Provocative concepts of tuberculosis.

T his conference has been marked by provocative concepts regarding tuberculosis treatment and control offered by leading scholars and clinicians in chest medicine. It is evident that our understanding of tuberculosis has radically changed in the past decade and that medical education, clinical practice, and public health control programs must reflect these changes. There is a continuing need for basic and clinical research in tuberculosis, but some areas of emphasis must be reassessed. At the opening of the conference, Dr. Sbanbaro pointed out that treatment of tuberculosis has come “full circle” and that the goal of bringing tubenculosis patients out of the sanatoria and into the mainstream of the health care system is being attained. Secondly, newly diagnosed cases of tuberculosis in the United States have decreased to approximately 30,000 per year, low enough to mean that most physicians will not encounter even one case a year. These developments, though certainly encouraging, also pose a critical challenge. With patients no longer concentrated in specialized cane facilities, how can quality of care best be maintained? In order for a key group of physicians to maintain competence in clinical tuberculosis, they must play a significant role in the management of these relatively few cases. This problem will vary in different regions of the United States but should be of concern to all chest physicians. Some fundamental guidelines can be developed. First, interested physicians who have a demonstrated competence in chest medicine should he those primarily responsible for the initial diagnostic evaluation and planning of treatment for those persons with culture-positive tuberculosis. This would mean that a small number of physicians could have a major influence over most of the newly diagnosed cases. How can this be implemented? An inherent advantage in the tuberculosis cane system is that it has traditionally been in the domain of government control long before this concept was acceptable for many other diseases. In most states today, an agency of state government has responsibility for tuberculosis programs, and program directors have an opportunity to encourage the treatment of tuberculosis patients in selected general hospitals by competent chest physicians. The definition of competence in this regard nlust be very broad. A special certificate on a defined period of training in chest disease, although desirable, need not be mandatory, but a high degree of competence in the management of these problems must be demonstrated by clinical practice. Once a patient’s diagnosis and treatment program have been defined, the level of training and competence required to maintain a quality treatment program becomes less demanding, and physician extenders on physicians who have no particular expertise in chest medicine can do this well in most instances. There are approximately 15 million persons in the United States who are infected with tubencle bacilli but not diseased, and management of such patients is usually simple and straightforward. Most physicians will encounter such patients and can give preventive treatment when required, according to critenia established by various expert committees.1 The sanatoria have provided the background of training for many physicians with special interest and competence in tuberculosis today. With the rapid disappearance of these institutions,2 it is important to insure that persons trained in disciplines relating to chest disease are prepared to join the cadre of individuals responsible for treatment of tuberculosis in the future. Although they will not provide direct care in all cases, they must be qualifled to influence and recommend diagnostic procedures and treatment regimens in the great majority, in order to maintain a high quality of care. Today it is possible to complete a thonacic surgery residency or a training program in pulmonary disease in many institutions and have very minimal experience in tuberculosis. Pulmonary training programs, particularly in internal medicine and pediatrics, are largely unregulated as to content. It is difficult at present to influence such programs, but perhaps this can be accomplished to some degree by a reassessment of the certifying and recertifying examinations in the various specialties and subspecialties. Correction of those instances where none on very few questions