosis of rheuma-
toid arthritis, which was first suggested in
1957 by a committee of the Rheumatism
Section of the Arthritis Foundation. These

criteria continue to serve a most useful

purpose; and they deserve the constant
reappraisal that was suggested by the
original committee and, recently, begun.
Thus, there is need for clinical investiga-
tion of the foregone conclusions of the
past, as well as of the new tools, ideas, and
modalities of today.

Early identification of the disease con-
tinues to be a problem; but it should now
be extended to efforts to identify suscep-
tible individuals before overt onset of dis-
ease. What is the meaning of serum rheu-
matoid factor in healthy individuals?
Studies of rheumatoid arthritis in popula-
tions, both at one point in time or with
continuing reappraisal of a population
sample, have proven to be useful, in terms
of defining the magnitude of the problem
and of permitting the drawing of conclu-
sions as to its nature. For example, the
low order of familial aggregation that is
found in surveys of special populations
raises important questions about the dis-
ease, which appears in certain families at
a rate far beyond that expected.

The natural history of the disease de-
serves constant study, as do its relation-
ships to other illnesses, such as chronic
ulcerative colitis or psoriasis. The recently

changing views of the distinctions between
rheumatoid arthritis and ankylosing spon-
dylitis provide evidence that this type of
nosological effort is still valid today. In-
deed, there are cogent reasons to believe
that  "rheumatoid arthritis" is not one
disease, but several. For example, are the
monarticular, large joint disease of ado-
lescence, the destructive, nodular disease of
the metacarpophalangeal joints in young
adults,  and the chronic  inflammatory
synovitis of shoulder and knee of did age
the same disease of the same cause?

More information is needed about such
freely used terms as "active," "inactive,"
"suppressed, " `Lburned-out," and "in re-
mission." They have received careful at-
tention in recent years, but one cannot
escape the fact that the local destruction
of a wrist, for example, seems, on occasion,
to progress inexorably, while the systemic
disease is regarded as inactive. Can dis-
tinctions be drawn  and quantitation
achieved between "local" and "systemic"
activity? Would it be worthwhile to de-
velop prognostic indices for individual
joints?

The fundamental need to distinguish pat-
terns, classes, and types of disease rests
not in a desire to create more eponymic


syndromes, but, for our purposes, to
achieve a more definitive prognosis. This
is a prerequisite to properly planned thera-
peutic investigation, as well as to an en-
lightened treatment program for any one
individual. This, too, has been done in the
past, both retrospectively and prospec-
tively. But new data handling methods,
coupled with precise, prospective definition
of the variables, should produce new in-
sights.

The events that surround remissions and
exacerbations of the disease deserve study.
Such changes are regarded as spontaneous,
but it seems likely that there are unrecog-
nized contributing events, be they psycho-
social, infectious, traumatic, or environ-
mental.

The entire area of treatment, or man-
agement, lies open to clinical investigation.
Only in recent years have properly con-
trolled studies of corticosteroids, gold, and
antimalarial therapy become available.
Some attention has also been directed to
non-medicinal approaches, such as long-
term hospitalization, or immobilization, in
reducing joint inflammation.

Among physical measures that are often
recommended, few have been validated by
exacting studies. Such matters as bed rest,

range of motion and muscle-building exer-
cises, the role of heat in its various forms,


There has been much recent interest in
and preventive exercises deserve analysis.

local therapeutic measures. Both (intra-
articular)  injections and surgical ap-
proaches have been advised. No controlled
studies are available. Early synovectomy
-that is, before cartilage damage-can-
not readily be advised nor accepted by the
patient, unless it is established that it is
not, in itself, a damaging procedure and
that joint disintegration can be prevented.
Reparative surgery has been in use longer,
and its benefits are more evident, al-
though, even here, it is essential to define
results in terms of useful function, rather
than in terms of pleasing cosmetics. De-
spite the many variables that are involved,
appropriately designed studies, evaluated
over an adequate period, should provide
the needed definitive evidence on which to
construct therapeutic plans.

Il. Inhibitors of Clinical Investigation
The present paucity of studies of the
type that have been described is readily
accounted for: they are difficult to per-
form. In considering or conducting such
studies, the investigator often finds himself

stopped by an insuperable problem or by
a combination of problems. It is appro-

The nature of the disease, itself, is obvi-
ously the key factor. It is chronic, very
priate to examine some of them.


different from patient to patient, given to
abrupt, seemingly inexplicable changes in
activity, and thoroughly intermingled with
the emotional and physical nature of its
human victims. There are no comparable
animal models. These facts force the con-
clusion that appropriate studies require
large numbers of patients and extended
periods of study, measured in years and
decades, rather than in weeks or months.

The investigator, then, must have qual-
ities that are far from universal, such as
infinite patience; the ability to design ap-
propriate studies that are based on an
exhaustive knowledge of the disease; a
foresighted perception of what questions or
problems will be of significance when his
work comes into its final phases; the abil-
ity to inspire and to stimulate his asso-
ciates;  and the sustained and commu-
nicable concern for his patients that is the
mark of the good physician. One of the
inhibitors of clinical investigation in the
rheumatic diseases is immediately clear:
such paragons of virtue are rare, if not

29


30

altogether unknown!

A stable and reliable patient population
of sufficient size is not always available.
In many areas, this factor may hinge upon
adequate transportation facilities.  Many
studies require a degree of patient under-
standing and cooperation that can rarely
be attained in the average clinic popula-
tion.

Patients who are able to pay a fee for
services should be included; presumably,
no charges would be made while they are
"in" a study. There are major ethical
factors that inhibit (perhaps properly)
some work. Is it ever appropriate to per-
form sham surgery or to give a lactose
placebo over years?

Inadequate  cooperation between the
various  medical specialties is  another
potent inhibitor. Occasionally, this is based
on long tradition or petty jealousies; more
often, it is rooted in a failure to take the
time to understand the ideas, methods, and
motives of another discipline.

The expense of prolonged hospitaliza-
tion, crucial to some work, has been an
inhibitory factor where "free beds" are not
available to the investigator.  The high
cost of this type of hospitalization within
the institutions in which clinical research

is being done has made this form of sup-
port difficult to obtain.

An additional important problem is the
pressures that are put on the physician who
does have a few such beds at his corn-
mand. The demands and the need for
chronic hospitalization are so heavy and
so pathetic that it requires a heart of stone
to maintain the integrity of such a unit
for investigational purposes, alone.  The
only reasonable solution is the provision
of a chronic disease facility, with beds at
a lower cost than those in the general hos-
pital, but in close geographic proximity to
the medical center. Such a facility is con-
sonant with the rapidly increasing propor-
tion of chronic to acute problems that is
now being noted in medical practice, with
the increasing mean age of the "average
American," and with the overwhelming
need for better training in chronic disease
for all of the health professions.

   To return to the inhibitors of clinical
investigation, freedom. when it is denied
the clinical investigator, is an inhibitor
that deserves more deliberate mention.
Creative work requires time, imagination,
effort. and an environment that encourages
opportunistic ventures into the unknown.

The investigator cati readily find himself

nailed to the rack of a protocol that was
written years before, unable to exercise his
originality and imagination. Worse than
this, he can be so burdened by the multi-
tude of administrative responsibilities that
are sure to result from the problems that
have already been cited that he lacks the
spirit or mental energy to pursue even his
protocol. much less anything new, His free-
dom must be preserved.

In the last analysis, monumental effort
on the part of the investigator can over-
come most of these problems. Then, the
urgency and the pertinence of the hypothe-
sis that is to be studied become of over-
riding importance. It is obvious that an
hypothesis that involves basic attributes of
the disease process is more compelling than
an hypothesis that will require hundreds of
man hours and scores of patients to deter-
mine whether Pill X or Procedure Y has
an effect that is beyond that to be expected
from chauce. alone.

111. Encouragement of Clinical
investigation

Our discussions will center on possible
means of encouraging clinical investiga-
tion. A major srgtnent of the problem,
which might be entitled "The Care and
Feeding of the Clinical Investigator," is


considered next (IV). Other factors that
apply include :
a. Where should this type of investiga-
  tional activity be done? Within a
  medical school? Within a research
   institute?  Within the practice of
  medicine, either by individuals or in
  groups?  What financial arrange-
  ments are appropriate for hospital-
  ization for clinical investigation?
b. Cooperative studies. Should all or
  any portion of this work be car-
   ried out with central direction to a
  number of operating units? How
  should these ventures be organized
  and by whom?

c. The enthusiastic support of the local
community, both lay and medical,
can make a great difference. How
can this be assured?

d. The services that are required in any
particular study-laboratory, physi-
cal medicine, transportation, follow
up, etc.-will differ; but they must
be available. Almost all will require
consultative  assistance in  experi-
mental design and statistical analy-
sis. How can such facilities be made
  available?

IV. Training for Clinical

In the last analysis, the ideas that will
investigation

build tomorrow must come from the mind
of a man today. The research team, as a
group, contributes to the environment of
each individual on it; but an individual
concerns us here. Any improvement or in-
crease in clinical investigation has a single
sine qua non-the investigator himself. As
suggested above, he must be a man of
many parts.

It is desirable that the creative individ-
ual be identified as early as possible and
be introduced to the field in such a way
that he will wish to enter it. Important
consequences of this view are that training
units for rheumatic disease should be
widely dispersed in our educational sys-
tem; that they should be in a position
to recruit men to the field; and that the
process of early identification is to be ex-
pected to bring many more into training
than will actually perform adequately as
independent clinical investigators.

The training will have to be flexible.
The only requirement should be that the
trainee must attack and master one area,
no matter how limited, in depth. It seems
unwise that all trainees be versed in a pre-

clinical discipline, although this would be
the course for many. It is assumed that
the trainee will be involved in clinical in-
vestigation and that the majority of his
training will come in the one-to-one rela-
tionship with the preceptor, who is jointly
involved in his problem.

All training units cannot (and should
not) have competence in all disciplines.
The trainee should be directed to the best
possible position for the accomplishment
of his purpose, be it a basic science unit,
another rheumatic disease training unit, or
a specialized institute or program.

Starting independent work represents
the point of greatest attrition, perhaps
rightly so. Appropriate support mecha-
nisms should be available to permit the
truly competent man to pursue his problem
in a status beyond that of trainee. During
this period, which might extend to three
or four years, he should be free of heavy
administrative or teaching responsibilities.
He should complete the period ready to
assume a permanent role as a clinical in-
vestigator.

He should be assisted and guided in
finding a post that will permit the full
utilization of his talents. As of today, this
post is usually conceived of as an academic

31


32

appointment within a medical school. As
more emphasis is placed on the investiga-
tional aspects of patient care, however, it
seems likely that suitable posts will open
up in hospitals, private clinics, and founda-
tions; with proper direction and relation-
ships, a suitable environment can readily
be developed in such circumstances.
The mode of support for the clinical in-
vestigator is crucial. The rapidly recurring
need to demonstrate "progress" to the
granting agencies, both private and gov-
ernmental, has tended to direct efforts to-
ward limited and short-term goals. dn
the other hand, the difficulties of a carte
blanche program of, for example, 15 years
duration are obvious. Some intermediate
mode may be necessary for people who
work in the field of treatment of the rheu-
matic diseases.

Some of the unsolved, and perhaps un-
solvable, problems of training investigators
for work in rheumatic diseases include the
following :
a. Is all of medical school necessary to
produce a specialized clinical investi-
gator? There are reasons to believe
that advancing age and the brainwash-
ing of the average medical school cur-
riculum smother originality. Should

there be "short cut" routes to clinical
investigation?  Might some subject
areas be dropped and others fortified?
b. Should training of clinical investigators
be the responsibility of a few (less
than ten) strong and especially organ-
ized training units?

c. How can the trainee be encouraged to
keep his breadth of vision wide while
he is concentrating on a limited prob-
lem and using circumscribed modal-
ities? Should he be exposed to a sur-
vey period during which he would
study a wide range of techniques and
  their limitations?

d. Would a regular pattern of rotation of
trainees among several training units
serve a useful purpose?

e. Is a critical investigator born, or can
the talent be developed? The ability
to design clinical studies, to select prop-
erly matched controls, to analyze the
many variables that are involved, and
to appreciate what has and what has
not been shown to be fact, seems to be
  rare. Are these talents "teachable?"
If the answer is affirmative, should the
teaching be by precept only, or can
formal courses or programmed instruc-
tion be a major benefit?

Workshop 6

Voluntary and Public
Agency Activities and
   Programs

William D. Robinson, M.D., Chairman

In spite of the growing recognition of
the importance of the effect of rheumatic
diseases on the health and economy of the
community, there is little precise informa-
tion available on the prevalence of these
diseases in the general population. Accord-
ing to the United States National Health
Survey of 1961-1963, rheumatic diseases
caused a loss of 12 million man-days each
year, with 13 million people in this coun-
try estimated to be affected. An estimate
of the degree of crippling that was at-
tributed to these diseases was also pro-
vided by this survey: 157,000 individuals
were confined to their homes because of
rheumatic diseases.

Another index of incapacitation is pro-
vided by the roles of applicants for dis-
ability benefits  under Social Security.


During the period of this three-year survey,
30,000 arthritic applicants a year were
unable to work for six months and were
eligible for Social Security disability bene-
fits. The reason for this is clearly related
to the age and sex distribution of indi-
viduals who are eligible under this pro-
gram, since it does not include individuals
where the impact of certain types of crip-
pling arthritis are most heavily felt. Only
18 percent of the individuals in this pro-
gram were under the age of 50 years, and
only 20 percent were women. Of the ap-
plicants for Social Security disability bene-
fits, 56 percent had osteoarthritis and 27
percent had rheumatoid arthritis (1). A
National Health Education Committee, in
Washington, D. C., estimated that each
year 320,000 persons in the United States
are rendered totally unemployable by rbeu-
matic diseases. While more accurate data
is certainly desirable, there is no question
that this Workshop is dealing with a prob-
lem of considerable magnitude.

There are at least forty different forms
of arthritis and related diseases that can
lead to temporary or protracted disability,
or to permanent crippling. Of these, the
one that bulks largest, in terms of human
suffering, that is characterized by a pro-

tracted or recurrent course, and that pos-
sesses the greatest capacity for producing
irreversible crippling is rheumatoid ar-
thritis. While osteoarthritis is, statistically,
a more common disease (indeed, tech-
nically almost every individual who is over
the age of 40 can be regarded as having
some degree of osteoarthritis) this condi-
tion is very gradual in its onset and pro-
gression. It permits adaptation of the pa-
tient's level of activity over a long period
of time and rarely causes a severe degree
of difficulty.  In contrast, rheumatoid ar-
thritis strikes unpredictably. It affects a
younger age group at the time of maximum
responsibility,  in family relationships,
striking the wage earner in his most pro-
ductive years and the housewife at times of
maximum family responsibilities.

Specific infections of the joint and gout
can also cause crippling, but in these situ-
ations effective medical management is well
defined and the primary problems are ac-
curate diagnosis and patient cooperation.
A variety of forms of nonarticular rheu-
matism may cause temporary disability of
considerable magnitude, but these condi-
tions, in a great majority of cases, are
limited to a few weeks or months in dura-
tion; and, with proper management, they

should not result in irreversible crippling.
Therefore, in this Workshop, rheumatoid
arthritis may be regarded as the prototype
of the crippling diseases, not only because
it is the least well understood and the most
difficult to manage, from the medical point
of view, but also because of its important
impact on the individual, on his family,
and on his ability to function in society.

Also pertinent to the purpose of this
Workshop is the fact that any sound pro-
gram that is developed to meet the problem
of disability from rheumatoid arthritis will
automatically include the measures that
can be brought to bear on other forms of
disability from rheumatic diseases. Indeed,
it would be virtually impossible to develop
an adequate program for rheumatoid ar-
thritis that would not accomplish this
purpose.

Basic Consideratione

In the prevention of disability from
rheumatoid arthritis, there is one fact that
has been repeatedly demonstrated and
agreed upon by virtually al1 workers in the
field-the importance of early hospitaliza-
tion and subsequent medical and social
support. A powerful argument can be made
in favor of hospital treatment early in the
course of rheumatoid arthritis and for the

33


provision of adequate medical and social
supervision, on a long-term basis, follow-
ing discharge from the hospital. It is clear
that these measures are important in the
maintenance of the functional ability of
patients with rheumatoid arthritis and,
therefore, in the prevention of disability
and crippling from this disease.
The importance of early hospitalization
was clearly outlined by Short and Bauer
and their associates (2)) and it has been
repeatedly confirmed in additional studies.
All of these studies indicate, clearly, that
the course of the disease is better in those
patients who are admitted to the hospital
within one year of onset of their disease.
Because of the importance of this thesis
to the subject of this Workshop, it is
worthwile to look at, in some detail, at least
one of these studies.

The most recently reported study (3, 4,
5) consisted of an original group of 307
admissions to the Rheumatism Unit of the
Northern General Hospital in Edinburgh,
Scotland, between June 1948 and July
1951. Admission to the hospital had been
decided upon because of active disease, the
presence of deformities, or both. The mean
duration of stay in the hospital was 9.4
weeks. While in the hospital, all the pa-

tients were put under the same basic regi-
men, which was comprised of rest in bed,
the application of plaster splints to affected
joints, aspirin to limits of tolerance, physi-
otherapy, and a graduated return to the
highest attainable functional level. Drugs
other than aspirin were avoided. After
discharge, the patients were seen at regular
intervals and their treatment was modified
as the need arose. Splints were removed
and help was provided in domestic and
employment problems. At this stage, drugs
were given whenever they were indicated.

Careful assessment of disease activity
and functional capacity was made at the
time of admission to the hospital, at the
time of discharge from the hospital, and
at intervals of two, four, six, and nine years
following discharge from the hospital. Of
the 200 survivors who were available for
assessment some nine years after discharge
from hospital, 20.5 percent were without
significant residual disability, 41 percent
were moderately incapacitated, 27 percent
were more severely crippled, and 11.5 per-
cent had become entirely dependent on
others.

Between discharge from the hospital and
the first assessment, some two years later,
the overall pattern reflected maintenance of

nearly all the improvement that had oc-
curred during hospitalization, with an over-
all pattern of some further improvement.
From two years onward, there was a grad-
ual but progressive deterioration in the
functional status of the group, as a whole,
due, in part, at least, to increasing age and
degenerative changes in previously dam-
aged joints. The disease remained moder-
ately active in the majority of patients
throughout the period of observation, but
functional capacity and the capacity for
useful employment was reasonably well
maintained among the survivors.

A study of social and economic factors
indicated a close relationship between
domestic or financial difficulties and the
degree of crippling, as might be expected;
but the relatively small number of unre-
solved problems in the last assessment was
a clear indication of the important part
that is played by medical social workers
in the long-term care of the disabled.
Maintenance or loss of morale was also
intimately related to the degree of dis-
ability.

The group that showed the greatest ini-
tial improvement was comprised of those
whose musculature was likely to be most
efficient-the young, rather than the old,


men, rather than women, and manual,
rather than sedentary workers. This, as
well as other observations, would suggest
that benefit that was derived from treat-
ment was more attributable to the physical
measures that were used in the maintenance
of function than to the effectiveness of
measures that were directed toward reduc-
tion of disease activity.

There are two points that must be kept
in mind in generalizing from studies of
this sort. The conclusions, with respect
to the course and prognosis of rheumatoid
arthritis, are naturally based on cases that
are severe enough to be selected for hos-
pital treatment. They do not necessarily
apply to the milder cases, with little or no
disability, which may never be referred
to a hospital.  Several surveys indicate
that such mild cases, with little or no dis-
ability, make up a considerable portion of
the total number of people with rheuma-
toid arthritis in the whole population.

It must also be borne in mind that the
death rate among such groups of patients
with rheumatoid arthritis is higher than
in the general population, in all ages and
in both sexes, although the causes of death
do not appear to differ from the expected
pattern. Mortality is highest among those

most severely affected by rheumatoid ar-
thritis. The fact must be borne in mind
in reviewing late followup results, since
the removal of the more severely affected
segment of the group may give rise to an
over-optimistic view of the long-range
results.

0 b jectiver

In order to make available to all patients
with rheumatoid arthritis the advantages of
early hospitalization, combined with sub-
sequent careful medical and social super-
vision, effort must be directed toward at
least three objectives:

A. Acceptance by the patient and by the
general medical profession of the fact
that early intensive treatment is both
necessary and of value. This involves
a public education program, as well as
an education program for physicians
and for paramedical workers. It also
underscores the necessity for early and
accurate diagnosis, with the associated
responsibility of insuring that facilities
for early and accurate diagnosis are
  available.

B. Availability and adequacy of facilities
for hospitalization. This clearly in-
volves a significant economic problem.

C.

In addition, it is important that op-
timal facilities be available, in terms
of both trained personnel and physical
resources, to provide the services that
are needed for the arthritic patients.
Required are physicians who are skilled
in the medical, orthopedic, and phys-
ical medicine aspects of rheumatic dis-
eases. Required, also, are the special
skills and experience of physical ther-
apists, social service workers, nursing
personnel, occupational therapists, nu-
tritionists, and dietitians. A soundly
based program must, clearly, be in-
volved with the training of such indi-
viduals, as well as with their appro-
priate utilization.
Availability and adequacy of resources
for the medical and social supervision
that must follow the period of intensive
treatment during hospitalization and,
also, for those patients whose disease
is not severe enough to require hos-
pitalization. This involves the estab-
lishment, distribution, and setting of
proper standards for arthritis clinics,
in order to provide the necessary med-
ical supervision. It also involves the
services of all of the paramedical pro-
fessions who are concerned with the

35


hospitalization facilities that are listed
above. To be successful, this aspect of
the program must also enlist the serv-
ices of many agencies, such as public
health nurses, visiting nurses, voca-
tional and recreational programs, and
rehabilitation efforts, which are not di-
rected primarily at the arthritic pa-
tient. Although the efforts of these
organizations are not restricted to pa-
tients with arthritis, they have much
to offer in terms of both experience
and objectives, which can be beneficial
to the achievement of the ultimate goal
of preventing disability from rheumatic
diseases.

It is the specific assignment of this Work.
shop to review the present activities and
programs of voluntary and public agencies,
with the objective of determining what is
being done at the present time and how
these programs and activities can be made
more effective.

36

Voluntary Agencies that are
Concerned with Arthritis
The Arthritis Foundation. Within the
past year, The Arthritis Foundation has
emerged as the voluntary agency that is
concerned with both the professional and

the lay effort in the field of rheumatic
diseases.  Formerly,  the Arthritis and
Rheumatism Foundation, its national pro-
gram is concerned, primarily, with both
lay and professional education. Through
its regional chapters, it is directly involved
in the support of arthritis. clinics and in
the administration of other facilities that
bear directly on the care of the arthritic
patient. Its organization is closely inter-
twined with that of the American Rheu-
matism Association (now, the Rheumatism
Section of The Arthritis Foundation), as
far as professional guidance and policies
are concerned. Currently, efforts are un-
derway to make the coordination of the
lay and professional medical effort in this
field still more effective. The National
Foundation, which previously had a pro-
gram in arthritis that was directed par-
ticularly toward juvenile rheumatoid ar-
thritis, has concentrated in other areas
since the emergence of The Arthritis Foun.
dation as the strong voluntary organiza-
tion.

The Rheumatism Section 01 The Ar-
thritis Foundation (formerly, American
Rheumatism Association). This is the pro-
fessional organization of physicians who
have a special interest in the field of rheu-

matic diseases. It currently numbers more
than 1,600 members. It provides leader-
ship in professional education and fur-
nishes professional resources and "know-
how" to public education programs of The
Arthritis Foundation.

  Community Hospitals and Medical Cen-
ters. There is an accelerating tendency for
the hospital to become the focal point in
the provision of all aspects of medical care.
This is true with respect to both diagnostic
resources and treatment facilities. In addi-
tion, because the hospital supplies a setting
in which the physician can function most
effectively and efficiently, it is often only
in the hospital that the more refined diag
nostic procedures are available. The hos-
pital is the setting in which the physical
therapist, dietitian, occupational therapist,
and social service worker can function
most effectively; indeed, in all but a few
areas, it is the only place where such indi.
viduals and facilities are available. Through
their internship and residency training
  programs, these hospitals exert an im-

'  portant influence on professional educa-
&on. They are also often the focal point
in the training of the paramedical pro-
fessions, whose services are so important
in the care of the arthritic patient.


Hospitals that are associated or aflili-
ated with medical schools and medical
centers are involved in direct service to
patients to the extent that they function
to meet community needs. They also serve
an important function in the training of
individuals in the medical and paramedical
professions and in the demonstration of
effective organizations and procedures in
meeting the needs of the arthritic patient.
Arthritis clinics have tended to develop
entirely in relationship to hospitals-most
frequently, in relationship to hospitals that
are concerned with teaching and residency
training. The National Foundation pio-
neered in the financial support of arthritis
centers that serve as demonstration units,
and it is projected that continuing efforts
in this area will be supported by The
Arthritis Foundation.

The outpatient department of the hos-
pital plays a particularly important role
in dealing with the problem of arthritis,
since there is need for continuing medical
supervision, as well as for episodes of hos-
pitalization.

Other Voluntary Agencies. Numerous
agencies that are concerned with the prob-
lems of chronic incapacitating disease in-
clude patients with arthritis in their pro-

grams. In many areas, such programs as
visiting nursing programs are coordinated
and, to some extent, supported by the activ-
ities of the chapters of The Arthritis Foun.
dation. In many areas, there is a lack of
effective coordination of these programs
into the effort to improve care of arthritic
patients.

Public Agencies that are
Concerned with Arthritis Programs
The United States Public Health Service
The Bureau of State Services, through
its Division of Chronic Diseases, has a
combined Diabetes and Arthritis Program,
which is responsible for the efforts of the
United States Public Health Service in the
arthritis field at a national level. The activ-
ities of this Program have ranged from
the preparation and dissemination of ma-
terial for public education to the prepara-
tion of recommendations for community
arthritis projects and programs in county
and local health departments. Its public
education activities have been closely CO-
ordinated with those of The Arthritis Foun-
dation. In some areas, it has cooperated
with State health departments and chapters
of The Arthritis Foundation to sponsor
symposia, postgraduate courses, and dem-
onstration programs to provide improved

facilities for the care of the arthritis pa-
tient. The primary charge of this program
is to seek more expeditious application of
the scientific techniques we now know and
of those that are becoming available
through research.

Nationcrl Institutes of Health (National
Instilute oj Arlhrilis ,urul Metaboli4: I&
eases). This research arm of the United
States Public Health Service supports a
large program for research in arthritis and
for the training of research workers in this
field. While programs of this Institute may
not be directed immediately to the care of
the arthritic patient, they indirectly exert
an important influence on professional
education and in the development of facil-
ities for patient care. The centers for re-
search and training in research are located
in the same institutions that are providing
leadership in the development of facilities
for care of the arthritic patient. There is
a fine tradition of cooperation between the
National Institute of Arthritis and Meta-
bolic Diseases and The Arthritis Founda-
tion.

State Health Departments. In most
State health departments, no specific ac-
tivities are directed solely to arthritis.
Most State health departments support a

37


number of projects, throughout the State,
that directly or indirectly influence care for
the arthritic patient. These may include
chronic disease diagnostic clinics, rehabil-
itation centers and services, nursing serv-
ices to the chronically ill, stimulation of
home-care services, with available consul-
tation subsidization, homemaker services,
and nursing home services. Programs that
are concerned with facilities for the care
of crippled children and crippled and af-
flicted adults may include appropriate
patients and arthritis.

38

It is apparent that in several States the
activities of the State health departments
are closely coordinated with those of the
chapters of The Arthritis Foundation. Such
activities may include symposia and dis-
semination of literature for public educa-
tion, the joint sponsoring of symposia for
physician education and, also, for the edu-
cation of nurses, physical therapists, and
social service workers, and the preparation
of a directory of arthritis services that
are available throughout the state. In sev-
eral States, key staff members of the appro-
priate division of the State health depart-
ment are members of the Medical and
Scientific Committee of the State chapter
of The Arthritis Foundation.

Examples of Activities in Which
State Health Departments Have
Provided Leadership or Have
Participated

Pennsylvania: In cooperation with the
Pennsylvania chapters of The Arthritis
Foundation, two State conferences on ar-
thritis have been conducted for medical
and paramedical groups. Seven institutes
on diet and arthritis have been conducted.
Equipment has been made available for
physiotherapy demonstration projects. In-
stitutes on rehabilitation and restorative
services have been conducted. Training
programs in rehabilitation have been con-
ducted for nursing home staffs.

New Jersey: Program activities include
promoting community resources for con-
trol of arthritis, including continuity of
care services, rehabilitation services, and
diagnostic services. The department has
encouraged and facilitated research stud-
ies and provided education in arthritis and
allied disorders. Arthritis symposia have
been sponsored jointly by the State health
department, medical school, and county
hospitals. The State health department has
prepared a directory of arthritis services
that are available in New Jersey, including
agencies,  clinics,  educational materials,

physical medicine, and rehabilitation re-

sources.

Colorado: The State health department
cosponsored a three-day institute on "Man-
agement and Rehabilitation of Patients
with Arthritis" with the Rocky Mountain
Chapter of The Arthritis Foundation, the
University of Colorado Medical School, and
the State department of rehabilitation.
Plans were formulated to provide assistance
to the Rocky Mountain Chapter of the AF
for purchase of equipment for physical
therapy home service programs and craft
rehabilitation projects. Assistance is also
being developed for professional lay edu-
cation through the procurement and util-
ization of educational materials and audio-
visual aids. Other services relate to con-
sultation to nursing home administrators,
including occupational and physical ther-
apy consultants, community homemaker
services in Denver, and extension of pro-
grams for home nursing care of the sick.

Kansas: Courses sponsored in self-help
and rehabilitation for nursing home per-
sonnel include service to arthritics, as
well as to stroke patients. Rehabilitation
courses are conducted for registered nurses.
Also programs for nursing care of the
sick at home are being developed. The


Kansas statewide arthritis education pro-
gram is a cooperative agreement involving
the Kansas Chapter of The Arthritis Foun-
dation, the Kansas State Health Depart-
ment, and the U.S. Public Health Service.
The objectives of this program are to pro-
vide up-to-date information to physicians
and paramedical personnel on techniques,
particularly physical therapy, that are used
for care of arthritics. It also seeks to
organize and mobilize community resources
to improve the care of the arthritic.

Minnesota: A project entitled "Home
Economists in Rehabilitation" has been
sponsored jointly by the State health de-
partment, the Minnesota Heart Association,
the State agricultural extension service,
and the Minnesota Chapter of The Arthritis
Foundation. This is a project to assist
homemakers with physical handicaps to
accept the knowledge that will encourage
them to develop both realistic attitudes to-
ward homemaking and enable them to
accomplish some, or all, of their home-
making tasks. A series of four classes are
held. They cover different aspects of home-
making. This program reached about 160
homemakers in I3 counties in 1963.

County and Community Health Depart-
ments. It is difficult to get significant in-

formation about the activities of county
or community health departments in the
field of arthritis. It is clear that such
health departments are in a position to play
a key role in community arthritis projects.

An example of the way in which rehabil-
itation services to arthritis patients has
been extended by a generalized public
health nursing agency is provided by
Tulsa's arthritis program. The first steps
were to ascertain the number of rheumatic
disease victims in the community who re-
quired home nursing service and to decide
on the type of inservice education that
would best prepare the nursing division of
the City or County health department to
take care of them. On the basis of the in-
formation and prior experience of a spe-
cialized program that had been established
by the local chapter of The Arthritis Foun-
dation, the staff nurses became acquainted
with the patients, familiarized themselves
with the patient's disabilities, and gained
considerable insight into the needs of these
patients, with respect to the medical, nurs-
ing, and physical therapy techniques that
are needed. This was followed by formal
lectures and demonstrations and the par-
ticipation of staff nurses in training pro-
grams that were available elsewhere. It

is of interest that, in one year, about 12
percent of 7,620 visits for nursing care in
the home were made to arthritic patients.
During the same year, 191 new arthritic
patients were admitted to the nursing
service.

There are also a number of both govern.
mentally supported and voluntary organ-
izations that are concerned with the
provision of diagnostic, treatment, and
rehabilitation programs for the chronically
ill patient at the community, regional, and
national levels, with programs and facil-
ities that play an important role in services
that are available to the patient with ar-
thritis. One of the purposes of this con-
ference will he to obtain more information
concerning such programs and to develop
recommendations for more comprehensive
and extended care of the arthritic patient,
through coordinated health activities and
through the integration of health informa-
tion.

Educational Activities of Voluntary
and Public Agencies

Public Education. A sound pattern for
the provision of authoritative information
on arthritis has developed, usually with The
Arthritis Foundation taking leadership in
preparing  appropriate literature, fre-

39


40

quently with the advice or participation
of committees of the Rheumatism Section
of The Arthritis Foundation (formerly,
American Rheumatism Association). Dis-
semination of this information is carried
on, to a considerable extent, through the
chapters of The Arthritis Foundation, the
Division of Chronic Diseases of the United
States Public Health Service, and the State
health departments. Examples are the
booklet entitled, "Strike Back at Arthritis,"
informational booklets about quackery in
the arthritis field, and authoritative in-
formation about fact and fancy and the
relationship of diet to arthritis. The Ar-
thritis Foundation also prepares and dis-
tributes informational pamphlets, directed
toward the education of the patient that
is afflicted with arthritis, that deal with the
various types of rheumatic diseases.
Professional Education. Several organ-
izations are concerned with keeping the
medical profession up-to-date on advances
in the diagnosis and management of ar-
thritic disease. These efforts are usually
well coordinated, and several of them are
undertaken on a cooperative basis. An
example is the "Primer on Rheumatic I%-
eases," which is prepared periodically by
a committee of the Rheumatism Section of

The Arthritis Foundation and published
in the Journal of the American Medical
Association. Through The Arthritis Foun-
dation, copies are distributed to every
medical student in his junior or senior
year in medical schools throughout the
United States and Canada. Information
concerning advances in research are dis.
seminated in the monthly Bulletin of Rheu-
matic Diseases, a joint enterprise of the
National Institute of Arthritis and Meta-
bolic Diseases and The 4rthritis Founda-
tion, which is distributed to approximately
60,000 practicing physicians in the United
States, primarily through the chapters of
the Arthritis Foundation.  A periodic
Rheu,matism Review, prepared by a com-
mittee of the Rheumatism Section of The
Arthritis Foundation, is widely distributed
with the financial support of The Arthritis
Foundation.  Symposia and postgraduate
courses that deal with the diagnosis and
management of the arthritic are frequently
cosponsored or organized by the Rheu-
matism Section of The Arthritis Founda-
tion, or its regional affiliated societies, and
The Arthritis Foundation and its chapters,
sometimes, with the joint sponsorship of
the State health department.

Education of Clinical Specialists in

Arthritis. There has been a substantial
increase, in the last fifteen years, in op-
portunities for advanced training for phy-
sicians who wish to concentrate in the field
of rheumatic diseases. This has tended to
occur, particularly, in centers in which
there is an ongoing research program. It
has been stimulated by the training grants
program of the National Institute of Ar-
thritis and Metabolic Diseases (PHS).
However, since such training grants have
concentrated in the training of younger
physicians for research in the field of
rheumatic diseases, there has been a real
problem, financially, in providing training
for men who are not primarily interested
in research, but who wish to develop their
proficiency in the diagnosis and manage-
ment of the arthritic patient. The Arthritis
Foundation, both at the national level and
through its local chapters, has tried to
meet this need to a limited extent. There
is a very real need for financial support
for men who are seeking advanced train-
ing in this field in order that they may be
better prepared to provide care for the
arthritic patient.

We are not aware of comparable train-
ing opportunities for the other professions
that are concerned with providing health


care. Chapters of The Arthritis Foundation
and governmental health agencies have or-
ganized one and two-day symposia to pro-
vide public health nurses, visiting nurses,
nutritionists, .physical  therapists, social
service workers, vocational, recreational,
and social rehabilitation workers with some
information  concerning  the particular
problems of the arthritic. Most of the real
experts in these paramedical professions,
as far as the arthritic patient is concerned,
have developed through "on the job train-
ing" by participating in the activities of
an arthritis center, rather than through an
organized program of training.

Hospitalization Problems

Organizational a& Financial Considera-
tions. Both hospital organization and plan-
ning and the patterns of defraying the
costs of hospitalization in this country have
tended to center on care for the patient
with acute illness. There is a limitation to
the extent to which such patterns can be
adapted to the needs of the patient with
chronic disabling disease. Physical facilities
and administrative organizations, which are
quite suitable for the care of patients who
are hospitalized for a week or two, are often
not appropriate for providing optimum

care for patients whose hospitalization is
a matter of months. Similarly, hospitaliza-
tion insurance plans, which are adequate
in meeting the cost of acute illness, are in-
adequate when applied to patients who
require long-term hospitalization.

Hospitalization programs for the ar-
thritic patient have tended to develop in
training centers, usually in connection with
medical schools. The problems that were
cited above become more pertinent if rec-
ommendations  are considered for the
extension of the development of such re-
sources in the community and voluntary
hospitals. An easy solution might appear
to be the development of hospital facilities
that are designed, organized, and financed
to meet the specific needs of the arthritic
patient. But there are obvious disadvan-
tages in the development of such facilities:
They tend to become isolated from the
mainstream of medical progress and care,
and they are difficult to integrate with fol-
lowup services that are much more likely
to be part of an overall community or
regional program.

It is apparent that those who set out to
make realistic recommendations for pro-
viding adequate hospitalization facilities
for patients with arthritis must weigh the

above considerations carefully.

Standards of Ezcelknce in Hospitahza-
tion Resources. The most important aspect
of the quality of care that is provided dur-
ing the hospitalization of patients with
arthritis is clearly dependent on the pro-
fessional qualifications of the staff. In
addition to the general diagnostic and con-
sultation services that are usually found in
a general hospital, the special skills of men
who are trained in rheumatology, ortho-
pedic surgery, and physical medicine are
required. Special training is also needed
in the paramedical health professions that
are concerned with the care of such pa-
tients. These include nursing, social serv-
ice,  vocational rehabilitation, and psy-
chological testing workers. The public and
voluntary agencies can be most effective in
providing support for the training of such
individuals, and also in insuring adequate
budgetary provision for the variety of skills
that must be brought to bear in the care
of the arthritic patient.
Continuing Medical and
Social Supervision

Continuing medical and social super-
vision is usually provided by outpatient
clinics that are closely affiliated with the
institution that is providing the resources


42

for hospitalization of the arthritic patient.
It is clear that the organizational and finan-
cial problems, as well as the maintenance
of quality in such continuing activities,
are dependent on much the same factors as
those that were outlined above, under the
heading of hospitalization. However, it is
in this area of continuing supervision that
the role of the physician becomes less pre-
dominant and dependence on adequate
programs in the home nursing, physical
medicine, and social aspects become in-
creasingly important. It is also in this area
that integration with other community pro-
grams that deal with the chronically ill
patient can be most effectively utilized.
Currently, most of the activities that are
directed toward this aspect of the care of
the arthritic patient have developed through
the local and regional chapters of The
Arthritis Foundation. Such activities have
included aid in the establishment and con-
tinuing support of arthritis clinics; the pro-
vision of physical therapists to work with
the visiting nurses' and public health nurses'
programs; financial aid in the provision of
corrective supports, splints, and wheel
chairs to severely handicapped individuals;
the maintenance of mobile physical therapy
units for the homebound arthritic; and

participation in community homemaker,
recreational,  rehabilitation,  and home
nursing efforts. The Arthritis Foundation
has developed a set of recommendations
for standards for the organization and op
eration of such arthritis clinics.

Summary

Today, we, in this country, can bring
excellent resources to bear on the problems
of prevention of disability from rheumatic
diseases. A significant segment of the
medical profession is interested in rheu-
matology; nearly 2,000 members of that
profession are organized into an effective,
professional organization.  We have a
strong and outstanding voluntary health
agency that is concerned with the problem.
Our research activities are the envy of the
rest of the world, and we have a preponder-
ance of eminent investigators and clinicians
in the field of rheumatic diseases. There is
a focus of special interest in rheumatic
diseases in nearly two-thirds of our medi-
cal schools,  and there are over three
hundred special clinics for patients who
suffer from these diseases. The U. S. Public
Health Service is committed to helping the
American people find the answer to chronic
disease, and State and local health author-
ities are dedicated to serving the health

interests of those for whom they are re-
sponsible. And regional and community
organizations are concerned with the med-
ical and social aspects of chronic incapac-
itating disease. With stronger interaction
and liaison between these groups, advances
can be made "which will convert the prob-
lem of rheumatic disorders from a public
liability to an area of competence in disease
control, rehabilitation and prevention of
disability." (6)

Bibliography

1. Roemmich, W.: Disability and rheumatic dia-
eases: social security data. Arch. Environ-
mental Health (Chicago) 4:490, 1%2.

2. Short, CL and Batter, W.: The course of
rheumatoid arthritis in patients  receiving
simple medical and orthopedic measures. New
England J. Med. 238:142, Jan. 1948. Also
Short, CL, Bauer, W.. and Ropes, M.W.:
Rheumatoid Arthritis. Harvard Univ. Press,
Cambridge, Mass., 1957.

3. Duthie, J.J.R., Thompson, M., Weir, M.M.
and Fletcher, W.B.: Medical and social aspects
of the treatment of rheumatoid arthritis, Arm.
Rheumat. Dis. 14:133, June 1955.
4. Duthie, J.J.R., Brown, PK., Knox, J.D.E.
and Thompson, M.: Course and prognosis in
rheumatoid arthritis.  Ann. Rheumat. Dis.
16:411, Dec. 1957.


5. Duthie, J.J.R., Brown, P.E., Truelove, L.H.,
Barager, F.D. and Lawry, A.J.: Course and
prognosis in  rheumatoid arthritis. Ann.
Rheumat. Dis. 23:193-204, May 1964.

6. McDonald, O.H. and Penn, LM.: Tulsa's Ar-
thritis Program.  Nursing Outlook, Vol. 10,
Sept., 1962.

7. Edwards, M.H.: National and International
Review of Arthritis Programs: Conference on
Arthritis as a Public Health Problem, Hous-
ton, Texas, Feb. 4 and 5, 1964. U. S. Public
Health Service,  Division Chronic Diseases,
Washington, D. C 20201.

Workshop 7

Socioeconomic Aspects
(Financial Resources)

Ronuld W. Lamont-Hawers, M.D., Chairman

Arthritis has been a problem with which
the individual patient and his immediate
family have had to cope since antiquity.
Today, however, the impact of arthritis is
so great that it has become, in .addition, a
public health problem of major importance
to the Nation, as well as to individual com-

munities.  This is well illustrated in the
selected statistical data that is available.

These statistics must be interpreted,
however, with an understanding of the
many factors that are involved in their
compilation. Some of these will be explored
during the Workshop session.

Arthritis patients seldom have arthritis
as their only problem. The general age
group is such that other chronic and acute
diseases as well as the infirmities of age,
are frequently concomitant companions.
Invariably, the psychosocial consequences
of the disease are a major burden. These
multiple problems must be taken into con-
sideration. In many respects, therefore, the
study of arthritis can be viewed as the
prototype of studies of chronic disease
problems that normally face the community.

The clinical aspects of arthritis and the
rheumatic diseases generally will not be
discussed. Background information on this
aspect can be obtained from the "Primer on
the Rheumatic Diseases." Of all the various
diseases that are classified under the rheu-
matic diseases, those of greatest socio-
economic importance are rheumatoid ar-
thritis and osteoarthritis.

Other sections of the Workshop will be
discussing many of the problems that con-

front the individual and the community,
from the standpoint of needed facilities
and personnel. This Workshop on socio-
economic aspects will concenfrate, pri-
marily, on the problems that are associated
with the major economic impact of arthri-
tis upon the patient and the community.

It is expected that a number of areas
that are in need of additional study and
information will be identified. Typical of
these areas are the following: The need for
assessing services and facilities for the ar-
thritic in the local community; the difficult
problem of implementing actions so noted;
and the manner in which the unique needs
of the arthritis patient and of those with
chronic disease, generally, can be inte-
grated into the present health care plans.

43


44.

Workshop
Reports and
Discussions

Public Education and
  Information

Chairman: William S. Clark, M.D.

The effect of crippling arthritis on the
Nation's health  and  economy  consti-
tutes an emergency that the public can
no longer ignore. Arthritis is the Nation's
number one crippling disease. It exacts
an enormous toll in human and material

resources.

Arthritis is a growing and spreading
problem. Something can be done about it
now. Intensified and sustained programs
of public education and information are
essential to the achievement of effective
control of the crippling effects of all major
forms of arthritis.

  The extraordinary amount of personal
disability and the burdensome cost of the

individual to his family, to the community,
and to the Nation that result from arthritis
can be attributed, in part, to the general
lack of information and the considerable
abundance of misinformation about the
nature of the arthritic diseases. It can be
attributed, also, to the lack of motivation
to develop and utilize optimal professional
skills, meaningful facilities, and resources
for treatment and care.

Moreover, misconceptions about arthritis
are being perpetuated by counter propa-
ganda for the promotion of legitimate and
fraudulent treatments for arthritis. Public
education cannot be clearly separated from
professional education, either in concept or
in practice. As one panelist put it: Every
physician is a layman in some area of the
medical sciences.

Moreover, the level of information of
the general public is proportionate to the
degree of professional knowledge. The sub-
ject, Public Education and Information,
could well be included on the agenda of
each of the six other panels that are ar-
ranged for this conference.
Responsibility for public education and
information rests with all agencies that are

1  concerned with the problem of arthritis,
as well as with individuals in the medical


and paramedical specialties who are in-
volved in the care of the arthritic patient.
Public education cannot take place in a
vacuum. It must begin with the patient
and relate to meaningful and attractive
services that are available for effective

treatment.

In this discussion, we will consider the
patient to be a part of the public. A high
priority objective in the prevention of crip-
pling arthritis is bringing the patient into
points of contact with skillful professional
personnel and effective medical facilities.

The purposes of public education and
information can be stated as follows: The
goal of the effort against arthritis is to
reduce or prevent disability in its victims
now and, as soon as possible, to develop
techniques for cure or total prevention.

Our Workshop believes that there is sub-
stantial factual information on arthritis
that is not now reaching patients and the
rest of the public. We believe that bring-
ing such information, in a proper way, to
those who need it can motivate them and
influence their behavior, thus contributing
toward a solution of the problem of
arthritis.

The public information program for ar-
thritis should include the following pur-

poses: To motivate those with arthritis to
seek qualified medical care, to seek it
sooner than they might otherwise, and to
stick with it; to improve attitudes toward
arthritis and the arthritic individual, re-
placing despair with justified hope; to
motivate educators at all levels to pay more
attention to arthritis; to create in the public
an awareness of the size and seriousness
of the arthritic problem (it being noted
that the decisions of individuals who are
not physicians, but who serve on hospital
boards, or on legislative bodies, or who
support and participate in voluntary or-
ganizations, will largely determine what
will actually be done about arthritis) ; to
stimulate widespread interest in a major
effort against arthritis and in the challenge
the problem poses.

The Workshop notes that while doctors,
nurses,  and other health workers are
trained by professional educators, it is
usually exposure to public information that
stimulates them to select their careers.

The more that is said about arthritis in
newspapers, in private sayings, in maga-
zines, books, and over radio and television,
the more excitement will be generated
about it and the more young people will
be drawn to careers in it.

What is done in the public sector of
information, if done well, can also have a
massive impact in the area of improving
the amount, quality, and effectiveness of
professional education.

Whom to educate . . . The public, at
large, including the physician, as well as
the layman, is the audience to which public
education and information programs on
arthritis must be addressed.  Programs
should be directed to specific groups, phy-
sicians, paramedical specialists, educators,
pharmacists, community leaders, and others
who, in effect, educate or advise the public
or mold public opinion.

Certain segments of the arthritis prob-
lem have especially pertinent application
to certain groups. There is reason for con-
cern about the patient's understanding of
his own problem.
Content . . . The public information and
education program on the arthritic diseases
should contain the following basic elements
in its approach:

The public must be made aware that
many of the rheumatic diseases are man-
ageable and preventable and that tremen-
dous public health problems have been
conquered by their demand.
The importance of early diagnosis must

45


he continually emphasized. With proper
medical care, severe crippling can be pre-
vented in most cases of arthritis, and most
patients are able to maintain significant
measures of function, or significant meas-
ures of independence, regardless of the
stage of progress of the disease or the
severity. Lost function can be retained or,
to a great extent, restored.
Treatment must he administered by qual-
ified physicians; and it should be the pol-
icy of public education programs to
identify and explain the elements of ade-
quate care. These include regulation of
physical activity and environment, proper
diet guidance when appropriate, proper
selection and administration of drugs, the
use of physical medicine, and specialized
care, such as orthopedic surgery, psychi-
atric treatment, and rehabilitation tech-
niques.

Methods and techniques . . . The devel-
opment and support of a trained adminis-
trative staff and personnel for planning,
implementation, and continuity is essential.
There must be national, State, and com-
munity programs of information and edu-
cation about arthritis.

46

There must be development of sources
of information and cadres of individuals

to convey information through a variety
of conference and group techniques, in-
cluding neighborhood and patient group
discussions.

There must be development and selective
utilization of  audience-specific   terms.
There must be development of interest and
support by mass media for comprehensive
educational programs for arthritis care.
Conclusions and recommendations: It is
the consensus and unanimous agreement
of our group that more money should be
invested in public education and informa-
tion by all agencies. There must be a con-
tinuing and sustained effort. There must
be education of a special group of people
who need information in depth to act in
the capacity of educators and informers.
There must be research in the motiva-
tion of patients to seek and to accept ade-
quate treatment; and there must be
research in the comprehension of the in-
formational materials that are supplied to
patients, their families, and the public.
There must be intensified programs and
expansion of existing programs.  There
must be cooperation among agencies and
the avoidance of duplication; and we must
encourage greater involvement of all media
in the problem.

For the discussion, I have asked the
four people who helped prepare this report
to sit at this table and help me answer
questions, because I don't want to do all
the talking.

Discussion

DR. MCDONALD: I have no questions,
only a comment; and it is complimentary
to the group that you represent. I think
that this was a very good statement, and
that it will help to guide our Program in
the next several years. Thank you very
much for this report.

DR. WILLIAM CLARK: Thank you for
the gracious comments, Glen.
DR. TRAEGER: When you talk of con-
tinuity, just what do you mean?
DR. WILLIAM CLARK: We mean that
this shouldn't be a short burst, a one-shot
affair, that it should be a sustained pro-
gram and that there should be continuity
of knowledge, objectives, and planning.
We are not talking about a project for
1965. And programs in public education
must be adapted to increasing knowledge,
not only to knowledge about the nature of
arthritis diseases, but about the patient
and the public's acceptance of this knowl-
edge and about their motivation to act on
the problem.


DR. STILLMAN: I think that you have
done such a superb job that I have nothing
to add. I congratulate you and your com-
mittee.

DR. DECKER: Did the committee talk
about over-publication to the general pub-
lic of investigative advances that are not,
perhaps, pertinent to the status of any one
individual, but which can give him major
hunks of unfortunate information?

DR. WILLIAM CLARK: I don't know
that I understand the question, hut I am
going to let someone over here answer it.
Dave, do you want to take a crack at it?
Incidentally, my panel is, from my left
to my right, Mr. David Preston, science
writer, Dr. Theodore Bayles, Director of
Research, Robert B. Brigham Hospital
in Boston, Mr. Lee Curren, Director of
Public Information of The Arthritis Foun-
dation, and Dr. Ralph Jacox, Dept. of
Medicine, University of Rochester. Mr.
Preston will answer.

MR. PRESTON: The committee did not
specifically talk about that problem, but I
think it was the consensus of the committee
that we need a lot of specific material for
people with specific arthritic diseases and
conditions.

I think that if those materials were well

enough prepared and if they met the need,
the individual patient would not be likely
to be led astray by an occasional story
of the kind of which you are thinking.

DR. WILLIAM CLARK: Such as
DMSO.

MR. FRALEY: I think that this ties in
with what Dr. Traeger said-that you have
to raise the level of knowledge in the gen-
eral public continuously, on a sustained
basis, so that when there is premature pub-
licity the general public has some kind of
background in which to judge any specific
piece of information.

DR. JACOX: I think our committee
did devote considerable discussion to the
education of the patient as being an im-
portant way to make them less vulnerable
to these ill-advised press releases. And our
committee felt, generally, that if the pa-
tient had a good knowledge of his or her
disease, he would not only cooperate more
readily with treatment suggestion, but he
would be in a much better position to read
things, perhaps, that come out in the news-
papers about arthritis.

DR. JOHNSON: I am concerned about

the prevalent-and I say that guardedly-
idea that prevails among physicians who
are rendering firstline medical care to peo-

ple who have this crippling diseas+noth-
ing can be done for the arthritic.

I see arthritics in my office and in other
areas who were told, one, two or three
years before they came to me, that they
had one of the arthritides and that there
was nothing that could he done for them.
They had gone home and slipped into the
passive and recessive group. They had
accepted it.

How can you tell these people that, re-
gardless of the fact that one person in
medicine told them nothing can be done,
they should seek a physician who is inter-
ested in the process and who wants to get
something done for them? Is not that in
your purvey of services here?

DR. WILLIAM CLARK: Yes, sir. We
would like to respond to that, Dr. John-
son. Dr. Bayles?

DR. BAYLES: Well, I think one thing
that came out of our discussion was that
public education and information had to
be across the board. We even decided that
doctors were people, that nurses were peo.
de, that physical therapists and other
health workers were people, that high
school students and college students were
people, and that junior high school stu-
dents were people.  We had the strong

47


conviction that this kind of approach of
public education and information, while
it may be layered to different levels of

Mr. Fraley and our other science writ-
ers pointed out that we have to adjust the
reception, is an important function.


information to the people who are receiv-
ing it. And I think, in answer to this, we
would feel that the doctor who has told
the patient that there is nothing to do
about arthritis needs as much education
as the arthritic patient, his family, the
public, or those whom Bill Clark calls
opinion molders in the community.

So, I think it can be said that we are
not neglecting any category of individuals;
and we hope that we can reach, with dif.
ferent material, hopefully, every strata, or
every phase of people, as we call them, in
our country.

48

DR. WILLIAM CLARK: We emphasize
that public education begins with the pa-
tient and with those who are responsible
for the patient or on whom the patient
is dependent for any kind of assistance.
DR. ROBINSON: Mr. Chairman, some-
times one finds that when one has informa-
tion one thinks is useful for public
education, the journalist feels that this
doesn't fill the bill because it has no par-

ticular interest to them. Now, I find that
this might be exciting news, and they think



DR. WILLIAM CLARK: Yes, it did.
it is not. We have to get together on these



Dave?
matters. Did the committee consider this?

MR. PRESTON: I think that journal-
ists, important as they are, are a small
part of the total chain of communication
between people who know about arthritis
and the patient and the rest of the public.

I think that the journalist has to deal
in large measure with what he considers
to be new. I think an important message,
such as the fact that something can be
done about arthritis with what is known
now, will have to be delivered to the pa-
tient and other segments of the public by
many, many means.

It is my own personal guess that if we
had complete control of all the science
writers and journalists in this country, we
would still find that 75 percent of the in-
formation on this subject that patients and
the public were getting would be coming
from other sources.

DR. TOONE: I would like to make a
plea for the patient. I think this is the
individual who requires our attention and
our particular effort. I think it came out

in our discussions that, in many ways, he
has been greatly neglected, not only be-
cause of our shortcomings in treatment
measures, but in the fact that he never was
given the proper information about his dis-
ease. I think this all points up to the fact
that the patient is the individual at whom
we need to point most of our attention.

DR. WILLIAM CLARK: 1 did want to
make one other comment and amplify it.
Mr. Fraley made the point that we could
have sliced this differently and that the
public information and education could be
a part of each panel discussion.  Would
you wish to amplify that, Pierre?

MR. FRALEY: No, 1 think you covered
it. 1 would make a plea, too, that when-
ever any aspect of this disease. or of the
treatment and care that can be given it,
is under consideration, that the public in-
formation and public educational aspects
be takcan into consideration.

1 am particularly strong on the point
that research. for instance, is never done
until the results of the research are com-
municated not only to those people who
apply it to patients. but all the way out
ta the general public.

MR. CURRAN: I agree with Dr. Jacox.
It flas been a very rewarding session and


I have learned a lot. I think that some of
the statements and deliberations of our
group will help us at The Arthritis Founda-
tion to broaden our thinking and our pro-
grams that bring the facts about arthritis
to our people.

DR. BAYLES: Perhaps I had just bet-
ter point out to the group that we are all
going to go home with the responsibility
to help in this effort to spread the word,
or the party line, or whatever you want
to call it.

MR. NILES: I would like to make one
comment in amplification of Pete Fraley's
comment  that educational information
must essentially be on a horizontal basis
across all of the activities of the other
Workshops. From the other Workshops,
we will get the tools with which we can
work; and Pete Fraley and other science
writers and educators, and so forth and
so on, can use these tools and apply their
skills to hammer these points home.

Also, I think that we did not identify
one group in our panel. We identified
doctors as people, nurses as people, and
so forth, as people. Health educators were
identified as those who hold the lantern
while their mother chops the wood.
MR. PRESTON: Having been in the

field of science writing for many years,
since the time when there was very nearly
open warfare between the immediate pro-
fession and science writers, it is extremely
gratifying to find lay science writers called
here by the government to work with doc-
tors and other health professionals to try
to solve the problem. I think it is very
encouraging.

DR. WILLIAM CLARK: Thank you.
That completes our report.

Diagnosis and Treatment
     Facilities

Chairman: Ephraim P. Engleman, M.D.

  Ours, as you know, is the Workshop
that was concerned with facilities for diag-
nosis and short-term treatment. The par-
ticipants  were practicing physicians,
fulltime medical academicians, an epi-
demiologist, a hospital administrator, an
expert on automated diagnostic screening,
a consultant on community planning, a
medical social worker, and a nurse. It was
agreed that there is an urgent need for
more facilities to permit more widespread
early diagnosis and treatment of patients

with arthritis. The immediate questions
were: What are the best available meth-
ods of diagnosis and treatment? Where
can they be found?

It was recognized that proper diagnosis
depends on painstaking clinical history and
physical examination and on certain labo-
ratory and X-ray findings; that the most
effective program for patient management
is multidisciplinary and time-consuming;
and that optimal methods of diagnosis and
treatment are found in certain existing
arthritis teaching units. These centers are
university-based units, in which knowledge
of arthritis is pursued and applied and
in which there are personnel and facilities
for exemplary diagnosis and patient care,
for professional education at both under-
graduate and postgraduate levels, and for
research.

Prior to World War II, there was only
a handful of such centers in the United
States;  and all were in a few Eastern
States. Following World War II, three
significant developments  made possible
establishment of additional -arthritis centers
that fulfilled the above description: (1 J
creation of The Arthritis Foundation; (2)
establishment of the Training Program in
Arthritis of the National Institute of Ar-

49


thritis and Metabolic Diseases (PHS) ;
and (3) the entry of the National Founda-
tion into the field of arthritis.

Nevertheless, in 19a, when the National
Foundation withdrew its support, there
were scattered throughout the United States
no more than 38 exemplary arthritis
centers, of which 17 are currently (1965-
1966) supported by The Arthritis Founda-
tion. It is by no means certain that The
Arthritis Foundation will be able to con-
tinue this support after July 1, 1966. To
further compound this problem, there is a
critical shortage of arthritis service clinics
in the United States. There are only 300
such clinics, approximately one to every
23 accredited hospitals; and in many, the
services are inadequate. Recommendations
1 and 2 are designed to preserve existing,
qualified arthritis centers and clinics, to
upgrade the services of others, and to
create new service clinics, as personnel and
funds become available.

50

Recommendation 1. Certain existing ar-
thritis centers should receive continued
support to enable them to sustain their
exemplary functions.  These should be
identified as Regional Arthritis Centers
and should fulfill criteria and provide
services as follows:

a.

b.

C.

d.

e.

They should be university-based, or
affiliated with large medical centers,
and should provide facilities for pro-
fessional training and research.
They should be distributed according
to geographic and population needs.
(See appendix).

They should provide facilities for diag-
nosis and comprehensive care of out-
patients. Comprehensive care includes
prevention of disability and provisions
for optimal physical restoration, per-
sonal and emotional adjustment, and
vocational guidance, training, and/or
placement of all candidates.
Medical personnel should include a full-
time director, who is a physician with
training in rheumatic disease, part-time
consultants in internal medicine, ortho-
pedics, physical medicine, and pediat-
rics, and other qualified consultants.
when necessary.  Trainees,  house of-
ficers, and students should also attend.
Paramedical personnel should include
a physical therapist, a medical social
worker, a nurse, a secretary, and other
qualified personnel, when necessary.
One of these should also serve as the
" coordinator of  patient  services."
While these people will work full-time

f.

in the parent institution, all but the co-
ordinator might also contribute to other
chronic disease facilities within the in-
stitution.  The coordinator of patient
services, a full-time member of the ar-
thritis center, is defined as one who
collaborates with all members of the
team in planning the patient's program.
He will provide the integration of pro-
fessional activities that will ensure the
provision of diagnostic and treatment
services with maximal efficiency and
effectiveness. Any one of the paramed-
ical personnel may serve as coordinator,
but he must have knowledge of the
local health agencies and their services.
Patient services should be readily avail-
able and should be utilized effectively.
Cordial relations should exist between
the center and the sources of patient
referral, such as local physicians, ar-
thritis clinics, public agencies, house
ofhcers, and others.  In addition, the
patient admittance policies should be
flexible and compatible with those of
the parent  institution.   Consultants
should be available within the confines
of the clinic. New and problem patients
should be seen by both the medical and
paramedical staffs, in order to ensure


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

69


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-

73


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


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.