Presidential Address to American Rheumatism Association

The Researchers, Practitioners and Teachers of Rheumatology

By JOSEPH LEE HOLLANDER

N THE EARLY days of the American Rheumatism Association the few who I banded together came from various backgrounds and disciplines of medi- cine, but all had a common bond of interest in the ubiquitous but little under- stood group of rheumatic diseases. Some of these pioneers in rheumatology spoke with the voice of authority, all spoke with the voice of experience, but little in the way of scientific evidence was available to confirm or refute the fervent empiricism. The most exact science available was the pathologic examination of tissue, and close behind was the clinical laboratory examination of blood, synovial fluid, or roentgenogram.

Now that the American Rheumatism Association has grown to include more than 1500 members, vast changes are obvious. The present size and content of the scientific programs epitomize the development best. Whereas it used to be great sport attending the meetings to see how many speakers there were with whom we could disagree, we now wonder how many of the speakers we can understand. Cold scientific facts have replaced the eloquent voices of authority, and only colder and more specific facts can refute them. The techno- logical campaign against rheumatic disease now embraces complex immunol- ogy, biochemistry, biophysics, genetics and other intricate disciplines of re- search, leaving the bewildered practitioner of rheumatology wallowing in a morass of statistical analyses, structural formulas. ultracentrifugation technics, radioactively tagged molecules, fluorescein labelled antibodies, ultramicro- scopic particles, x-ray diffraction patterns and tissue cultures.

Clinicians often wonder what of this newer basic knowledge about rheumatic disease could possibly be of use to them in their efforts to relieve human suffer- ing. Some leave the meeting with the frustrated determination not to return until they see enough clinical papers on the program to make the trip seem worthwhile. They want “to bring something home to their patients.”

This dichotomy of the scientific versus the pragmatic is not new, either for science in general as opposed to humanities,lJ or for the science of medicine as opposed to the art of The problem has been well discussed in several books, has been the subject of distinguished lectures, and has recently become a favorite topic for presidential addresses to medical societies. It is un- doubtedly presumptuous to attempt to follow the example of such distinguished medical leaders as Dr. William B. Castle, Dr. Cecil J. Watson, Dr. W. Barry Wood, Jr., or our own Dr. Walter Bauer in discussing what they have col- lectively regarded as the greatest problem in Medicine today, but the dichotomy of clinicians and researchers in the American Rheumatism Association tends to become wider each year. Demands upon the program committee for more clinical papers, or for more papers on basic science, and demands upon the

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editor of our Arthritis and Rheumatism Journal for more papers of direct use to the physician, versus those for more papers on fundamental progress, are becoming more insistent and numerous. Basic researchers become increasingly fond of isolating themselves into small groups for “working conferences,” and clinicians also are banding into groups for discussion of topics of more imme- diate interest to them. Where does this leave the American Rheumatism Associa- tion, and what should be done?

In his book “From Miasma to Molecules” Dr. Barry Wood comments on the modern doctor’s dilemma in his struggle to keep up with scientific develop- ments while facing the task of treating the whole ~ a t i e n t . ~ Dr. Cecil Watson notes: “The crescendo outpouring of medical scientific knowledge in the 20th century has made the physician spend more and more of his time and interest in the acquisition and application of scientific methods, and less and less to the cultural attributes of natural philo~ophy.”~ Dr. J. Russell Elkinton, editor of the Annals of Internal Medicine, recently reviewed the problem of the “two cultures of medicine” in an excellent edi t~r ia l .~ He states: “The rift between the art and science of medicine has been widened by the vast sums of public monies being poured into medical research, the public pressures for progress in treatment of specific diseases, the prestige value of the image of the research- er, and, most of all, the astounding revolution in the biological sciences that has taken place over the past 15 years.”

Dr. Walter Bauer6 recently proposed as a solution: “We must struggle to demolish the artificial barriers that separate the disciplines and practitioners . . . Nonclinical investigators, holders of Ph.D. degrees, must enter the hospital. Clinicians and investigators must join their interests and objectives.” Dr. Elkinton concludes: “The physician-scientist must remind himself of the enormous difficulties that face the physician-practitioner in translating scientific knowledge into useful treatment of the diseased human being. The physician- practitioner must make allowances for the tremendous and accelerating com- plexities that face the physician-scientist. In varying proportions every physician must be both scientist and healer. For yesterday’s research is today’s treat- ment, today’s research will be tomorrow’s treatment; in the physician, the scientist and healer are 0ne.”5

The suggestions above are splendid and eloquent, but as practical answers to our problem they somehow remind us of the fable of the owl and his cure for arthritis. A centipede was the victim of arthritis in every joint of every leg of his small body. Lacking physicians in his home forest, he sought counsel from the wise old owl for a solution to his problem. After impressive deliberation, the owl instructed him: “Change yourself into an earthworm, because they have no joints.” “An excellent idea” replied the centipede, ‘but how can I do that?” The owl screeched angrily, “I’ve told you what to do to be rid of your arthritis. Can’t you at least work out the details yourself?” The task of practical application has been worked out by Dr. Bauer for his own problem in a university hospital, but the American Rheumatism Association must also find a practical approach for minimizing the dichotomy within it.

What have the practitioners of rheumatology, who constitute the great major-

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ity of members, done to increase this split in our interests? Although many have attempted to keep up with scientific advances as reported in our meetings, their zeal has been dampened by the esoteric nature of some of the communica- tions. Almost yearly, entirely new disciplines of research are brought to bear on problems in rheumatic disease, leaving the clinicians with the helpless feel- ing that here is something else about which they know nothing. The busy practitioner neither has the time nor urge to study up on each new science, and soon feels he is a straggler on this road of knowledge. He feels he is “just a practitioner” and cannot expect to understand all these new developments. His own clinical astuteness suffers from this inferiority complex. If he tries to report his clinical research, and finds that his abstracts lose out in competition for places on the program to other papers, he must realize that the other papers were not more acceptable becaue they contained more fundamental research, but because they were better conceived, planned, controlled and documented. Clinicians will soon see many more clinical papers on the program or in ARTHRITIS AND RHEUMATISM if they strive to make their studies adequately controlled, present their data in an orderly and scientific manner, and above all, make their style of presentation show inspiration and originality.

The astute clinician should be the key man on any research team. It is he who conceives the ideas and approaches to the problems from his intimate experience. The distinguished clinical investigator, Dr. William B. Castle, summed this up admirably: “As I see it, the all-important task of the clinical investigator is to take the essential first step away from the bedside toward the laboratory. This may be an achievement requiring new scientific insight, the invention of a method never before used or even a wild surmise. How- ever, once his discovery is in the laboratory, it becomes available to all bio- logical workers. To proceed much beyond this point then runs the risk of attempting something that others are better suited to accomplish."^ The clinician, therefore, is the “idea man.” With all the facilities available for re- search today, the trained personnel, and the millions of dollars to support them, the one real shortage is of original ideas. Astute clinicians can make up this deficiency.

Researchers in the basic sciences contribute to our dichotomy by presenting their reports often in an esoteric manner. It is erroneous indeed to assume that the audience here knows all the background in each special field. It is a mistake to present material in a way which shows only how much the in- dividual has learned, as though he was writing his thesis for a degree. His use of multiple abbreviations, formulas, and complex methodology leaves most of the audience with a certain respect for his prowess as a technologist, but he should better emphasize in what way his work contributes to knowledge of rheumatic diseases, and how it may be important to all in this field. When- ever possible, the scientist should follow Dr. Bauer’s advice and come closer to the bedside for a broader view of the problem.

There are those who have even proposed a third category of physicians in addition to the practitioners and researchers. Academicians are supposedly those with a primary interest in teaching. Paradoxically, this has suggested a

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solution to the whole problem, for there is actually no member of the American Rheumatism Association who is not a teacher. Every practitioner teaches his patients, his nurses, and his internes even though he may not conduct formal lectures in a medical school. Every medical researcher or scientist teaches his technicians, his assistants and associates. Every member of either group teaches when he presents or publishes a paper. Here is the common denominator for the entire society: the common responsibility and goal should be better teach- ing, or, if preferred, better communication.

A good teacher is one who presents any complicated subject simply and comprehensibly in a manner interesting to his audience. The good teacher strips the jargon and complicated details from the facts, and concentrates on the fundamental points he wishes his audience to grasp. An excellent illustrative example occurred recently when an expert electrical engineer tried for more than three hours to explain to a group of vitally interested physicians how a complicated piece of electronic apparatus functioned. The baffled physicians felt stupid and frustrated at the end of the dissertation. A renowned professor of physics happened to visit next day, and in a few minutes explained the apparatus, its functions, and how to use it. His presentation was so clear that none of the group will ever forget his words. Both the engineer and the physicist knew all the details of the apparatus, but the engineer had had little experience, and no skill, in teaching. His explanation was so encumbered with details that the principles were lost.

Complicated technical jargon is not good English, but rather a language of convenience to the technologist. Good teaching requires a minimum of jargon, abbreviations and formulas, as each of these require translations into English in the listener's mind, often causing loss of continuity in his comprehension of the presentation. A maximum of time should be allowed for explanatio'n of principles, conclusions, and thought-provoking conjecture. We would all do well to try out our paper first on someone of intelligence who knows nothing of our research and little of our discipline. His reactions and questions will soon show us where we have become esoteric and cease to be good teachers.

The American Rheumatism Association needs both its practitioners with their wide clinical experience and new ideas, and the basic scientists of many disciplines, with their special knowledge, ingenuity, and almost unlimited power of resourcefulness, to achieve its purpose. We all belong to this society to learn more about rheumatic disease, but we must all strive to become more effective teachers so that our new knowledge can be understood and ap- preciated by all.

REFERENCES 1. Standen, A.: Science is a Sacred Cow. 3. Wood, W. B., Jr.: From Miasmas to

New York, E. P. Dutton & Co., Molecules. New York & London, Co- 1950. lumbia University Press, 1961.

4. Watson, C. J.: The physician and the Scientific Revolution. New York, Cam- two cultures. Tr. A. Am. Physicians bridge University Press, 1959.

2. Snow, C. P.: The Two Cultures and the

74:1, 1961.

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5. Elkinton, J.: “Genetics and ironing,” or medicine, science and learning. New the two cultures and the physician. England J. Med. 265:1292, 1961. Ann. Int. Med. 56:523, 1962. 7. Castle, W. B.: Functional stresses with-

6. Bauer, W.: The responsibility of the in full time departments of medicine. university hospital in the synthesis of Tr. A. Am. Physicians 73:1, 1960.

Joseph Lee Hollander, M.D., Chief of Arthritis Section, Depart- ment of Medicine, Hospital of the University of Pennsylvanb; Professor of Medicine in the School of Medicine and Graduate School of Medicine, University of Pennsylvania, Philadelphia,

Pa.