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Forward Thrust the Presidential Address
GASTROENTEROLOGY Official Publication of the American Gastroenterological Association ©
VoLUME
CoPYRIGHT 1967 THE WILLIAMS
53
&
WILKINS Co.
SeptembeT 1967
NuMBER
3
FORWARD THRUST
THE PRESJDENTIAL ADDRESS W ADE VOLWILER,
M.D.
University of Washington, Seattle, W a.~hington
Forward Thrust is the title chosen in 1966 by a volunteer group of leading Seattle citizens for their new program of community effort for progress. Sensing the tremendous social impact and challenge of the coming industrial and population growth in the Puget Sound basin, this committee of 200 wise leaders informally set for itself the tasks of visionary planning, stimulation of creative leadership, and implementation of sound ideas to solve many of the regional social and cultural needs anticipated for the decade ahead. The very words "Forward Thrust" indicate a wisely planned, forcefully pursued program for progress. If skillfully pursued under sound organization with courage and persistence, such a movement in any fi eld should have tremendous impact and produce far reaching accomplishment. Just such a Forward Thrust program is urgently needed in our country in the field of - digestive diseases. Fortunately, some components of such a movement have already begun to operate. But far more is urgently called for in breadth, depth, and develop-
ment. To muster the components will take much energy and dedication. In February 1967, a "milestone" Conference on Digestive Diseases as a National Problem was held in Bethesda, Maryland, under the joint auspices of the American Gastroenterological Association, the National Institute of Arthritis and Metabolic Diseases, and the Digestive Disease Foundation. There, for the first time, leading representatives from industry, govcm m ent, the military, and scientific and educational organizations met to examine together five areas: ( 1) the magnitude of digestive diseases in our citizens, (2) the state of our knowledge of the most prevalent and disabling gastrointestinal di sorders , (3) the current manpower available to attend to digestive illness in our communities, (4) the current manpower employed to teach and to pursue research in this field, and (5) the amount of support and encouragement now provided for training and for research in Gastroenterology. Accurate facts were culled from many sources. These proved strikingly that, during the most productive decades of the Presidential Address delivered at the 68th lives of our citizens, disorders of the gasAnnual Meeting of the American Gastroenterotrointestinal system currently lead as the logical Association, Colorado Springs, Colorado, principal cause of misery, absenteeism May 26, 1967. from work, and economic disability. Address requests for reprints to: Dr. Wade The National Center for Health StatisVolwiler, School of Medicine, University of Washington, Seattle, W ashington 98105. tics reported that digestive diseases are 3G7
368
PRESIDENTIAL ADDRESS
the leading cause of hospitalization in our general population, produce more days of hospita l stay than illnesses of any other body sy stem, are, for all decades, the second m aj or cause of days lost from work, and are the third leading cause of death. A very large survey by the American Cancer Society shows that half of our population over 30 years of age has significant digestive complaints. Diseases of the digestive system are among the principal causes of noneffectiveness in our military units. A cross the United States, 17% of all hospitalized patients have primarily digestive disorders, and 23% of all nonobstetrical surgical operations are executed for gastrointestinal diseases. In the large priv ate clinics of this country, digestive problems lead the list of reasons for patient r eferra l. Thirty-one per cent of all cancer d eaths expected in the United States in 1967 will be from neoplasms of gastrointestin a l origin. Cirrhosis of the liver is now the fourth cause of death in this country in m a les over 40 years of age. For the 800,000 employees of the American Bell T elephone System, gastrointestinal illness is the leading cause of sickness among the m a les ; resulting benefit p ayments for time lost from work for these employees alone approximates $12 million per year. Among the workers of the Metropolitan Life Insurance Company, digestive diseases lead in disability claims. A study by the Rand Corporation indicates that the total cost of peptic ulcer alone in 1963 in the United States was over one billion dollars. In our Veterans Hospitals, direct care costs for gastrointestinal illnesses are now $83 million annually. "\iV e are woefully ignorant of the cause of and solution to the majority of the principal gastrointestinal disorders in our citizens. Our knowledge of the cause of peptic ulcer is fragmentary. Although associated with gastric acid production, other factors r elating to the defense of mucosal integrity are probably of greater importance, and ·we know almost nothing about them. "\Vhereas we can with skill remove gallstones surgically, we know almost nothing about the reasons that these arise in 10% of our m en and 20% of our women. Of all
Vol. 6.'1, N o. 3
chronic recurring diseases of the digestive system, inflammatory bowe l disorders lead in the d egree of recurring invalidism and economic stress: our know ledge of these conditions is largely descriptive. We have no sp ecific medical t her a pies, but can readily extirpate diseased segments-only to await frequent recurrence. Gastroenteritis rivals the common cold as a cause of military ineffectiveness a nd absenteeism from work. We know almost nothing about the cause of this condition. Jl;ven in viral hepatitis, a leading civilian and military problem, we have never identified the causative agents and have no therapy to offer; our knowledge is epidemiological and descriptive. Manpower is threateningly short in all categories of United States medical personnel. But compared to the prevalence and importance of the digestive disorders, the current situation here is fa r worse than for most other categories of illness. It is estimated that there are only 2000 physician s in the entire country who express a specific interest in and knowledge of gastroenterology; of t hese, only 540 have been certified as gastrointestinal specialists. In each of 24 states of the Union, there are not even 10 physicians expert in this field, and four states have none at all. In our medical school faculties there are only half as many full time gastroenterology teachers as cardiology teachers. The a mount of research effo rt, measured in a nnual dollar support, now being expended to solve the digestive disease problems in our country is pitifully small compared to that devoted to the cardiovascular diseases. Although a variety of agencies contribute significantly, the main current source is from the National Institutes of H ea lth. The annual extramural research and tra ining support from all institutes of NIH for the digestive disease area was last year only about $22 million, or just 2.5 % of the total alloca tions. Currently, the NIH does not possess a significant, comprehensively developed, intramural research program in gastroenterology; less than a handful of high quality, individual investigators pursue single project areas commanding only $400,000 yearly in sup-
Septembe1· 1967
PRESTDEN1'IA L ADDRESS
port. The NIH does not have an over-all central advisory and planning body specifically concerned with the digestive field. The home of gastroenterology has been in the National Institute of Arthritis and Metabolic Diseases, where the quality of work is indeed excellent. But gastroenterology at times is almost "buried" among the 12 specialties fostered by that Institute. One can contrast this state of affairs with that of the cardiovascular disorders, for which a special Heart Institute exists with a strong fo cus of attention and leadership planning for cardiovascular and related disorders, expending last year over $87 million for extramural direct research grants alon e. The reasons for these disparities are numerous and complex. It is not r eally so much t ha t government sources have fail ed the digestive field in the past, as that the recent ra pid growth and challenges of our field are far outstripping the existing mechanisms for support and planning. Nowadays, other leading medical fieldR possess nationally well d eveloped, lay volunteer organizations of considerable influence, closely affiliated with their corresponding professional societies. By disseminating information to the lay public, and by implementing and expediting unique educational and research enterprises, these organizations, if wisely constructed, can very greatly enhance the progress of a medical spec ialty. The Digestive Disease Foundation is a high quality and wisely arranged organization, although currently very small. Its possible expansion a nd development on a. truly national scale is beginning to be di:::cussed. In the specialist training field, currently about 200 physicians are in gastroenterology training programs as compared with at least 65% greater numbers in cardiology. The extramural research training programs in gastroenterology of the National Institute of Arthritis and Metabolic Diseases are of high quality and capably administered. But our country does not have currently any national or significant source of funds to support the training of physician specialists specifically for the
3()9
practice of gastroenterology in our communities and amon g our citizens. Can there be any doubt that a Forward Thrust program in our country for the broa d fi eld of digestive diseases is now haunting us with a plea for accomplishm ent? The American Gastroenterological Association would certainly be expected to play a key role in such a movement. Yet it h as many characteristics and problems which could inhibit its entering effectively into the full opportunities and meeting the challenges clearly evident ahead. Our organization is actually the oldest medical subspecialty society of American medicine, founded in 1897. It has traclitionally been a proud honor society, carefully selecting its members on the basis of competent professional, scientific, and personal qualifications to join in scholarly discussions of clinical and scientific aspects of digestive tract disorders. It has sponsored a relatively small number of excellent achievements in scientific communication a nd professional education. These include such important recent items as our occasional postgraduate courses, the 1958 World Congress of Gastroenterology in Washington, D. C., the 1962 P a n American Congress of Gastroenterology in New York City, the much improved journal Gastroenterology, and occasional special program features of our annua l scientific sessions. L et us be proud of but not complacent a bout these fine contributions of the past. Quantitatively much more waits to be accomplished. This Association has always assumed that it was the leading spokesm a n for its subspecia lty, but until very recently our society has skillfully avoided undertaking strong official roles of public influence and leadership, for such objectives as (1) the expansion of specialty training programs, (2) the substantial furthering of research efforts, and (3) a broadening of techniques and extent of professional communication and education. In the past, this A ssociation has often failed to compete successfully with other societies for the initi a l presentation of the most exciting research in the digestive
370
PRESIDENTIAL ADDRESS
fi eld; fortunately this situation is improving. Our society has cla imed to be the leading organization for fostering expert clinical practice of gastrointestinal medicine, and yet it has not in the last decade encouraged practitioners interested in the gastrointestinal field who seek both basic and practical information for the care of the American public, nor h as it featured to any sizeable extent at its annual sessions, information directed primarily to clinical practice. The Association has made some attempts to bring together in its m embership and programs leaders of a variety of scientific fields working with the digestive system. However, such endeavors for groups other than internists have been characterized in the past by brief and somewhat temporary spurts. The AGA is now in a strategic position with opportunity to widen its influence a nd activities so as to knit more firmly together all scientific disciplines concerned with the gastrointestinal system. It could readily fa cilitat e arrangements whereby the special bran ches of medicine may collaborate in a variety of research and educational ventures. The manpower and information shortage in our country in the fi eld of digestive disorders is also truly a burden of responsibility at our doorstep . Through wise leadership and influence , this Association must assume additional responsibility in national efforts to improve training and educational activities for G astroenterology. At our annual sessions, a far greater variety of program activities would be helpful ; possible examples include added varieties of special t opic workshops, orientation sessions in molecular biology for our practicing specialists, postgraduate courses covering in depth limited areas of this large field (to be added, of course, to the traditional courses covering very bro a d territory), simultan eous ly held programs for small subgroups focusing on quite specialized interests, and the provision of more material of immediate use to the practicing specialist. The dissemination of current knowledge in our field
Vol. 53, N o. 3
would be greatly enhanced by the provision of a monthly bulletin on concepts and recent d evelopments, analogous to the publications Modern Concepts of Cardiovascular Disease and The Bulletin on the Rheuma tic Diseases, which are widely available at a nominal cost. The accomplishment of su ch important goa ls can be thwarted severe ly by lack of ambition and zest, lack of a sense of national responsibility, lack of leadership manpower and its suitable arrangement, lack of fin ancial support, or by political or personal selfishness. At the present time, this organization does not possess either the machinery or the fin ancia l structure for mounting such a barrage of Forward Thrust programs. But are not these types of enterprises suitable and desirable objectives for the American G astroenterologica l Association? Do we not have the courage, energy, and leadership to reach more r apidly in these directions ? American medicine, propelled by growing social and political pressures from our citizens, is now entering rapidly into t he acceptance of r esponsibility for many types of Forward Thrust programs. Will this Association improve its alertness, a mbition, leadership, a nd influence so as to contribute strongly to this further flowering of American m edicine ? Or will it retreat into sleepy clubbishness with protective, limited perspectives, thereby developing the pediatric syndrome termed "failure t o t hrive"? I believe sincerely that the members of this association and its current leaders have already decided that our organization should embark on a full , high quality Forward Thrust program with responsibility a nd with pride. But, m embers and colleagu es, it will require conscientious effo rt, persistent hard work, unwavering determination, original actions, and unselfishn ess in order to achieve these proper, much-needed contribut:ons t o the effectiveness of American medicine in behalf of the citizens of our country. Exciting opportunities are knocking at our t hreshold with urgent pleas.
VoLUME
CoPYRIGHT 1967 THE WILLIAMS
53
&
WILKINS Co.
SeptembeT 1967
NuMBER
3
FORWARD THRUST
THE PRESJDENTIAL ADDRESS W ADE VOLWILER,
M.D.
University of Washington, Seattle, W a.~hington
Forward Thrust is the title chosen in 1966 by a volunteer group of leading Seattle citizens for their new program of community effort for progress. Sensing the tremendous social impact and challenge of the coming industrial and population growth in the Puget Sound basin, this committee of 200 wise leaders informally set for itself the tasks of visionary planning, stimulation of creative leadership, and implementation of sound ideas to solve many of the regional social and cultural needs anticipated for the decade ahead. The very words "Forward Thrust" indicate a wisely planned, forcefully pursued program for progress. If skillfully pursued under sound organization with courage and persistence, such a movement in any fi eld should have tremendous impact and produce far reaching accomplishment. Just such a Forward Thrust program is urgently needed in our country in the field of - digestive diseases. Fortunately, some components of such a movement have already begun to operate. But far more is urgently called for in breadth, depth, and develop-
ment. To muster the components will take much energy and dedication. In February 1967, a "milestone" Conference on Digestive Diseases as a National Problem was held in Bethesda, Maryland, under the joint auspices of the American Gastroenterological Association, the National Institute of Arthritis and Metabolic Diseases, and the Digestive Disease Foundation. There, for the first time, leading representatives from industry, govcm m ent, the military, and scientific and educational organizations met to examine together five areas: ( 1) the magnitude of digestive diseases in our citizens, (2) the state of our knowledge of the most prevalent and disabling gastrointestinal di sorders , (3) the current manpower available to attend to digestive illness in our communities, (4) the current manpower employed to teach and to pursue research in this field, and (5) the amount of support and encouragement now provided for training and for research in Gastroenterology. Accurate facts were culled from many sources. These proved strikingly that, during the most productive decades of the Presidential Address delivered at the 68th lives of our citizens, disorders of the gasAnnual Meeting of the American Gastroenterotrointestinal system currently lead as the logical Association, Colorado Springs, Colorado, principal cause of misery, absenteeism May 26, 1967. from work, and economic disability. Address requests for reprints to: Dr. Wade The National Center for Health StatisVolwiler, School of Medicine, University of Washington, Seattle, W ashington 98105. tics reported that digestive diseases are 3G7
368
PRESIDENTIAL ADDRESS
the leading cause of hospitalization in our general population, produce more days of hospita l stay than illnesses of any other body sy stem, are, for all decades, the second m aj or cause of days lost from work, and are the third leading cause of death. A very large survey by the American Cancer Society shows that half of our population over 30 years of age has significant digestive complaints. Diseases of the digestive system are among the principal causes of noneffectiveness in our military units. A cross the United States, 17% of all hospitalized patients have primarily digestive disorders, and 23% of all nonobstetrical surgical operations are executed for gastrointestinal diseases. In the large priv ate clinics of this country, digestive problems lead the list of reasons for patient r eferra l. Thirty-one per cent of all cancer d eaths expected in the United States in 1967 will be from neoplasms of gastrointestin a l origin. Cirrhosis of the liver is now the fourth cause of death in this country in m a les over 40 years of age. For the 800,000 employees of the American Bell T elephone System, gastrointestinal illness is the leading cause of sickness among the m a les ; resulting benefit p ayments for time lost from work for these employees alone approximates $12 million per year. Among the workers of the Metropolitan Life Insurance Company, digestive diseases lead in disability claims. A study by the Rand Corporation indicates that the total cost of peptic ulcer alone in 1963 in the United States was over one billion dollars. In our Veterans Hospitals, direct care costs for gastrointestinal illnesses are now $83 million annually. "\iV e are woefully ignorant of the cause of and solution to the majority of the principal gastrointestinal disorders in our citizens. Our knowledge of the cause of peptic ulcer is fragmentary. Although associated with gastric acid production, other factors r elating to the defense of mucosal integrity are probably of greater importance, and ·we know almost nothing about them. "\Vhereas we can with skill remove gallstones surgically, we know almost nothing about the reasons that these arise in 10% of our m en and 20% of our women. Of all
Vol. 6.'1, N o. 3
chronic recurring diseases of the digestive system, inflammatory bowe l disorders lead in the d egree of recurring invalidism and economic stress: our know ledge of these conditions is largely descriptive. We have no sp ecific medical t her a pies, but can readily extirpate diseased segments-only to await frequent recurrence. Gastroenteritis rivals the common cold as a cause of military ineffectiveness a nd absenteeism from work. We know almost nothing about the cause of this condition. Jl;ven in viral hepatitis, a leading civilian and military problem, we have never identified the causative agents and have no therapy to offer; our knowledge is epidemiological and descriptive. Manpower is threateningly short in all categories of United States medical personnel. But compared to the prevalence and importance of the digestive disorders, the current situation here is fa r worse than for most other categories of illness. It is estimated that there are only 2000 physician s in the entire country who express a specific interest in and knowledge of gastroenterology; of t hese, only 540 have been certified as gastrointestinal specialists. In each of 24 states of the Union, there are not even 10 physicians expert in this field, and four states have none at all. In our medical school faculties there are only half as many full time gastroenterology teachers as cardiology teachers. The a mount of research effo rt, measured in a nnual dollar support, now being expended to solve the digestive disease problems in our country is pitifully small compared to that devoted to the cardiovascular diseases. Although a variety of agencies contribute significantly, the main current source is from the National Institutes of H ea lth. The annual extramural research and tra ining support from all institutes of NIH for the digestive disease area was last year only about $22 million, or just 2.5 % of the total alloca tions. Currently, the NIH does not possess a significant, comprehensively developed, intramural research program in gastroenterology; less than a handful of high quality, individual investigators pursue single project areas commanding only $400,000 yearly in sup-
Septembe1· 1967
PRESTDEN1'IA L ADDRESS
port. The NIH does not have an over-all central advisory and planning body specifically concerned with the digestive field. The home of gastroenterology has been in the National Institute of Arthritis and Metabolic Diseases, where the quality of work is indeed excellent. But gastroenterology at times is almost "buried" among the 12 specialties fostered by that Institute. One can contrast this state of affairs with that of the cardiovascular disorders, for which a special Heart Institute exists with a strong fo cus of attention and leadership planning for cardiovascular and related disorders, expending last year over $87 million for extramural direct research grants alon e. The reasons for these disparities are numerous and complex. It is not r eally so much t ha t government sources have fail ed the digestive field in the past, as that the recent ra pid growth and challenges of our field are far outstripping the existing mechanisms for support and planning. Nowadays, other leading medical fieldR possess nationally well d eveloped, lay volunteer organizations of considerable influence, closely affiliated with their corresponding professional societies. By disseminating information to the lay public, and by implementing and expediting unique educational and research enterprises, these organizations, if wisely constructed, can very greatly enhance the progress of a medical spec ialty. The Digestive Disease Foundation is a high quality and wisely arranged organization, although currently very small. Its possible expansion a nd development on a. truly national scale is beginning to be di:::cussed. In the specialist training field, currently about 200 physicians are in gastroenterology training programs as compared with at least 65% greater numbers in cardiology. The extramural research training programs in gastroenterology of the National Institute of Arthritis and Metabolic Diseases are of high quality and capably administered. But our country does not have currently any national or significant source of funds to support the training of physician specialists specifically for the
3()9
practice of gastroenterology in our communities and amon g our citizens. Can there be any doubt that a Forward Thrust program in our country for the broa d fi eld of digestive diseases is now haunting us with a plea for accomplishm ent? The American Gastroenterological Association would certainly be expected to play a key role in such a movement. Yet it h as many characteristics and problems which could inhibit its entering effectively into the full opportunities and meeting the challenges clearly evident ahead. Our organization is actually the oldest medical subspecialty society of American medicine, founded in 1897. It has traclitionally been a proud honor society, carefully selecting its members on the basis of competent professional, scientific, and personal qualifications to join in scholarly discussions of clinical and scientific aspects of digestive tract disorders. It has sponsored a relatively small number of excellent achievements in scientific communication a nd professional education. These include such important recent items as our occasional postgraduate courses, the 1958 World Congress of Gastroenterology in Washington, D. C., the 1962 P a n American Congress of Gastroenterology in New York City, the much improved journal Gastroenterology, and occasional special program features of our annua l scientific sessions. L et us be proud of but not complacent a bout these fine contributions of the past. Quantitatively much more waits to be accomplished. This Association has always assumed that it was the leading spokesm a n for its subspecia lty, but until very recently our society has skillfully avoided undertaking strong official roles of public influence and leadership, for such objectives as (1) the expansion of specialty training programs, (2) the substantial furthering of research efforts, and (3) a broadening of techniques and extent of professional communication and education. In the past, this A ssociation has often failed to compete successfully with other societies for the initi a l presentation of the most exciting research in the digestive
370
PRESIDENTIAL ADDRESS
fi eld; fortunately this situation is improving. Our society has cla imed to be the leading organization for fostering expert clinical practice of gastrointestinal medicine, and yet it has not in the last decade encouraged practitioners interested in the gastrointestinal field who seek both basic and practical information for the care of the American public, nor h as it featured to any sizeable extent at its annual sessions, information directed primarily to clinical practice. The Association has made some attempts to bring together in its m embership and programs leaders of a variety of scientific fields working with the digestive system. However, such endeavors for groups other than internists have been characterized in the past by brief and somewhat temporary spurts. The AGA is now in a strategic position with opportunity to widen its influence a nd activities so as to knit more firmly together all scientific disciplines concerned with the gastrointestinal system. It could readily fa cilitat e arrangements whereby the special bran ches of medicine may collaborate in a variety of research and educational ventures. The manpower and information shortage in our country in the fi eld of digestive disorders is also truly a burden of responsibility at our doorstep . Through wise leadership and influence , this Association must assume additional responsibility in national efforts to improve training and educational activities for G astroenterology. At our annual sessions, a far greater variety of program activities would be helpful ; possible examples include added varieties of special t opic workshops, orientation sessions in molecular biology for our practicing specialists, postgraduate courses covering in depth limited areas of this large field (to be added, of course, to the traditional courses covering very bro a d territory), simultan eous ly held programs for small subgroups focusing on quite specialized interests, and the provision of more material of immediate use to the practicing specialist. The dissemination of current knowledge in our field
Vol. 53, N o. 3
would be greatly enhanced by the provision of a monthly bulletin on concepts and recent d evelopments, analogous to the publications Modern Concepts of Cardiovascular Disease and The Bulletin on the Rheuma tic Diseases, which are widely available at a nominal cost. The accomplishment of su ch important goa ls can be thwarted severe ly by lack of ambition and zest, lack of a sense of national responsibility, lack of leadership manpower and its suitable arrangement, lack of fin ancial support, or by political or personal selfishness. At the present time, this organization does not possess either the machinery or the fin ancia l structure for mounting such a barrage of Forward Thrust programs. But are not these types of enterprises suitable and desirable objectives for the American G astroenterologica l Association? Do we not have the courage, energy, and leadership to reach more r apidly in these directions ? American medicine, propelled by growing social and political pressures from our citizens, is now entering rapidly into t he acceptance of r esponsibility for many types of Forward Thrust programs. Will this Association improve its alertness, a mbition, leadership, a nd influence so as to contribute strongly to this further flowering of American m edicine ? Or will it retreat into sleepy clubbishness with protective, limited perspectives, thereby developing the pediatric syndrome termed "failure t o t hrive"? I believe sincerely that the members of this association and its current leaders have already decided that our organization should embark on a full , high quality Forward Thrust program with responsibility a nd with pride. But, m embers and colleagu es, it will require conscientious effo rt, persistent hard work, unwavering determination, original actions, and unselfishn ess in order to achieve these proper, much-needed contribut:ons t o the effectiveness of American medicine in behalf of the citizens of our country. Exciting opportunities are knocking at our t hreshold with urgent pleas.