and these four HLA specificities colitis due to Yersinia enterocolitica. provide our "HLA identity". The sys- Susceptibility to sacroiliitis in patients tem describes antigenic determinants with such conditions is also strongly asthought to be present on all cell mem- sociated with HLA-B27 positivity. Thus, branes; their biologic function is un- it appears that some link exists between known. This system arose from studies susceptibility of the sacroiliac joint to of the graft-v.-host rejection reaction in an inflammatory process of unknown organ transplantation. Transplantation cause and one specific cell antigen, of organs that differ in HLA-antigen which is determined genetically. specificity from the host provoke a The implications of this new knowlmore vigorous rejection response than edge of individual susceptibility to diswhen the antigen specificity is matched. ease are immense. HLA-B27 is present Genetic transmission of the HLA de- with equal frequency in males and terminants, as in the Rh system, is females but ankylosing spondylitis is inevitable and is not related to sex. not. Ankylosing spondylitis commonly Associations between certain antigen begins in the 2nd or 3rd decade of life; specificities and other diseases have apparently it can also begin in early been identified - multiple sclerosis, childhood, but its onset is exceedingly Hodgkin's disease, nonspecific colitis rare after age 40. What kind of hostand psoriasis are examples. However, environment interaction can be invoked the association between HLA-B27 and to explain these patterns? ankylosing spondylitis is the strongest. From data gathered so far, the gross Clinically, ankylosing spondylitis is "risk" of development of ankylosing an enigmatic disease. Not only is it spondylitis for HLA-B27-positive males thought to be more common in men is about one in five. This is certainly than women, but sacroiliac involve- true for Haida Indians and for those ment, a sine qua non for the diagnosis Caucasian populations studied. It is difof this disease, is more frequent than ficult to know what environmental facexpected in a variety of seemingly un- tor might provoke or trigger the disease related conditions, including psoriasis, in these susceptible subjects, for it must Reiter's syndrome, idiopathic uveitis, be common to the Haida Indians and ulcerative colitis, Crohn's disease and to Caucasians living in Los Angeles
or in London, England, and, furthermore, is apparently of equal influence in all three populations. The fact that about 10% of patients with clinical ankylosing spondylitis are HLA-B27 negative is provocative. Current work suggests that the HLA-B27 gene locus, and presumably the cell antigens dictated by it, may not be the critical determinant at all. Rather, the HLA-B27 gene may be a fortuitous label for other genetic factors, probably related to immune response genes. These would have to be located close to the HLA-B27 marker on the chromosome. HLA-B27-negative ankylosing spondylitis would then be explained by the separation on the chromosome of the marker HLA-B27 from the gene conferring "susceptibility", the patient possessing this gene but lacking the HLA-B27 label. Whatever the outcome of these studies, our understanding of this bafling group of diseases is certain to be advanced. It is to be hoped that soon prevention will be a reality and that rehabilitation in rheumatic diseases will be relegated to the archives of history. J.P. GoFroN, MD, FRCP[CJ Associate professor Department of medicine University of British Columbia Vancouver. BC
Medical education: edifice or edification? Medical education and research are ignored in the current controversy surrounding physicians' incomes and the cost of patient care. Medical schools are trampled as governments attempt to rectify monumental errors in planning by limiting the activities of hospitals, blaming physicians for overuse of facilities, and trimming support of that area where it is hoped the voter will not notice - research. Medicine is a complex and inexact science, and therefore extraordinarily difficult to teach. Medical education *differs from all other disciplines in that it demands the active participation of a third party - the patient. Failure to grasp that fundamental truth has led to the construction, in Canada, of glittering medical palaces remote from the hurly-burly of medical practice. Such edifices no more guarantee patients, teaching and research, than the shell guarantees the oyster (let alone the pearls of wisdom). Meanwhile, active general hospitals, serving large outpatient populations they can scarcely accommodate, struggle for subsistence. Here is the front line of medicine. Here is where the art should be taught, where money for
education can be spent most effectively, and where, logically, clinical research should be pursued. Surely we should start with patients and create around them medical schools, rather than erect academic shrines to which a supplicant population might be attracted. Obsolete structures must be modernized, replaced or in some cases relocated, but even more desperately needed is support for academic activities where clinical problems occur. People, not bricks, are the essentials. Medical education depends upon three activities: patient care, teaching and research. None is independent of the others. Medical teachers should include the busy practitioner and the medical scientist. The practitioner, generalist or specialist, should be forced daily to come to grips with the reality of medical care, yet be sufficiently free from financial constraint that he can see to the education of students. The medical scientist needs to be at the forefront of medical research, yet be able to communicate and work with practitioners and students in order to ensure the best in teaching and research. Neither one should dominate the other and there is ample need for
750 CMA JOURNAL/MAY 8, 1976/VOL. 114
hybrids of the two. What is important is that students, both undergraduate and postgraduate, should study the real problems of real patients, and have ready access to the skills and intellect of their clinical and scientific mentors. Where else can this be but the busy, large community hospital? It is sad that such an ideal does not exist in most teaching hospitals. Where appropriate patients and their problems are available, staff members are too busy with medical practice to be educators. Usually too little space is allocated to the medical scientist, who must base himself in another building, often at the other end of town. On the other hand, when hospitals are planted in the bucolic surroundings of the university campus, full-time academicians tend to see success in research as their sole purpose, and are pleased to immerse themselves in some obscure subject unhampered by the problems of "unscientific patients" or querulous students. Canada has long had a free ride with respect *to medical education. First, most bedside teaching has been done by volunteers who have donated their talent and time in return for a univer-
sity appointment. Second, our most fruitful research has been done by dedicated amateurs who asked for little but a place to work. The discovery of insulin, for example, cost very little. Finally, in 1975, Ontario alone registered more than 300 physicians from overseas, a practice undeniably cheaper than producing home-grown physicians. But times are changing. The private practitioner finds that an hour of unpaid teaching at a medical school, although intellectually rewarding, is penalized by the expense of his idle office. Research, like open tennis, has become too competitive and expensive for the dedicated amateur. Developing countries and the National Health Service of Great Britain will not indefinitely foot the bill for the training of a large proportion of our doctors. Medical education in this country needs direction. Since governments are "paying the shot", leadership to some extent must come from them, without endangering academic freedom. Medical schools must be centred where the action is: in community hospitals with extensive outpatient activities capable of providing primary, secondary and tertiary care. Medical staff at these hospitals should be chosen for their
clinical competence and their interest in academic medicine. Support must be provided, sufficient to remove financial insecurity yet retaining clinical or research incentive. The clinical teacher must be based in the hospital in order to be available to his students, yet have extensive community, primarycare or referral responsibilities, and so provide a continuing flow of patients to maintain the clinical relevance of medical education. Researchers must function in the hospital to expose students to the frontiers of medical science and yet remain in touch with the local medical scene. Restraint or no, can we not make better use of existing institutions by giving our clinical staff a base from which to teach? Offices in the hospital with expanded outpatient facilities could be provided. Clinical scientists could be equipped with laboratory facilities near the object of their ultimate interest: patients. Incentives to teach, innovate, administrate and research should be rewarded by academic advancement. This should depend not upon the flamboyance of one's specialty or the sheer weight of one's publications, but on the individual's exemplary patient care, his contribution to the
education of medical students, and the excellence of his research. Finally, medical research must be supported. The current freeze in research funds suggests a government misapprehension that we don't need to do research in Canada, that we can rely on that of others. Aside from the immorality of such a "cop-out", the danger is that, with the collapse of medical research, our standards of clinical science wiH decline, breeding a generation of physicians unable to interpret or implement advances made elsewhere. This attitude indicates a lack of perception of the inherent value of research in medical education. Thus, our university hospitals must become our medical schools. University and hospital administrations should work as one to achieve the best standard of medical care while ensuring that the finest teachers and medical scientists are available to the student. Such an endeavour needs to be vigorously supported by the government, the profession and the people, who surely have no interest in the decline and fall of medical education. W. GRANT THOMPSON, MD, FRCP[C]
Associate professor Department of medicine Ottawa Civic Hospital and University of Ottawa Ottawa, ON
Physicians, the scientific community and the future of science While it may be useful from time to time to check the bylaws, as it were, of the scientific community, it also may be desirable to examine the basic structure of this community and to scrutinize its general rules as they appear today. If scientists, physicians included, do not pay enough attention to this problem, others will, and it might then turn out that the whole construction is in need of some adjustments. Physicians, who must interpret many of the advances of medical science to their patients, particularly must pay heed to this problem. Physicians have long had a kind of guild with a high degree of independence and self-perpetuation. The same might be said of scientists. It cannot be denied that scientific training, at least at the higher levels, is administered by a relatively small group of leading men, who accept, guide, evaluate and promote the disciples who are looking for a future in the field. This means also that the problems selected by the masters, and offered to the disciples, will be selected by the same individuals who
are well acquainted with the situation and the frontiers of research. Their judgement will determine which research problems should be given priority. There are certain tendencies now - as has probably always been the case - to favour certain branches of research that appear to be fashionable. It is, of course, not wrong to join the herd that is grazing in a popular field or, to give a specific example, to enjoy a new, sophisticated and often expensive type of apparatus or equipment, but it may indicate some lack of independence. If a large number of parallel studies are made in a field enjoying temporarily special popularity, often much time and money may be wasted. Unfortunately, granting committees seem to think that the scientist then is working on problems of high priority, which might pave the way for research grants. Much of this behaviour could be avoided or prevented if the granting committees exercised more restriction in supporting such work. There is also a tendency to support work of limited
significance only if it promises to yield results useful for their statistics. Such work mostly can be expected to give results simply because it does not involve too many uncertain factors; hence it may be looked on as a good investment. Granting committees, however, should consider more earnestly withholding support to unnecessary work in a fashionable field and instead supporting significant new work involving greater risks. If the future of science is not to degenerate into the future of scientists, such tendencies should be looked for and corrected. Some scientists seem to identify themselves with the idea of science and to think that they are part of a suprastructure of almost magical qualities.1 The results of the scientific inquiry, it may be believed, then possess their own intrinsic value, distinct from the scientists producing the results. One may ask, To what extent are the consequences of scientific work and of knowledge gained by science a matter of responsibility for the scientist? Fran-
CMA JOURNAL/MAY 8, 1976/VOL. 114 751
or in London, England, and, furthermore, is apparently of equal influence in all three populations. The fact that about 10% of patients with clinical ankylosing spondylitis are HLA-B27 negative is provocative. Current work suggests that the HLA-B27 gene locus, and presumably the cell antigens dictated by it, may not be the critical determinant at all. Rather, the HLA-B27 gene may be a fortuitous label for other genetic factors, probably related to immune response genes. These would have to be located close to the HLA-B27 marker on the chromosome. HLA-B27-negative ankylosing spondylitis would then be explained by the separation on the chromosome of the marker HLA-B27 from the gene conferring "susceptibility", the patient possessing this gene but lacking the HLA-B27 label. Whatever the outcome of these studies, our understanding of this bafling group of diseases is certain to be advanced. It is to be hoped that soon prevention will be a reality and that rehabilitation in rheumatic diseases will be relegated to the archives of history. J.P. GoFroN, MD, FRCP[CJ Associate professor Department of medicine University of British Columbia Vancouver. BC
Medical education: edifice or edification? Medical education and research are ignored in the current controversy surrounding physicians' incomes and the cost of patient care. Medical schools are trampled as governments attempt to rectify monumental errors in planning by limiting the activities of hospitals, blaming physicians for overuse of facilities, and trimming support of that area where it is hoped the voter will not notice - research. Medicine is a complex and inexact science, and therefore extraordinarily difficult to teach. Medical education *differs from all other disciplines in that it demands the active participation of a third party - the patient. Failure to grasp that fundamental truth has led to the construction, in Canada, of glittering medical palaces remote from the hurly-burly of medical practice. Such edifices no more guarantee patients, teaching and research, than the shell guarantees the oyster (let alone the pearls of wisdom). Meanwhile, active general hospitals, serving large outpatient populations they can scarcely accommodate, struggle for subsistence. Here is the front line of medicine. Here is where the art should be taught, where money for
education can be spent most effectively, and where, logically, clinical research should be pursued. Surely we should start with patients and create around them medical schools, rather than erect academic shrines to which a supplicant population might be attracted. Obsolete structures must be modernized, replaced or in some cases relocated, but even more desperately needed is support for academic activities where clinical problems occur. People, not bricks, are the essentials. Medical education depends upon three activities: patient care, teaching and research. None is independent of the others. Medical teachers should include the busy practitioner and the medical scientist. The practitioner, generalist or specialist, should be forced daily to come to grips with the reality of medical care, yet be sufficiently free from financial constraint that he can see to the education of students. The medical scientist needs to be at the forefront of medical research, yet be able to communicate and work with practitioners and students in order to ensure the best in teaching and research. Neither one should dominate the other and there is ample need for
750 CMA JOURNAL/MAY 8, 1976/VOL. 114
hybrids of the two. What is important is that students, both undergraduate and postgraduate, should study the real problems of real patients, and have ready access to the skills and intellect of their clinical and scientific mentors. Where else can this be but the busy, large community hospital? It is sad that such an ideal does not exist in most teaching hospitals. Where appropriate patients and their problems are available, staff members are too busy with medical practice to be educators. Usually too little space is allocated to the medical scientist, who must base himself in another building, often at the other end of town. On the other hand, when hospitals are planted in the bucolic surroundings of the university campus, full-time academicians tend to see success in research as their sole purpose, and are pleased to immerse themselves in some obscure subject unhampered by the problems of "unscientific patients" or querulous students. Canada has long had a free ride with respect *to medical education. First, most bedside teaching has been done by volunteers who have donated their talent and time in return for a univer-
sity appointment. Second, our most fruitful research has been done by dedicated amateurs who asked for little but a place to work. The discovery of insulin, for example, cost very little. Finally, in 1975, Ontario alone registered more than 300 physicians from overseas, a practice undeniably cheaper than producing home-grown physicians. But times are changing. The private practitioner finds that an hour of unpaid teaching at a medical school, although intellectually rewarding, is penalized by the expense of his idle office. Research, like open tennis, has become too competitive and expensive for the dedicated amateur. Developing countries and the National Health Service of Great Britain will not indefinitely foot the bill for the training of a large proportion of our doctors. Medical education in this country needs direction. Since governments are "paying the shot", leadership to some extent must come from them, without endangering academic freedom. Medical schools must be centred where the action is: in community hospitals with extensive outpatient activities capable of providing primary, secondary and tertiary care. Medical staff at these hospitals should be chosen for their
clinical competence and their interest in academic medicine. Support must be provided, sufficient to remove financial insecurity yet retaining clinical or research incentive. The clinical teacher must be based in the hospital in order to be available to his students, yet have extensive community, primarycare or referral responsibilities, and so provide a continuing flow of patients to maintain the clinical relevance of medical education. Researchers must function in the hospital to expose students to the frontiers of medical science and yet remain in touch with the local medical scene. Restraint or no, can we not make better use of existing institutions by giving our clinical staff a base from which to teach? Offices in the hospital with expanded outpatient facilities could be provided. Clinical scientists could be equipped with laboratory facilities near the object of their ultimate interest: patients. Incentives to teach, innovate, administrate and research should be rewarded by academic advancement. This should depend not upon the flamboyance of one's specialty or the sheer weight of one's publications, but on the individual's exemplary patient care, his contribution to the
education of medical students, and the excellence of his research. Finally, medical research must be supported. The current freeze in research funds suggests a government misapprehension that we don't need to do research in Canada, that we can rely on that of others. Aside from the immorality of such a "cop-out", the danger is that, with the collapse of medical research, our standards of clinical science wiH decline, breeding a generation of physicians unable to interpret or implement advances made elsewhere. This attitude indicates a lack of perception of the inherent value of research in medical education. Thus, our university hospitals must become our medical schools. University and hospital administrations should work as one to achieve the best standard of medical care while ensuring that the finest teachers and medical scientists are available to the student. Such an endeavour needs to be vigorously supported by the government, the profession and the people, who surely have no interest in the decline and fall of medical education. W. GRANT THOMPSON, MD, FRCP[C]
Associate professor Department of medicine Ottawa Civic Hospital and University of Ottawa Ottawa, ON
Physicians, the scientific community and the future of science While it may be useful from time to time to check the bylaws, as it were, of the scientific community, it also may be desirable to examine the basic structure of this community and to scrutinize its general rules as they appear today. If scientists, physicians included, do not pay enough attention to this problem, others will, and it might then turn out that the whole construction is in need of some adjustments. Physicians, who must interpret many of the advances of medical science to their patients, particularly must pay heed to this problem. Physicians have long had a kind of guild with a high degree of independence and self-perpetuation. The same might be said of scientists. It cannot be denied that scientific training, at least at the higher levels, is administered by a relatively small group of leading men, who accept, guide, evaluate and promote the disciples who are looking for a future in the field. This means also that the problems selected by the masters, and offered to the disciples, will be selected by the same individuals who
are well acquainted with the situation and the frontiers of research. Their judgement will determine which research problems should be given priority. There are certain tendencies now - as has probably always been the case - to favour certain branches of research that appear to be fashionable. It is, of course, not wrong to join the herd that is grazing in a popular field or, to give a specific example, to enjoy a new, sophisticated and often expensive type of apparatus or equipment, but it may indicate some lack of independence. If a large number of parallel studies are made in a field enjoying temporarily special popularity, often much time and money may be wasted. Unfortunately, granting committees seem to think that the scientist then is working on problems of high priority, which might pave the way for research grants. Much of this behaviour could be avoided or prevented if the granting committees exercised more restriction in supporting such work. There is also a tendency to support work of limited
significance only if it promises to yield results useful for their statistics. Such work mostly can be expected to give results simply because it does not involve too many uncertain factors; hence it may be looked on as a good investment. Granting committees, however, should consider more earnestly withholding support to unnecessary work in a fashionable field and instead supporting significant new work involving greater risks. If the future of science is not to degenerate into the future of scientists, such tendencies should be looked for and corrected. Some scientists seem to identify themselves with the idea of science and to think that they are part of a suprastructure of almost magical qualities.1 The results of the scientific inquiry, it may be believed, then possess their own intrinsic value, distinct from the scientists producing the results. One may ask, To what extent are the consequences of scientific work and of knowledge gained by science a matter of responsibility for the scientist? Fran-
CMA JOURNAL/MAY 8, 1976/VOL. 114 751
