DEAR TOM: The intent of an arthritic professional educational program is to increase the awareness of all practitioners in the multiple problems of rheumatic disease. This can be accomplished in two ways: (A) with arthritis demonstration clinics and (B) regional arthritis seminars. Furthermore, a system for continued education of practicing physicians can be introduced so that professional education can be continued.

A demonstrative clinic is an out reach program by a team of experts that go into a community and conduct an arthritis clinic with local patients for local doctors. The patients receive expert consultations while the physicians see first hand how the rheumatologist conducts the examination, employs diagnostic techniques and executes therapy. Physicists and orthopedic surgeons are part of the team and are also used where indicated.

The seminars are didactic presentations at a professional level for formal educational purposes.

OBJECTIVES

(1) To increase the awareness of practicing physicians, including family practitioners, peditricians, internists and orthopedists of the multiple diagnostic, emotional, social, and therapeutic problems of patients with rheumatic diseases. (2) To provide a basic pathogenetic mechanism of the various rheumatic diseases so that intelligent diagnosis and management may result.

(3) To augment the clinical diagnostic acumen of practicing physicians regarding both the common and more esoteric rheumatic diseases.

(4) To inform the practicing physicians of the nature and availability of the several laboratory and roentgenographic tests of rheumatic diseases.

(5) To broaden the differential diagnosis of rheumatic disease presentations and provide skills for precise diagnosis.

(6) To familiarize the physician with the multiple management disciplines utilized in the care of rheumatic disease patients. These will include drug therapy, physical modalities, occupational therapies, surgery, psychosocial support and sexual and marital counseling.

(7) To increase the practicing physician's ability to appropriately manage a number of incomplicated arthritic problems.

(8) To provide guidelines for the referral of a rheumatic disease patient to a rheumatologist and to make substantial improvements in patterns of referrals

to the arthritis demonstration clinics especially of complicated rheumatic disease problems.

(9) To provide guidelines and indications for hospitalization of patients. (10) To increase the practicing physician's awareness and utilization of rehabilitation mechanisms for arthritis treatment.

(11) To facilitate a positive attitude on the part of physicians toward an intense contact experience with and the higher utilization of the allied health professionals who are necessary in the complete care of arthritic patients.

(12) To provide background information so that the practicing physician may serve as a coordinator in the basic care and rehabilitation of the arthritic patient.

(13) To promote effective collaborative relationships between the primary care practitioners and those in the specialties concerned with the treatment of arthritis.

(14) To provide strong links between the clinical arthritis centers and the outlying areas of the Greater Delaware Valley region.

(15) To evaluate the effectiveness of arthritis seminars which will be held periodically throughout the year and in conjunction with the arthritis demonstration clinics.

(16) To provide a stimulus for continuation of the educational activity after the expiration of this grant program by forming a strong bond between the physicians throughout the region and the specialists involved in this programmatic effort.

These symposia should consist of lectures by outstanding rheumatologists and orthopedics on both the diagnosis and management of a variety of rheumatic disorders. A symposium should last approximately 8 hours and will be conducted at a convenient location. The material presented should be collated into a manual presented to each course participant. Slides and film should augment the lectures. Audio tape cassettes can be available for those who prefer them. At each of the arthritis symposia, small group discussions can be provided in order to solve specific educational problems of some of the physicians. These sessions will be geared to problems in both diagnosis and management of rheumatologic disorders. Lectures and demonstrations will be standardized from clinic to clinic. Cognitive material to be presented should include but not be limited to the following:

1. Rheumatoid arthritis in adults and treatment-its diagnosis and treatment.

2. Rheumatoid arthritis, the "problem patient" and the team approach to a solution.

3. Diagnosis and management of ankylosing spondylitis and similar diseases including Reiter's syndrome and arthritis of ulcerative colitis. regional enteritis or psoriasis.

4. "When to diagnose a connective tissue disease?", specifically systemic tupus erythematosis, systemic sclerosis and polymocytis.

5. Infectious arthritis-early diagnosis and treatment.

6. Osteoarthritis-basic approaches to the common case and recognition that all cases can be effectively treated.

7. Nonarticular rheumatism in office practice

fibromyositis tendonitis.

8. Gout and pseudo-gout-methods of early diagnosis and managements.

9. Psychosocial aspects of patients with arthritis.

10. Sexual problems of the patient with arthritis.

11. Techniques of intraarticular aspirations and injections.

12. Management of the patient with chronic low-back pain.

13. Early and reconstructive surgery for arthritis.

14. The place of physical medicine and physical rehabilitation in the treatment of rheumatic disease.

This project represents a major effort to increase the knowledge and ability of primary care physicians and specialists concerned with arthritis, notably the diagnosis, management and rehabilitation of rheumatic disease patients. The conduct of the educational program for practicing physicians can provide an experience yielding continued benefits.

In the Delaware Valley alone, it is estimated that a minimum of 1,500 physicians per year could be retrained in this disease complex. The resources of the Arthritis Foundation are a natural mechanism for implementation.

Very sincerely,

53-100 0-75

JOHN L. SBARBAOR, Jr., M.D.

Mr. MASTERSON. The designation of the subject of my testimony before this committee this afternoon is a little misleading.

I am here on behalf of the eastern Pennsylvania chapter of the Arthritis Foundation as a member of its governing board to give the committee the benefit of the views of one of the countless thousands of volunteers who assist the foundation's 73 chapters across the Nation, attempting to bring public knowledge of, and support for, the early detection and treatment of this most crippling disease.

Later on in this committee's proceedings, Dr. Evan Calkins will appear before the committee with an eloquent plea concerning the overriding need to fund basic research and to establish regional treatment centers for this disease.

I am here to make a somewhat narrower point, basically, to ask that the committee do what it can to assure that of the funds eventually appropriated for the massive attack on arthritis that Congress has already indicated it is determined to mount on the Nation's No. 1 crippler sufficient funds be made available through appropriate agencies so that an ongoing systematic, professional education program can be carried on to bring to the physicians in the field the benefits of what we already know about how to detect, treat, and manage this disease.

We prepared, if the Chair please, a simple exhibit which I am going to refer to, because I think it graphically describes the problem.

This is a simple map of the 22-county area with which the eastern Pennsylvania chapter of the Arthritis Foundation deals.

The numbers tell a story, once you relate them to the key. The numbers in black are the numbers of sufferers of arthritis in the respective counties.

The numbers appearing in blue in brackets are the number of physicians in those counties.

The numbers appearing in red in brackets are the numbers of physicians who have been members of the American Rheumatism Association and, therefore, who have had advanced training in the modern technique of early diagnosis and treatment of the disease and the numbers in red, without brackets, are the numbers and location-I should say represent the numbers and locations of qualified rheumatologists. Now, just looking at the gross figures, this little chart tells a story. In the 22-county area, there are approximately half a million sufferers of arthritis in one of its many forms.

In that same area there are 44 trained rheumatologists. That makes a sufferer-patient ratio of about 1 to 13,000. In the same general area there are about 90 physicians who are members of the American Rheumatism Association and who have made it their business to maintain currency with respect to the techniques of diagnosis and management or arthritis.

That gives a ratio of approximately 1 trained man for every 6,000 patients.

If you will look at Luzerne County, Mr. Chairman, the map would indicate there are approximately 34,230 sufferers of arthritis; there are 411 physicians throughout the county, and there are 4 physicians who are members of the American Rheumatism Association.

Mr. FLOOD. Of all the counties in the United States, why would you pick Luzerne County?

Mr. MASTERSON. I thought the Chair might have some familiarity

with it.

Another interesting thing that this map demonstrates, which I would suspect would be fairly typical-is that of the approximately 42 trained rheumatologists in the whole 22-county area, there are 13 counties which not only do not have a trained rheumatologist but they do not even have a physician who is a member of the ARA.

Mr. FLOOD. Is Philadelphia included?

Mr. MASTERSON. Yes, sir. Philadelphia is down here, it is the smallest county in terms of geographic area.

Mr. FLOOD. It is in that batch?

Mr. MASTERSON. Right down at the very bottom of the chart.
Mr. FLOOD. I know where it is.

Mr. MASTERSON. And that tells another story.

Of the 42 trained rheumatologists in the whole surrounding 22 counties, 41 of them are in Philadelphia, Delaware, or Montgomery Counties, and that is because they work closely with the six medical teaching hospitals in Philadelphia. But the net result is the whole northern part of this territory is virtually virgin territory so far as persons trained to deal with this particular disease.

Now, the significance of that is this: If you just look at these numbers, it is graphically clear that the ordinary sufferer of arthritis is not going to get to an ARA member, let alone a fully qualified rheumatogolist. He has to depend upon his family physician, the general practitioner, to help him with the disease.

There rises the problem because, as a result of the research that has been done, much of it funded by the Federal Government in the last 20 years, there has been an explosion of knowledge about the nature and treatment for this disease, such that no busy physician can possibly cope with what we now know concerning detection and treatment of this disease.

The net result is that there is a tendency for sufferers from this disease to appear before a physician complaining of a vague pain in the back or a pain in the joint and the normal thing for the physician to do is to treat it symptomatically, give them some aspirin, and so forth. What happens very frequently is that that person has a form of progressively crippling rheumatoid arthritic disease which, if properly diagnosed early enough, can be fully arrested; but, unfortunately, very often it is not diagnosed properly soon enough, with the net result that that patient ultimately becomes crippled, and by the time the symptoms reach the point where the local physician recognizes that specialized treatment is in order, it is too often too late.

Now, referring back to this chart again, it is really a simple logistic problem.

Down here where you see all the red, where you see the trained rheumatologists and the clustering of the members of the ARA, in those hospitals and in those laboratories there presently exists today knowledge which, if translated out here, could help countless numbers of these patients who, for want of that knowledge, will become cripples and add to those enormous statistics that are in the recitals of the 1974 Arthritis Act.

I have attached to the written testimony a two-page statement by Dr. Sbarbaro of what has been done on a pilot basis in this area.

It has been accomplished in the last year on an appropriation of a little under $200,000. Basically, it is an attempt to translate the laboratory and hospital knowledge that exists down here in the south

eastern corner out into the field. The way that is done is by having seminars lasting 2- and 3-days at which doctors or physicians are brought in to be exposed to lectures and demonstration clinics by these specialists whose life is this disease.

They bring with them the train of experts which have now been developed in the highly organized medical centers to treat this disease. Dr. Calkins will have more to say about those teams.

Mr. FLOOD. I am sure he will.

Mr. MASTERSON. But what we ask, sir, is that in considering this entire problem, that you remember simply this: That we all want to see money to fund research, to find the cause and cure of this disease, but at the same time, it is equally vitally important to the millions of people who suffer from the disease, that the knowledge we already have concentrated in medical centers be disseminated to the practicing physicians who are the people on the firing line who are going to be treating the disease.

Mr. FLOOD. Thank you very much.
Mr. MASTERSON. Thank you, sir.

SIDNEY FARBER CANCER CENTER

WITNESS

DR. NORMAN JAFFEE, SIDNEY FARBER CANCER CENTER, HAR

VARD MEDICAL SCHOOL

Mr. FLOOD. Dr. Norman Jaffee of the Sidney Farber Cancer Center, Harvard Medical School.

Dr. JAFFEE. Thank you, Mr. Chairman.

Mr. FLOOD. We have these two charts that you have shown us.

Dr. JAFFEE. Yes, sir, I will refer to them. I have no statistical tables with me, but I do have those two charts and I shall refer to them shortly.

Instead, I would like to tell you how some of the appropriations from this committee are spent on a day-to-day basis in the treatment of bone cancer.

I will say about 700 words and submit a written statement for the record. Bone cancer afflicts children and youth mostly.

Ordinarily, it arises in the thigh, upper part of the leg, or upper part of the arm near the shoulder, though any part of the skeleton might be affected.

Mr. FLOOD. Why does it start there?

Dr. JAFFEE. The reasons are undetermined.

Mr. FLOOD. All right.

Dr. JAFFEE. The standard treatment has been to amputate wherever possible. The kind of research I and others are doing proves that some burn amputations can be avoided and life can be extended. But even if amputation is, so to speak, successful, the majority of patients have microscopic tumors in their lungs, so-called metastases, at the time the so-called bone cancer is diagnosed. This is what they die of. The survival rate in the most favorable circumstances varies from 15 to 20 percent. This is illustrated in chart No. 1 if you would kindly refer to it. The patient on the left-hand side has a tumor in the leg.