PROCEEDINGS: VOLUME | JANUARY 17-19, 1968 WASHINGTON, D.C. + WEL UTE i) ul Tea ee SERVICE « U.S. DEPARTMENT OF HEALTH, EDUCATION, AND ang 13 4 PROCEEDINGS: conference- workshop on REGIONAL MEDICAL PROGRAMS VOLUME | Plenary Sessions e Panel and Discussion Groups e Related Background Information on Conference-Workshop (Appendices) VOLUME H 15-Minute Papers on Regional Activities and Ideas JANUARY 17-19, 1968 * WASHINGTON, D.C. » NATIONAL INSTITUTES OF HEALTH PUBLIC HEALTH SERVICE + U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Publication No. 1774 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C, 20402 - Price $1.50 (paper cover) PREFACE The January 1968 Conference- Workshop on Regional Medical Pro- grams, the proceedings of which are reproduced in these two volumes, was significant in origin, content and purpose, and marked a milestone in the development of Regional Medi- cal Programs. Growing out of a specific request of the Program Coordinators at their meeting in June 1967, this meeting was planned by the Steering Com- mittee of Coordinators under the Chairmanship of Dr. Stanley W. Ol- son, Program Coordinator of the Tennessee Mid-South Regional Med- ical Program. Its purpose was to pro- vide those directly involved in the development of Regional Medical Programs the opportunity to ex- change ideas and information which would be of benefit in the further implementation of their programs at the regional level. The focus was on what Dr. Lowell T. Coggeshall in his summary paper called “the emerging substance” reflected in the on-going activities in the regions, particularly as they related to the key issues of this program, the quality and avail- ability of health care for heart dis- ease, cancer, stroke, and related diseases. To achieve these goals the Steering Committee invited all regions to pre- sent papers on regional activities and ideas; to submit exhibits which could be viewed and demonstrated; and to participate actively in panel discus- sions. This invitation resulted in the presentation of 60 representative pa- pers and more than 40 exhibits. Fur- thermore, virtually every invited speaker accepted the opportunity to discuss the major issues of the Con- ference-Workshop. The University of Mississippi Med- ical Center and the Stanford Univer- sity School of Medicine kindly grant- ed leave to Dr. John A. Gronvall and Mr. Robert G. Lindee, respectively, to act as Conference-Workshop Co- chairmen. These two men established and directed the Conference Office located in the Division of Regional Medical Programs at the National Institutes of Health in the months preceding the Conference-Workshop. Other outside consultants who con- tributed richly to the success of the program were Mr. Greer Williams, who worked on the actual publica- tion of these Proceedings from the re- ceipt of the first abstract until publi- cation, and Mr. Greer Hermetet and Mr. John Craner, who worked with exhibitors and on Conference ar- rangements. At the time of the Conference- Workshop, many of the 54 existing regions were completing their opera- tional proposals. The meeting served as a catalyst, so that at the present time operational applications from a total of 24 of the regions have either been approved or are under review. The members of the Steering Com- mittee have expressed their satisfac- tion that the meeting met the needs and purposes for which it was de- signed. From the Division standpoint, the Conference-Workshop was a major source of substantive informa- tion concerning progress within the programs which was invaluable as testimony before the Subcommittee on Health of the House Interstate and Foreign Commerce Committee on March 26 and 27 in support of the bill to make necessary amendments and to extend Public Law 89-239. Finally, and most important of all, is the probability that this Conference- Workshop will emerge historically as the time when the definition of goals, organizational arrangements, and planning turned in the new direc- tion of initial operational activities in the regions. It is interesting to contrast these facts with those of the first National Conference on Regional Medical Pro- ili grams held a year earlier in January 1967. That meeting had been called by the Division of Regional Medical Programs to obtain information from a representative group of knowledge- able individuals, which could be used in preparation of the required Report on Regional Medical Programs to the President and the Congress (PHS Publication No. 1690}, and further to provide an interchange of infor- mation on planning and on the goals of the program. Dedicated principally to the problems of definition and elaboration of the concepts of cooper- ative arrangements, local initiative and evaluation, that first meeting as reported in its Proceedings (PHS Publication No. 1682) did much to characterize the program in its early stages of development. To look back over the past 2 years and see how far we have come is to realize that Regional Medical Pro- grams are no longer a concept, but are becoming an increasingly impor- tant resource for improving the care of patients with heart disease, cancer, and stroke. Robert Q. Marston, M.D. Associate Director, National Institutes of Heaith, and Director, Division of Revional Medical Programs March 31, 1968 iv eee Altar ae CONTENTS SUMMARY OF CONFERENGE-WORKSHOP ON REGIONAL MEDICAL PROGRAMS. .......0.0.....-. Lowell T. Coggeshall, M.D. QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO— SCIENCE AND SERVICE................5000000055 Carleton Chapman, M.D. REGIONALIZATION OF HEALTH SERVICE....... Lester Breslow, M.D. DEVELOPMENT OF PERSONAL HEALTH SERVIGE. 2.00. i teens Dwight L. Wilbur, M.D. THE POPULATION.........00 00000 c eee tees Panel: Roger O. Egeberg, M.D. (Chairman) Ray E. Trussell, M.D. Frank P. Lloyd, M.D. Amos Johnson, M.D. DIVISION OF REGIONAL MEDICAL PROGRAMS REPORTS ON— PROGRESS AND ISSUES... 1... ce eee eee Robert Q, Marston, M.D. Karl D. Yordy A NEW EMPHASIS.........0000.000 ee eee tenes Alexander M. Schmidt, M.D. Richard F. Manegold, M.D. OPERATIONS RESEARCH AND SYSTEMS ANALYSIS....0.0.0.000 0000 c cece ees Robert Bucher, M.D. Jack Hall, M.D. Herbert P. Galliher, Jr., Ph. D. Maurice E. Odoroff Page 10 34 38 4] vii A NATIONAL VIEW OF DEVELOPMENTS IN— HEART DISEASE........... 00000 cee cee eee Donald S. Fredrickson, M.D. = CANCER 0 ooo cc ccc ccc cee v tec ce cect event eee ees = Kenneth M. Endicott, M.D. STROKE. ...0 02. eee ren Richard L. Masland, M.D. : PANEL DISCUSSIONS ON— HEART DISEASE............ 000000 c cece ce eee Panel: Jesse Edwards, M.D. (Chairman) Samuel M. Fox Ill, M.D. William Likoff, M.D. Theodore Cooper, M.D. Campbell Moses, M.D. CANCER. 0... ne eee ees Panel: Sidney Farber, M.D. (Chairman) e Michael J. Brennan, M.D. | Juan del Regato, M.D. a Kenneth M. Endicott, M.D. Guy F. Robbins, M.D. STROKE........ 0000200 ee Panel: Nemat Borhani, M.D. (Chairman) Clark H. Millikan, M.D. James F. Toole, M.D. William A. Spencer, M.D. Richard L. Masland, M.D. GROUP DISCUSSIONS ON— HEALTH MANPOWER—REVIEW OF COMMIS- SION REPORT.....0..00.00.20.000 00200 cee eee. Discussants: James C. Cain, M.D. (Moderator) Leonard Penninger, M.D. Cc. H. William Ruhe, M.D. A. N. Taylor, Ph. D. Dwight Wilbur, M.D. vill 68 78 90 104 REGIONALIZATION.....0000.. 000.0000 cee eee Discussants: Lester Breslow, M.D. (Moderator) Walter J. McNerney William R. Willard, M.D. URBAN PROBLEMS..................0..2.00.0000.0.. Discussants: Paul Ward (Moderator) Roger O. Egeberg, M.D. Frank Lloyd, M.D. Anne R. Somers Ray E. Trussell, M.D. RELATED FEDERAL PROGRAMS.................. Discussants: Daniel Zwick (Moderator) James H. Cavanaugh, Ph. D. Donald Chadwick, M.D. Carruth Wagner, M.D. Eugene Veverka HEALTH SERVICES RESEARCH................... Discussants: Paul Sanazaro, M.D. (Moderator) Morris E. Collen, M.D. Caldwell B. Esselstyn, M.D. John Thompson John Williamson, M.D. CONTINUING EDUCATION AND TRAINING, FOR Discussants: Patrick B. Storey, M.D. (Moderator) Luther Christman, Ph. D. George E. Miller A. N. Taylor, Ph. D. DATA COLLECTION AND REGISTRIES........... Discussants: Abraham M. Lilienfeld, M.D. (Moderator) James F. King, Jr. Andrew Mayer, M.D. John E. Wennberg, M.D. HOSPITALS. 0000.0 ee Discussants: 1. Eugene Sibery (Moderator) Pearl Fisher, R.N. John W. Nauffinan Edward H. Noroian 106 108 109 COMMUNITY INVOLVEMENT...0....0..00....... 114 Discussants: Robert M. Cunningham, Jr. (Moderator) Alan GC. Davis Howard Ennes, M.P.H. Pierre C. Fraley Marc J. Musser, M.D. OPERATIONAL PROGRAM DEVELOPMENT....... 115 Discussants: Charles E. Lewis, M.D. (Moderator) 1 C. Hilmon Castle, M.D. T. A. Duckworth Albert E. Heustis, M.D. Donal R. Sparkman,M.D. A NONPROFESSIONAL LOOKS AT REGIONAL MEDICAL PROGRAMS.............520.000 00200 e ee eee 118 Irving J. Lewis REMARKS.........0 0000 ccc cece cette ene eee eee 122 Honorable Melvin R. Laird APPENDICES 1. CONFERENCE-WORKSHOP PROGRAM........ 126 ie 2, COORDINATORS’ STEERING COMMITTEE.... 143 3. LISTING OF REGISTERED PARTICIPANTS... 143 4. REVIEW COMMITTEE AND NATIONAL ADVISORY COUNCGIL...............0..002005. 158 5. DIRECTORY OF DIVISION STAFF.............. 159 6G. DIRECTORY OF REGIONAL MEDICAL PROGRAMS .....00.-.0050 000200 e eee eee 161 7. PUBLIC LAW 89-239. 00.000... 00000000000 cee 176 8. REGULATIONS. 0000000000000 eee 178 ix SUMMARY OF CONFERENCE-WORKSHOP Lowell T. Coggeshall, M.D. ON REGIONAL MEDICAL PROGRAMS SUMMARY OF CONFERENCE-WORKSHOP ON REGIONAL MEDICAL PROGRAMS Lowell T. Coggeshall, M.D. Vice President Emeritus University of Chicago t the outset of this meeting, Robert Marston spoke of the “emerging substance” of the Re- gional Medical Program. In so doing he made my summing-up task so much the easier by providing, in one modest but apt little phrase, the key- note for the entire proceedings. Read- ing the proceedings of a year ago, | vaguely recognized the form of the program. Now, in addition to form, I find substance. In medical science and practice— health care—the ultimate substance is advancement of knowledge or method that makes some worthwhile difference in the lives of people. That is, what we as members of the health professions and the great American public look for is to be found under the tormenting, unforgiving, one- word label: RESULTS. If we do not have in hand the kind of good results we want, and this is certainly the case in heart disease. cancer, and stroke, then we are prone to speak in terms of PROMISE. I do not mean false promise in this instance. | mean rea- sonable hope for enriching as well as prolonging life. What are the goals we seek to accomplish? As Laura G. 2 Larson from the Mountain States Re- gional Medical Program has so intelli- gently pointed out: “Goals are essen- tial to the success of any project because no one gets what he wants until he knows what he wants.” REGIONAL ACTIVITIES AND IDEAS The corpus of this conference is found in the 60 reports selected, I understand, from 100 papers sub- mitted. These 60 have been presented to you in the last 2 days and, with astonishing spced, published in two bound volumes and placed) in’ your chairs, day by day and volume by volume.* 1 will address my first flecting re- marks to this body of reports entitled 15-Minute Papers on Regional Ac- tivities and Ideas. Since the total pro- gram, both in its planning and initial operating phases, exclusive of a short leadtime, is hardly more than a year old, it is a little early to speak about results. So, quite logically, we find little about results in these reports. Rather, most of these reports run much in the vein of the one from the Tennessee Mid-South region, as pre- sented by Lloyd Elam from Meharry Medical College. Let me give you enough of the sense of Elam’s report to make my point about emerging substance and, in sum, provide a *The 60 reports are available as vol- ume II of the Conference-Workshop Proceedings. frame of reference for a reaction to the Regional Medical Program that I find I share with a good many others. It would be inaccurate in the extreme to say that I came to sneer and stayed to cheer, but I did arrive at this con- ference in a state of ignorance and I am going away much impressed with what I have Jearned, and with a great deal of enthusiasm for the program’s future. I will try to make this enthusi- asm a little more specific later on. Elam, in the introduction to his re- port, points out that- im contrast to its dramatic exploration of causes, chagnoses, and treatment of disease American medicine “has conducted only rudimentary research into how this new knowledge can be distributed and whether it makes much difference when it is.” He points out what so many of us know but not all of us can make rigorously clear when we go to the White House or Congress for the money: “Yet,” he says, “we have no precise knowledge of whether com- prehensive medical care coupled with modern technology can be effective in improving the health of our citizens.” In this frarne of mind, this volun- tary program, headquartered jointly at Vanderbilt and Meharry, is at- tempting to find out whether com- prehensive, family-oriented health care in a neighborhood health cen- ter coordinated with an automated multiphasic screening laboratory will result in improved mortality, mor- bidity, health service utilization, and health attitudes among impoverished people. Further, can this approach reduce the costs of illness, and can it preserve or restore the family? This program, I am delighted to find, prefers the experimental to the exhortatory method of health prog- ress. It is dividing its study popu- lation into three groups. One will deliver comprehensive care in a neighborhood health center plus multiphasic screening laboratory serv- ices to one group. It will give only the screening laboratory services to a sec- ond group. And it will save a third group for control, leaving it to obtain traditional medical services as best it can. The meaning of comprehensive health care, by the way, has-been de- fined here as compassionate, per- sonal, continuing, family-oriented, relating the patient to one doctor but giving him specialist group reinforce- ment and a modern technological backup. Further, the participating members of the community will have a direct voice in policymaking at the center. This is but one example, and per- haps more sophisticated than some, but is fairly typical of many other re- gional efforts, I think. The effort is sober, sensible, and. devoid of any claim or promise overrunning the evidence or defying reality. It is an effort in which any of us in clinical, academic, and scientific medicine would be proud to take part. Indeed, I think it is an approach we have been groping for. The willingness to experiment, to try and risk negative results is a source of strength in these programs. DR. COGGESHALL The program reports reflected both a wide variety of plans and a general sense of progress but, because no one as yet has the recipe for in- stant health, it was a progress of ex- pectations rather than of realization in most instances. In the time avail- able I can give only a few examples. As Breslow pointed out, the grand- daddy of American regional medi- cine is the Bingham Associates Fund of the Tufts-New England Medical Center, which has been operating in the State of Maine since 1932. This program still flourishes, now under Regional Medical Program auspices. It is pleasing to find that innovation still flourishes, too. As reported by George Robertson, a guest resident program has been placed in opera- tion. Tufts sends residents and clini- cal fellows from Boston to work in selected small community hospitals of Maine. These postdoctoral students go to Maine as teachers without diplomas. They cannot be used for routine hospital work because their presence is discontinuous. The local doctors do not think of the guest resi- dents as teachers so much as channels of information from the medical cen- ter. They seem happy to learn, through these young men, how the professors currently handle various problems. It seems that you can teach an old dog new tricks, provided you know more than the dog. Put a nicer way, it always has been possible for the old to learn from the young. We find another kind of innovation involving geography and logistics in the program of the Mountain States Regional Medical Program, operated by an organization called WICHE (pronounced “Whichy’”’)—the West- ern Interstate Commission on Higher Education. Here is a region covering all or part of four States—Idaho, Montana, Wyoming, and Nevada-- an area of 440,000 square miles with only 2,100 physicians, 15,000 other health professionals, and no homing institution, that is, no university med- ical center. Yet, I am told, this pro- gram has one of the most active and enthusiastic organizations and has found a cordial reception in the medi- cal centers serving it from outside of the Mountain States region. Much emphasis has been placed on the need for innovation in the Re- gional Medical Programs, but it is not all innovation, of course. Many of the principles of good health care that do require innovation for wider and more effective delivery are deeply rooted in the traditions of medicine as well as community organization. We find frequent reference to the importance of “concern” and “in- volvement” and at one point Willard A. Krehl wraps the matter up by stating: “The important objective is concerned involvement.” Speaking of the “educational pack- age,” William G. Cooper says: “One of the major overall objectives of Regional Medical Programs is to en- hance the learning of all members of the health care team in order that they in turn will be able to provide 3 medical care for their citizenry. The ‘learner’ in this case may be the doc- tor, the nurse, the medical technolo- gist, the physiotherapist, other mem- bers of the team or indeed the patient himself.” The Albany Regional Medical Pro- gram approaches continuing educa- tion by turning the tables on the medical center, as Frank M. Woolsey implies. If the mountain, that is, the practicing physician in the commu- nity, will not come to Albany Medical College for further training, Mahom- et, that is, the medical center, will go to the mountain. The strategy is “community hospital learning cen- ters” and the instrument is a so-called medical juke box, now in its develop- mental stage. This juke box plays rec- ords and projects pictures of whatever the medical center is pushing, educa- tionally speaking. The basic machine is actually a commercial juke box, and the new jargon is wonderful: “Dial-access carousel projectors have been added.” We find a great deal about auto- mated multiphasic screening at the rate of 60 tests a minute in the pro- gram reports, and a heavy emphasis on the familiar subject of continuing medical education. I am pleased to find Margaret Sovie from Syracuse reporting on continuing cducation in nursing, using the teaching facilities of a university hospital nursing serv- ice. Again, as throughout the pro- gram, we find a resort to electronic communications techni jues, televi- 4 sion, the telephone, and so on. The medical and nursing professions are capitulating quite brightly and grace- fully, it appears, to the offerings of the visual and audio communications industries. Yet I am enchanted to learn, although not from a formal paper, that a network of small rural hospitals in the southwestern area of North Carolina called the “State of Franklin” plans to resort to carrier pigeons to transport laboratory speci- mens back and forth. The pigeons can carry the load. But for transplant- able hearts, I assume, it will be necessary to employ falcons. Actually, a pigeon homing on a hospital lab- oratory serving smaller institutions, to me, expresses the very essence of regionalization, But Luther Christman, Dean of the School of Nursing at Vanderbilt, a sociologist, sounds a warning that I can appreciate, from a career lifetime in internal medicine: “... Be- cause messages about care must filter through many people, the messages may become garbled or not reach their target at all. Much time must be spent scurrying around . . . to in- sure that everyone is informed about the necessary care measures for each patient. Under this set of conditions there is likelihood of many errors of omission. . .. Thus, patients may be placed in some jeopardy by the very system set up for their care.” It warms my heart to find a sociologist preaching this essential point of first- class clinical medicine. Vincent Larkin, from the New York Metropolitan Regional Medical Program, a megalopolis constituting one of the largest regions in the Na- tion, diverts our attention from the limitations of the average practition- er, about which we hear so much, to those of the medical schools, so often assumed to be the ideal base for regional medicine: “On closer inspection we can see that the medical school falls far short of being able to play this central role effectively. Institutions which have focused on the training of medical students are asked to focus on the pa- tient; faculties which have been de- voted to the education of medical stu- dents, interns, residents, and fellows are asked to instruct practitioners; high walls which were erected to pro- tect the standards of the ivory towers are to be demolished without assur- ance that the standards will not be lowered and the ivory towers sullied ; in short, the racing car is to be har- nessed to the plow.” Therein lies one of the less obvious but more difficult problems in our heaven - and - earthmoving project, otherwise known as regional medi- cine. I can speak with the authority of a retired dean who has had many times to move his faculty in the direc- tion of desirable change, sometimes finding that having moved these clis- tinguished men he has to move them again at a later time and over the same ground. ISSUES RELATING TO QUALITY AND AVAILABILITY OF HEALTH CARE Having felt my first responsibility was to do justice, however inadequate, to the Regional Medical Programs in action, I can now, as the program for the opening session suggested, focus on the issues, in summary fashion. The first three speakers were ex- tremely well chosen for a diversity of viewpoint and as conversely it turned out for the general harmony of their remarks. On essentials, [ think, there was not discord but general agree- ment, a wonder to contemplate since they projected the disparate images of medical dean, public health official, and medical politician. I grant that each represents a great deal more than these one-dimension profiles as anyone who knows Carleton Chap- man, Lester Breslow, and—most pertinently—Dwight Wilbur might protest. I speak of this professor of medicine as a medical politician only because I doubt that anyone can rise to become president-elect of the American Medical Association with- out engaging in the politics of orga- nized medicine. Because the Regional Medical Pro- grams now seem to be developing, explicitly or implicitly, as a reason- able and acceptable idea, and do have the approval of the American Medical Association, I am sure the Regional Medical Program's coun- cils and staff would as leave forget the program’s rather opportunistic conception and bizarre gestation, but our speakers, with a sense of history that scholars can hardly abandon without impairment of their spirit of free inquiry, could not leave genesis quite alone. Chapman remarked that the ena- bling legislation was born “arnid talk of crisis in medicine,” and added, “There has been so much talk about the crisis in medicine that we are beginning to consider all the shout- ing with suspicion instead of alarm.” Wilbur, reflecting on origin and in- tent, agreed that “in many respects this act is quite extraordinary.” Cer- tanly none of us who had the oppor- tunity to read the DeBakey report from an objective position can ex- press anything but pleasant surprise that the heart discase, cancer, and stroke program has turned out so well. Whatever zround the infant lost in questionable percentage or difh- cult delivery, it has been made up through skillful legislation and admin- istration, as well as being demon- strated in the emerging substance I mentioned. Due in part to the infor- mation overkill on heart disease, cancer, and stroke and in part to the simple fact that planning and organ- ization strike the public as dull, the Regional Medical Programs until now have not had much of a story to tell. Speaking perhaps gratuitously for regional medicine, I would say the story is getting better all the time. T am much impressed with it. Under the title, “Science and Serv- 31 ice,’ Chapman’s primary message was that research is service, even as teaching and patient care are serv- ices. There is really no quarrel here, and his is a nice way of promoting healing of the conflict resulting from the overemphasis on medical re- search at the expense of teaching and patient service. Chapman speculated that Federal participation in the creation of a cli- mate favorable to research is trace- able to the career officers of the Pub- lic Health Service; in this, I should differ with him by amplifying those responsible to include not only cru- sading Public Health Service officers but health-minded politicians and re- search-minded physicians from the medical schools and research insti- tutions. As a matter of fact, the first sizable medical research grants to nonprofit institutions and their in- vestigators came from private phi- lanthropy, followed by national voluntary health organizations. The Federal Government embraced such support after World War IT and greatly augmented it. Chapman further speculated that the “politics of the research climate,” have “kept us from developing a mechanisrn capable of looking at the health problem for what it ac- tually is: A tightly interrelated, enormously complicated, and over- whelmingly important unity.” He pointed out that we as yet do not have an organizational pattern that is strong enough to foster balanced development of research, teaching, and practice. Chapman denied that medical practice has failed to bring the fruits of biomedical research to the pa- tients bedside, but agree that the de- livery of these fruits has been spotty. He also justly contradicted the com- mon charge of a gap between labora- tory discovery and application in medical practice, suggesting that if the biomedical researcher has any fault, it is that “he rushes into print and sometimes onto the television screen much too readily and uncritically” with findings described as break- throughs. So, “it is small wonder that both physicians and laymen become bewildered when so many break- throughs are either forgotten or proved wrong a year or two later.” This speaker conceived the prob- lem to be one of equal access to health services on the part of all peo- ple, and concluded that the Regional Medical Programs is a moderate, evo- lutionary measure designed to carry out the prophecy that public dollars spent for research can bring us better health. . Those who believe that social groups with long-established and well-defined self-interests are apt to be moved only by threats or by prom- ises have been made skeptical of the outcome of a program which de- pends, by direction of Congress, on voluntary cooperation of practicing doctors, academic medicine, public authorities, and a variety of others not wholly distinguished for their compatibility. I must admit to having shared this skepticism until the last three days. Wilbur, however, was more san- euine about our capacity for social action and progress by common con- sent. He recalled that “De Tocque- ville identified this unique American ability to become associated with oth- ers to plan and operate programs in the absence of central governmental direction and control.” Here, beyond a doubt, is the key to the future success or failure of a Re- gional Medical Program that has the singular characteristic of being im- posed not from the top down but the bottom up and therefore leaves the distinct impression of having no strong and inspired leadership. The potential genius of the Division of Regional Medical Programs is that it insists that the ideas and the initia- tive, the organization and the stimu- lus, come from the grassroots, so to speak. There are some students of their fellow man and his motivations who regard all this as too good to be true, yet as far as the arrangements in 54 different regional programs have gone it is true. Wilbur praised Dr. Marston and his staff for “the creation of a local and regional climate which engen- ders voluntary cooperative action to improve the health care organiza- tional patterns and delivery system which currently exist,” and later added, “in a sense, the program com- bines the better features of the liberal and conservative approaches to a cre- ative society.” At the same time, Wilbur spelled out the position of organized medi- cine’s cooperation in unmistakable terms. It is well known, I should note, that physicians and hospitals have credentials and qualifications by which they attempt to assure them- selves of each other’s competency and hope to insure their patients of a high quality of medical care. Since a poor quality of care is sometimes worse than none at all, it is natural for in- tellizent patients or their group rep- resentatives—such as organized labor or welfare agencies—to apply the profession’s own standards to obtain the “best medical care.” There is, of course, no guarantee. Wilbur warned: “... If RMP becomes an instrument for the estab- lishment of national standards with the coercive compliance compelled by such standards, it will arouse nation- wide resistance from physicians, insti- tutions, and allied health profes- sionals. What can be gained by coop- eration and meaningful participation will surely be lost if the use of coercive power, which for the moment lies dor- mant in Public Law 89-239, becomes its dominant characteristic.” This was practical advice on how to avoid conjuring up old devils, such as the fear of “socialized medicine.” Breslow touched on other kinds of problems in the regionalization of health, such as the fact that those interested in environmental health control and those planning patient care services “have remained almost entirely oblivious of each other,” he 6 also mentioned runaway costs: “The tremendous costs involved in apply- ing just one set of advances in medi- cal science, namely, organ transplan- tation, are causing top budgct officials in Federal and State governments to burn the midnight oil. How fast should we develop these new proce- dures and how can economy be maintained?” We must hurry on without answer- ing these questions. Roger O. Egeberg wished to give no ground on the need for excellence, but pleaded that availability of serv- ices was every bit as important as their quality. Ray E. Trussell conceded that the pursuit of high quality care was time- consuming and costly, and supported Wilbur’s position against national standards in regional medical care, yet he held that at his level (the city of New York) it is necessary to limit public funds to medical and hospital services that meet minimum stand- ards. “Training bright) practitioners to give betler care to private patients will not satisfy the intent of RMP,” he said. “There has to be an improve- ment in service... .” Frank P. Lloyd explored the tech- niques of involvement by which the quality of medical care can be raised-—for example, by persuading practitioners to give routine Papani- colaou smears. Amos Johnson, the articulate general practitioner from a rural North Carolina community at- tacked the issues of quality and avail- ability from still another standpoint: How you persuade doctors to come to and stay in small towns. One good way is to begin with a community at- tractive to the doctor’s wife. Any- thing that makes life tolerable for the doctor also helps. Johnson demon- strated himself to be quite comfort- able with the idea of upgrading the quality of the practitioner’s services. DISCUSSION GROUPS A kind of rough and ready valida- tion of the choice of issues and points pursued by the program speakers came out of the discussion groups. In some instances, discussants stated their problems and their opinions more forcefully than the speakers. This was the case in the group that pondered urban and related prob- lems. Their concern had to do with the difficulties of promoting com- munity involvement and organizing regional programs in metropolitan areas containing a wide variety of overlapping or conflicting institu. ions and agencies hospitals, voluntary healdi and wel- fare agencies, or the like. I listened, and heard lively discussion but no answers. In these discussions, no one ques- tioned the existence of a health man- power shortage, nor did anyone quite know what to do about it. Partici- pants appeared to agree that no one knows for sure how many doctors and other health professionals the country needs, inasmuch as there is medical schools, presently no way to measure the qual- ity of care they are giving, the efh- ciency of their methods, the validity of “felt needs,’ or the number of persons not getting adequate health care. The suggestion that the Regional Medical Programs offered an extra- ordinary opportunity to pin down some of the variables in meeting man- power demands and thus make a be- ginning toward solution obtained ready acceptance. In my own opinion, the organization, distribution, and more effective utilization of the serv- ices of health professionals is equally as important as, if it does not have higher priority over, large increases in the production of doctors, nurses, and others. ADMINISTRATION OF REGIONAL MEDICAL PROGRAMS Presentation of the Regional Medi- cal Programs through the eyes of Bob Marston and his staff provided an excellent demonstration of the divi- sion’s genius for drawing attention not to itself but to its regions, whence all things come and where all things hap- pen, according to the law. In all probability, those Hsteners who con- cluded that the staffers of this divi- sion of the National Institutes of Health were a lot less interesting than the people from the field were merely uncomprehending of the devotion of Bob and his staff to the concept that leadership must come from the com- munity or region and not from Wash- ington bureaucracy. Tt was a highlight of the confer- ence, from my standpoint, to find that the members of both the division and the staffs of the programs themselves were, at every level, persons of appar- ent high caliber. The observation ex- tends to the many bright, young peo- ple I met. The analogy of the university came to mind; the institu- tion is precisely as strong or as weak as its faculty. Talent was plainly visi- ble in the division staff and the re- vional coordinators and their staffs. If this unusual policy of lIeader- ship-—someone called it “creative anarchy ’—-survives its inherent dis- advantages, such as the apparent lack of aggressiveness and articulateness, it will constitute one of the great tours de force in the history of public ad- ministration. Phe idea of carrying out the effective organization and opera- tion of a program based on the neces- sity of voluntary cooperation and im- plernented by letting leadership come from the outside in and the bottom up is difficult to get used to, I con- cede, Once one appreciates what is happening, however, he is not dis- posed to change it, but becomes rather intrigued with how it will come out. The division staff otherwise gives every evidence of being extremely able. There seems to be method in their madness. Marston quoted his chief, James Shannon: “Although we must con- tend with many diverse geographic and social circumstances, NIH, in 292-414 O—65———-2 administering the Regional Medical Programs, will strive to preserve existing centers of excellence in sci- ence, education, and service, while, at the same time, working with State and local forces, evolve a system that will make available to the bulk of the population medical services that are excellent in quality and adequate in quantity—at least in a major segment of the diseases that plague us all.” I have little doubt that his ap- proach would have been extremely puzzling to some of the earlier pro- phets of regional medicine, such as John Grant of the Rockefeller Foundation or Joe Mountain of the Public Health Service, as it may also perplex some of the advanced stu- dents of social systems and processes. But if we regard the program as an experiment we may also conceive it as a rather starting innovation. It has the great virtue of keeping the enterprise well removed from that battlefield where we can still see the unburied bones of many a social planner and social reformer—that is the battlefield of socialized medicine. Alexander M. Schmidt, chief of the Continuing Education and Training Branch, sums up the situation in this articulate fashion: “The challenges faced by Regional Medical Programs are now readily apparent and, while great in size and scope, are matched by the potential for solution offered by the programs. The fragmented niedical services, the rising costs of care, the shortages, the impersonalized and disjointed sys- tem, and the educational imperfec- tions are the fabric of our health care crisis. The new emphasis being placed on these major issues by Re- gional Medical Programs is being re- flected by the developing resources and energies of the programs.” It is significant that the staffers speak of not one program but of “programs” in the plural. In other words, we have borne witness in these three days to the emerging substance of 54 “happenings,” that is, 54 Re- gional Programs now in existence. In place of the old medical analogy of the three-legged stool of teaching, re- search, and service to patients, I should like to introduce a new one to fit the occasion. I see the Federal Government as the hub of a wheel in which the spokes are teaching, re- search, and service, and the rim bind- ing them together is Regional Medi- cal Programs. QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO. SCIENCE AND SERVICE Carleton Chapman, M.D. REGIONALIZATION OF HEALTH SERVICE Lester Breslow, M.D. DEVELOPMENT OF PERSONAL HEALTH SERVICE Dwight L. Wilbur, M.D. THE POPULATION Panel: Roger O. Egeberg, M.D. Ray E. Trussell, M.D. Frank P. Lloyd, M.D. Amos Johnson, M.D. QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO— SCIENCE AND SERVICE Carleton Chapman, M.D. Dean, Dartmouth Medical School Hanover, N.Af. Reever! Medical Programs is a concept that was concerned, and is now being implemented, amid talk of crisis in medicine. There is so much talk today about the crisis in medicine that we are be- ginning to consider all the shouting with suspicion instead of alarm. We are becoming so used to talk of crises and dire predictions that we are get- ting a little bored with the whole thing. But there is a crisis in medicine, misdefined but real, one which has been gradually gathering force for a long time. All three aspects of our profession—research, practice, and education—are caught up in it and there obviously is no easy resolution. The three components have coexisted to now, each leading a relatively inde- pendent existence despite overlaps here and there. Each component has, from time to time, teamed up with 10 one of the others for special—usually defensive—purposes but the preser- vation of independence has still been paramount. This, contrary to the views of some groups, has not always been a bad thing. On the contrary, it has for generations been a reason- able modus vivendi under which a great deal has been accomplished if we persuade ourselves to take the long view of it. But it has, at the same time, allowed the problems we must now solve to develop. We cannot now go our separate, independent ways and that, to my mind, is one of the chief things the Regional Medical Program law is all about. SCIENCE IS SERVICE My topic—Science and Service—is a very appropriate one by means of which to approach today’s problems, although I know in advance that I run the risk of being too diffuse in coming at it from this angle. But I should say at the outset that if we don’t approach the problem dif- fusely-—-or at least in general terms— we will fail to reach above the special privileges, functions, and obligations our individual professional callings impose on us. And we will fail to per- ceive the elements of nobility that are inherent in the taxing and gruelling effort that lies before us. In this connection ] should like to persuade you that science is service, that however basic and specialized it may be, its relation, immediate or dis- tant, is to human need, hopes, and aspirations. The term “research in the service of mankind” has very funda- mental meaning despite the fact that it has become so hackneyed and its context so restricted that it rubs many of us the wrong way. The basic re- searcher, no less than the conscien- tious schoolteacher or medical prac- titioner, is engaged in rendering a service to the public. He may succeed, within the confines of his laboratory, in improving the lot of millions; or more likely he will accomplish a much less dramatic objective. But he is en- gaged in public service all the same. Unfortunately, the more unobtru- sively he works and the more remote his research area from immediately discernible need, the more likely he is to be regarded as a supernumerary, a parasite, on the social body. Or it may be assumed that if he works part time at some task that is visibly and immediately useful he may be al- lowed, more or less grudgingly, the right to do basic research on a lim- ited basis. In other situations, the investigator is viewed with tolerance because he is obviously capable; but he is at the same time considered to be so impractical that someone in au- thority must tell him what work he can and cannot undertake. THE CREATIVE CLIMATE ‘All these views are, in their un- diluted forms, grossly wrong and are in themselves a public disservice. The question no one, the scientist in- cluded, is really willing to face is: How does society produce its Curies, the Floreys and Flemings, the Enders and Salks; the Einsteins, the Bohrs, and the Fermis? It is not, in our own bewildering and complex day, an ac- curate answer to say that outstanding and gifted men will rise to promi- nence no matter where they happen to be born and live out their lives. We know, of course, that a man like Wil- liam Withering made his methodical observations while he was engaged in a busy medical practice and he did it without a shred of encouragement from His Majesty’s government or from a university. Such men will un- questionably appear from time to time even though the climate of their time is one of indifference to investi- gative effort. But it happens ex- traordinarily rarely. We know also that phenomena like Leonardo de Vinci have sprung up from time to time in what seems superficially to be the most unpromising settings. Leonardo, at the start, had little more than a proud father to urge him on. But we tend to forget that he had his patrons in his formative years; men like Lorenso di Medici, who made it possible for him to work independ- ently for something like 15 years. Whenever extraordinary talent has flourished, the ambient society has al- most always had a hand in it by cre- ating, one way or another, a favorable climate. Today, the patrons of research are mainly the great foundations and the Federal Government, acting through the universities. Quite early in the life DR. CHAPMAN of the American republic, our univer- sities attempted on their own to pro- vide a limited climate for research creativity as it was then understood. Our Government at first had its hands full with other matters and took no direct action to support re- search but in Britain the identity of research and service was compre- hended relatively early. Victoria had been on the throne little more than a decade when the Parliament gave sci- ientific creativity a boost, using tax- payer’s money for the purpose. It did it by setting up a system of grants- in-aid to individual scientific investi- gators, to be administered by the Royal Society. The Society itself was a bit suspicious of the government’s intent but the system was accepted and the first grants were made in 1850. Socially and politically, it was a monumental event in the English speaking world; yet one can search all the standard authorities on Vic- torian Britain and find hardly a men- tion of it. The scientists themselves failed to comprehend the social im- portance of what was happening. They may, possibly, have been a bit ashamed of it and they grumbled about threats to their independence; but, even so, they accepted the funds and went to work. No one, least of all the scientist, seemed to understand that the creation of a healthy climate for that form of public service we call research is in important meas- ure a political matter with all that that entails. Someone who is knowl- edgeable about politics and other so- cial forces, as well as about science, had to point out the need for such a climate and had, at the same time, to be able to make the concept politi- cally acceptable. It was and remains a subtle and tedious process; and the key to success was and is a convincing presentation to the public and to leg- islators of the fact that, in the short term and in the long, research is serv- ice and must not be defined too narrowly. In the United States, Federal par- ticipation in the creation of a climate favorable to research in the health field seems to have come not from our great research societies—not di- rectly from the most renowned of our scientists—but from an arm of the Federal Government itself: The U.S. Public Health Service. The effort be- gan about the turn of the century and the most significant step was taken in 1937, when the National Cancer Act not only set up the National Can- cer Institute but also gave the Public Health Service authority to award grants-in-aid and fellowships to in- dependent investigators working out- side Federal institutions. The subse- quent evolution of the system, and the fundamental features which have made the National Institutes as we know them today so extraordinarily successful were the work of percep- tive and dedicated career Public Health Service officers. The importance of all this is, I be- lieve, very fundamental indeed. The politics of the research climate is a poorly understood and badly ne- 11 glected academic topic. I should hope that before very long an enlightened scientist, perhaps working with other men from other disciplines, will study the matter exhaustively and that, in so doing, he and his colleagues will put ail these forces—political, scien- tific, social—into proper perspective. Such a study has not, to date, seemed very important. Had it been other- wise, and had the very term “re- search climate” been viewed realis- tically instead of as a justification for emulating across the board the ex- ample and method of the medieval university we might be much further along. It would, I believe, have led us to create an orderly technique for self-examination and broad projec- tion. But the influences and currents that have tended to keep the biomedical researcher, the educator and the practitioner on his own narrow path have by the same token kept us from developing a mechanism capa- ble for looking at the health problem for what it actually is: A tightly, in- terrelated, enormously complicated, and overwhelming important unity. We have not developed an organiza- tional pattern that is strong and re- sourceful enough to foster simulta- neous and appropriate development of all three main components. And now that the imbalance is apparent at all a counterreaction has set in which tends at times to exageerate the imbalance and to set the stage for remedial action which may turn out to be less than optimal. Unless an ef- 12 fective common meeting ground is quickly established, our actions in the immediate future may do nothing more than to create a new type of imbalance, fully as unfortunate as the present one, in which the research climate is attenuated while one or both of the other clements is built up. This, some of my colleagues in the academic world are saying, is pre- ciscly what is happening and they may be right. The danger of creating a new imbalance is a very real one. The uni- fying force of the future, as the Re- gional Medical Program law recog- nizes, will probably be the emerging medical center, an agglomerate of hospitals, medical and health train- ing facilities, community health cen- ters and programs, and varying amounts of input from parent uni- versities. This may not be ideal, But, since our system has developed no other unifying force, it is coming to be the fact. Paul Sanazaro recently defined the “broad outlines of aca- demic, scientific, and social adapta- tions in our medical (centers).” He cites a redefinition of goals to include broad community involvement and restructuring of the medical schools, administratively and curriculumwise. His hope and apparent expectation is that all this can be done so judi- ciously that none of the good in the present, admittedly outmoded, sys- tem will be lost. This may possibly be the case if the process is an orderly and evolutionary one. There are those, on the other hand, who feel that the goals are so patently clear, and the present situation so blatantly bad, that only revolution will suffice. But these gentlemen, I believe, fail to understand that revolution is a process which injects an element of violence and disorder into a progressive move- ment that is already underway. And fully as often as not, the end result is a destructive one and an obscuring of noble and necessary goals which have themselves already arisen by evo- lution. But the least we in the aca- demic world face, as we go about re- designing our methods and tailoring or expanding our total product to meet the Nation’s needs, is a degree of internal dislocation and redistribu- tion of emphases. The Regional Medi- cal Program law, the cynics notwith- standing, is designed to minimize the disturbing effects. THE PROBLEM ITSELF There are those who ask: What problem? What crisis? The problem has been defined, in what I think to be unfortunate terms, as the failure of the fruits of biomedi- cal research to reach the bedside. The fact is that they are indeed reaching the bedside—but very spottily. If the biomedical researcher has a fault it is certainly not that he locks up his find- ings in his files. On the contrary, he rushes into print and sometimes onto the television screen much too readily and unerilically. ‘Phe public and the practicing physician come all too quickly to be apprised of research findings most of which are likely to be described as breakthroughs. And it is small wonder that both physicians and laymen become bewildered when so many breakthroughs are either for- gotten or proved wrong a year or two later. Some of them unfortunately reach the bedside almost immediately and produce results of which, under- standably, very little is subsequently recorded. To intimate, as the Presi- dent’s Commission on Heart Disease, Cancer and Stroke did in Jate 1964, that the researcher is revealing his findings only to other members of his own particular research brotherhood is, I think, to avoid the major issue. There is no conspiracy of secrecy in- volved. But it is quite another matter to point out, as the Commission also did, the undeniable fact that equal access to full and effective health services ts not available to all our peo- ple. And it is a diversion to engage in debate on whether adequate health services are a privilege or a right. However the statutes read, the strong probability is that our electorate comes closer to regarding these bless- ings as a right than as a privilege. Our country has been sold on the proposition that if we use public funds to enhance the development of a climate favorable to biomedical re- search, the country’s health will be the better for it. This proposition is quite correct as far as it goes: but it is not complete in itself. [t has taken us only part of the way toward the realization of the public expectation and, I believe, of the intent of the Congress. Regional Medical Programs is a moderate, evolutionary measure designed to take in the rest of the way. THE REST OF THE PACKAGE To complete the job so well begun, complementary steps are obviously necessary and we begin to run into conflicts of interest and philosophies. This stage, as I have already in- timated, might have been avoided had we developed a unifying plan- ning mechanism as we proceeded in the development of a very necessary climate favorable to research. But this has not happened and it is rea- sonable to ask why it has not. Should the researcher, public serv- ant that he undeniably is, have done it? Should the medical schools have taken the lead in it? Or should the practicing physician, busy man that he is, have brought it about? The obvious answer is that for various and complex reasons no one of the three arms of our profession has been able to operate above the principle of in- dependent coexistence. The researcher, accustomed as he is to logical and methodical ap- proaches to biomedical problems, might have helped by broadening his definition of research to include some aspects of the distribution of health services. This could probably have best been undertaken through the re- societies; but it has not happened. The tendency, on the con- search trary, has been to establish a strati- fed attitude toward research; the top stratum is the most abstract; the low- est strata are those items which deal with such mundane matters as com- munity structure, the distribution of health personnel, emergency and screening mechanisms, and the like. Our research societies have accepted, not implausibly, the upper strata as their proper bailiwicks and have, in effect, continued down the years to create valuable and_ indispensable forums for their members. But most of them have shown no great interest in the lower strata and have at times, in fact, unofficially reacted against proposals to attack such problems in depth. There has been an unhappy resistance to the fact that the strata are interdependent and, indeed, con- tinuous. Nor have the medical schools been notably successful, as a group, in creating some sort of planning mech- anism that would have prepared us better for what we must now under- take. Many of our schools have inaugurated or participated in efforts to shore up the educational process itself and to assist in correcting the maldistribution of physicians by set- ting up programs designed to en- courage young graduates to tackle general practice in relatively large areas. These efforts have failed. The schools cannot by their own efforts counter the forces that are produc- ing major shifts not only of physicians and other professionals but also of the population at large. Nor have they any way of undoing the simple fact that many of the most effective of modern diagnostic and therapeu- tic methods are much too expensive to be installed and staffed in every town and village in the country. And the lack of access to such methods is one reason physicians decline to set up shop in small communities. Medi- cal school researchers have devised most of these advanced methods and have, therefore, indirectly partici- pated in the maldistribution of phy- sicians, Should we therefore now de- stroy these tools and dismantle the system that produced them so that, as in the early 19th century, our great medical centers will have no more to offer than one man carrying the tra- ditional doctor’s bag of instruments? No one today seriously argues that we should take such a course al- though one occasionally sees nostalgic statements that have somewhat the same effect. Obviously, what is needed is an effective link between the patient, wherever he is, the physi- clan, the investigator, and the medi- cal center. The Regional Medical Program law was designed to develop such a linkage and to improve those that already exist. And it puts the primary responsibility on regions. The medical schools and their in- vestigators, along with the consumer and the physician, are inevitably specified by law as participants. CAN IT SUCCEED? But can the law really succeed in accomplishing such a goal? Will it really succeed in inducing relevant but disparate elements, which have never before actually pooled their resources to the extent that the mag- nitude of the problem unquestion- ably requires, to do so now? Very frankly, I doubt that anyone can say. The law will not of itself fundamentally change the goals of the basic researcher and the service he renders, items which are in them- selves justifiable and necessary to so- ciety. The law will not overnight transform the desperation many of our physicians feel as they battle to carry their service loads; nor will it necessarily convince all our physi- cians, or for that matter the entire public, that our traditional system of health service needs updating. And as for the consumer, the law provides him with new avenues of participa- tion in planning but it will not neces- sarily educate him in distinguishing between what is reasonable and professionally justifiable, on the one hand, and what is not only medically indefensible but also extravagant and wasteful, on the other. The back- ground against which the law is be- ginning to operate is not, in itself, especially favorable. We are passing in all aspects of our national life from a period of spacious, eager, and re- sourceful projection to one in which our attitudes are much more anxiety ridden and our outlooks much more constricted than was the case a few years ago. A sequel, in Secretary Gardner's words, is “. . . the bitterness and anger toward our institutions that wells up when high hopes turn sour. 13 No observer .. . has failed to note the prevalent cynicism concerning all leaders, all social institutions. That cynicism is continually fed and re- newed by the rage of people who ex- pected too much and got too little . soaring hope followed by rude disappointment is a formula for trouble.” It is a dangerous time in the life of the Nation, and onc in which we are all too likely to fall into the paradox of blaming the very accomplishments of our recent past for the dilemma we now face. But none of this actually changes the prob- lem at hand. It will not simply go away because we are frightened by national and international events that he outside the field of health alto- gether. It is fortunate indeed, in my view, that the Regional Medical Pro- gram concept emerged when it did. It was basically a late product of that period of eager, resourceful projec- tion but must now be implemented in a very different setting. I have heard the law referred to as the worst, most ill-conceived piece of health legisla- tion ever passed by Congress. But, im- perfect though it undoubtedly is, it is potentially the most important and its basic concept the most enlight- ened. Politics aside—-as much as one can set it aside—the law does great credit to the Congress that passed it. The reason is simply that it provides a common workshop in which the components of our profession can now, with consumer participation, be- gin to hammer out the system our burgeoning Nation needs. 14 Initial cooperative efforts have, for the most part been encouraging. The basic goal so far, and it is indeed basic, is to help the physician and other health workers outside our great centers provide more adequately for the needs of their patients. The focus is on the physician and gives him full voice in, if not total control over, the planning process. It does not, per se, tamper with the all-important cli- mate for research but it does strongly indicate the necd for new types of research and research training. So far, it is indeed moving us toward a more complete, or balanced, view of the health problem. One can predict, I believe, that firm directions will emerge from the planning, that inadequately defined regions will restructure themselves along lines that make sense, and that the peripheral physician will begin to get the help he needs. The essential service the researcher must render is in helping to design planning experi- ments and in evaluating results. If his own field of training and interest make it inappropriate for him to render this service, he must at least comprehend the need for research- ers who can. All this is beginning to happen. So far, so good. But the future, depending in some measure on circumstances outside the health field, may bring a time when the researcher and some of our medi- cal schools become so disinterested and indifferent as to disengage them- selves. Practitioners may follow suit. The consumer may make demands that are neither justifiable on health grounds nor within the means of the Nation, rich though we still are. If all this should transpire, it will be clear that the course of evolution and moderation is not appropriate, that stronger medicine is required. The differences between the three compo- nents of our profession will appear to the layman to be irreconcilable and his natural tendency will be to assume that we can make no contribution, other than purely technical, to the solution of the health problem. And we will be in no position to preserve the valuable and the good that has been so painfully built up in the past; the way will then be: Out with the old and in with the new. But—and this is the key question—who will say what the new is to be? A moment of truth in health plan- ning is at hand and the processes of polarization have already begun. The concept of Regional Medical Program in this troubled environ is the concept of reason and good sense. There is nothing else that holds serious promise of doing the job ef- fectively and judiciously. And it is heartening indeed that it seems to be working in its initial phases of im- plementation; that as a result of the power of the concept disparate ele- ments are becoming less disparate; that effective inquiring and sensible planning are getting under way. It doves not insure the triumph of intel- figence and moderation but it does induce us to examine the probable effects of doctrinaire extremism. CONCLUSION My assignment was science and service. Altering the title slightly, I have stressed the point that research, however rarified, 1s service. I have plead for the preservation of a favorable climate for research and have tried to indicate that the de- struction of the present climate in the hope of accomplishing the broad and necessary goals—in solving the crisis if you will—-will have no such effect. On the negative side, I have in- dicated that researchers and their or- ganizations have given little evidence of understanding what is involved in the genesis, the care, and the mainte- nance of the research climate. The medical schools have tried to be everything to all men. They have made ingenious but ineffectual efforts to build a world for the researcher and to discharge an incredible array of service and educational obligations as well. The service, research, and educational elements have not yet found the common ground, the uni- fying instrument they need in order to bring the total health establish- ment to the level of development the situation now requires. If the Regional Medical Program law is not a perfect mechanism for creating that unifying instrument, it is the closest approximation on the current scene. And while the early results of its implementation are not altogether orderly and uniform, they are in sum encouraging. QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO— REGIONALIZATION OF HEALTH SERVICES Lester Breslow, M.D. Professor of Health Services Administration School of Public Health University of California at Los Angeles io those concerned with the im- provement of health care in this country, regionalization has become the order of the day. The regionaliza- tion idea is growing both rapidly and in a variety of forms. For example, recently covering most of the populated areas in the United States is a network of several score regional voluntary health fa- cility planning bodies. They are us- ually based on metropolitan areas and extend beyond local govern- mental jurisdiction over geographic areas with populations of several thousand to several million. Initiated largely by hospital groups, these agencies vary in strength and scope of effort. They have been principally concerned with planning hospital fa- cilities. To some extent, they have also undertaken cooperative en- deavors in health manpower devel- opment, patient care such as labora- tory services, administrative services, and other aspects of health care. To safeguard our environment in the interest of health, as well as aes- thetic considerations, water pollution and air pollution control districts are being established in many parts of the country. Similar efforts will soon be underway with respect to solid waste, and possibly noise. The new environmental control agencies tend to lie somewhere between State and local government, both functionally and geographically. Prodding by the Federal Government is playing a big role 'in their evolution. Those con- cerned with regional planning of pa- tient care services and those in the environmental field have remained almost entirely oblivious of one an- other. This is unfortunate, because both have the goal of protecting and improving health, and each could learn from the other’s experiences with many similar problems with re- spect to regionalization. Groups re- sponsible for environmental measures and those responsible for patient care services—to advance health—have more in common than they usually realize. The Congress has recently estab- lished two major programs involy- ing regionalization of health services. One of these is the object of our concern in this Conference-Work- shop, the Regional Medica] Program for Heart Disease, Cancer, and Stroke. All of us here are generally familiar with the legislative history and intent of the program and its present state. The other extensive endeavor that is concerned with regionalization undertaken recently by the Federal Government in partnership with State and other agencies is compre- hensive health planning. The latter seeks to organize comprehensive planning for health through State governmental action and the forma- tion of areawide or regional bodies within and between States. The scope embraces both environmental and personal health services, as well as de- velopment of health facilities and personnel. It seems clear that the Congress intends comprehensive health planning to be a global effort, bringing together what is done in the environmental health field, in the Re- gional Medical Program, and in health facility and manpower plan- ning—with an emphasis throughout on regional considerations. Why this rather sudden emphasis on regionalization? Probably it derives principally from our Nation’s coming to grips with the changed character of our life, especially the trend toward met- ropolitanization. Migration from ru- ral areas and small towns of the United States to the cities in recent decades has not only expanded cities but has brought adjacent cities into large metropolitan complexes. The latter have a quite different relation- ship to surrounding suburban and rural areas from that experienced by many of us in childhood. This new set of living circumstances is inducing many changes, particularly in the service industries such as transporta- tion, education——and now health. We can no longer plan in this country solely on the basis of the small com- munity; we must also plan for the big community—the region. Another force toward the regional concept is growing public belief that health care costs must be held down somehow, perhaps by greater atten- tion to organization. The Congress, reflecting that belief, has called for more efficiency in the health indus- try. The tremendous costs involved in applying just one set of advances in medical science, namely organ trans- plantation, are causing top budget of- ficials in Federal and State Govern- ments to burn the midnight oil. How fast should we develop these new pro- cedures and how can economy be maintained? Furthermore, Congress has expressed a public feeling that the benefits of medical science are not being applied uniformly enough to all segments of the population. This latter point has been well docu- mented during the past decade or so in the case of new immunizing agents despite the fact that their application was organized by local health au- thorities and the medical profes- sion.* the slower and uneven spread of the cy- Reflection on much tologic test for cancer? and other well-known medical advances, where 15 relatively little systematic effort has been undertaken, will indicate fur- ther justification for the public feel- ing that improved organization, per- haps on a regional basis, would lead to better as well as less costly health care. Regionalization also arises from growing recognition within the health field that the present complexity and specialization of health care requires exploration of new patterns of organization. Hence, the trend toward metro- politanization, public concern about the cost and use of health care, and professional response to the now highly specialized nature of health care-——all these and possibly other in- fluences are focusing attention on the possible advantages of regionalization in health care. As with all such social phenomena, one can, and for better understand- ing should, trace the origin back into history. What we now sec is the sud- den flowering of an idea that has roots in other times and places. In 1920, the Dawson Report to the Ministry of Health of Great Britain projected a network of primary and secondary hospitals, affiliated with teaching hospitals, as a pattern for achieving effective integration of hos- pital services throughout the coun- try® Over the years, this has served as a model for regionalization In varlous countries. Beginning in 1931, the Bingham Associates Fund inaugurated a re- gional system of health services 16 throughout Maine and part of Massa- chusetts, in connection with Tufts Medical School and the Pratt Diag- nostic Hospital in Boston, with sec- ondary centers at Lewiston and Bangor, Maine.* The services in- cluded complete diagnosis and sur- gery in Boston for patients selected by participating physicians in the sur- rounding arcas; consultation in lab- oratory diagnosis, radiology and elec- trocardiography; and postgraduate education through teaching clinics at several hospitals and courses at the medical center. The medical school thus entered into direct support of individual practitioners, with the aim of improving the quality of medical practice. Around Rochester, N.Y., with sup- port from the Commonwealth Fund, the Council of Rochester Regional Hospitals was organized in 1946 to provide: Continuing education for all categories of health personnel, ad- visory service in clinical medicine and hospital administration, joint hospital services on a regional basis, and stand- ards for hospital operation. The Rochester University Hospital and other large hospitals in Rochester served as the base for this effort. Other medical schools, including those of the University of Virginia and Tulane University, from time to time have sought to establish closer working relationships with physicians and hospitals in the areas around the medical centers." This effort has taken the form mainly of postgradu- ate education. A potentially big boost to regional- ization of health services came with the passage of the Hill-Burton Act in 1946. Two years earlier, Thomas Parran, then Surgeon General of the Public Health Service, had proposed regionalization of hospitals as a means of raising the level of medical care in a community. When Congress appropriated funds for assistance in hospital survey and construction, re- gionalization was incorporated into the program design. However, even with the subsequent authorization of specific funds through the Hill- Burton mechanism for studies and demonstrations, little was done to promote regionalization until the 1960's. There was a 15 to 20 year lag in national action. During that time progress was being made only by oc- casional voluntary, privately sup- ported efforts such as in Rochester and Boston. “Chis Lage in national action restted in part at least from Opposition in some quarters toward governmental participation in the planning and organization of health care. Widespread advance began in the early 1960’s when the Public Health Service gave grants-in-aid to the locally organized, regional volun- tary health facilities planning bodies. These have grown in number from one in 1945 to a handful in 1960, to about 80 at the present time. As noted above, these bodies have pro- vided diverse ranges of service and have achieved varying degrees of ef- fectiveness. Until the advent of the Medical they Regional Program, represented the principal nationwide movement toward regionalization in the health field. In other countries, some progress has been made toward regionaliza- tion and, as in the United States, principally with respect to hospitals.’ For example, in 1946, the National Health Service in England created a system of Regional Hospital Boards responsible for both hospital con- struction and operation. Under the authority of the Ministry of Health, the regional boards cultivate sys- tematic and cooperative relationships with respect to purchasing supplies, recruitment and training of person- nel, consultant services and other aspects of management among all the hospitals in their areas. The medical schools with their large teaching hos- pitals, however, report separately to the Ministry--not through the re- mional boards, Por purposes of hospital service, Sweden has been divided into seven regions each consisting of 3 or 4 coun- ties. At the heart of each region is a highly developed medical center, in five of the seven regions a medical school. A typical county in the region will have one general hospital with relatively specialized services and us- ually some smaller general and cot- tage hospitals. Following this brief review of the background, it may now be appropri- ate to consider a definition of region- alization, and some of the current: is- sues surrounding it. DR. BRESLOW While several definitions have been set forth, it seems most useful to use a broad definition such as: Regionalization is the organiza- tion and coordination of all the health resources and services with- in a defined area, for the purpose of maintaining the highest possible level of medical care, and of adapt- ing a comprehensive health pro- gram to the characteristics and needs of the area.® If the latter part of this definition is taken to include environmental health services and health education of the public (as I believe it should), then it encompasses all activities directed toward the improvement of health. The scope is more specifically indi- mi cated in the following list taken from the same source as the definition: In essence, a range of desirable goals for developing regional sys- tems of health services would include: (1) (2) Continuous opportunities for postgraduate education for all levels of health personnel. Participation of the regional organization in planning and expanding of systems of under- graduate education conducive to attracting and maintaining an adequate flow of health workers from every health dis- cipline into service. Advisory services to small in- stitutions and agencies unable to attract and support the full range of medical, technical, and administrative specialists. Development of systematic utilization and = sharing of equipment and personnel within the region based on distribution and availability as related to adequacy of health services, such as: (a) hospital beds and services, (b) laboratory facilities, (c) public health and visiting nurses, (d) blood bank operations, (e) purchasing of clinic and hospital supplies. Uniform methods of report- ing financial, professional, and all other service activities to make possible continuous com- parative and evaluative ap- praisal of services rendered and costs of medical care. (6) Development of programs of research specific to area or regional interests and prob- lems; opportunities “‘to learn the truth about matters which otherwise must be accepted on faith, and to stimulate cor- rective action.” (7) Continuous study of medical care given outside the hos- pital toward improvement of office and home services, as well as recommendations of new forms of health services for the region. (8) Creation of a program of health education related to all aspects of the regionaliza- tion system for the general public. (9) Encouragement of participa- tion in regional health pro- grams of the physicians with only home and office practice, the dentist, the pharmacist, and the nurse, medical records librarian, and all other tech- nical and administrative per- sonnel throughout the region.® With regionalization viewed thus broadly, it becomes clear that both regional planning of hospital facili- ties and Regional Medical Programs for Heart Disease, Cancer, and Stroke are important components of it. Understanding this relationship of Regional Medical Programs and other components to regionalization of health care in its totality is es- sential to maximum advance in the current situation. One major issue in implementing regionalization thus is: What shall be the scope of any particular component? Shall one element, for example, be limited to the placement and size of hospitals? Shall it also consider spe- cific facilities such as for laboratory work and radiation therapy? Further, shall it include educational, advisory, and consultation service on clinical matters to physicians in the partici- pating institutions? Shall it provide for the actual transfer of patients, when deemed appropriate medic- ally, from one hospital to another? Shall it endeavor to link up services within a health facility to those avail- able outside in the community? Shall administrative, rather than clinical, services in health facilities be the focus? Shall effort be devoted to standardization of procedures and records for purposes of evaluation? This brief listing of potential scope in hospital regionalization implies two sets of questions for those involved in Regional Medical Programs: (1) What shall be the scope of activity in a particular regional medical pro- gram? and, (2) how shall this relate to regional development of hospital facilities and to comprehensive health planning in the region? Rather than struggling over juris- diction with others engaged in region- al health care planning and develop- ment, those responsible for Regional Medical Programs might do better to 17 determine the most important contri- bution they can make to the improve- ment of health care, which now ap- pears destined to be planned on the basis of regionalization. That contri- bution may be, on the one hand, to extend the excellence of the medical center in handling heart disease, can- cer, and stroke, among the region’s hospitals and physicians; and, on the other hand, reflect back to the medi- cal center the substantial obstacles to achieving excellence throughout a re- gion, such as isolation of individual physicians and inadequate planning of facilities. Regional Medical Pro- grams are clearly intended to become a two-way street; and some believe that those in the medical centers have as much to learn as those elsewhere in the region. An approach by Regional Medical Program leaders, based on such a concept of their relationship to other current regional developments, may be useful. Certainly, Regional Medi- cal Program personnel are encounter- ing in their regions, States and the country, persons who call themselves hospital planners, comprehensive health planners, and the like. Even though initially startled by the en- counter and reacting momentarily on the fairly low biosocial level of “my jurisdiction,” perhaps Regional Med- ical Program leaders can move ener- getically into the negotiations neces- sary to establish an appropriate role for their programs in the complex, fast-paced progress that is occurring in health care regionalization 18 throughout the country. In defining and gaining acceptance of a proper role, it will be essential not only to specify the particular scope of func- tions to be undertaken by the Region- al Medical Programs, but also to work out their relationship to other health care developments which are based on a regional concept. Study of the history and current status of the other developments, as well as consideration of the main strength of the Regional Medical Programs—-medical excel- lence—will be helpful in working out the relationship. What to do, in the sense of scope of function, may seem a sufficiently large issue for consideration today. But perhaps brief attention can be given to two other issues in regionalization of health care: Geography and spon- sorship. The question of size and distribu- tion for Regional Medical Programs is, of course, largely determined by the availability of medical centers for participation. More generally, with respect to regionalization of health care, “the fundamental re- quirements as to size appear to be: (1) Each region should be large enough to include (or warrant the inclusion of) such an amount and va- riety of resources for health services that, when they are properly inte- grated, the region will be self-suffi- cient for most purposes; (2) cach re- gion should be small enough to make the administrative center or any other unique feature accessible to all parts of the region. Regional popula- tions vary from one-half to 10 mil- lion, and distribution from center to periphery might vary from 25 to 250 developments as well as consideration or more miles’”.° In developing Re- gional Medical Programs, as in other aspects of health care regionaliza- tion, the primary focus should be on function; area considerations are secondary. What to do and the re- sources necessary to do it should de- termine the geographic boundaries of the enterprise. Again, it would seem desirable that Regional Medical Program leaders study carefully the geographic as- pects of other regional health devel- opments. Understanding their his- torical, functional, and philosophic bases will be extremely useful in ar- riving at mutually acceptable defini- tions of roles. For Regional Medical Prograrns, initiating sponsorship has come large- ly from the medical centers, as one might expect. Participating and ad- visory elements come from the region generally. In the case of other cur- rent regional health developments, such as hospital planning and com- prehensive health planning, sponsor- ship has come from hospital groups and State health authorities. Other agencies in wide variety now are be- coming involved in areawide and regional health planning: Medical socicties, welfare councils, local and regional governmental bodies, inde- pendent commissions and councils, and others. Again, it will be important for Regional Medical Program leaders to appreciate the motivation and com- petence of these agencies, both the well-established and the newer ones, their potential for health develop- ment, and their ultimate community of interest with Regional Medical Programs. Eventually, the several major agencies sponsoring regional health activities must enter into con- structive relationships with one an- other. This could be accelerated by carly, objective analysis of the his- torical role and current regional health activities of the various agencies. Consider for a moment the plight of the Surgeon General in this regard, He must ultimately respond to the several regional health endeavors which the Public Health Service is now sponsoring: Regional Medical Programs, hospital development and comprehensive health planning. He would surely be grateful for field solu- tions to the problem of interrelation- ship among these programs. In summary, the Regional Medical Program for Heart Disease, Cancer, and Stroke is one important compo- nent in the rapid development of health care on an areawide or region- al basis in this country. To fulfill its particular mission, those responsible will have to define scope of function, geographic coverage, and sponsor- ship--all in relation to other regional health activities which are also getting underway. In clarifying these rela- tionships, it may be useful for those here today to adopt a very broad con- cept of regionalization in health af- fairs, specify the particular activities which Regional Medical Programs will undertake, become sensitive to the other major agencies and pro- grams involved in regionalization, and ultimately achieve a complete pattern varied in different parts of the country according to circum- stances, in which Regional Medical Programs can make their maximum contribution to the improvement of health care for the American people. References (1) Merritt, M. EH., et al.: Amer. J. Public Health 48: 146 (February) 1958. (2) Brestow, L. and Hocustim, J.: Sociocultural Aspects of Cervical Cytology in Alameda County, Calif, Pub. H. Rep. 79: 107 (February) 1964. (3) Interim Report on the Future Pro- vision of Medical and Allied Serv- ices. Consultative Council on Medical and Allied Services, Ministry of Health of Great Brit- ain. London: HMSO, Parliament Command Paper 693, 1920. (4) Garianp, J. E.: An Experiment in Medicine: A History of the First 20 Years of the Pratt Clinic and the New England Center Hospital of Boston. Cambridge: Riverside Press, 1960. (5) RosenFetp, L. S. and Maxkover, H. B.: The Rochester Regional Hospital Council. Harvard Univ. Press (Commonwealth Fund ) Cambridge, 1956. (6) Roemer, M. J. and Morris, R. C.: Hospital Regionalization in Per- spective. Pub. H. Rep. 74 (10): 916-922 (October) 1959. ) Roemer, M. I.: Personal commu- nication. (8) Building America’s Health. Report of the President’s Commission on the Health Needs of the Nation. Vol. 2. Superintendent of Docu- ments, U.S. Government Printing Office, Washington, D.C. 1952. (9) McNerney, W. J. and Riepet, D. C.: Regionalization and Rural Health Care. University of Michigan, Ann Arbor, 1962. QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO— DEVELOPMENT OF PERSONAL HEALTH SERVICE Dwight L. Wilbur, M.D. Palo Alto, California President-Elect American Medical Association his Conference-Workshop pro- vides an excellent opportunity to consider the potential impact of the Regional Medical Programs author- ized under Public Law 89-239 on the development of personal health serv- ices. It is especially fitting that those most active in conducting this com- plex and potentially highly beneficial activity be brought together at this time to review planning efforts of the last 2 years and consider their transla- tion into operational implementation. In many respects this act is quite ex- traordinary. Its genesis and promo- tion as described in the recent article in the Atlantic Monthly are intrigu- ing, to say the least. The diverse in- terpretations among various observers of its long-term objectives suggest REET many misunderstandings and an un- certain but hopefully great future. The zeal and enthusiasm of the men and women-—including numerous medical leaders—reflect the dramatic appeal that it has for many individu- als of good will and high hopes. The vaguely defined authority of the act seems to many inadequate to bring about the innovation and organiza- tional changes they seek. To Battistella,t the act's promise is to facilitate— “.. . the planning, organization, and delivery of health services within a functionally-based _ re- gional framework, capable of cir- cumventing State-local political boundaries and orthodox health channels. Additional excitement centered on the possibility that, once launched and _ successfully demonstrated, the application of regionalism might spread to en- compass a number of other prob- lems pressing in on the health field, and might lead eventually to a complete reorganization of health services,” In another portion of his recent paper, Battistella * has this to say: “". . to have insisted upon a more comprehensive and idealistic ver- sion would have been politically naive and would have precluded the passage of any legislation at all. To this way of thinking, a slice of pie is better than no pie at all. Some of the bill's supporters take an evolutionary point of view, and suggest that a combination of es- 19 calating problems in the delivery of health services and rising expec- tations for better and more eco- nomical care, will inevitably trig- ger an expansion of the program. Eventually, they see the seeds planted by the Heart Disease, Cancer, and Stroke Act leading to a complete reorganization of all health services within a regional framework.” The article by Clark? also pro- poses a national blueprint and sug- gests various models which might be followed in establishing this nation- wide program. Any impartial phy- sician, who studied the Clark-Battis- tella thesis, as presented in their papers, would reach the conclusion that RMP was in fact designed to provide an instrument by which the organization and delivery of health care of the American people could be changed in a revolutionary manner. These articles are well written and have the commendable characteris- tics of unequivocation and candor. Although one might disagree with the conclusions, one cannot impugn the authors’ motivations. The fact re- mains, however, that the issues as presented by this school of thought are not designed to stimulate strong physician support of these programs. Dr. Marston and his staff, on the other hand, and many of you who are active in the program, have sought through talks, articles, and actions to promote a different basic concept of the program, that is, the creation of a local and regional cli- 20 DR. WILBUR mate which engenders voluntary co- operative action to improve the health care organizational patterns and de- livery systems which currently exist. As Marston has so well expressed it in several addresses: “The focus is on the patient; the mechanism is coop- erative arrangements; the emphasis is on local initiative, flexibility, and de- cisionmaking; and the reason for the program is the relationship between science and service.” The two key assumptions on which the purposes of Public Law 89-239 rest, according to Mayer,” are: “(1) That there are differences in the quality of diagnostic and treatment capabilities available to different patients within this Na- tion, in the area of heart disease, cancer, stroke, and related diseases; “(2\ That through the mecha- nism of regional cooperative ar- rangements of the people, institu- tions, organizations and agencies involved in health in that region these differences can be lessened.” According to Mayer, this program is designed to strengthen existing in- stitutions rather than to create new ones. He stresses the point that this is not a national program but a regional one, and he underscores that word “cooperative.” He points out further that— “... it is important to under- stand that the Regional Medical Programs are not simply another kind of mechanism of funding in- dividual projects. It does represent a new kind of conceptualization in the approach to health care and education. Whether it is capable of serving this function only time will tell.” I applaud this point of view and the emphasis given to these aspects of the program by the division of Re- gional Medical Programs. If the pro- gram in fact is clearly one designed to catalyze and to facilitate the develop- ment of better programs that now exist to serve patients and their physi- cians, it will undoubtedly receive en- thusiastic cooperation from the medi- cal profession and related groups. We know that the law and its legislative history stress the voluntary coopera- tive nature of the program and that interference with existing patterns is specifically prohibited. As Dr. Mars- ton * said in a recent talk— “These programs face the chal- lenge of influencing the quality of health services without exercising Federal or State governmental con- trol over current patterns of health activities.” Public statements of this type are encouraging evidence of the under- standing by those responsible for di- recting this program of the pro- foundly complex problems and social and community interrelationships that confront all those who will be participating. The innate difficulties of achieving a consensus among a large number of disparate local agen- cies, all traditionally striving to main- tain their independence and special prerogatives, are well known, Rational decisionmaking by inde- pendent public and private entities on a voluntary basis, however, is an objective that is worth pursuing. Un- like many other countries, our Na- tion has reached its preeminence in many arcas of activity because of this unique combination of multiple inde- pendent focal points of activity co- operating on a voluntary basis to achieve a commonly desired goal. De Tocqueville identified this unique American ability to become asso- ciated with others to plan and op- erate programs in the absence of central governmental direction and control. If RMP maintains its cur- rent emphasis on the working to- gether of regional groups, it will ful- fill its purpose of improving the quality, accessibility and availability of health care, physician and institu- tional performance, and consumer satisfaction. On the other hand, if RMP becomes an instrument for the establishment of national standards with the coercive comphance com- pelled by such standards, it will arouse nationwide resistance from physicians, institutions, and allied health professionals. What can be gained by cooperation and meaning- ful participation will surely be lost if the use of coercive power, which for the moment lies dormant in Public Law 89-239, becomes its dominant characteristic. I have dwelt on these basic issues at some length because one cannot discuss this subject from the perspec- tive of personal health services with- out first considering the basic issues involved in the development of the program as a whole. Change is ex- pected by the vast majority of think- ing persons; and the medical profes- sion, like others, is changing its tech- niques and opcrational procedures constantly. Sometimes these changes are forced by external environmental factors which lead to improved pre- vention, diagnosis, and therapy of disease. At other times, changes are forced which are unacceptable to physicians and their patients. The current health manpower shortages and escalating health care costs are examples of external pressures that compel changes, some of which may be favorable and some undesirable. RMP is in a strategic position to bring about changes acceptable both to physicians and their patients that will improve performance and patient satisfaction without under- mining patterns of behavior that are traditional, and, more significant, considered by the medical profes- sion essential to the preservation of high quality care. The sensitivity of medicine to the possible establishment of national standards under RMP for the treat- ment of certain diseases was demon- strated recently when it appeared that RMP might be moving toward such a development. I have been assured by Dr. Marston that no proposals for such national standardization have received any sympathetic hearing and that, on the contrary, it is his feeling that such proposals run counter to the spirit of the legislation and the manner in which it is being admin- istered. I applaud this attitude, and I urge that it become a part of the fabric of your thinking as you con- duct these regional programs. Another aspect of the currently evolving RMP program that deserves commendation is its scientific spirit— that is, its willingness to depend upon observation and experimentation be- fore reaching firm conclusions. The danger of national blueprints or models is their usual inflexibility. Your objectives arc laudable, and they require implementation which per- mits ready change. It would be difh- cult to disagree with this statement from the Report on Regional Medical Programs to The President and The Congress ® of June 1967— “ee . every person whose life and well-being may be in jeopardy from one of these diseases should have the full strength of modern medical science available to him through the cooperative efforts of the medical and related resources of the region in which he lives. These are the goals to which Re- gional Medical Programs are dedicated.” This utopian ideal, however, will be realized in varying degrees depend- ing on the ability of the medical pro- fession and the health care industry to make available such services and facilities, and upon the patient popu- lation to utilize resources as they be- come available. I am deeply impressed by a recent article by Lahav ° on ‘‘Methodologic Problems in Health Manpower Re- search.” His observations are espe- cially. germane as you develop meth- odology for effective implementation of this law. He identifies some of the countless variables that make health economic research so difficult and facile conclusions and recommenda- tions so perilous. He notes, for ex- ample, that Government sponsored programs can contribute to a more rational distribution of medical and other health facilities but that their ability to effect a comparably rational distribution of health personnel is relatively small because, in a free so- 21 ciety, distribution of professional manpower is predominantly a func- tion of personal decisions made by in- dividual practitioners. In discussing rural health centers in rural northern Michigan, where McNerney and Riedel* found that their productivity was low in terms of unit cost and that they had diffi- culties in attracting and maintaining qualified professional and administra- tive personnel, Lahav noted that the difficulties in this situation could not be modified easily under conditions of ‘“‘nonsocialized medicine” where practicing physicians had a large measure of independence. The keen observation that decisionmaking on a voluntary basis may tend to frus- trate the impatient administrator with limited authority clearly applies to RMP. I urge a frank discussion of this question and your resolution of the problem in favor of voluntarism, for the gains that you will make in terms of flexibility and physician sup- port will far more than offset any losses you may incur. Another important point made by Lahav is his emphasis on the coordi- nation of scarce resources rather than the mere creation of new ones. It may well be, as we strive together to create the best possible health care system for our nation, that the emphasis is of RMP on cooperation, coordination, and regional planning will turn out to be far more productive than pro- grams designed simply to increase the output of health professionals. Cer- tainly, the latter is necessary; but their 22 placement in an efficient, rationally organized, and economically con- ducted system may be even more important. In this connection, the recent com- ments by Dr. Marston® when he talked to a group in Illinois are es- pecially appropriate— “As one views the current health scene, it seems inevitable that, as an increasing proportion of our na- tional wealth is devoted to health and as the expectation for health services continues to rise, there will be marked pressures for the most effective allocation of health re- sources. These pressures will exert influences in such critical areas as the distribution of resources be- tween short and long goals, that is, between biomedical research, for example, and the immediate de- livery of service. Within service it- self, there will be pressures for the distribution of effort between im- provements in quality on the one hand and extensions of access to health care on the other; the allo- cation of resources for general pur- poses as opposed to targetive ob- jectives; exploration of mechanisms to alleviate the acute shortage of all health talent; and the need to explore the division of responsi- bility between those health respon- sibilities carried out through the governmental sector and the re- sponsibilities of the voluntary in- stitutions and organizations.” I want now to turn to another sub- ject of special interest to medicine: Continuing education. The problems of medical care and continuing medi- cal education are inseparable. In fact, continuing medical education offers the greatest potential for rapid wide- spread solution of the identified prob- lems or difficulties in the general area of patient care. In the planning and early operational RMP programs, it plays a major role. The AMA is es- pecially anxious that this aspect of the evolving program be emphasized. Marston and Mayer,’ in their article on “The Interdependence of Re- gional Medical Programs and Con- tinuing Education,” indicate— “The following two points con- cerning the development of contin- uing education activities within a given Regional Medical Program are of prime importance. First, the Division of Regional Medical Pro- grams can make grants for two pur- poses only (a) to plan or (b) to establish Regional Medical Pro- erams. It cannot make grants for the establishment of continuing ed- ucation programs.” Understanding the preclusion of support of regional continuing edu- cation programs alone, we hope that special emphasis will be given to this aspect of a regional program, since to a significant degree the gap that may exist between science and service can be minimized by such continuing education. Incidentally, this problem of continuing the education of physi- cians and other health professionals in a rapidly changing scientific cli- mate was considered at. length by the recent Presidential Commission on Health Manpower on which I had the privilege of serving. You will re- call that one of its rather controver- sial recommendations was that reli- censure of physicians be considered as one means of stimulating physi- clans to continuously to review new information. Whatever technique is used to assure a physician's up-to- dateness, the provision of continuing education through the development of core curricula and other tech- niques, and the utilization of com- munications technology now rapidly becoming available, must be pursued vigorously. The RMP program has stimulated widely favorable reaction from the medical profession. As a whole, the medical profession at the beginning of the year 1968 is probably more deeply involved in the planning proc- ess to determine the nature of the Re- gional Medical Programs than it has been in the planning of any previ- ous Federal program. Many of our. most distinguished medical leaders are participating full or part-time in the Regional Programs. Many State and county medical socities are cooperating actively or in an advisory capacity and have ex- pressed their enthusiastic support. Dr. Gullatt,! for example, in the Oklahoma State Medical Association journal for April 1967 said: “The Regional Medical Pro- gram has the potential of making remarkable improvements in the continuing education of | physi- cians, an objective to which we have always been dedicated.” North Carolina prepared a special issue?! devoted to RMP in May 1967. In an editorial in that issue, the following comment is made: “In the months and years ahead, these early times of the program will no doubt be regarded as the critical period, when the shape of things to come became apparent. Thus far the Medical Society has played a creative role and our State’s program is out ahead of many others because of this atti- tude. The only sensible course is to continue to act intelligently and constructively.” Dr. Frank Jones,’* the president of the Medical Society of the State of North Carolina at that time, said: “.. . the medical society repre- senting the physicians of North Carolina is involved in the Re- gional Medical Program. It was involved in a somewhat similar program before Heart, Stroke, and Cancer was birthed, and it will continue to be involved, working with the representatives of the public and the other deliverers of health care and the involved State governmental agencies in a con- tinuing program directed toward quality care at all levels.” In the same Journal, Dr. Musser,” executive director of the association established to conduct this program, said: 292-414 O--G8———33 “There is no question of the pro- fession’s ability to do the job. The important step is to direct our total talent and energy to it. The job— well done—will reassert and secure our leadership in health affairs and assure an ever improving state of national health.” In Georgia, Dr. Battey,’* a mem- ber of the steering committee for the program, said: “" . . it is the intent and sincere desire of the members of the Georgia Regional Medical Pro- gram advisory group that this ap- proach, during the planning phase, will seek out and find those in- terested individuals all over the State who will be anxious to take part in what may well be our great- est opportunity tu achieve the best of medical care for all patients utilizing the regional and the truly cooperative approach.” In Missouri, a physician who ini- tially had serious misgivings about this program is now conducting a valuable regional project on the man- agement of cardiac emergencies. Under his direction, certain defi- ciencies have been identified and many individuals and facilities are cooperating enthusiastically to rem- edy these deficiencies. I am impressed also by an article in the Onondaga Gounty Medical So- ciety “Bulletin? in New York re- counting the specific projects being considered their Regional Medical Programs. All available rec- ords are being analyzed to evaluate under existing facilities; rural medical man- power is under study; a number of hospitals have opened their records for review of current handling of pa- tients with heart disease, stroke, and cancer; communications among hos- pitals within a region are being ap- praised; interconnecting color tele- vision among these hospitals is being considered, as well as the educational television network; the transporta- tion of laboratory specimens to central areas is under study; the use of heli- copters for transport of the sick and, perhaps, physicians, is a possibility, and an extensive library project is already underway. The strong sup- port of the County Medical Society is implicit. This same attitude of study, inquiry, and active implementation exists in many other medical groups in the country. Clearly, RMP has stimulated a healthy atmosphere of voluntary co- operative review of current health programs and a refreshing willing- ness to express self-criticism of a con- structive type. In a sense, the program combines the better features of the liberal and conservative approaches to a creative society. The traditional liberal dependence on the Federal Government as a means of solving all problems is mitigated and redirected into a new type of program sponsored, it is true, by the Federal Government but emphasizing the use of local as well as Federal funds and depending upon local regional decisionmaking and significant participation by the private nongovernmental] sector. The conservative also can feel reasonably comfortable in the context of this pro- gram because it is not intended to be a revolutionary substitute or a na- tional blueprint for existing patterns of behavior. Rather, it builds upon the past and the present, adding new features, changing old ones, as local demands and resources make possible. Its flex- ibility, pragmatism, and acknowledg- ment of regional variations, particu- larly appeal to me as wise emphases. This program can make a real con- tribution to personal health services if it continues to pursue what appears to be its main thrust today—to serve as a catalyst for and to facilitate those winds of change which blow in the right direction. If your zeal and en- thusiasm are tempered with a sym- pathetic understanding of the tradi- tions and basic motivations of those who now render health care, I pre- dict that they will cooperate willingly with you, and that in this cooperation you will have the basic ingredient for success. Basically, we all have the same desire: To help the American physician to provide the best quality of care to the American people, in the American tradition. References (1) Battistetta, R. M.: The Course of Regional Health Planning: Re- view and Assessment of Recent Federal Legislation. Med. Care 5: 149-161 (May-June) 1967. (2) Crarx, H. T., Jr.: The Challenge of the Regional Medical Pro- grams Legislation. J. Med. Educ. 41: 344-361 (April) 1966. 23 (5) (6) (9) 24 Mayer, W. D.: Regional Medical Programs—A Progress Report. J. of Med. Assn. of Georgia 56: 143-147 (April) 1967. (Presented at the Second Georgia Conference on Medical Education, Mar. 4, 1967, Callaway Gardens, Pine Mountain, Ga.) Marston, R. Q. and Script, A. M.: Regional Medical Pro- grams: A View from the Federal Level. (An address delivered to the Continuing Medical Educa- tion Section of the Association of American Medical Colleges, Fri- day, Oct. 27, 1967.) Report on Regional Programs to the President and the Congress. Sub- mitted by William H. Stewart, M.D., Surgeon General, Public Health Service, U.S. Dept. of Health, Education, and Welfare. U.S. Government Printing Office (June) 1967, Lauay, E.: Methodologic Problems in Health Manpower Research. The New Eng. J. of Med. 277: 959-962 (November) 1967. McNerney, W. J. and Ruiever, D. C.: Regionalization and Rural Health Care: An experiment in three communities. Ann Arbor, Mich.: Univ. of Michigan Press, 1962, p. 175, Marston, R. Q. University Hour sponsored by Alpha Omega Alpha, University of Tllinois, Oct. 4, 1967, unpublished. Marston, R. Q. and Mayer, W. D.: The Interdependence of Re- gional Medical Programs and Continuing Education. J. Med. Educ. 42: 119-125 (February) 1967. (Presented to the Section on Continuing Medical Educa- tion at the 77th Annual Meeting of the Association of American Medical Colleges, San Francisco, Oct. 21, 1966.) (10) Guuiatt, E. M.: President’s Page. J. of Okla. State Med. Assn. (April) 1967. (11) N. Carolina Med. J. Vol. 28 (May) 1967, (12) Jones, F. W.: The Medical Society and the Regional Medical Pro- gram in North Carolina. N. Caro- lina Med, J. 28: 173-175 (May) 1967. (13) Musser, M. J.: North Carolina Regional Medical Program. N. Carolina Med. J. 28: 176-182 (May) 1967. (14) Barrey L. L.: Georgia Regional Medical Program. J. of Med. Assn. of Georgia 56: 141-142 (April) 1967. QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO— THE POPULATION Panel: Roger O. Egeberg, M.D. (Chairman) Dean, School of Medicine University of Southern California Los Angeles , Calif. Ray E. Trussell, M.D. Director, School of Public Health and Administrative Medicine Columbia University New York, N.Y. Frank P. Lloyd, M.D. Director, Medical Research Methodist Hospital Indianapolis, Ind. Amos Johnson, M.D. Garland, N.C. This transcript has been reviewed and approved by the participating panelists. [DD Eceperc. Now, we are talk- ing about excellence or quality and availability of medical care. And I have been beating the drums for ex- cellence for the last 8 or 9 years. I do not want to lessen my feeling about excellence or give anybody the impression I am not in favor of ex- cellence as far as we can bring ex- cellence, but we need to think of availability from the point of view that excellence is fine, but if it is not available it really isn’t very helpful to any particular patient. And I thought I would go back to an experience I had in the war. Mr. (Stephen) Ackerman told me this morning that I had used this once before, but I hope it was a different group or smaller group, because as I came east on the plane yesterday I thought, “There is the basis of what I want to say.” I was at Western Reserve at the beginning of the war and helped form the fourth general hospital there; and we were commissioned. The unmar- ried men became lieutenants, those who were married became captains, and if you had a number of children you might make major. Well, I had four children so I became a major, and that was the way it was done in that outfit; possibly for the same rea- son, I was the assistant chief of the medical service. This was a talented group, as the general hospitals affiliated with uni- versities were, in the sense that they had assistant and associate and other professors and clinical professors in the various specialties. There was a talent in depth here. We arrived in Melbourne and set up. Soon I was assigned to the job of setting up a venereal disease hospital because that seemed a little more im- portant than a general hospital at that point in our history. But, after a while, I managed to feel that there was romance in New Guinea or some- body needed me there and I managed to get there. It was the experience I had in New Guinea—the fact that I got through it—that has driven me into the things I am interested in now. In the front lines one could find a lieutenant who had recently gradu- ated or, if one were visiting the Aus- tralians, a sergeant who did not have a medical education except as taught by the doctors, but who was avail- able to the people when they were wounded or when they were first ill with malaria or when they first had the beginning of an emotional break. He was available to stem things just as they started, and he handled, I would say, probably 80 percent of the cases that came to him. It was my considered opinion after being there for about a year that prob- ably more good was done in the thea- ter and more help was given the sol- diers by the doctors or corpsmen who were available at the time help was needed than by those who might have been better trained in narrower spe- cialities, but who were two or three hospitals away. I think the same problem exists in society at the present time. Doctors who have been in practice have been taught for years, for generations, per- haps since Hippocrates, that they shouldn't go out and look for work: they should do the best they can with the work that comes to them. And now, with the advances in medicine that have occurred in the past two or three decades, it perhaps becomes necessary for some representatives of those doctors to go out and seek the work for themselves or for others. There are 30 million people in the United States who hardly know what medical care is. As some of you know, we have started a project in the Watts area of Los Angeles, and we are work- ing with a group of pcople there hop- ing that we can turn the project over to them when it gets going well. When we first got this group to- gether, we asked them what they thought they needed most in Watts— finally, a woman got up and said, “What we need is a slab on every DR. EGEBERG corner.” And a little further question- ing showed the slab was to lay them on while they are waiting for the am- bulance or the hearse. And further questions brought out that this was the concept they had of medicine. And I am sure this applies in large areas of our country to certain parts of our population. Now, to take Los Angeles as an ex- ample again, I have long been asso- ciated with the Los Angeles County Hospital, which is an excellent hos- pital. And for those who are acutely ill and for those less ill it gives very, very good care. But it is about 13 miles from Watts. And it is 13 miles from many other areas of Los Angeles where people also get sick and can- not on the whole afford private physicians. I think we should picture a woman in one of those areas who has a child who is sick. I have seen these infants and small children come in moribund who should have been in a couple of days carlier. Even if a mother with a family of two or three or six children knows that one of her children is sick and that she should take it to a physician, a hospital or a clinic it may be impossible because of the distance. For her 13 miles is prob- ably a greater distance than 50 or 60 miles is in a rural area. She may not even have the moncy for bus fare which is almost $2 a round trip. She can’t impose on her neighbors be- cause there aren’t that many cars in the areas we are talking about. And the transportation of care to such patients, or of them to care, becomes a vital part of any program that is going to succeed in this Regional Medical Program. The transportation of care, the availability of care, is just as impor- tant as the excellence of care. We must think of these things as a coor- dinated plan where we use, insofar as we can, the people who are already working in the areas, and bring peo- ple into those areas where they have not chosen to work because there wasn’t much reward of the kind they really had to have. So just to begin, I would like to make the plea that availability in our case is every bit as important as excellence. Dr. TrusseL. I would like to talk to the issues of availability and quality and the opportunities for and chal- lenges to our RMP from some urban experiences which I have had, from some New York State experiences, and from some frustrations I have had being a member of HIBAC, which is the council that establishes policy for medicare subject to the ap- proval of the Secretary of Health, Education, and Welfare. Each Regional Medical Program operates in a different climate. There are different precedents, different things going on, different understand- ings, different degrees of willingness to face up to the realities. And Re- gional Medical Programs may be the leaders. I have described RMP legis- lation as the first legislation in this country that ever gave the scientific 25 community a chance to get together and tell the public what it needed and how they would like to do it. Regional Medical Programs may be the leader and innovator, or RMP, as is true in some urban areas, has to find a way to fit itself into what is already going on in order to achieve its goals and make the kind of addi- tive contribution to which Dr. Bres- low addressed himself so well this morning. I think that many in this room would do well to think seriously about Dr. Breslow’s message because it was the voice of experience. If you look at the studies of quality of care in this country—and they are time consum- ing and expensive—you find a wide range of excellence in care. Almost invariably, the highest scores are achieved in the medical centers with teaching programs and the lowest scores In the small proprietary and voluntary hospitals. I don’t think there is any reason to argue that there are not differences in quality of care in a given city or in this country. There are exceptions to the rules that T have mentioned. I can think of sev- eral excellent small hospitals, and I can think of several poor large hospi- tals. Nevertheless, the generalization emerges from the studies that have been done in this direction. One thinks about remedies to un- even quality of care. One immediately supports Dr. Wilbur’s view that there shouldn't be a national standard be- cause, as somebody pointed out, a na- tional standard would have to be a 26 minimum. This is what medicare is faced with. Congress enjoined us to see to it that any hospital which had a utilization committee and was ac- credited by the Joint Commission on Accreditation of Hospitals must be certified as a provider, if it also com- plied with Title VI. That is a mini- mum standard. There were a lot of hospitals which were not accredited. So we took the Joint Commission standards, and modified them and said if the hospi- tals met those and had a utilization committee and complied with Title VI, they could be certified. That is an DR. TRUSSELL even more minimum standard. As a national instrument, medicare con- tributes nothing to raising standards of care in most hospitals of any size and importance, There are absolutely no controls on the quality of the med- ical care or on the utilization of the care outside of hospitals except as carriers may draw attention to excess utilization which, as a result of fee review, may appear to them to have occurred. So each Regional Medical Pro- gram offers a marvelous instrument to further stimulate an interest in and furtherance of standards. It has an opportunity to draw on the profes- sional talent in the region (and there is a lot of talent in every part of this country) and let that professional climate develop which one finds in centers of excellence which we all strive for and realize we will never have completely. But let RMP be the professional leader to the extent that is possible. Let RMP speak out for the person who is getting poor care and in favor of that person getting better care. But this is voluntary, and it does require courage. I would point out that we are now in a much larger ball game than we were at the turn of the century. There are many organized ap- proaches to the delivery of care, and these offer excellent opportunities for dealing with the subject of qual- ity. There are administrative deci- sions that can be made and have been made in certain settings. For example, at one time, I had a study made of what kind of care I was paying for in voluntary hospitals in New York City. It that time, I was authorizing about $60 or $70 million of care for poor people in the voluntary system, in addition to spending a couple of $100 million in the municipal system. We found that 85 percent of the care we were purchasing from the voluntary system was in approved teaching programs, and T would sus- pect that, as a national score, that is pretty good. But 15 percent of that care was in hospitals that were ap- proved for nothing. They didn’t have interns. They might have had 1- or 2-year approvals in a couple of spe- cialties. “‘Phese hospitals were the same hospitals that turn up in medi- cal audits with low scores, in health department inspections with low scores, in laboratory testings with low scores. And so, through the auspices of the Interdepartmental Health Coun- cil, which was started by Commis- sioner Leona Baumgartner when she was Commissioner of Health in New York City, we set up some standards which were agreed to by all the city agencies—by the city controller who disbursed the money, by the Board of Hospitals who established policy for the Department of Hospitals, and by the Inter-Departmental Health Council. And we just set out some simple little guidelines. First, we announced we would not pay for care in a voluntary hospital which was not accredited. Secondly, we prohibited payment for care of children on pediatric serv- ices which were not approved for residency training. Third, we required that adults eith- er be cared for on a service approved for residency training or be taken care of by qualified specialists. We set up some other standards through the Interdepartmental Health Council, using expert advice from outside of government, on what kinds of services amputees needed. The city then offered all the institu- tions in the city an opportunity to be certified as amputee centers. And 14 out of the vast array of health facili- ties in New York City qualified. The city then adopted a policy of paying for services to amputees only in those 14 centers. With the help of a group of outside experts, all nongovernmental with the exception of one who happened to be a cancer expert in the City Health De- partment, we established some stand- ards to guide the payment for the care of patients with cancer and limited payments to the hospitals that met those standards. These were administrative deci- sions which were made about the use of public funds, but called on expert advice outside of government to achieve them. Finally, we had to come to sorme- thing that is not new in this country: thats. sorne sort of regulatory mecha- nisms. A hospital code was developed with the help of an expert committee of about 80 people to govern propric- tary hospital codes. For example, the code prohibits major surgery by men who are not trained to do major surgery. This code has now been upheld through the Federal Supreme Court, thereby determining the right of gov- ernment to protect all patients in in- stitutions which have been licensed rather than just patients who are paid for by public funds. This code has now been adopted essentially for all hospitals in New York State. We now have a code in New York State which affects all hospitals and which establishes a minimum which is far beyond the requirements of the Joint Commission. In fact, one of the requirements is that every hospital must become accredited. I once re- quired every proprietary hospital in New York City to become accredited, and 33 became accredited compared to 13 that had already been. When it comes to availability of service, there have to be some very large-scale public decisions made. | am all for continuing education. We have one of the largest continuing education programs in my school [Columbia] of any School of Public Health in the country, but training bright practitioners to give better care to private patients will not satisfy the intent of Regional Medical Pro- grams. ‘Vhere has to be an inprove- ment in the service which is made available in urban settings to people who are entitled to free care. And Regional Medical Programs has to make a conscious decision to allocate its money and its policy in that di- rection. And finally, in some parts of this country, regionwide planning has gone far ahead of this recent RMP program. In New York State, we have a system of seven councils cov- ering the entire State. There can be no building, no modification of a building, no establishment of a build- ing, without approval of this local regional council which is a locally elected group broadly representative of the community, then the approval of a State Council which is again broadly representative, but appointed DR. LLOYD by the Governor, then approval by the State Commissioner of Health. Whatever Regional Medical Pro- grams is going to achieve in the way of major program changes and facil- ity changes in New York State will have to be done through this pre- existing network of mandatory com- munity planning. By some people, this has been viewed as the end of voluntarism, by others the beginning of a control of excess costs through preventing unnecessary building and of rational planning for health serv- ices. Dr. Lroyp. Health is a major re- source of a community and a nation, and it should spend its money to protect its health. I do not believe that spending money for research and continuing education compro- mises the delivery of health care serv- ices. And the country need not delete funds from research and from educa- tion to finance the delivery of medical care. The delivery of medical care is spotty and the quality varies within the country. Regional Medical Pro- grams can work in a variety of ways in our communities. One of the best ways that it can function is by devel- oping in areas that do not have com- prehensive health care planning and undertaking the development of com- prehensive programs that will deliver quality health care to the population. We do not believe that there is an unusual rising expectation for un- usual medical care. I believe that the legitimate expectations of the citizens of this country regarding medical care have not been really fulfilled and that this country has paid for the delivery of medical care that has not been rendered under the systems that we now have. If the country was receiving ade- quate medical care and the delivery was good and the quality was good, there would be no real reason for the Regional Medical Program. The mere fact that we are here means that in some way the volunteer sys- tem has failed in delivering quality medical care to its population. I believe also that we need to re- evaluate the delivery of medical care; and I feel that the private practi- tioner may not be able to be available for all of the services that he has been available for before and that we should look much more into provid- ing that first line of medical care with other personnel. In continuing edu- cation, I believe that the programs, although extensive in the country, have failed in getting into the physi- cian’s office. We have been concerned with one small program and having physicians, private practitioners, do Pap smears in their office. We held several meetings in which all practitioners in the community were invited. And then, we checked the laboratories to see if the number of Pap smears increased: the Pap smear statistics did not show a large increase. So we did a different thing. We took a page out of the pharmaceutical 28 house sales technique, and we sent into the private practitioner’s office individuals with a small, 3-minute movie that showed how a Pap smear should be done. We left samples of twenty Pap smear kits and paid for them, to be read and returned. This has increased the use of the Pap smear in the community in which we have been working some 200 percent. I believe that the Regional Medi- cal Programs should be a mechanism for further experimentation in the delivery of medical care. Now, we must go outside of the medical pro- fession for help in the delivery of medical care. I do not believe that we can depend totally upon the uni- versities or the public health depart- ments for the delivery of care. It is community involvement, and it must be a community involvement, that will make health care much more available to the population and also have some control over the quality of care that is rendered to the population. I believe that the Regional Med- ical Program can serve this purpose. If it serves the purpose only of per- petuating the type of care that we are now giving, it will be just another line of frustrations for those who are looking to the Government for the provision of adequate and quality medical care. Dr. Jounson. I guess I was chosen to talk to you here today to bring to you a message about remote areas and the provision of health care in these areas. And in order that you know how remote I am and back to what fundamental basis of primary medical care I go, I practice in my village where I was born, and I have been practicing there 34 years. When I went back to practice in my village, it had 642 people in it. But after World War II, we had a population explosion and we have got 700 people now. Tt is my contention that people who live in, Dr. Egeberg, the Watts dis- trict of Los Angeles or, Dr. Trussell, the Harlem district of New York, are perhaps more remote from the stand- point of having adequate available health care for them than are most of the people who live in rural com- munities throughout the United States. There has come to be in my thinking another dimension of what constitutes adequate health care cov- erage. And that dimension relates to time. And I firmly believe that any person who is within 30 minutes of adequate health care facilities avail- able is adequately covered for the matter of health care. Now, we realize, those of us who come from small communities and rural communities, that every cross- road in every community wants a doctor just like they want a preacher and sometimes need an undertaker. And in my village, the man wanted to be convenient so he built directly across the street from me. But that is a little bit too close, and that stimu- lated me to upgrade my quality of care. I firmly believe that every small community does not need a physician. And I believe that many of the small communities in this country who now have physicians will no longer have them when the ones who are there now pass on. I am sure my commu- nity will not have another one when Tam gone. And I don’t think they need one, When I came there, people who lived 5 miles from my community were over 30 minutes away from my office. Now, we have paved roads running in every direction, a hospi- tal 17 miles on each side of us, where- as we had a hospital 45 miles away when I started there. And by auto- mobile or ambulance, a person can be in either one of these hospitals with- in 15 or 20 minutes if they are in a big enough hurry. So that I think it is axiomatic that any community that cannot support at least two physicians, a measure of group practice, can ill expect to re- tain one. And I think that the prob- lem that we are going to have to face in this country and it is going to have to be faced at a community level, per- haps with some measure of stimula- tion from regional programs and other approaches to the provision of health care for people, is to stimulate these small communities to combine into a larger community. In many instances, it is entirely possible to take four or five smaller rural communities, where each of the communities is within a measure of 20 or 30 miles of another community, and somewhere in the center identify DR. JOHNSON a location where two, three, four, or five physicians can locate and do ex- cellent work, Well, now, a community that can support four or five physicians can also afford to have an attractive com- munity where a physician and his family might want to move and to raise a family. Certainly not every crossroads can do this. I have re- gretted many, many times that I raised my children in the small com- munity where I did because I had to send them off to preparatory school when they were about 8 or 9 years old, and I am-sure I lost much of the contact that would have been good for me to have had with my family. And I don’t think I would do this again, 3ut if we can, by working with the commnunitics and allowing the con- sumers to have a part in the planning, get a half dozen communities to agree each to give up their little one com- munity and form a larger community in which the community can support half a dozen doctors more or less, can support an excellent school system, can support excellent religious facili- ties, can support good cultural facil- _ities, then, there is reason to believe that there will be physicians who will be willing to move into these areas. But we do have to have a com- munity adequate to be attractive to physicians if we are going to get phy- sicians in there. And one key to at- tracting a physician and keeping a physician in this sort of a commu- nity is having a situation which is tolerable to the physician’s wife, a litle bit attractive to the physician’s wife. ‘here is no one factor more in- volved in where a physician lives, particularly as it involves smaller communities, than the satisfaction that his wife gets from living in that community. Now, also, a group of physicians can reasonably expect to provide con- tinuous and comprehensive care for their people around the clock and around the calendar, because one per- son can take night calls this week, an- other next week, and maybe you only have to take the night calls one week out of every month or every fifth week. The same thing with weekends. One physician can cover all of the emergencies for the entire group dur- ing one weekend, and the other three or four can have time off. And that will make life tolerable so that a per- son can live with his family and help to bring his children up and keep his family a closely knit unit. So I think that the one thing that we must do—and maybe the Re- gional Program can be the stimulus— we must have some effort to consoli- date the smaller communities and have medical care available within the time limit of 30 minutes. Now, if we are going to do this, we have to have the type of physician who can earn a living in a small com- munity. And that physician has to be trained a little more broadly than the presently conceived specialist. ‘This physician has to be able to take care of something like 75 or 80 per- cent of all of the ills that beset man- kind. And if we are going to have this physician, the meclical schools are going to have to face up to the fact that they have to produce a family physician or a primary physician. And no place else except the medical schools can do this. And if they are going to do it effectively, they must have an on- going program providing this sort of care within the confines of the medical school and the hospital as- sociated with the medical school in order that the medical students can identify with this system of the pro- vision of health care. Otherwise, the medical students will not identify with it and will not go into it. A little story about the ability of the Regional Programs to produce: We have seven counties in southwest North Carolina, in the Appalachian region, that are quite unique. They are mountainous counties, and they do not have too many resources. They have 110,000 people. They have 62 doctors. They have eight hospitals, two of which are accredited by the Joint Commission on Accred- itation of Hospitals. This community got a little bit of catalystic aid from the Regional Pro- gram interested in community plan- ning. They organized a community planning corporation. The doctors organized an Academy of Medicine, all 62 of them. The hospitals agreed to have the Joint Commission on Accreditation of Hospitals come in and survey every hospital there with the idea in mind that, after the survey was done, there would be an effort to build in the center of this area which, incidentally is called the “State of Franklin,” a facility that would upgrade the facilities available for every person in the community and those going to every hospital in the community—the X-ray treat- ment, the electrocardiographic work, laboratory work, multiphasic screen- ing. And they agreed that the Joint Commission would work with this project with the idea in mind of doing some innovative work in this area and that ultimately, within a 29 year or two, the situation would be so improved, as to the provision of qual- ity care in this area, that the Joint Commission would agree to accredit all of these eight hospitals with their central unit—-to upgrade them as one unit. I have been on the Joint Commis- sion now for 7 years, and I am work- ing with it. And I think that that is going to be a demonstration project that all of the Regional Programs may well look to with pride. And it may cut a pattern whereby we can im- prove the quality and availability of health care for the people in the re- mote areas of this country. Dr. Ecenerc. Now, I am going to address a question or two and per- haps people will disagree with one another here. I would like to start with Dr. Lloyd if he doesn’t mind. He stressed something very im- portant—community involvement in the delivery of inedical care. And 1 wonder if he would take a couple of minutes to enlarge on this just a bit— lay versus medical. Dr. Lioyp. I believe that the lay- men can be sophisticated enough to have something to do with talking about the quality and the delivery of medical care. I believe that third parties who are paying for the care can certainly, again, have something to say about the quality of care they are paying for and how the care is to be supplied. You are not afraid at all of other involvement when you are delivering 30 good care. I have been sitting on a tissue committee in a large hospital, and have noted that men who are practicing good surgery don’t mind getting the unusual letter that they get from the tissue committee, for whom they have nothing but the high- est respect. It is men who are not doing good work really, I suppose, who move to other hospitals when the tissue committee looks critically at their work. We must give the type of care that a community would like to have. We have given the kind of care that we would like to give at times, and it has been not what has been wanted in that community or needed in that community. The community many times will know much more of what they need than we do. And we must talk to people in communities—I am talking about groups, civic leagues, labor unions, and the like-—-who have much to tell us about the delivery of medical care, I was in practice for about 10 years, too, so that I can talk as a prac- titioner. A physician’s office is a very inefficient operation. It is only be- cause we have so much profit built in that we can run the business the way we do it. It is a very inefficient operation, and we have shown that we can take many procedures, that physicians have been doing all the time because of the history of them doing them, and get people who have much less training to do these pro- cedures even better than the phy- sicians. Again, with regard to community involvement, we are not economists, we are not businessmen, and many times in the community, we can find these aids that we need. Dr. Ecrserc. Thank you, Dr. Lloyd. I think medicine has perhaps suffered from feeling that it has had to have a majority in most groups that decide on medical affairs. If they had worked more often with less than half the votes they might have had some more insight rubbed into them. Dr. ‘Trussell brought out one way of assuring a higher level of medical care which I thought was intriguing and almost needs repetition. It has been said that perhaps another way of assuring a higher level of medical care might be through having every- body in practice belong to some orga- nization responsible for the delivery of medical care. And I would like to ask Dr. Trassell what he thinks of that, Dr. Trussenn, [ think that every- body would agree that physicians who are in association with one an- other contribute to more thinking and self-criticism and that they are better doctors by virtue of belonging to some kind of an association. In urban areas and particularly in the New York City area, we have unknown thousands of doctors who have no recognized hospital appoint- ment. This creates some very real problems for RMP in trying to in- volve these individuals in continuing education. I don’t know what the answer is. To enlarge a little on vour state- ment about availability, Dr. Egeberg, one of our problems in New York City was too much availability. New York City has traditionally been the portal of entry for poor people. Right now, we have our immigration from the south and from Puerto Rico. These people need free care. And for decades they have received free care. The problem was that it wasn’t uni- formly good, and we had to undergo a massive reorganization. And I am sure Dr. Johnson, who obviously hasn’t been in Harlem, will be greatly relieved to know that Columbia University staffs the Har- lem Hospital under a city contract currently at the rate of $12.5 million a year. It is matching interns and filling residency slots. There is a new 800-bed hospital which will be open next year. And things are somewhat better in’ Tiarlens than they were a few years ago, Even the Governor is going to build a State office building just 10 blocks away from the hospi- tal—which is real progress. With respect to making things available also, Dr. Egeberg, again, I want to say you can do some things when they are of proven value by requiring them, at least where there is an institutional right to impose a requirement. It is generally recog- nized that cervical cytology is a pre- ventive technique which has a very high yield in women between the ages of 21 and 55—in fact, 70 percent of all cancer of the cervix in New York State that is reported is in that e on your state- ity, Dr. Egeberg, s in New York wailability. New ionally been the or people. Right umnigration from n Puerto Rico. ee care. And for ceived free care. at it wasn’t uni- had to undergo tion. , Johnson, who en in Harlem, ed to know that staffs the Har- a city contract of $12.5 million ing interns and There is a new ch will be open $ are somewhat an they were a the Governor is > office building from the hospi- YOTESS. making things igeberg, again, do some things ‘oven value by ast where there ht to impose a enerally recog- tology is a pre- ich has a very 1 between the fact, 70 percent cervix in New orted is in that age group. And in our State hospital code, there is now a requirement that any woman who hasn’t had a Pap smear within the previous year when she is admitted to any hospital in New York State and is in that age group has to have a Pap smear. There is also a requirement that anybody who hasn’t had a chest X-ray within the previous year has to have a chest X-ray unless the Com- missioner of Health deems it epi- demiologically unnecessary in that hospital to have this uniform requirement. There are some high-yield chest X-ray programs in Harlem, Bedford Stuyvesant, and the Bellevue areas. On the other hand, you can go 50 miles out of New York City, and it isn’t worth the money to take a chest X-ray on everybody. It is left up to medical judgment. But it is the phi- losophy in New York State, rein- forced by the law, where a preventive measure has proven of value to pri- vate patients as well as public pa- tients, it is now being built into the requirements on hospitals to provide that preventive measure for all hospitals. This does not, of course, extend to private practitioners in Dr. Lloyd’s program. And his description of en- couraging more doctors to do more Pap smears was a very exciting discussion. Dr. Ecreserc. Thank you, Dr. Trussell. Just one interruption here. I re- cently attended a medical association meeting in southern California where this question of Pap smear came up along these same lines. And there was a sharp difference of opinion. Every- body over the age of 60 thought this was a real interference with the prac- tice of medicine and that a county society was trying to tell people how to practice. Practically everybody below 50 thought it was a wonderful thing. Dr. Johnson, you talked about get- ting physicians into smaller com- munities. I am sometimes amazed how many people want to live in these large sores that we are breeding around the country, but apparently they do. I have heard that it is the wives who feel that they would rather live in a large community. And I have often thought that if some of these people could be introduced to a small community, maybe that would be all that would be required. I was on a medical manpower com- mittee concerned with the armed serv- ices not too long ago in which some- body suggested that perhaps the draft’s main drawback was that it didn’t involve everybody and perhaps everyone ought to take a year of some kind of service. Those who didn’t have to go into the armed forces might do their service in some small commu- nity, and many of them might stay there if they fell in love with the com- munity and their responsibilities. Would you care to remark on that? I know what you are going to say. Dr. Jounson. I would be very glad to comment on that. If you could introduce these people in their form- ative years to an attractive commu- nity, you might do something. But so many of them have gone out into preceptorship programs and have seen communities like the one that I live in where I am on call 24 hours a day 7 days a week around the clock around the calendar, and the educa- tional facilities, the cultural facilities, et cetera, are not up to par, and I would say that a preceptorship pro- gram, if it is a forced preceptorship program, will start with a bias built in against it. A preceptorship pro- gram has as much potential for harm as it does for good. But if you can in- troduce folks into an attractive com- munity and get them interested in fishing and hunting, and so forth, you can coerce them a little bit. Maybe you can teach the wife to shoot quail. I do believe this, however, that this business of putting communities together cannot be done by bureau- crats; it cannot be done by medical educators; it cannot be done by peo- ple from the top down; it cannot be done by people who represent a mass pool of practical ignorance, you might say, about how to provide health care services for people in these communities. But we are going to have to make health care available, and I do agree that the physician is going to have to learn to use his time better. I have four assistants, and I assure you that my productivity is much greater be- cause of that, and I don’t have to charge as much in order to pay the bills at the end of the month. We are going to have to make medical care more available, but I don’t want us to get way out in left field and make it available from those who cannot supply quality care. 31 DIVISION OF REGIONAL MEDICAL PROGRAMS REPORTS ON, PROGRESS AND ISSUES Robert Q. Marston, M.D. Karl D. Yordy A NEW EMPHASIS Alexander M. Schmidt, M.D. Richard F. Manegold, M.D. OPERATIONS RESEARCH AND SYSTEMS ANALYSIS Robert Bucher, M.D. Jack Hall, M.D. Herbert P. Galliher, Jr., Ph. D. Maurice E. Odoroff 33 DIVISION OF REGIONAL MEDICAL PROGRAMS REPORTS ON— PROGRESS AND ISSUES Robert Q. Marston, M.D. Associate Director National Institutes of Health and Director, Division of Regional Medical Programs Karl D. Yordy Deputy Director, Division of Regional Medical Programs he progress and issues in the im- plementation of individual Re- gional Medical Programs are stated in your agenda. They are the same progress and issues faced by the di- vision viewed from a slightly different perspective, This year your steering committee has focused this entire Conference- Workshop around the question of quality and availability of health serv- ices. In our report to you this morn- ing, the division of Regional Medical Programs will present reports on selected areas related to this general problem. Dr. Bucher will report for his group on progress in the use of operations research techniques and methodology. Dr. Schmidt will docu- ment the increasing activity in the di- vision centered on the substantive im- provement of health services. 34 I would like to focus on some of our contemporary issues by quoting suitable words from the past. “Our knowledge of the clinical pathology of the heart has advanced with such rapidity during the last decade, and the subject as a whole has become so technical, that at the present time it is difficult or well-nigh impossible for the general reader to keep pace with its progress. The writings are scat- tered; they call, in the reading, for considerable preliminary knowledge of the subject matter discussed. “In contemplating the work of the past few years, it seems to me that a stage of the enquiry had been reached at which it was possible to give a review of the main results of the numerous researches, and to place before the student of general medi- cine the evidences upon which the chief conclusions of the present day rest. “A number of phenomena, ob- served in clinical and experimental studies, are described side by side in this book, and an attempt is made to show the manner in which abnormal actions of the heart, as they occur in patients, may be identified with simi- lar disturbances artificially created in laboratory experiment.” This quote is from the preface of Sir Thomas Lewis’ book on “Mechanism of the Heartbeat,” published December 1910. T have chosen Sir Thomas Lewis because Dr. William Branch Porter, my professor of medicine, was a stu- dent of Lewis’ and always used a stethoscope given to him by Sir Thomas. Sir Thomas dedicated his book to his teachers, Makenzie and Kinthoven. Last week at the Univer- sity of Chicago Board of Trustees dinner for the faculty, Professor Chandrasekhar, in speaking of dis- tinction in science, traced the gencal- ogy of Nobel Prize winners in chem- istry in an unbroken student-teacher relationship back to 1901. He em- phasized the point that excellence begets excellence. Medicine has been particularly dependent on the precep- tor concept, the | to | ratio of student to teacher or physician to patient. The unquestioned validity of this ar- rangement to assure excellence, though proven through the years, constitutes a major challenge when you and I address the complex issues of the maintenance of excellence in the organization and delivery of health services. Two speakers on our program last year spoke pointedly on this issue. Undersecretary Cohen said, “Some have argued that there is an incon- sistency, or even conflict, between high quality and widespread use. They believe that excellence is such a rare and tender flower that it can only bloom in special and carefully protected environments. They have suggested that we can lose everything As I was proofreading this speech I was informed that one of my great teachers, Lord Florey, whose development of peni- cillin earned him a Nobel Prize, died Feb- ruary 22, 1968. (R.Q.M.) by trying to mass produce what re- quires the most skilled craftsmanship. “This point of view, I believe, is contrary to our national history and commitment. I think we have the capabilities as a society to make the very best available to all our people.” Dr. Shannon, in a paragraph that we have quoted often, stated, “al- though we must contend with many diverse geographic and social circum- stances, NIH, in administering the Regional Medical Programs, will strive to preserve existing centers of excellence in science, education, and service while, at the same time, work- ing with State and loca! forces, evolve a system that will make available to the bulk of the population medical services that are excellent in quality and adequate in quantity——at least in a major segment of the diseases that plague us all.” It is appropriate to consider for a moment the Regional Medical Pro- grams in the context of the Federal role in the organization and delivery of health services. In its present out- lines, that role is relatively new, ex- cept for the facilities programs and some of the previous stimulation of planning as described vesterday by Dr. Breslow. Experience with the ma- jor new components of that role is limited. The effects of medicare and medicaid are just becoming known. Most of the Regional Medical Pro- grams have not yet entered opera- tional phase. The experience with comprehensive health planning is at a still earlier stage of development. ice what re- aftsmanship. I believe, is | history and ve have the to make the our people.” ragraph that stated, “‘al- 1 with many yclal circum- listering the grams, will ig centers of ucation, and - time, work- orces, evolve available to ion medical it in quality —at least in diseases that sider for a fedical Pro- the Federal and delivery present out- sly new, ex- ograms and mulation of esterday by vith the ma- that role is edicare and ing known. fedical Pro- ered opera- rience with anning is at evelopment. DR. MARSTON An expanded health services research program is mostly intent. But the urgency and public awareness are in- creasing, and one can describe some characteristics of the road that lie ahead. The nature of this Federal role al- most certainly is different from the current Federal role in the support of medical research, such as the grant programs of the National Institutes of Health, or in the direct delivery of health services, such as the Veterans Administration hospital system. It will probably be different from the emerg- ing Federal role in support of medical education, though the fuller outlines of that role, while further along than the health services role, are still in the process of being determined. Federal research support is primar- ily involved in the support of some functions within an institution. Sup- port for medical education becomes more concerned with the viability and strength of the total institution. But it seems apparent that the Federal role in the organization and delivery of health services must be concerned not just with single institutions but with the interrelationships among many institutions, organizations, health personnel, and the consumers of health services. The importance of the consumer was described forcefully by Dr. Lloyd in his presentation yes- terday. It is clear that this role will not be characterized by the direct de- livery of health services by the Gov- ernment on the Veterans Administra- tion model. Rather, we see a fertile environment for the exercise of that peculiar propensity and genius of our society to invent new institutional and organizational frameworks to meet new challenges. In my previous re- sponsibilities, I have often heard young physicians and medical scien- tists from other countries praise our unique ability to bring together the skills of those from many disciplines to focus on particular problems. To carry this approach into the problems of health care will require not only the focusing of a variety of individual talents, but also a wide range of in- stitutions and organizations, each of which can make a particular and es- sential contribution to the solution of the health care problems. Regional Medical Programs them- selves have challenged our capacity for organizational invention with a va- riety of results. One concrete mani- festation of a creative organizational response has been the emergence of new nonprofit corporations to serve as the common arena where many institutional interests can meet for common purposes. These new orga- nizations will be tested in the com- ing years to see if they can truly en- compass the many relevant interests within a new unity of purpose, relate effectively to other activities in the health field, and avoid the dan- gers of becoming protective or static. In stimulating new structures and relationships in health, much of the Federal role will probably be indirect, through influencing a vast and dy- namic health endeavor that is based 35 on local institutions, organizations, and initiatives. A Governmental role will not pre- dominate at the actual meeting point ‘of the provider and consumer of health services, even though the pro- portion of financing through Govern- mental channels is likely to increase. The efforts to preserve voluntary ac- tion will continue to shape the char- acter of the Federal role. While maintaining local freedom of action, one aspect of the Federal role is clear: It must facilitate the im- plementation of productive and de- sirable change in areas affecting health services. One of the major forces for change is the strong desire for high standards of excellence that has permeated our medical activities and that has led to so much impres- sive accomplishment throughout the history of American medicine. The tradition of excellence and its con- tinued pursuit will continue to create much of the need for changes in the organization and delivery of health services. The same tradition will also continue to create opportunities for improved health care. The Federal commitment to the wider availability of the best in medical care and the continued support for the develop- ment of medical excellence are two aspects of the same interest. This re- lationship was a central theme in Dr. Chapman’s presentation when he re- ferred to research in the service of mankind. But to accomplish this role of facilitating productive change, it will be necessary to capitalize on all 36 of our resources and energies in the health field. We must be as concerned about integrating the public and pri- vate segments of the health endeavor as with avoiding the isolation of the ivory tower or the solo practitioner. There will be a continued need to focus on special problems, such as the critical health problems in the urban slums, but that special attention will need to include the development of relationships between these special efforts and the rest of the health serv- ices framework in order to avoid re- placing old isolation with new. If these are some of the possible outlines of the Federal role in the organization and delivery of health services, how do Regional Medical Programs relate? Dr. Breslow said yesterday: “To those concerned with the improvement of health care in this country, regionalization has be- come the order of the day.” Because regionalization is essential for ac- complishing the purposes of this pro- gram, we have chosen in our revision of the Guidelines to describe the mechanism for achieving the goal of the Regional Medical Programs as a process of regionalization. That goal is described in the Surgeon General’s Report on Re- gional Medical Programs as... clear and unequivocal. The focus is on the patient. The object is to in- fluence the present arrangements for health services in a manner that will permit the best in modern medical care for heart disease, cancer, stroke, and related diseases to be available to all.” We have described the process of regionalization in the following terms in the new Guidelines: Regionalization among the full ar- ray of available health resources is a necessary step in bringing the bene- fits of scientific advances in medicine to people wherever they live in a re- gion they themselves have defined. It enables patients to benefit from the inevitable specialization and division of labor which accompany the ex- pansion of medical knowledge be- cause it provides a system of working relationships among health personnel and the imstitations and organizations in which they work. This requires a commitment of individual and insti- tutional spirit and resources which must be worked out by each Regional Medical Program. It is facilitated by voluntary agreements to serve, sys- tematically, the needs of the public as regards the categorical diseases on a regional rather than some more nar- row basis. Regionalization within the context of Regional Medical Pro- grams has several other important facets: It is both functional and geo- graphic in character. Functionally, regionalization is the mechanism for linking patient care with health research and education within the entire region to provide a mutually beneficial interaction. Regionalization provides a means for sharing limited health man- power and facilities to maximize the quality and quantity of care and service available to the region’s population and to do this as eco- nomically as possible. , Finally, regionalization also con- stitutes a mechanism for coordi- nating its categorical program with other health programs in the re- gion. As a result, their combined effect may be increased so that they contribute to the creation and maintenance of a system of com- prehensive health care within the entire region. Because the advance of knowledge changes the nature of medical care, regionalization can best be viewed as a continuous process rather than a plan which is totally developed and then implemented. This process of re- gionalization consists of at least the following elements: Involvement, identification of needs and opportu- nities, assessment of resources, defi- nition of objectives, setting of priori- ties, implementation, and evaluation, I will describe and discuss these seven elements in the process separately, al- though in practice they are interre- lated, continuous and often occur simultaneously. First, involvement. The involve- ment and commitment of individuals, organizations, and institutions which will engage in the activity of a Re- gional Medical Program, as well as those which will be affected by this activity, must underlie a Regional Program. By involving in the steps of study and decision all those in a re- gion who are essential to implementa- tity of care the region’s this as eco- on also con- for coordi- rogram with ; in the re- r combined so that they eation and em of com- . within the f knowledge edical care, ye viewed as ther than a veloped and wrocess of re- at least the nvolvement, nd opportu- yurces, defi- ig of priori- | evaluation. ; these seven parately, al- are interre- often occur he involve- individuals, \tions which ity of a Re- , as well as cted by this a Regional the steps of ose in a re- mplementa- tion and ultimate success, better solu- tions may be found, the opportunity for wider acceptance of decisions is improved, and implementation of decisions is achieved more rapidly. Other attempts to organize health resources on a regional basis have experienced difficulty or have been diverted from their objectives because there was not this voluntary involve- ment and commitment by the neces- sary individuals, institutions and or- ganizations. The act is quite specific to assure this necessary involvement in Regional Medical Programs: It de- fines, for example, the minimum com- position of Regional Advisory Groups. To insure a maximum opportunity for success, the composition of the Regional Advisory Group should go beyond the minimum requirements to be reflective of the total spectrum of health interests and resources of the entire region. And it should be broadly representative of the geo- graphic areas and all of the socio- economic groups which will be served by the Regional Program. The second element, identification of needs and opportunities. A Re- gional Medical Program must iden- tify the needs as regards heart disease, cancer, stroke, and related diseases within the entire region. Further, these needs must be stated in terms which offer opportunities for solu- tion. This process of identification of needs and opportunities for solution requires a continuing analysis of the | problems in delivering the best med- ical care for the target diseases on a regional basis. And it must go beyond a generalized statement to definitions which can be translated into opera- tional activity. Particular opportuni- ties can be identified by: ideas and approaches generated within the re- gion, extension of activities already present within the region, and ap- proaches and activities developed elsewhere which might be applied within the region as part of the process of regionalization. The third element, assessment of resources. This implies a continu- ously updated inventory of existing resources . . . an inventory of ca- pabilities in terms of function, size, number, and quality. Every effort should be made to identify and use existing inventories, filling in the gaps as needed, rather than setting out on a long, expensive process of creat- ing an entirely new inventory. In- formation sources include compre- hensive health planning agencies, hospital and medical associations, and voluntary agencies. This inven- tory provides a basis for informed judgments and priority setting on posed for development under the Regional Program. It can also be used to identify missing re- sources-—-voids requiring new invest- activities ment—and to develop new configu- rations of resources to meet needs. Definition of objectives is the fourth element. A Regional Program must be continuously involved in the process of setting operational objec- tives to meet identified needs and opportunities. Objectives are interim steps toward the goal of Regional Medical Programs, and achievement of these objectives should have an effect in the region felt far beyond the focal points of the individual activities. This ripple effect can be one of the greatest contributions of Regional Medical Programs. Element number five is setting of priorities. Because of limited man- power, facilities, financing, and other resources, a region must assign some order of priority to its objectives and to the steps to achieve them. Besides the limitations on resources, factors to consider include: (1) Balance be- tween what should be done first to meet the region’s needs, in absolute terms, and what can be done using existing resources and competence; (2) the potentials for rapid and/or substantial progress toward the goal of Regional Medical Programs and progress toward regionalization of health resources and services, and (3) program balance in terms of disease categories and in terms of emphasis on patient care, education, and research. The purpose of the preceding steps has been to provide a base and im- perative for action. Thus, implemen- tation is the sixth element. In the creation of an initial operational pro- gram, no region can attempt to deter- mine all of the program objectives possible, design appropriate projects to meet all the objectives, and then assign prioritics before seeking a grant to implement an operational program which encompasses all or even most of the projects. Implemen- tation can occur with an initial oper- ational program encompassing even a small number of well-designed projects, provided they will move the region toward the attainment of valid program objectives. Because re- gionalization is a continuous process, a region is expected to continue to submit supplemental and additional operational proposals as they are developed. After the implementation of an operational program, there are two potential threats to be avoided. One is the projects will lose their regional identities by becoming institutional projects, and thereby cancel the op- portunity for the operational program to have regional scope and effect. The other threat is that projects will lose the relationships one to another which maintain the interaction of patient care, education, and research. Preventing these breakdowns requires project and program administration of a high order. It also requires sus- tained communications, involvement, and the application of evaluation. This brings me to the final element in the process of regionalization: Evaluation. Each planning and op- erational activity of a region, as well as the overall Regional Program, should receive continuous, quantita- tive, and qualitative evaluation wher- ever possible. Evaluation should be in terms of attainment of interim ob- jectives, the process of regionaliza- 37 tion, and the goal of Regional Medi- cal Programs. Objective evaluation is simply a reasonable basis upon which to determine whether an activity should be continued or altered, and, ulti- mately, whether it achieved its pur- poses. Also, the evaluation of one activity may suggest modifications of another activity which would increase its effectiveness. Any attempt at evaluation implies doing whatever is feasible within the state of the art and appropriate for the activity being evaluated. Thus, evaluation can range in complexity from simply counting numbers of people at a meeting to the most in- volved determination of behavioral changes in patient management. As a first step, however, evaluation entails a realistic attempt to design activities so that, as they are imple- mented and finally concluded, some data will result which will be useful in determining the degree of success attained by the activity. By this rather detailed definition of regionalization, we arrive at the criterion for judging the success of a region in implementing the process of regionalization. Success is meas- ured by the degree to which it can be demonstrated that the Regional Pro- gram has implemented the seven es- sential elements of regionalization: Involvement, identificaion of needs and opportunities, assessment of re- sources, definition of objectives, set- ting of priorities, implementation, and finally, evaluation. 38 Ultimately, the overall success of any Regional Medical Program must be judged by the extent to which it can be demonstrated that the Re- gional Program has assisted the pro- viders of health services in developing a system which makes available to everyone in the region the best care for heart disease, cancer, stroke, and related diseases. In giving you some of the content of the revised Guidelines, I would like to reassert, as was done in the report of the Surgeon General to the Presi- dent and the Congress that the basic concepts of the Regional Medical Programs remain unchanged. As you review the revised Guidelines, which I hope to have available for you in draft form on Friday, you will find in- creased clarity, not surprises. I believe that it is important to point out that this program is still in its infancy. It has not yet been sup- ported by a critical mass of money, it still awaits extension of its initial legis- lation, and it still must document more firmly its value. However, all the pressures leading to its existence have intensified in the past two-years, and new conditions such as the im- plementation of medicare, medicaid, and a greater concern for increasing costs have become realities. We also have gained some meaningful experi- ence—exemplified best by this meet- ing itself. As the programs evolve, now and at times unexpected problems will emerge, and some of them will test sorely the stability of Regional Medi- cal Programs. For instance, the car- marking of some of the RMP funds by the Congress is viewed by some as a threat to the concept of regional ini- tiative and regional determination. We believe, however, that this will not occur. We must try to continue to estimate honestly the potential of RMP. One organization was de- scribed sardonically by the Economist as a “permanent institution devoted to proving there is not enough food in the world.” Results, not assertions, will be needed. And yet the consciousness of the problems of our society is not due pri- marily to our increased sensitivities but more to the strengthened power of the people in demanding that their needs be met. The question remains, however, whether the inertia of the system in a large and complex nation can be overcome. The energies and high hopes of those now working in the regions must overcome the problems of an ingrained system. Through no choice of any individuals, the time for change is now. The forces of evolu- tion should prevail and the system should move to respond to the de- mands of the Nation’s needs. DIVISION OF REGIONAL MEDICAL PROGRAMS REPORTS ON— A NEW EMPHASIS Alexander M. Schmidt, M.D. Chief, Conitnuing Education and Training Branch Division of Regional Medical Programs Richard F. Manegold, M.D. Associate Director for Program Development and Research Division of Regional Medical Programs LD Manegold and I appreciate the invitation extended to us by your program committee to re- port on some significant recent de- velopments in Regional Medical Programs. These developments have two things in common: They orig- inated in regions, but have stimulated change here at the division of Re- gional Medical Programs. Secondly, they reflect the current status of the programs. These developments rep- resent a new emphasis on the rele- vance to patient care of both the pro- grams and the division. During the next few minutes, I would like to characterize further this new emphasis. To gain perspective, I would re- mind you of the first National Con- ference on Regional Medical Pro- ISION OF MEDICAL — a co < 3 << O 4 «K and that at the upper end of the curve there might be a saturation effect wherein large additional increments in teaching time might produce no significant increase in manpower pro- duction. However, the part of the curve with which we are usually con- cerned is probably close enough to the straight line to allow the relationship to be expressed as a linear one. No attempt will be made to illus- trate all of the mathematical state- ments which describe this problem, 46 but a few examples can be shown and explained. The next slide (6) illus- trates the general statement of the amount of capability which exists at a given time, The equation reads as follows: N;(t) (the amount of j-type capability at time period ¢) is equal to the amount of j-type capability which existed at the previous time pe- riod plus the summation of the time expended in teaching the j-type student by the i-type teacher times the factor relating teaching time to production of j-type persons by i-type teachers during time period ¢ and minus the loss of j-type personnel dur- ing the preceding time period. Each activity can be represented in mathe- matical symbols and each positive statement of fact becomes a mathe- matical formula. Up to this time the operations re- searcher did not know what specific methodologies and techniques could be utilized. As the situation was dis- played it was possible to identify that it could be approached best in terms of a multitime period linear program. We can anticipate in the medical system that some models may defy existing known methodologies. In these cases, the operations researcher may have to derive new methodolo- gies. Or occasionally in the interest of expediency, simplification of the problem to put it into known methods may allow usable approximations of solutions. One other thing which must be done is to constrain the computation so that it will not produce unaccept- able solutions. Two constraints in this problem are illustrated on the next slide (7). The quick solution would be to turn everyone’s efforts toward teaching and therefore pro- duce the needed manpower rapidly. However, this would be unacceptable since the level of care rendered would be intolerable at the current time. Thus, the first constraint states that a total of all of the types of capability rendering care in a given time period must be greater than or equal to some minimum level of care which 1s stated. Another constraint is that the amount of capability devoted to care and to teaching must not be greater than the total amount of capability existing within the system itself at any one time. While construction of a mathe- matical model is within the sphere of competence of the operations re- searcher. it is important to recognize that he cannot do this alone, but must SLIDE 5 q.X% CAPABILITY PRODUCED TIME EXPENDED IN TEACHING x have the partnership of someone familiar with the system and one who can assist in obtaining the most ap- propriate methods of measurement. As was stated, this particular problem has been defined as a multitime pe- riod linear program. Without en- deavoring to explain what a linear program is, I would only state that it is one which has been used for many purposes, and computer programs exist to enable the solving of those which are complicated and extensive e.g, in the automobile industry a linear prograin on the assembly op- eration is run each night). In brief, the methodology picks the optimal strategy by selectively searching among the totality of all feasible com- binations and permutations of al- locating time expenditure for each of the capability types in each time pe- riod to each type of care and to the teaching of each specific type of stu- dent in cach time period. This partic- ular model with the hypothetical four types of care and personnel results in a linear program problem consisting of 110 formulas and 200 variables. Once the data has been inserted, a man using a calculator could solve the problem in several weeks. The computer, however, can solve it in sev- cra] minutes. Of course, this is a sim- plified hypothetical situation utilized to develop the model. Real situations, when placed into the model form, will often result in an increase in the number of variables and computa- tional time will rise in relationship to this increase. While this may prohibit manual solution, computer solutions may nevertheless be feasible at a cost that is reasonable in relation to the planning priority. Credit for the mathematical meth- odology for this problem is due to Mr. Leonard Krystynak, a graduate stu- dent working with Dr. Galliher. He has derived the initial solution and is currently subjecting the model to further testing. We are now prepar- ing real-life data for insertion into the model. However, it is not our purpose to examine this specific model, and further discussion on it will await another time. Hopefully, it may have helped to give some insight to those of you unfamiliar with operations research on the way in which it functions. It is essential that there be an atmosphere of partnership and par- ticipation between the operations re- searcher and a teammate who can identify a problem, state the problem clearly and precisely in English or graphic illustration and assist in find- ing the most suitable units of meas- urement. The operations researcher can then formulate the mathematical statements which summarize, in un- ambiguous specification, the exact facts and principles of the problem. From here, he can identify the specific type of mathematical processes to be utilized in identifying the optimal strategy. SLIDE 6 THE AMOUNT OF TEACHING TIME EXPENDED THE ATTRITION WHICH OCCURRED DURING THE PREVIOUS TIME + Saijp-xij'? - 27! THE TOTAL AMOUNT OF CAPABILITY EXISTING AT A TIME THE AMOUNT OF CAPABILITY WHICH EXISTED AT PREVIOUS TIME THE AMOUNT OF CAPABILITY PRODUCED BY A UNIT OF TEACHING t-1) OBJECTIVE ———-——__MINIMIZE E alt) 47 SLIDE 7 CONSTRAINTS 1. SZ pij(t) 2 Mj (t) TOTAL OF CAPABILITY RENDERING CARE MINIMUM LEVEL OF CARE STATED 2. Spi? + xxij"t < onount OF CAPABILITY DEVOTED TO CARE AMOUNT OF CAPABILITY DEVOTED TO TEACHING TOTAL AMOUNT OF CAPABILITY EXISTING The last slide (8) illustrates the process and, in addition, indicates the magnitude of input needed at cach stage by operations researchers and by medical people familiar with the sys- tem and capable of making value judgments. One can see that the bulk of the effort in all but two of the stages must be contributed by medical people. The actual solution is purely mathematical and the model testing phase is often heavily mathematical. The particular methodology used in the. example given (linear pro- graming) is only one of many which are available, and this is but one of 48 nil) a number of problems to which the group has directed its attention. A major portion of our activity has been expended in reviewing the accom- plishments of OR~SA in other areas and assessing possibilities of relating these accomplishments to health problems. A few specific examples are cited: 1. Within industry and the mili- tary services, OR-SA has developed theories and methodologies related to the prediction of demands for prod- ucts and services. One example of a health problem to which these may be applied is that of coronary care, and a mathematical model has been de- veloped and is being validated. A stochastic model is being attempted with the objective of determining how many coronary care units should be provided in each locality. If success- ful, the model may be useful for each region. 2. The methods of approaching production scheduling problems in in- dustry may be applicable to a host of medical problems. The example cited today is one of these. Another on which work is progressing is that of coronary care capability programing. This represents a multitime period capability programing of coronary care modalities and of manpower provision. The objective would be to determine as accurately as possible how the division and the regions should allocate their funds and other resources in the establishment of coro- nary care units and manpower. The time dynamics in this problem are comparable to those shown in the ex- ample. 3. A rheumatic heart disease con- trol model, which includes a multi- stage model of the disease and con- tains both epidemiologic and profes- sional training components, is being developed. This utilizes decision- theoretic methodologies which have been developed for process and qual- ity control, and military surveillance. 4. Regional economic problems in industry related to location of plants, warehouses, and sales regions have been assisted by another set of mathe- matical processes which give promise in approaches to regional economics’ in health care. The group has ex- amined this and some preliminary work has been done. 5. The study of patient trajec- tories has also been instituted. The methodologies in this problem are re- lated to those which have been de- veloped and used in marketing research and consumer behavior. It is our conviction that we are just entering upon the threshold of a new scientific development in med- ical care. Hopefully, we may leave two major points with you at this time. First, health operational research will be successful only as there is full teamwork between the operations re- searcher and medical people. Full time commitment of significant med- ical manpower is essential. Second, Regional Medical Pro- grams represents an operational ex- periment. Operations research is the science of operational experimenta- tion. Thus, those of us here assembled have one of the best opportunities for a leadership contribution in the development of its application to health. << oF wm OO 1 Oe Ye REAL LIFE FORMULATE PROBLEM Be a ee ee SLIDE 8 CONSTRUCT MODEL be ee ee ee ee ee wee ee ee ee DERIVE SOLUTION fe ee ee oe oe J em we eee APPLY SOLUTION v OR ESTABLISH CONTROLS TEST MODEL A NATIONAL VIEW OF DEVELOPMENTS IN. . . . HEART DISEASE Donald S. Fredrickson, M.D. CANCER Kenneth M. Endicott, M.D. STROKE Richard L. Masland, M.D. A NATIONAL VIEW OF DEVELOPMENTS IN— HEART DISEASE Donald S. Fredrickson, M.D. Director, National Heart Institute National Institutes of Health Sr time ago I would have con- sidered this morning’s program best defined as an ‘interfaith mcet- ing.” My judgment and pronuncia- tion have improved alike. I now know that this is better described as an “interface meeting.” Defining the surfaces at which the programs of the categorical institutes and the Re- gional Medical Program mutually interact is a difficult exercise, but essential to perform. In organizational language the mission of the National Heart Insti- tute is to develop new knowledge that will lead to both a reduction in the rate at which healthy individuals de- velop cardiovascular diseases and improved care of those who have such diseases. The major mission of Regional Medical Programs would seem to be to promote the application of that knowledge and to see that its benefits are available to the greatest number. This separation of the concepts of discovery and delivery seems splen- didly convenient. It is also not very helpful and could be absurdly wrong if interpreted as a perfectly workable 32 division of labor as we all move to- gether to meet the Nation’s needs for better health care. Our mutual involvement in this common endeavor obviously is com- plex and our roles are not so clearly divided, for discovery and application are not easily separated. Society—not unreasonably—supports all of our ac- tivities because it expects something better for itself. It gains when dis- covery is applied. In this sense, dis- covery may only become real! when it becomes practical and safe and clearly beneficial, and when it be- comes available to those who need it. Thus, the Heart Institute has its stake in delivery of such gains it may achieve through research. And RMP has its stake in applying the mecha- nisms of discovery. For how shall you know, save by applying the best of experimental methods, how to solve the problems of application, to deter- mine the needs, and to evaluate the worth of interventions? And how shall new techniques be taught and disseminated most widely except by those who have acquaintance with the method of their discovery. We have common purposes, then, and must be prepared to blend and exchange our efforts, expertise, and resources at many points of contact. As we sec the programs in the re- gions unfold, there are several inter- faces between these programs and those of the Heart Institute that are particularly identifiable at this point mouime. ‘These Heart Institute activities are of three or four major types. The first concerns training of individuals in the techniques of cardiovascular research, diagnosis, and care. Our training pro- grams have several aims of impor- tance to regional activities. Currently we have as fellows or trainees pri- marily learning how to do research, nearly 1,800 individuals. Since its in- ception, more than 11,000 scientists have been trained under the training grants and fellowships program. Some of these men are now lIcading and participating in aspects of Re- gional Medical Programs, and more will follow. Of more direct relevance is a rela- tively new program of clinical train- ing grants. Begun in 1966, 35 of these grants are currently being supported by the Institute. The objective here is to train physicians who understand enough of research to make it easier for them to apply new developments and to teach them to others. They are an essential “hybrid” ingredient of the plans to upgrade the practice of cardiovascular medicine. They will not all remain in university centers and most are not expected to pursue research as a major means of their livelihood. Their contributions should have a major impact on the success of Regional Medical Programs. The Heart Institute is also inter- ested in some aspects of the training of special paramedical skills. On an experimental basis, we have been sup- porting, for example, the Duke Uni- train) physician versity effort to assisiants, ‘Vhese individuals save ply- sician time by taking over tasks in intensive care units, hyperbaric cham- bers, emergency rooms, hemodialysis, and other functions. The Institute has looked upon such an effort as re- search, for all discoveries of impor- tance are not molecular in nature. The broader application of successful portions of such prototype experi- ments is not within the resources of the Institute and is distant from the center of its mission. It is much closer to Regional Medical Programs. A second program of direct impor- tance to Regional Medical Programs is the development of cardiovascular research and training centers. These are units envisoned in the President's Commission for Heart, Cancer, and Stroke and for which planning funds were first awarded in fiscal year 1966. With respect to the Cardiovascular Research and Training Centers pro- gram, I should begin by stating that no centers are presently in existence. At least one is ready for funding and. 10 are now in the planning stage, but the first specific operational grants under the center concept are expected in 1969. Thereafter, given available funds to support the operation of such centers, the NHI timetable calls for two to become operational in 1969; a total of five in 1970; seven in 1971; 10 in 1972; and 12 in 1973. What will these centers be? We hope they will represent true car- diovascular “‘centers of excellence” as envisioned by the — President's ‘ - Clominission, DR. FREDRICKSON As we are now planning for them, each center will be an organizational unit, existing within the framework of a university or similar institution, for the purpose of attacking a broad range of cardiovascular disease problems. Ideally, the center would be orga- nized under a single outstanding «i- rector. It would be staffed with a corps of scientists and clinicians rep- resenting not only the clinical disci- plines, but also the physical, engineer- ing, and social sciences. Provision will be made for such scientists to work in sufficiently close proximity to encourage free exchange of information, ideas, and construc- tive criticism. While the center will be conducting a broad range of studies, it will also be involved in research directly rele- vant to the solution of clinical prob- lems posed by the cardiovascular diseases. Thus it will provide, or else be closely allied with, personnel and fa- cilities essential to the conduct of ad- vanced diagnostic and therapeutic procedures, The operational grant will provide funds for the care of re- search patients both on an inpatient and outpatient basis. The center will be a clinical resource for referral of patients requiring highly sophisti- cated diagnostic or therapeutic pro- cedures not generally available in the average community hospital or clinic. The center will provide a training resource for equipping scientists and physicians with the skills and tech- niques of modern biomedical re- search. Through its clinical training. programs, it should be a focus for ef- fective dissemination of the fruits of its research to the region which it serves, The activities of the center will be national or even international in scope but it will exert its strongest influence on cardiovascular research and clinical care in the region where it is located. It is axiomatic that a good clinical research program in a hospital has a way of improving the medical care received by the regular ward patients in that hospital. In the case of the center, we hope that it will serve as a standard of excellence for hospitals in its sphere of influence. We also ex- pect them to be foci of activities rele- vant to Regional Medical Programs. We expect to increase the number of planning grants to 20 or 30. This will provide a competitive basis for selecting the 10 to 12 that will qualify eventually for full operational sup- port. The criteria of excellence that we have set for these centers are ad- mittedly high. Given the continued availability of funds for this program, we expect that enough institutions will gradually develop the capabilities needed to qualify for an equitable geographical distribution of centers to be achieved. Meanwhile, there are many units, smaller than the centers envisioned above, which are now being funded as program projects. They, too, pro- vide a combined attack on cardio- vascular discascs by multidisciplinary support. The Institute was a pioneer in creating such programs and be- lieves they have significantly enriched the clinical capabilities in major hos- pitals, both university and unafhl- iated. Again, the basis for funding is primarily research productivity. The quality of the diagnosis and treat- ment in these institutions, however, has invariably gone up hand in hand with research. T expect that Dr. Masland will deal with activities relative to stroke centers, for his Institute has a far larger share than ours in such a pro- grain. We are pleased to be able to participate in joint council activities concerning this program, offering such program help as is primarily vascular rather than cerebral in origin. A third kind of program of interest to our discussion this morning is coordinated research. Much of it is funded by contracts and aimed at solving specific problems of general interest and judged to be especially important. Generally these deal with accelerating developmental research or testing out on a large scale the efficacy of possible interventions. Both are the inevitable byproducts of more basic research. All tend to be expensive, complicated, and highly demanding, both of Institute and community resources. They are also essential for advancement of means for managing cardiovascular disease. The first of these is our Artificial Heart-Myocardial Infarction pro- gram. This program is combining bioengineering and biomedical ap- proaches to the problem of heart disease in gencral and the acute heart attack in particular. The bioengineering attack on this enormous health problem is being carried out by the Artificial Heart branch. It is presently concentrating on the development and refinement of devices to provide pumping assistance to damaged or failing hearts. There is reason to believe that temporary car- diac assistance can salvage patients dying of a temporary loss of sufficient cardiac pumping reserve. We need better devices and more investigation to prove their capabilities as well as their limitations. Within the present 53 constraints, we are also supporting re- search aimed at solving certain vital problems of materials, pumps, en- ergy, and controls necessary for development of a permanently im- plantable device to replace the heart. It is presumed—and I think cor- rectly—that such a device will be feasible. It will only be desirable if it permits complete rehabilitation of a productive individual. We proceed on this premise. In this regard it should be noted that heart transplan- tation and artificial devices are not mutually exclusive. Indeed, develop- ment of both possibilities—as a total problem of ‘cardiac replacement” needs to proceed collaterally. Of more direct pertinence to Re- gional Medical Programs is the co- ordinated program to improve all phases of medical management of the acute heart attack. This is the primary goal of the Myocardial Infarction branch of the Artificial Heart-Myo- cardial Infarction program. Presently it is supporting the estab- lishment of Myocardial Infarction Research Units, or MIRU’s, at five university medical centers. Even- tually, 10 to 12 will be established. Each of these units will be espe- cially equipped and staffed to conduct intensive research on acute heart at- tacks and their complications while providing unexcelled medical care to heart attack patients. These units will attempt to learn as much as possible about the pres- ently unpredictable clinical course of acute heart attacks. They will attempt 54 to determine what drugs or other measures might be used to minimize heart-muscle damage resulting from the attack. They will seek to understand better the development of arrhythmias, car- diogenic shock, and other potentially lethal complications of the acute at- tack and means for more rational management. They will evaluate, more precisely and thoroughly than has previously been possible, both accepted methods of treatment and promising new ones, including assisted-circulation techni- ques and devices. The units themselves will be well equipped and instramented and staffed for round-the-clock research and patient care. An aim is to attract to this neglected problem those who have felt infarction to be too hopeless or complex for application of their special skills. The MIRU’s will be training grounds for medical and paramedical people needed to extend acute coro- nary care to as much of our popula- tion as possible. The ultimate effec- tiveness of the MIRU program is dependent upon the development and dissemination of new knowledge and techniques that can be applied when- ever and wherever heart attack cases start. The Myocardial Infarction pro- gram will do more than develop MIRU’s. It will actively support a program to develop animal models of infarction, study contracts to close gaps in knowledge, and to examine the problem of sudden death, that large segment of infarctions or other coronary deaths which do not reach the hospital. The Myocardial Infarction pro- gram will seek to coordinate the ac- cumulation of knowledge of many aspects of its specific concerns. Its co- operating research units need not be restricted to 10 or 12 large operations. Ways are being considered now of how the facilities of the Regional Pro- gram might be utilized and joined in this effort. Of direct importance to the Re- gional Programs is an example of coordinated research to try out the eMicacy of a propram to prevent myocardial infarction, “This is the Coronary Drug project-~a secondary prevention trail. Mortality from first heart attacks is about 30 percent; but with each recurrent heart attack the patient’s chances of survival decrease sharply. Most heart attack deaths are due to recurrent attacks; and, with each re- currence, the likelihood increases that death will be sudden or else occur so swiftly that hospitalization proves impossible. The goal of the Coronary Drug project is to sec if lipid-lowering drugs can improve long-term © survival among heart attack patients by re- ducing the incidence of recurrent heart attacks and other complications of preexisting coronary heart disease. Elevated blood lipids, especially blood cholesterol, have been found consistently associated with increased susceptibility to atherosclerosis and coronary heart disease. It thus seems reasonable to suppose that elevated blood lipids also adversely affect sur- vival among patients who have sus- tained heart attacks by increasing their susceptibility to recurrent heart attacks and related complications of preexisting coronary heart disease. We hope to establish that long-term reduction of blood lipid levels will confer some protection against these complications and thus improve long- term survival among these patients. We hope that one or more of the lipid-lowering drugs being tested will reduce the 5-year mortality rate by 25 percentor more, ‘Vhe drugs being evaluated are con- jugated equine estrogens, d-thyroxine, nicotinic acid, and chlofibrate. All are known to reduce blood lipids and to be free of serious toxicity, and all are currently available to the practicing physician. The study involves 553 clinics throughout the continental United States, Hawaii, and Puerto Rico. Eventually, it will involve a total of 8,500 patients, more than 1,200 of which are already enrolled. The clini- cal phase will be completed in 1974. Among the clinics participating are some involved in Regional Medical Programs. Here is an example of how Regional Programs with its coordina- tion, access to large number of patients and special expertise in patient management may find op- portunity for important research. Field trials are indispensable. for and seers vated t sur- 2 $us- asing heart ns of se, -term will these long- nts. f the 1 will oy 25 con- xine, All sand d all the inics ited Zico, al of 0 of slmi- 974. are dical how lina- of determining applicability of research findings. Through RMP the “field” is now better organized and can be more helpful than ever before. There are other NHI field trials, such as effect of relief of extracranial occlusions on incidence of strokes, of the value of renovascular repair or of treating pyelonephritis, or hyperten- sion, of gamma globulins in prevent- ing hepatitis after open heart surgery, to name a few. Again, some partici- pants in RMP units are already involved. Finally, there is one more new co- ordinated program that deals with problems of great national and re- gional concern, the availability of blood and blood fractions. This is the National Blood Re- source program, now in its second year of operation. Although head- quartered at NEIL, this prograin is a cooperative cndcavor involving a number of Institutes and divisions of NIH, other Federal agencies, and non-Federal organizations such as the American Red Cross and Ameri- ean Association of Blood Banks. “‘Vhe participants share a coramon interest: All are concerned in some way with the acquisition, processing, storage, distribution, usage, or study of blood and blood products. The major goal of the program is to improve all phases of technology related to the handling of blood and blood products. Only through more efficient production, storage, and dis- tribution of blood products can a steadily. accelerating demand for 292-414 O—68 3 these products be met without serious strains on existing blood resources. The clinical demand for specific blood components such as red cells, platelets, or specific protein fractions has increased rapidly during recent years. It will probably increase far more rapidly in the near future, for the use of whole blood where some specific blood component is called for is being increasingly considered un- desirable and wasteful. The list of such components is increasing, and includes frozen cells, as well as pro- teins, platelets, and leukocytes. The use of the specific blood com- ponent to correct a specific deficit yields superior clinical results while diminishing the risk of transfusion reactions. At the same time, it makes it possible for a single unit of blood to serve the needs of many patients. One of the specific goals of the National Blood Resource prograa is to insure an adequate supply of blood fractions to meet clinical and re- search needs. With contract support from this program, the American National Red Cross is working on an integrated blood fractionation system for the large-scale production of specific blood components. When perfected, such a system could be installed in large, strategi- cally located blood banks around the country to serve regional needs for blood and plasma fractions. Other major concerns of the pro- gram are rescarch on ways to reduce the losses of whole blood and cellular components of blood that occur through outdating in storage. This includes the study of chemical addi- tives as well as the storage of cellular components at very low tempera~- tures. Present freezing techniques, which are expensive and rather cumbersome, need to be streamlined and, where possible, automated if their full potential is to be exploited. The National Cancer Institute, like- wise, has a considerable program re- lated to blood products, particular platelets and other formed elements. It is planned that the National Blood Resources program will also study the feasibility of better com- puter-based inventory systems for blood and blood products than are now available on a regional basis. These, then, are some of the present goals of the National Blood Resource program. ‘The ultimate woal, of course, is to insure that an adequate supply of whole blood, plasma, or specific blood fractions is always available whenever and wher- ever it is needed. How some or all of these programs will specifically interlock with re- gional activities is to be resolved. Your presence will be of the greatest importance in making our own pro- grams more meaningful. We’re glad you’re here. We will do our best to work with you and for you in every way we can. A NATIONAL VIEW OF DEVELOPMENTS IN— CANCER Kenneth M. Endicott, M.D. Director, National Cancer Institute National Institutes of Health Reet and important develop- ments in the field of cancer at the moment are not in its treatment and diagnosis, but its prevention. The pace of discovery in the relationship of viruses in the production of cancer is indeed rapid. I personally regard it as certain that viruses play an im- portant role in causation of human cancer and I entertain some optimism that we may, indeed, discover an ap- proach in that direction in the pre- vention of this disease. ‘This has al- ready been accomplished with regard to certain cancer in experimental ani- mals and I do not think man is all that different. That is the only hope I see at the moment for any general solution of the problem. Now we are certainly not lacking causes for cancer. There are at least a thousand different chemicals that can produce the disease in animals. We do not know how many of them have something to do with human cancer. Several forms of radiation produce cancer. Various hereditary factors seem to operate from time to time; endocrine imbalance and, in the light of some recent studies, probably arrangements of the immune mech- 55 anisms have something to do with it. There are so many causes of cancer that to eliminate them all would be a superhuman task. But the virus ap- proach, I think, offers much hope. Now, that is not to say that there are not advances in the diagnosis and treatment of cancer. There is slow, steady progress in surgical manage- ment and improvements in radiation therapy. Of particular interest to me, because of my background, has been progress in chemical treatment of can- cer so it is now possible to say that some forms of human cancer can be cured with drugs. That is an impor- tant development, even though the field of application at the present time is quite limited. Chemotherapy, in the better centers, has come to represent an important therapeutic device for palliating advanced and disseminated cancer. Its skillful use can keep many, many people reasonably comfortable and productively engaged until vir- tually the end of their disease. We have long been concerned at the Cancer Institute with the problem of the provision of services. The Na- tional Cancer Institute, which is the oldest institute, was charged by the Congress, with the total job of bring- ing the disease under control. The Cancer Institute, created in 1937, had authorization from the beginning to engage in the provision of services as well as in research and education. It is interesting to look back and see what has been done about this. Two of the first things done included pro- curement of a large supply of radium 56 and its preparation for loans to phy- sicians and hospitals around the coun- try. That program is still in existence but as you can well appreciate, the developments in the field of radiation since 1937 have somewhat diminished the importance of radium use. The second was a grant to Dr. E. O. Law- rence in California for examining the potential of the cyclotron for the treatment of human cancer. The institute was very small and consisted largely of an intramural basic research program until 1946 when the present phenomenal growth of NIEf began. Shortly after that a number of new programs were estab- lished by the National Cancer Insti- tute which were aimed at the problem of the provision of services. The first of these programs was a teaching grant to medical schools and dental schools for improving the undergrad- uate education in the diagnosis and treatment of cancer. That program was discontinued about 2 years ago and replaced with a new one which has a much broader target. It is called the Cancer Clinical Training Grant program and is aimed at improving the educational environment in the medical schools and university-teach- ing hospitals to enhance the educa- tional experience of everyone who is receiving education and training in that institution. The training program no longer aimed just at the medical student but at the house officers, nurses, paramedical personnel, and postgraduate students such as prac- ticing physicians. Approximately half of the medical schools have qualified and are being funded under this pro- gram. IT might indicate that our ad- visors recommend that every effort should be made to make this new program, in your terms, “interde- nominational or interfaith,” so we have encouraged the medical schools to involve multiple departments and establish a program which does not become a captive of a single depart- ment, In the late 1940’s, radiation was a field of intense interest, and the ra- diologists were very much interested in hardware. I’m happy to say that they still are. One of the new pro- grams at that time, which has a real relevance here, was the development and installation of a series of mega- voltage instruments for exploration of their therapeutic possibilities. From this has come the present generation of linear accelerators and betatrons and the like. This program has just been brought out and dusted off and given a new start within the past year or two. The radiologists advising us believe that the present generation of high energy sources is outmoded and that it is possible to create a new gencration of radiation sources, par- ticularly linear accelerators and elec- tron beam sources which will be much more suited to modern day treatment. We have a development program un- derway. I hope within a matter of a few months to let contracts for the fabrication of the first new machines, which will go on trial in’ perhaps three or four places so we may be able to make available something much better than you have now for high voltage therapy. One of the great shortages, we believe, so far as the proper management of cancer pa- tients is concerned, is the shortage of radiation therapists. At the risk of being shot down by some of my col- leagues in the audience who are gen- eral radiologists, I would like to re- port that we have been advised and we agree that the training generally given in therapeutic radiology in the course of ‘preparation for general radiology is quite inadequate. About 6 years ago we Jaunched a program to improve and increase the training of therapeutic radiologists. It was startling to discover that in 1960 there were some 15 therapeutic radiologists in training in the United States, of which eight were foreign nationals. After 6 years of intensive effort in this field, the number of American na- tionals in training has gone from sev- en to 70. There is quite a little em- phasis given to radiation biology and radiation research in the course of training. About 15 or 16 are being trained each year. They are being snapped up in the medical centers and schools and we could place many more than we have. We are continu- ing to expand the training base as more persons complete the training and move to an institution where they can set up a new focus. I would think it may be from 5 to 10 years before there will be enough to ade- quately man the medical schools that will be in existence at that time. DR . ENDICOTT The field of cancer is somewhat unique in terms of its research base. Along about the same time that the Congress was establishing the Na- tional Cancer Institute, several com- munities or States did the same thing. The State of New York established the Roswell Park Memorial Center at Buffalo. The State of Texas estab- lished one in Houston, the M. D. An- derson Hospital. Private philanthropy established the Sloan-Kettering Insti- tute in New York City which became associated with Memorial Hospital. Through Dr. Farber’s effort, the Chil- dren’s Cancer Research Foundation was established in Boston. There was another one in Philadelphia, one in Detroit, and these have come to be the backbone of cancer research and advanced cancer clinical training in the United States. If they have a uni- versity affiliation, most have a rather tenuous one, and many of them have none at all. These are the cancer cen- ters in the United States—some of them are large and very expensive or- ganizations. I think the budget for the Memorial Sloan-Kettering may be on the order of $25 million a year, including the hospital. Such centers as Memorial Sloan-Kettering, M. D. Anderson, Roswell Park, have what I regard to be an adequate clinical base to serve geographic regions in terms of training, consultation, and of accepting referred patients afflicted with almost any form of cancer. It is quite obvious that in the near future we are not going to have 50 M. D. Anderson hospitals or Sloan- Kettering Institutes distributed around in the 50 regional medical programs with which you are con- cerned, This is not to say that there is no. cancer potential. I wouldn't want to suggest this but we have very few complete centers. This has been a matter of great concern to the Na- tional Cancer Institute for a long while and, since 1960, we have had funds provided by the Congress to do something about this. These are cancer center funds; Dr. Fredrickson mentioned the same thing in the heart field. We had a running start on him because we al- ready had some complete centers and some bits and pieces that might be put together around the country. So we have tried to build upon whatever nuclei we could find. And I might mention some of the things that we encountered. In one institution, per- haps, the department of surgery would be sufficiently interested in the cancer field to be willing to set aside a substantial number of research beds to create a cancer clinical research cen- ter which then might take on some ‘“Gnterdenominational”’ flavor and serve as a focus for other departments. In other medical schools, it would turn out to be the department of radiology. In a few, very few I might add, the department of medicine was interested, and we began with a clini- cal center that was oriented primarily for chemotherapy. It is most unusual, in fact, I am sure I wouldn’t use all of the fingers on one hand to list medical schools that had a strong in- 57 fers terest in the three major areas. We began making these grants in 1960. I think there are perhaps 20 by now, most of ther limited pretty much to one field. At the time, or shortly before the legislation was passed which created this program, we were given an ap- propriation of funds for planning grants by the Congress and have made a number of such grants, some of which looked to ambitious cancer programs. One, in a large metropolt- tan area in the west, envisions the construction of a 700-bed cancer hos- pital in connection with a general hospital which would provide serv- ices, serve as a research and teaching center, and as a geographical referral center. The entire administrative and staff support for this is being included in the planning. I don’t know if it will ever come into being, but at least someone is taking a swing at it. Our involvement in therapeutic trials has been extensive, and has stretched over many years. I am sure there isn’t an institution represented here that has not participated in these trials at one time or another, or in one way or another. As you know, cancer is the second leading cause of death, but that doesn’t mean very much because it is really a collection of relatively rare diseases. I don’t know how many types there are, you can't get the pathologists to agree on that, but there are probably well over 100. This presents very serious prob- lems in therapeutic trials because no single institution, no matter how 58 large, is likely to see enough patients of the right varicty in a reasonable time to carry out a therapeutic trial. So it became necessary to set up some kind of cooperative network in which a number of institutions could work on a common protocol to compare this therapy with that therapy. We were particularly interested because we had a large drug development program and this meant nothing unless the drugs were given clinical trial. So beginning about 1956, a series of cooperative groups were established which have involved hos- pitals and primarily medical school faculty members all over the United States. They began in the field of chemotherapy. They were later ex- tended to examination and combina- tion therapies, surgery and chemo- therapy, radiation and surgery, and different modalities of radiation so that at the present tine approxi- mately one-sixth of our entire budget is invested in therapeutic trials of one sort or another. In some instances, these have been organized on a re- gional basis. This usually happened with the more commen types of tumors where you could find enough patients in a region. More ordinarily, they have been organized on the basis of specialties. ‘The pediatricians scat- tered around in the children’s hospi- tals band together to study the therapy of acute leukemia or rhabdo- myosarcoma or what have you. We made one effort in studying drugs in what is called Phase 2 studies where you try a new drug against a broad spectrum of different kinds of cancer. We tried organizing this on a regional basis, eastern, middle west- ern, far west. [t didn’t work very well and we finally collapsed the thing about 2 to 3 years ago and put it on a national basis operated by the Uni- versity of Wisconsin at the present tine. We have reached the stage where we do not believe that the present or- eanizational framework for thera- peutic trials is adequate to mcet our needs for the testing of new drugs and we are going to set up a much smaller organization for that, concentrated within just a few institutions. How- ever, the uscfulness of cooperative network still remains; in fact it is about the only way to test out new therapeutic ideas in a reasonable time. Of course, we are not going to abandon this program; we are going to keep it going. However, I think that we have a common task here to see whether much of this could be better orga- nized and better accomplished within the framework of the RMP. ‘There are obviously some of the regions that haven’t a large enough population base to make this feasible. If you are going to study a disease which has an incidence of perhaps 10,000 cases in the United States in a year, then the intermountain plateau out in my home country just will not generate enough cases to do much with. [f this were to be undertaken in some of the more sparsely settled sections of the country, it would probably be neces- sary for several adjacent regions to coordinate and consolidate their «l- forts. We made a little try about a yei ago with a special problem I might mention in the ficld of choriocarcin- oma in women. It is now possible to treat this clisease with drugs, to save the uterus, and for the women to have successful pregnancies afterwards. ‘To do so requires rather extensive labor- atory facilities and treatment facil- ties and specially trained physiciai and laboratory people. The incidence is low in the United States. Phe cases are under 1,000, so it was proposed bs some of the leaders in this field tha: a regional approach be made to thi problem by setting up perhaps a hal! dozen centers scattered at strategi centers throughout the country where the disease could now be not oni diagnosed but also treated. These ol viously would be engaged in research We approached Dr. Marston abou! this problem and it developed that 11 was very awkward to try to do this hs the RMP beeause everything in RMP has to be initiated locally and get filtered by the Jocal committee and come to Washington. That would be pretty hard to enginecr, we thought at least at that stage. We sought an other way to handle this problem unt the RMP can shake down a little bit. but I think it is a good example o! what might be done intelligently to handle a collection of relatively rare diseases that are extremely difficull and expensive to treat. Finally, T would like to adant that we are kibitzing. We should be able to do a lot more about cancer and so are engaging in a luxury of kibitzing. And we have several studies in prog- ress that may turn out to be useful to you. One is the evaluation of the re- quirements in the field of radiation therapy for an adequate therapy cen- ter in terms of equipment, personnel, the population base that it can serve, probable case load per population base. The group which is working on this, created by one of the study sec- tions, is a group of academic radiolo- gists. They are going to try to develop some outline for the ideal center. One can learn a lot about this from Europe where they tend to have Radiurnhe- mat and where they do almost all radiation therapy. They are also de- veloping what they call halfway houses. These, I think, are a more realistic plan of what we could do to- day with the manpower we have and with the resources. Iam happy to report to you that 1 think we have more resources that we need in one area. I think we have more cobalt machines than we need and one solid contribution would be a cobalt collection program to get some of them back. Thank you. A NATIONAL VIEW OF DEVELOPMENTS IN— STROKE Richard L. Masland, M.D. Director, National Institute of Neurological Diseases and Blindness National Institutes of Health am sure the excitement we have felt here in Bethesda at secing Re- gional Medical Programs come into being has not been as great as yours in the regions, because you can look forward to the thrill of being in di- rect contact with the people you are helping. But perhaps we do get a more frequent look at the national picture, and I can assure you that to- day there is considerable excitement in that. The whole concept of blanketing the country with regionally based programs for improving distribution of medical services and speeding the application of research and technical advances was so revolutionary that many of us expected great opposition and difficulty. The opposition turned out to be negligible compared with the enthusiasm, and although en- deavors of this kind are never easy, the launching of 51 programs and in- volvement of over 1,700 people in less than 2 years is nothing short of spectacular. If we can maintain this momentum, we will soon begin to see practical realization of one of our highest goals. Drs. Fredrickson and Endicott have very ably presented their In- stitutes’ programs in heart disease and cancer as they relate, or will ulti- mately relate, to your work in the re- gions. I would like to review for you the form and some of the substance of the program of the National In- stitute of Neurological Diseases and Blindness in stroke. Our effort and, in fact, the whole national effort in the stroke field are as yet extremely inadequate in rela- tion to the size of the problem. Esti- mates place stroke mortality at 200,- 000 deaths a year, and morbidity at 2 million. Costs exceed $1 billion per year in medical and nursing care and loss of earnings. JOINT COUNCIL SUBCOMMITTEE Our program in stroke began to take shape about 7 years ago with DR. MASLAND 39 formation of a Joint Council Sub- committee on Cerebrovascular Dis- ease consisting of National Advisory Council members from the Heart and Neurology Institutes, and other con- sultants expert in specific areas. ‘This group is the chief guiding force of the program, and has been in large part responsible for its coordination and development. Advice to the Councils and Institutes, sponsorship of meet- ings, conduct of surveys, provision of the “push” to get new teaching pro- grams started are a few examples of the work of this subcommittee. The whole program is under its constant review, and much of the program is a direct result of the group’s recom- mendations. CENTER GRANT PROGRAM By about 1960, it had become ap- parent that many of the broader ques- tions in medical research would prob- ably never yield to the piecemeal ap- proach of simply supporting the proposals of individual scientists, project by project, as they came in, no matter how worthwhile they were, individually. We therefore began sup- plementing our project grants by awarding funds for centers where major aspects of chronic disease prob- lems might be given a team approach. We feel that we are thus responding to two great needs: (1) The support of specific projects, for the answering of the more discreet questions, each answer adding a little to the growth of biology, or refining in some degree our knowledge of life and disease, and 60 (2) the support of broader, coordi- nated attacks on groups of problems by perhaps as many as 15 to 20 physi- cians and scientists, plus various kinds of technicians and other supporting staff. We now have [6 of these centers working exclusively in cerebrovascu- lar disease, and two more have been approved by our council but not yet funded. The centers vary consider- ie d ; 7 \ f 5 Nene - | j ee Pome, ! i oped j } i | | ( i ! \ ably, depending on the problems they are attacking. Several are devoted ex- clusively to single approaches, such as epidemiology, or the study of aphasia; others are workine with several re- lated approaches, such as the physical mechanics of cerebral blood flow, cerebral cellular metabolism, and ef- forts to affect these factors with drugs, inhaled gasses, and other means. Al- though most of these centers are less FIGURE 1 than 3 years old, reports are beginning to flow from them in considerable vol- ume, and we have very high hopes for this part of our program. More recently, on recommendation of the Joint Council Subcoimmitice, we have offered vrants for a new type of facility which we will be calling the outpatient clinical research cen- ter. These units should substantially expand our opportunities in epide- STROKE RESEARCH CENTERS SUPPORTED BY NINDB -!1968 a7 hE y \ ~ i VS “ ot 1 +] | @ MINNEAPOLIS cg BOSTON | | @ ROCHESTER oye | [enn Lo a4 Y 7@ENEW YORK | omy a . \ | \ ' PHILADELPHIA i L 1 ¢ i \ —_ QF ‘ \ wy F BALTIMORE ® BLOOMINGTON vi Ost LOUIS ia ak \. eee ye @ CURHAM feucuryse Lr _ WI NSTON- “SALEM MIAMI FIGURE 2 CEREBROVASCULAR RESEARCH PROJECT GRANTS ~ NINDB — 1968 yp i ] eee | I | Pomme MINNEAPOLIS ry t ORANGEBURG@ ‘~~ G@ BOSTON / MILWAUKEE oe p mS ROCHESTER. @ —_ eurFALol ye ~ PoE ‘ _ NEW YORK \ f pod | ~ Noe CLEVELAND Ew YO ! j owA city@) outico Ok @ re aoe.PHe \ ; i Tee, ; vA LEQ BALTIMORE Ly wy ! @ ! Po “NOTANAPOLIS © ‘ MORGANTOWN , S | SALT LAKE CITY | O o; \o: pudawikicTON Be . Sb | | KANSAS CITY | ST LOUIS. ee Pee Sd pe ple _. WINSTON- “SACEW@ © OURHAM ~Q LOS ANGELES i; 1 “@menpuis. Ce me i > | | ro 7 ‘ f I, | / ‘ MS \ j ALBUQUERQUE oo el / \ S\ @CHARLESTON aS i YA NN | J OVACKSON | Ll @ = Number of Grants miology and other areas where ambu- latory patients can be helped and can make a contribution to research at the sarne time. Project grants.—In addition to the broadly targeted work of the centers, about 50 research projects are being conducted with Institute support. These cover practically the entire spectrum from basic laboratory studies in such fields as neurophysiol- ogy and biochemistry to clinical in- vestigations of drug effectiveness, the improvement of diagnostic devices and techniques, and development of ever more ingenious surgical approaches. Cooperative studies. — Another promising approach to the problem of stroke is through cooperative sta- tistical studies, because of the large amount of data that can be collected and analyzed through the combined efforts of a number of institutions. The Institute has been supporting a Cooperative Study of Intracranial Aneurysms and Acute Subarachnoid Hemorrhage among 24 university- based centers here and abroad since 1938. Personnel at a central registry at the University of Iowa have analyzed the accumulated data on over 6,000 cases and have published a wealth of carefully derived statistics of value to physicians in deciding upon courses of treatment. This study has produced data on the most common causes of subarachnoid hemorrhage, suscepti- bility of various age groups, sex dis- tribution, most common sites of aneurysms, sites related to age and sex, percentages of patients who had warning signs, the relation of environ- mental events to hemorrhage, and the value of angiography in detecting multiple aneurysms. Also produced were new analyses of the mortality of nonsurgically treated cases, the risks of death and of rebleeding at various time intervals after hemorrhage, the statistically critical size of aneurysms, and the influence of age, sex, aneu- rysm site, and general patient condi- tion on survival. Among the study’s highlights was the statistical verifica- tion of intracranial aneurysm as the most common cause of subarachnoid hemorrhage-—-51 percent. Next most common is hypertensive arterioscle- rotic cerebrovascular disease—15 per- cent. Other findings were that the peak frequency for hemorrhage due to aneurysm lies with the 50 to 54 age group and that hemorrhage from an- eurysm is more common in women by a ratio of 3 to 2, though men pre- dominate below age 40. The study also revealed that headache and dizzi- ness occur before hemorrhage in at least 90 percent of the cases. 61 FIGURE 3 COOPERATIVE STUDY OF INTRACRANIAL ANEURYSMS AND SUBARACHNOID HEMORRHAGE With the discovery and use of ef- fective antihypertensive drugs has come a decrease in the number of peo- ple dying of strokes. But no one knows the degree of protection these drags afford, which antihypertensive drugs have the greatest effect on stroke, or whether the effect could be enhanced. The Institute is supporting a coop- 62 NINDB - 1968 \ XK, \ fp Tr | | | i erative study at cight institutions of hypertensive patients showing signs of cerebrovascular disease, in order to learn the answers to these and other questions tionship. Some of you are also familiar with the National Heart Institute’s joint study of extracranial arterial occlu- about this important rela- @ wooearitek | | - — “us “IOWA CITY oy @ st oomneron! XS \ \ Let @ BOSTON oF ger BUFFALO oe cee NA NEW YORK ea ARBOR c i @- PHILADELPHIA Ae Nd Le rs r ary x @ LOUISVILLE 4 = “7” ~~ @ DURHAM re et ‘ie MEMS WINSTON SALEM \ \ 8 AUGUSTA sion. The purpose of this study is to improve the criteria for selecting pa- tients for carotid artery surgery and to enable surgeons to predict in which types of Cases they can expect STICCESS with the procedure, vestigative teams are now contribut- ing to the study. Much valuable data has come from this project, and it ‘Twenty-seven ip- serves as another illustration of what can be done cooperatively. As the Re- gional Medical Programs develop, I am, sure they will provide many excel- lent new opportunities for collection and analysis of data. TRAINING One of the principal reasons for the modesty of our past efforts in stroke research has been the shortage of people trained in the necessary professional specialties and scientific disciplines. Since its establishment in 1952, the Institute has allocated about 25 percent of its budget to training support for teaching and re- search—approximately 9,000 people have received training during this period—-but it has only been within the past several years that we have been able to begin training programs specifically in stroke. Now, however, we are making considerable progress in this area with seven cerebrovascu- lar training programs at Minnesota, Wayne State, the University of Tennessee, the Medical College of Virginia, Bowman Gray, Massachu- setts General Hospital, and at the Mayo Clinic. These are in a sense supplemented by over 130 training programs in neurology, neurosurgery, and all the neurological other disciplines in- volved ino cerebrovascular disease. Most of our in fact discipline-oriented, training programs are so it 1s impossible to state very exactly what portion relates to stroke. FIGURE 4 COOPERATIVE STUDY OF CEREBROVASCULAR DISEASE pe i] i ix ij Of particular interest to you people may be another new type of support we have begun to offer which we call the cerebrovascular clinical traince- ship. These are for practicing physi- cians seeking a few weeks or more of intensive study of the latest devel- opments in diagnosis and therapy. We have a number of these trainee- i, AND HYPERTENSION NINDB -1968 \ ships active at the moment, and hope to expand the program substantially in the next several years. A new program for clinical train- ing of cerebrovascular nurse-special- ists is also underway. This program will give nurses who have the RN. degree 6 to 12 months of specialized “bedside” training in the field, and \ Mw \ t Z. SO ss) se oY 4 L.—- - pd | | | \ \@ YAcKSON | / oe DETROIT <7} v4 ( ‘ \ ANN ARBOR q /PHILADELPHIA | hei GS / , _ @ RICHMOND / eo is tongiy TT @ WINSTON-SALEM ee ~N ~~, ‘ ~ \e @ AUGUSTA on eee will give nurses holding the bacca- laureate degree 2 years of specialized training toward a master’s. Stipends for the trainees will be funded by the Public Health Service’s Division of Nursing, while salaries for the key faculty personnel will be derived from NINDB’s cerebrovascular cen- ter grants, or other sources. A com- mittee composed of three neurolo- gists, one ophthalmologist, and several nurses has been established in the Division of Nursing to review applications, and we are doing every- thing we can to move this program ahead as rapidly as possible. COMMUNICATION The improvement of communica- tion in the stroke field has been one of our most important program goals. Through our Joint Council Subcom- mittee, which I mentioned earlier, we sponsor scientific conferences, both on specific aspects of the prob- lem, such as aphasia and rehabilita- tion, as well as larger meetings cover- ing the whole field. One of these was the sixth in a series of biennial con- ferences at Princeton, N.J., which I attended last week. This was a tre- mendously exciting meeting, at- tended by virtually all of the leading people in the field. I think everyone felt that things are at last beginning to happen, and that a new day is dawning for the stroke patient. Coming up are several other meet- ings of particular interest. Dr. Arthur L. Benton at the University of Iowa is organizing a workshop for us on behavioral changes related to cere- brovascular disease. Also, the second annual meeting of the chiefs and senior staff members of our cerebro- vascular clinical research centers will be held next month in California. This meeting will be specifically con- cerned with an in-depth review of 63 Te, i i ope i U.CAL. SF ! PRESBYTERIAN | MED. CENTER | VA HOSP. -S.F. i hypertension as related to stroke, and will include sessions on neuroradi- ology of stroke, cerebral metabolism, therapy, and microcirculation of the brain, Another important aid to com- munication sponsored by the Insti- tute is a service providing a monthly package of reprints of stroke articles appearing in medical journals. This 64 ; TEXAS UNIV. 1 \ @ FIGURE 5 JOINT STUDY OF EXTRACRANIAL ARTERIAL OCCLUSION - 1968 tee eg r a a MINNEAPOLIS. 2% WAYNE STATE ee, a TULANE service, headed by Dr. Robert Siekert at Mayo, has been very well received by physicians and researchers, and may ultimately be expanded into an abstract journal when the volume of stroke literature becomes sufficiently heavy. Several other publications are of in- terest: we have published a Cerebro- vascular Bibliography regularly since : \ MEDICAL COLLEGE OF ALABAMA \ See v PETER BENT BRIGHAM \ HARVARD i \ MASS. GENERAL / GENERAL Hosp, @. HARPER HOSP, @ _ J ; DETROIT . j [ey —— ee N. gh cg MONTEFIORE joe of oe \ ) @ : é NEUROLOGICAL CLEVELAND METROPOLITAN © | e INSTITUTE GENERAL HOSP i UNIV PENN 'N.Y.U MED CENTER : eo om PN pie UNS Le x I CINCINNATI! I \ N (0 et GENERAL | i id ony HOSP. ! LOUISVILLE UNIV. oqo a i pee 6 ) pa | —-—-—- yf . DUKE \ | BAPTIST MEMORIAL é yes j | “HOSP, MEMPHIS ‘ he i | ‘ s, ON aye f i@ s @INSTITUTO DE NEUROLOGIA MONTEVIDEO, URUGUAY @ DI TELLA INST. CTR. NEURO. INVEST. BUENOS AIRES, ARGENTINA 1961. The bibliography, issued every 3 months, consists of a selection of stroke and related listings from the National Library of Medicine’s Index Medicus, and provides a continuing reference to virtually all research im the field. The Joint Council Subcommittee is also makine plans for revision of a Survey Report on Cerebrovascular Disease, reviewing the entire field and telling us where we stand in preven- tion, therapy, and rehabilitation. Our last edition, published in 1965, was well received, and is still available. The revision will probably require 2 to 3 years to produce, but it should be a valuable reference document when completed. These are the principal clements of our program in stroke. I would like at this point to mention the five or six major areas in which our scientists are working, and then move on to a very brief summary of the field’s most urgent needs. RESEARCH AREAS Epidemiology. — Epidemiological studies of stroke are of utmost impor- tance, because detailed knowledge of the distribution of the disease, corre- lated with genetic and environmental factors, diet, and other influences, could provide important clues to its causes and results. A considerable body of evidence has accumulated pointing to varia- tions in deaths from stroke in different countries; variations among popula- tion groups within some countries: variations from one time to another: and even seasonal variations. Ept- demiologists agree that some of the variations are doubtless accountable to difference in methods of classifi- cation and standards of reporting, but they also agree that some of the varia- tion in the rates is real, and they have made this the object of intense study. In addition to several project prants and two centers devoted to the epide- miology of stroke, the Institute is funding by contract with Johns Hop- kins a national epidemiological study. Data is being gathered and analyzed for comparisons of customs and prac- tices in certification of deaths, and is being correlated with hospital records and with physicians and household interviews. For the first time, accu- rate information will become avail- able about the incidence and mortal- ity of stroke and the validity of re- ported differences in different parts of the country. BLOOD BRAIN BARRIER Within the brain there is a sensi- tive barrier system which separates the brain tissue from the circulating blood and yet permits the exchange of nu- trients and waste products between the two compartments. Derangement of this barrier, which commonly oc- eurs after brain injury, can lead to serious complications. Considerable research effort is being invested in studies of this mechanism, with the aim of finding means of minimizing brain destruction following stroke or other injury. BLOOD FLOW STUDIES The occurrence of stroke is a dy- namic process. There are constant variations in the flow of blood through the brain. New methods using radio- opaque dyes or radioactive tracers are FIGURE 6 STROKE AND RELATED TRAINING PROGRAMS © = Number of Programs making it possible to obtain precise information about the condition of the arteries of the brain and the dis- tribution of blood flow through them. The development of simpler, less ex- pensive procedures can greatly in- crease the usefulness of these meas- ures for early recognition of the stroke-prone individual, and the pos- sible prevention of vascular throm- SUPPORTED BY NINDB -I1968 bosis within the narrowed blood ves- scl. Several of our centers are con- centrating on blood flow studies, and on the improvement of techniques and instruments for them. APHASIA Much can be done to remedy the disability of the paralyzed, aphasic, or otherwise neurologically crippled individual through modern methods of reeducation. Investigations on neu- rolovical control mechanisms are de- veloping greater knowledge of normal processes, as well as means whereby deranged channels of input and out- put may be supplemented or by- passed. Intensive study of normal and deranged higher nervous activities is providing means for remediation of 65 aphasia and other disorders of the intellect. TREATMENT EVALUATION Evaluation of methods of treatment is another major area of research ef- fort. In addition to the cooperative studies which I mentioned earlier, a number of our research centers are heavily involved in this, as well as in- dividual investigators. Development of improved methods of diagnosis is also of utmost im- portance. Angiography, isotope scan- ning, thermography, rheoencephalo- graphy, echoencephalography, and the EEG are among the diagnostic techniques undergoing constant im- provement and refinement. NEEDS IN THE REGIONS Now to summarize a few of the field's most urgent needs: In consid- ering the types of stroke programs which may evolve within the various regions, I think we should start with a review of the total needs of the stroke problem. For a total program, any society must be prepared to cope in some way with the following needs: 1. Stroke prevention.—In its ulti- mate, the prevention of stroke prob- ably depends upon the prevention of arteriosclerosis. Lacking this, we still have the ability to recognize the stroke-prone individual and to pro- vide for such an individual certain prophylactic measures. In general, the 66 stroke-prone are those with hyper- tension, with diabetes, or with very high-blood cholesterol levels. Pro- grams for the early recognition and treatment of such persons is thus a part of a total stroke program. Equally important are measures for the early recognition and prompt treatment of patients showing minor neurological symptoms, such as the transient ischmic attack. 2. Early accurate diagnosis of stroke Cerebrovascular disease may present itself in a variety of forms ranging from the most minor dis- turbance of sensation, movement or consciousness to sudden collapse, and profound coma. The differential diag- nosis is often difficult and may re- quire sophisticated diagnostic equip- ment. Each region must assure itself of the existence of such diagnostic competence, and of the orientation of the practicing physician regarding the need for and the availability of such special services. 3. Emergency treatment —The pa- tient with sudden cerebral hemor- rhage represents a medical emergency. Not all cases of cerebral hemorrhage are fatal. Nursing care for the coma- tose patient requires special skills. Lit- tle consideration has yet been given to the logistics of handling these diff- cult cases. In regard to treatment of the acute phases of stroke, here also there is much to indicate that the existence of programs and personnel especially concerned with applica- tion of currently available methods, could do much to reduce death and disability. 4. Surgical intervention.—TVhe use- fulness of surgical intervention in dis- eases of the extracranial arteries as well as in the management of intra- cranial aneurysms is still highly con- troversial. When our statistical stud- ies in these areas are concluded, we will know much more. I am con- vinced that there will be a continued role for surgery in some forms of stroke until large scale prevention is achieved. 5. Restoration of function.—The long-term nature of stroke residuals, and their devastating inpact on em- ployability are major elements in the problem. The distribution of rehabili- tating services, their relation to the general hospital, the nursing home and the community represents an- other important area for community action. 6. Long-term care.-—The patient with stroke residual disability repre- sents a major social and economic problem. One-sixth to one-seventh of the patients in our State neuropsy- chiatric hospitals are patients disabled by cerebrovascular disease. Yet this represents but a small fraction of the total problem. We need more infor- mation regarding the characteristics of this disabled population and the resources available to provide them with the best chance for a continuing useful or at least meaningful hie. Where and by whom are they best cared for? We have noted a serious lack of documents outlining guidelines and concepts for community-based stroke control programs that would utilize total community resources, Reports by expert committees have been pub- ished by the World Health Organi- vation for heart disease and cancer. but nothing is available in the stroke area. The Joint Council Subcommit- tee has formed a task force to develop and outline a community contro! pro- gram for stroke, and I know that this outline will be of great value to the Regional Medical Programs other public and governmental agen- cles when it becomes available. All of these needs are pressing, and it is hard to assign prioritics to them. But T might say in conclusion that the greatest necd of all ts recognition that much can be done for stroke pa- tients—much more than we are do- We can strokes, we can bring better diagnosis ancl ing now, prevent some and treatment to more people, and we can do more to restore function. Many thousands of stroke victims who could be helped He helpless, slowly deteriorating toward states of organic dementia. This is now within our power, and I know we will meet the challenge. PANEL DISCUSSIONS ON.... HEART DISEASE Panel: Jesse Edwards, M.D. Samuel M. Fox III, M.D. William Likoff, M.D. Theodore Cooper, M.D. Campbell Moses, M.D. CANCER Panel: Sidney Farber, M.D. Michael J. Brennan, M.D. Juan del Regato, M.D. Kenneth M. Endicott, M.D. Guy F. Robbins, M.D. STROKE Panel: Nemat Borhani, M.D. Clark H. Millikan, M.D. James F. Toole, M.D. William A. Spencer, M.D. Richard L. Masland, M.D. These transcripts have been reviewed and approved by the participating panelists. 67 PANEL DISCUSSION ON— HEART DISEASE Panel: Jesse Edwards, M.D. (Chairman) President, American Heart Association Charles T. Miller Hospital St. Paul, Minn. Samuel M. Fox III, M.D. Chief, Heart Disease Control Program National Center for Chronic Disease Control Bureau of Disease Prevention and Environmental Control Public Health Service Wilham Likoff, M.D. President, American College of Cardiology Hahnemann Medical College Philadelphia, Pa. Theodore Cooper, M.D. Associate Director National Heart Institute National Institutes of Health Campbell Moses, M.D. Medical Director American Heart Assoctation New York, N.Y. rR. Epwarps. As a Regional Medical Program panel on heart disease in January 1968, we are in an exciting atmosphere. The past has given us many gifts and we are to participate in shaping these for prog- ress in the future. 68 The progress I see for the future has three P’s: One, perfection; two, productivity; and three, prevention. By perfection we mean refinement and greater availability of the many techniques now present to treat the afflicted and the development of new techniques where applicable. By pro- ductivity we refer to the accomplish- ment, either in the home or on the job, of the person who has heart dis- ease. By prevention we mean accom- plishing the greatest of all accom- plishments, that of keeping the divine gift of the normal heart unaltered by disease. The three P’s have been translated into old terms; namely, treatment, re- habilitation, and prevention. But while the terms are old, we must ap- ply new imaginative ideas to make full use of the tools with which we now work. In a narrow sense treatment may be considered in the realm of putting out brush fires, that of taking care of illness when and where it happens. If treatment of an acute illness con- sists simply of shepherding the patient through his immediate physical prob- lem, the cruelest thing we can do to a patient is to discharge him from the hospital, for the disease treated in the hospital has many broad ramifica- tions outside of the hospital. Within our capabilities, discharge of the patient from the hospital in- volves opening broad avenues of ac- tivity, activity that pertains to the pa- tient’s illness. These include, among many others, physical rehabilitation of the patient, mental rehabilitation of the patient, evaluation of his ca- pacity for work, orientation of in- dustry as to the usefulness of the pre- viously ill, educating the families as to the dietary and emotional recep- tion of the patient upon his return home. In the past 2 days we have had demonstrated many sophisticated techniques for the physical care of the patient. These techniques absorb physicians’ time and energy. We must seck ways of developing nonphysician personnel capable of doing certain tasks now traditionally done by the physician. A reservoir of resources of various and diverse types is available to us from such units as the National Heart Institute, the Heart Disease Control program, and the American College of Cardiology. To consider development of many of the necessary and new services, the voluntary health agency, the Heart Association, has the know-how and the will to assist RMP in establishing a blueprint for the future. Dr. Fox. In thinking of new devel- opments in heart disease, the interest in coronary care units is a perfect example of the synthesis of new knowledge into a practical operation package with widespread usefulness. Unfortunately, we do not have all the statistical definitions of the cost- benefit ratios that support coronary operations. Dr. Jack Hall has a most interest- ing design in the wind from which we think we will learn much; but even with the lack of what we do desire in the way of justification on the statistical case for the coronary care efforts, there are very few who feel what we are doing across the Nation in this effort does not have real virtue. There are many opportunities for fascinating work that still remain and most of them appear to lend them- selves very well to the RMP type effort. This is a slide which I am sorry is a little complicated, but we will try to look at it in easy stages. It may illustrate some of the new approaches that perhaps will expand our present concept of coronary care. The boxes on this slide represent a sct of hypothetical units in a system of coronary care, a system in the sense of the practioneer rather more than system analysis. In the center of the boxes here is one labeled “Surveillance for Dys- rhythmia.” This and the box imme- diately below it, “Intensive Care,” such as we can provide for circulatory failure—and that perhaps poorly named but expressively conveyed con- cept of the cardiogenic shock—these represent the major loci of coronary care efforts at the present time. To the right here is a unit, “Con- tinued Surveillance and Care,” the first stave of rewressive care in which there is a significant mortality still to be conquered. Those cases who sur- vive through the surveillance area pass on to the progressive care unit. Above and further along is “Educa- tion and Rehabilitation,’ about which there is much enthusiasm but insufh- cient evaluated experience at this time. The Heart Disease Control pro- gram is very interested in looking at physical rehabilitation as well as ef- forts through an increase in habitual physical activity to prevent heart dis- ease in the primary sense. To the far right is ‘Preventive Pro- prams,” about which others will speak. We need to know a creat deal mere, as was brought out by Dr. Fredrickson yesterday. My opportunity is to look at what might be called the front end of this system, that into which we would like to attract people more prornptly. All together too many coronary victims dic before they even go into the hospi- tal, not to speak of a coronary care area. It is estimated, on the basis of what we must admit are not too adequate statistics, that over 200,000 individ- uals die outside of hospitals with acute coronary events as compared to es- sentially the same number dying within the hospital. This is a com- mentary on our inadequate systern, if you will. Most of those who die outside un- der these circumstances die acutely, They are not those with long-standing symptoms except in the very elderly who, as a matter of philosophy, are permitted to pass on in the warmth of their farnily, with which I think we must have some sympathy. Now, what can we do to persuade those needing the protection of coro- nary care services to make earlier prudent decisions? A coronary recep- tion areca might be of assistance. This is a concept about which nothing really has been done of which I am aware. The terms coronary care acrium or coronary triage unit were considered, but outside of the health professions these terms might not be well under- think their meanine might be a Hale amore stood, although I among us precise. What is suggested? Perhaps the receptive environment easy to enter, having a low impedience appearance, if we can paraphrase our electrical engineering colleagues, no admission delay, full monitoring prior to an in- vestigation of signs, symptoms, lab- oratory data and things of this sort, and above all, staffed by compctent personnel but possibly in Icsser num- bers than occur in the coronary care unit as we now have it constituted because the probabilities of acute elec- trical catastrophe presumably would be much less. Those would be pump failure and such things that would go on in an intensive care area as pres- ently constituted. Low cost would be a necessary part, acceptable, there- fore, to third-party insurance as is be- coming increasingly a part of our medical scene as to the person and the family. The lab backup for enzymes and such should be available; and indeed we need what we might classify as a low outpedience, namely, a means of getting sprung from such circum- stances back into active life if the probabilities seem reasonably accept- able that the episode which suggested the need for admission is not any longer acutely lycriptic. Later discus- sion might help define the opportuni- ties and problems of this area in somewhat more detail. In September of last year I had the privilege of riding out with the mobile which has attracted considerable attention ta Belfast, North dreland. Dr. Prank Pantridge will be before the cardiology mecting in San Francisco and I think he has done a great deal to lead the way in showing what can be done in the way of mobile services. A physician and a nurse go out from the coronary care unit where they are otherwise employed to mcet the ambulance at the pickup point. They quickly go to the scene with coronary unit claxon horn blowing except when. they approach the immediate locale at which time they make a very quict and thereby not too alarming entry. Most of the devices of the coronary care unit are taken out of the van into the home or site in which the suspect coronary Case is found—coc- tor, nurse, monitoring devices, medi- cation, including intravenous and defibrillator. They stabilize the pa- tient physiologically, reassure the patient and family, and then from the usually highly anxious circum- stances accompanying a heart attack they quietly move the patient off without horns and such to the coro- nary care unit at the main hospital. This is beautifully done in Belfast. Can we do this in the United States? I think there is no question we can. We must build some type of front end on the coronary care system and after we have done so, get more prudent decisions earlier in the course of the coronary experience. The Heart Disease Control pro- gram looks forward to continuing to work with those in the Regional Medical Programs on this and we hope thatwe will be able to help de- fine some of these circumstances. Dr. Lixorr. There resides in the broad field of cardiovascular disease ample reason why the Regional Med- ical Programs, structured as it is by law, affords a remarkable opportunity to improve health care. The intensity of the diseases of the heart and blood vessels overwhelms comprehension. Indeed, in this western culture, these afflictions are almost a way of life. The economic loss from abbrevi- ated and attenuated work rivals ex- penditures for prolonged armed conflict. Prevention is tragically en- snarled in concept. Hardly a fragment of clear fact supports a myriad of fashionable beliefs regularly. urged upon the public, and any standardi- zation is late and often uncertain. Treatment is as dependent upon nature’s generosity as upon scientific genius. The small capsule of effective measures often may lead to as much disability as it was designed to correct. In this arid environment, each fresh effort in treatment, even though only a hopeful inquiry, is understand- ably overdramatized as a break- through. For the stricken, accommodation to useful life is totally undisciplined. Guidelines, obscure enough in their own right, are misunderstood, misap- plied, or newly structured out of prejudice. Stung by peculiar public laws which hold employees forever respon- sible for the consequences of maturing heart disease, industry is a traditional foe of rehabilitation. Finally, the public is more than vaguely conscious of these facts be- cause we have trained it to be able to criticize and in its acknowledged restiveness it wants more of what is available, and more to be available. Embodied in this total issue are challenges to advance knowledge, to improve education, and to perfect ap- plication. The magnitude of what must be accomplished immediately has great confusion and, just as ad- mittedly, inertia. How can the wheel be loosened? The first plea is for simplication of objective, for a clear recognition of the boundaries that must be set for your effort. At least at the outset we are laboring under a practical law. Goals should be interpreted in that spirit, whether the intent is to ad- vance knowledge or improve the ap- plication of what is already known. Objectives, secondly, cannot be en- gaged as separate enterprises. Knowl- 70 edge, education, and application defy clear separation. Where the cardiac resides in your region, how great his number is, and what his fate is over the years may be a prosaic inquiry compared to molec- ular biology, the cardial sick cell, or any other unit in the body; but this simple discovery assumes new dignity if it has a frontal impact upon education and upon application. Sim- ple correlated goals then are reasona- ble and these are the attainable ones. Thirdly, judicious assumption of regional needs by responsible men of action is an essential requirement for a proper takeoff even though this is perhaps contrary to the spirit if not the letter of the law. How far off from actuality is the presumption, for example, that acute coronary care is delayed, that ausculation is a limping art, that clin- ical physiological correlations are poorly understood, that new instru- mentation is unavailable or its role not fully comprehended. It may be folly to expect action from the periphery when the needs themselves truly remain umnrecog- nized. There are two more simple determinants of sincere and definitive action. The first is the forthright en- listment of regional talent through whatever unit or organization or affiliate this cadre can be recruited; and finally, operations through ex- perimental modules probably repre- sent the most effective method of get- ting the show on the road. Dr. Cooper. As outlined by Dr. Fredrickson yesterday, we in the Heart Institute feel that we have a very practical interface with the Re- gional Medical Programs. We view our job as providing you with new practical means of treatment for cor- onary heart disease, a disease which has not yet seen a material benefit in terms of reduction of morbidity and mortality. About 2 years ago the Heart Insti- tute had a very small but elegant group of consultants surveying many of the medical centers in order to find out what the clinicians need in new findings for the treatment of coronary artery disease; the thing they found out was most needed was interest and research activity in this disease. Ap- parently coronary artery discase had become somewhat less glamorous for the investigators. Following upon this report, the In- stitute in the context of its already established Artificial Heart program initiated a “targeted” Myocardial In- farction program. This program is a supplement to the millions of dol- lars being spent already by Heart In- stitute grantees in areas of research which, under the grant mechanism of laissez-faire research, bear on the treatment and diagnosis of coronary artery disease. It was felt, however, that the more organized and focused program on the problem of coronary artery discasc would be a great stimulant to re- search efforts in the area. Increased activity would be helpful in identify- 292-414 0-—68—-——-6 ing some critical gaps in our infor- mation. These findings could then mature into means of practical treat- ment for this devastating disease. What was agreed upon at that time was a program of contractual research in myocardial infarction. The initial core of this program was designed as a series of research units which would be located in medical centers through- out the country. It was originally en- visioned there should be 12 such major research units. These are re- search units, I would emphasize, that are concerned with the clinical inves- tigation of the patient with myocar- dial infarction. All ancillary labora- tory work is directed toward this end. In the past year five such major units were implemented at a cost of roughly $5.1 million. In December of 1967 we received an additional set of bids for the enlargement of this network. We anticipate that in the coming year we should be able to add an additional three or four such units. Hopefully next year, if our budget permits, we will reach the critical mass of these 12 units. Around this core then we shall at- tempt to stimulate further interest in various segments of the country by having sort of mini-units which would be located in existing coronary care units. These smaller units could be the testing ground for the application of the new findings found in the centers of major investigational ef- fort. Finally, another segment of this program will direct itself to specific contractual research in such areas as pharmacological interventions on arrhythmia, furthering understand- ing of the pathology of coronary discase in man, etc. We have to reach the point where we have based about 50 percent of our effort in a major clinical investigational effort and 50 percent of our program in specific laboratory research projects related to the management and diagnosis of coronary artery disease. Complementing this, we have our Artificial Heart program. You will recall, on Dr. Fox’s diagram, one of the practical means of therapeutic support for the complication known as cardiogenic shock is mechanical circulatory assistance. We are now spending $8.6 million in contractual research designed to improve the ma- chines that are now available and to develop new types of mechanical as- sistance to the circulation. Perhaps in some years to come we shall be able to produce a total replacement for the heart, a mechanical prosthesis. Dr. Moszs. Within the Heart As- sociation we have tried to encourage our various affiliates and chapters to offer their assistance to RMP pro- grams around the country. In some places this has worked out quite effectively; in others, it hasn’t. In some, the Heart Associations have been really quite unaware of the ob- jectives of the RMP program. We are making strenuous efforts to cor- rect this because the RMP program offers an opportunity to provide real muscle to achieve many of the long term goals of the American Heart Association. The public and professional edu- cation programs of the Heart As- sociation have now with the RMP program a chance to expand and develop and to succeed, and we are very pleased that this is the case. Let me point out to you some of the areas where the various volunteer agencies can be useful to RMP. For example, in the area of personnel, whether we are talking about volun- teer personnel or professional staff. Many of the full-time RMP people have come from the professional staff of the Heart Association. This is entirely appropriate. At the volunteer level, RMP programs are providing support in dollars for some of the activities of people who were volunteers with the Heart Associa- tion. The same, I am sure, is true for the Cancer Society. One comes to Dr. Gordon Barrow who, of course, was very active as a volunteer in the Heart Association for many years and now is director of the Georgia program. One of the other areas where the volunteer health agencies can be of use in the RMP programs around the country is in the development of ef- fective educational materials. We have requests, for example, from RMP programs to develop 5-minute radio spots to be used in various places around the country, and hope- fully other associations such as the Cancer Society programs can be im- plemented, can help RMP programs 71 in many, many ways in the public education field. This interface has been used by almost every speaker in the last 2 or 3 days, but certainly the interface be- tween the public and the RMP that can be bridged by a volunteer health agency is a very realisuic one. After all, the volunteer health agencies have been for many years, long before RMP, interested in improving the level of patient care—particularly in cancer and heart disease. I would like to conclude with one reference to Dr. Fox’s diagram. You recall that in his diagram he had on one end of the scale the need for im- proved ways to provide better input into the coronary care formula-—the coronary reception area that he talked about—and at the other end of the scale he had the importance of education and preventive programs to achieve a more complete control of the coronary disease problem. Well, it is at these two ends of the scale where the Heart Association can be most useful in providing insight, and in providing people who are accus- tomed to working in the prevention and public education spheres. I urge you as professionals with the Regional Medical Programs to take advantage of the experience, of the background and dedication of the workers in the voluntary health agencies. I think if you will talk together, if you work together, you will find that both the voluntary health agencies and the Regional Medical Programs 72 are really working for one common goal and that is improved health care for the people of the United States. Voice. I wonder if Dr. Fox would give us his current estimate of the effectiveness, and in any way he wants to define this, of coronary care units in the present state of the art. Dr. Fox. Unfortunately, we don’t have the statistics we all would like. For a while before the aggressive ap- proach to prevent catastrophic events came in, we could say that so many patients had conditions considered to be lethal were it not for the inter- vention of a trained team and tech- niques with the monitoring system. At that time it would look as if there were essentially six to cight persons per hundred coronary admissions that were in the category where effective coronary care efforts were saving them. Now, the long-term meaning of the discharge of a patient having suf- fered myocardial infarction and hav- ing been resuscitated or otherwise preserved has not yet been defined; in the sociological sense this is most important. But I think there is an encouraging early trend to indicate these individuals do not become 5 or 6 month average survivals and then dic after an intensive attempt at re- habilitation and do not essentially be- come of critical importance as a part of their community or their families in the socioeconomic sense. There are no data that go much beyond this. Dr, Eywaros. [ suppose this ques- tion has two aspects to it. One, how many people are specifically saved by the resuscitative potential of the cor- onary care unit, and the other, docs the very presence of a coronary care unit with the training and attitudes of personnel that go with it have an in- direct influence on top of the specific benefits to the patient who required actual resuscitation? Dr. Lrxorr. I think that there is a growing belief that, in the area of electrical catastrophe, the acute cor- onary care unit has been successful in ameliorating the mortality and mor- bidity statistics and that in the area of power failure there has been no in- fluence whatever upon the mortality rate, There is also the very distinct im- pression that the presence of an acute coronary care unit in any one institu- tion upgrades interest, care, and per- haps the ability to treat as opposed to those institutions that do not have an acute coronary care unit. However, I remind you that this whole problem is up for examination. There are suffi- cient feelings on both sides of the fence to warrant, for example, that this topic matter was included as a controversy in cardiology at the forth- coming scientific sessions of the Amer- ican College of Cardiology. Dr. Moses. Another answer to this question is that with the introduction of continued surveillance we have really had a change in our interpret- ing of the results from the coronary care units. Initially, if a patient suf- fered a major catastrophe and was resuscitated, this was put on the credit side of the ledger. Now, since most of the electrical disturbances do give warning and there are some changes in the monitoring that indicate that this catastrophe is imminent, it’s now possible to prevent many of these and therefore we now say if you have a resuscitation event in a coronary care unit it’s probably a small black mark in the record because perhaps thev missed the warning signs. So it’s very difficult to answer your question accurately, but certainly the growing experience with it, if we can get some kind of data analysis, will be able to lead us to some intelligent judgments as to how these should be implemented and just how many we need to meet our population needs. Voice. I think that Dr. Moses’ re- marks should be immediately quali- fied about the black mark bit by say- ing that it’s no black mark at all if the patient also has power failure. Resuscitative efforts on power failure still occur frequently and are unpre- ventable. It would appear to me that the triage area can never really justify itself because presumably the setting would be in a hospital with a coronary care unit; trained personnel would monitor this from the unit or main- tain it from the unit. It could be very much more expeditiously resolved merely by changing admission policy to the unit, by having patients ad- mitted directly without delay to the unit providing there were a few more beds made available in the unit for this purpose. It’s almost implicit if it’s to work it has to have patients admitting themselves to the unit without physi- cian recommendation either to the triage area or to the unit, and this could pose a regular mare’s nest of problems. Dr. Epwarps. Dr. Fox, would you care to comment on this question? f think we should define a little bit what we are talking about. Dr. lox has already indicated that among fatalities in coronary disease about half occur outside the hospital. The individual, sometimes without any previous illness, that witnesses no pain at least, suddenly dies. Some pcople do have a preamble to death and in this preamble stage is where so much can be accomplished. Dr. Fox. I think what we are faced with requires some type of opcra- tional research. F hope Trade it clear that this concept of the reception area is only something to shoot at. I think we can do better. The problem that some of us see is that people are reluctant to enter themselves in anything that has the formality of the present coronary care circumstance; and if we can reduce what we as physicians don’t consider to be much of an impedience but which apparently is an impedience in the mind of the public, if we can re- duce the steps that they had to take prior to making prudent decisions and draw them in earlier in the symptom course, we have a chance of doing something if there is an amount of time from early, usually unappre- ciated, or unrecognized symptoms until more major catastrophes in a fair number of cases. Dr. Epwarps. I wonder if we could just have another comment. It is, of course, a problem to plan resus- citative measures or preventive meas- ures in the person who is about to die suddenly. Tow can we define this in- dividual, and do people really dig that suddenly from acute coronary disease, and do some of them not have symp- toms which even the physician and even the clectrocardiogram have failed to relate to major coronary disease? Dr. Lixorr. The potentiality of sudden death from coronary artery disease is recognized by all of us. Secondly, preamble to death, if it does exist, generally exists in the form of irregular or aberrant electrical acuvily of the heart. ‘Thirdly, it is unlikely that sudden death occurs as a result of independent so-called power failure, that this is a rather gradual event that is in effect predictable. Voice. One of the things that you brought up seems to me to be some- thing we haven’t thought about much here at all and that is the epidemi- ology of this problem. In what group, in what population do we look for these premonitory signs, and can we define the population in whom the incidence of myocardial infarction or other cardio accidents is highest? Dr. Coorrer. The epidemiological area has been of considerable interest from the pragmatic standpoint for research. Some months ago in the clinical literature there appeared the results of the Baltimore study, in which Lilienfeld and his colleagues said that, in the retrospective analysis, they were able to document that an overwhelming number of the persons who had died suddenly sought medi- cal advice for conditions related to cardiovascular disease. It may have been up to 90 percent. We need to have this type of retrospective infor- mation to develop and design pro- spective studies. We would like to help the people in the hospitals and the practicing physician identify these patients, and in some way monitor them, so as to prevent this so-called “sudden death.” I think it is becoming more and more apparent that sudden death in a com- pletely well individual is really not a very common entity. 1 think there is an areca where the public education programs of the Heart Association and the Regional Medical Programs could offer a great deal. Dr. Mosrs. But they have to be backstopped with the professional ed- ucation program and the physician has to have something reasonable to do in these people that are identified as increased risks and we are not quite so comfortable about that, aside from the very general things controlling the risk factors: High-blood pressure, shock, and hypercholesterol. Dr. Epwarps. Unless we can do something for them, we might scare them to death. We would have to plan something in the way of making avail- able a resuscitative measure and this is a major magnitude problem. I em- phasize again, this involves about an equal number of people to those who die in the hospital. Voice. I wanted to thank you for saying the “divine gift of the human heart.” So often many people think God is dead and they say nothing about what the Divine Physician docs in cooperation with other physicians. I just wanted to thank you for that remark made in public. Then I wanted to ask Dr. Moses if he would think a routine test with the electrocardiogram done on every pa- tient would help for better patient care. Dr. Lixorr. A routine electrocardi- ogram is almost worthless as a screen- ing instrument for the presence of coronary atherosclerosis. On the cor- relative studies that have been done on measuring anatomic changes in the arteries, it has been repeatedly demonstrated that the electrocardio- gram remains normal in the face of other considerable anatomical change. Dr. Cooper. I would like to take a little issue with Dr. Likoff on that response. We recently have reviewed some of the routine electrocardio- grams from the Framingham study. The study is still really in progress. In identifying those that had “sud- den death”, the retrospective analy- sis showed electrocardiograms re- vealed that over 50 percent of them had so-called benign arrhythmias; I don’t say that this necessarily demon- 73 “ail strates cause and effect, but I do think there is some merit to pursuing such an analysis in detail with mod- ern computer technology. The rou- tine electrocardiogram is a method for obtaining some further informa- tion on this difficult problem. Dr. Mosss. I think what Dr. Likoff meant was that any given individual cannot be labeled falsely or accu- rately from that data alone. Dr. Lixorr. That is very correct. Voice. I would like to say, with this incidence of the higher use of hospital beds, that it would be won- derful if we could assure a patient he could go into the hospital as rap- idly as possible with the first real knowledge of a coronary. That is a major problem in our area: Just to be assured that the patient could be ad- mitted to the hospital and let alone to this coronary care unit to be ob- served and diagnosed. Dr. Epwarps. I think we are talk- ing about an area of patient service that really has not been considered in developing hospital services with proper identification through mass studies of the need, and first of all, the magnitude and the potential for doing something about it. Therefore, it may very well be that our pattern of hospital construction and bed availability will ultimately change to overcome this problem and that is what we are here for. Voice. I would like to ask Dr. Fox in view of his recommendation that a mobile unit would be of value to supply, how in Ireland do they know 74 when to send the unit out. When the phone rings, do they all then go? Dr. Fox. I don’t believe I can really represent Dr. Frank Pantridge’s phi- losophy from the very brief time I spent here. It’s like a 2-week tour of Vietnam. I had 1 day’s tour of Bel- fast’s unit, but I had the impression that the physicians of Belfast and the area around were the prime calling source for this unit, that there was nothing verging on self-admission. On the other hand, the police am- bulances and nonmedical calls were received and responded to. The na- Gional restraint of the North Bure- pear might keep a system in control that might not be generally realized elsewhere. I hope I make myself clear in my ignorance of exactly what this means, but I think one of the very important operations problems to define is who calls the unit, under what circum- stances and under what level of rela- tive priority is the unit sent out and with what manning circumstances, particularly in large cities where mul- tiple calls might be concurrent. Dr. Epwarps. Dr. Fox, do you have any idea of what the distribution is of live patients to dead patients by the time the service gets there? Dr. Fox. No. Dr. Pemberton who is the epidemiologist in the area has some statistics and I am afraid I can’t give them offhand. The number of those found dead is I think rather minor and, in a recent letter from Dr. Pantridge, so far nobody, even those with complicated electromechanical coupling, heart block, and the like, has been lost in the ambulance; but he doesn’t feel this type of excellent record will be maintained at the 100- percent level. They have shortened the admission time now to less: than half an hour from the time of first call except for the time in which they stabilize, and become acquainted with, the patient on the scene. This stands considerably better than the 6-hour delay that is reported from Edinburgh, which as far as I know is a shorter period than any reported as an average figure after symptoms in the United States. Votes. One of the problems in the periphery or the grassroots is the ready, quick interpretation of electro- cardiograms by a practitioner in the field, particularly those in more re- mote areas. I wonder if Dr. Fox or the others would comment on this current evaluation of EKG for trans- mission by telephone and how close are we to more widespread applica- bility and availability of computer- ized interpretations. How good is a computer now on arrhythmias? Dr. Fox. Heart disease has abnor- mality. Dr. Caesar Caceres has been working on it for some 7 years now in getting this effort started. As an example, one Regional Medical Pro- gram, Missouri, is in large part dup- licating a system which will provide a means on the data phone, to com- puter on magnetic tape, and teletype feedback of electrocardiograms. The basis of the Caceres development is to have the ability to get a good ma- chine reading. The machine system maintained by paramedical and engi- neering personnel seems competitive with what is likely to be most availa- ble. The ability to put in a mobile front end to this unit though is still a bit of a problem. In other words, one has the electrographic machine plugged into the data phone which must be able to go through clean tele- phone lines, which don’t always exist, and as the result of priority selection, on the computer and back. This in- terfacing has not been resolved and I think we all learn a great deal from the practical experience to be under- taken in Missouri. We hope that in the system of coronary care that is being tried in some placcs in the country that ra- diotelemetry will be evaluated in a cost-benefit sense. The state of the art in science permits this to be un- dertaken, but at sizable cost and with some problems with the Federal Com- munications Commission. Some of these have to be worked out as op- erational problems, but they all lend themselves to reasonable solution. Dr. Epwarops. We have in the room Dr. George Wakerlin who is the past medical director of the American Heart Association and now is Mis- souri Regional Medical Program Di- rector. Dr. Wakerlin, would you care to respond? Dr. Waxerttn. I would make a comment about various things that have been discussed. For example, with reference to coronary care units and whether they really save lives or not, we have a specific example in the Missouri region of an intensive cardiovascular care unit which was manned under RMP auspices back in April. According to the figures of the people who are responsible for that unit, particularly the director, Dr. Glenn O. Turner, in the past 8 months or so 23 lives have been saved, men who otherwise would have died if they had come into that same hos- pital during the period prior to the setting up of the present form of the intensive cardiovascular care unit. This is only one unit, but I think there is no question about the fact that bet- ter care, closer attention to patients is bound to save some lives. While it’s very desirable to have Statistics, I think that we shouldn't wait on any large statistical gathering. RMP should proceed as rapidly as possible to assist in the setting up of intensive cardiovascular units and jor coronary care units in representative hospitals, particularly smaller com- munity hospitals within their regions. With reference to the use of com- puterized electrocardiography, this is underway as Dr. Fox indicated in Missouri and we are about to set up six terminals in various parts of the State. Hopefully there will be a total of 20 within approximately the first year, and one thing that I am sure will hasten this along will be the fact that Dr. Arthur E. Rickli, who is Dr. Fox’s predecessor as chief of the Heart Control Disease program, has joined the Missouri Regional Medical Pro- gram as Director for Operations of the program. So another important source for RMP personnel in addition to voluntary health agencies is the U.S. Public Health Service. For ex- ample, Dr. Earl Simmons who was with the Heart Disease Control pro- gram is also a member of the staff, an associate director for stroke of the Missouri Regional Medical program. I must say I was a little surprised to hear Dr. Moses recommend the Heart Association as a source of personnel in view of the fact it has lost some four or five of its key people. We must keep a strong Heart Association also, but I think all is fair in love and war and it is up to the individual himself to decide where he wants to go. Dr. Moses. What you are really after is the control of cardiovascular disease. The label or the hat, whether you are doing it for free or pay, is really not the most important thing. Dr. Epwarps. As president of the American Heart Association, I am unconcerned about the fact we are having a certain amount of traffic from the Heart Association to RMP. At the same time we are happy that we have people that are attractive to other organizations. But seriously, this whole subject of personnel is important as it relates to our areas of interest in this panel. There is no question about the fact that the more sophisticated methods of diagnosis and treatment of patients require more physician time. We have fewer doctors to do the job as we program things like the Re- gional Medical Programs and siphon physicians away in some instances from practice into administrative jobs. The matter becomes even more complex as we add the need for administrative people, and the volun- tary health agencies represent a very natural resource or reservoir for this type of person. I think we have reached the stage where among the other things that we have to con- sider is the universities’ providing an educational program which would train people for the jobs that health agencies and RMP require, just as the universities now train individuals to be hospital administrators. I think we have reached the point in our medical development, health devel- opment in this country, where uni- versities should take on the job of educating people who will be in- volved in the areas that we are discussing. Dr. Wernserc. I may have misun- derstood earlier, but I thought I heard Dr. Fox, in speaking of input im- pedience in the coronary care units, mention there was a certain resistance on the part of patients into entering those units. We haven’t found that. The patients like the units, They like the feeling of security in there and if anything, we sometimes have trouble in getting them out. They don’t like to leave to go to some other part of the hospital. Our problem in the in- put is more with the practicing physi- cian. He is likely to put in his high- risk patient with power failure, for whom we can do little. But the young patient who is a relatively good risk and the one, when he does have com- plications, who is likely to have one of an electrical nature and have a good chance of resuscitation, that is the one that he hesitates to put in. We are making some headway in pleading with the doctors to put those patients into the coronary care units, But that has been our biggest problem. Voice. Dr. Fox, could you elab- orate on the present state of the art in programing the computer to in- terpret arrhythmia? Dr. Fox. This is not as far advanced as is the interpretation of the stand- ard 12-scale electrocardiogram. There are programs going on in this at a number of places: Dr. Caceres’ group, Warner in Salt Lake City. There are quite a few groups in Cali- fornia and elsewhere. None of them is as definitive as a good arrhythmia- interested electrocardiographer at this time. However, they will do things which we at this time cannot economically afford in tying good arrhythmia talent to the monitoring of patients. They can present displays of the time rate of occurrence and of premature ventricular complexions whether they are essentially of the same form, presumably unifocal in origin or multifocal, on the basis of the variance in forms. This type of display will give us the ability to de- velop criteria on which rules, if you will, for nurses and others may be built. As such, I think that hand in hand with the development of a ca- 75 pability to “hack the dysrhythmia electrocardiogram,” to use jargon, will be an ability to know precisely what is its understanding for manage- ment. Voice. Dr. Fox spoke about using an identification card for those peo- ple at high risk for electrocardio- graphic or cardio accidents. Here is such a card. I am not member of that population. That is my normal electrocardiogram. Dr. Epwarps. Do you think this electrocardiogram is really normal? Voice. I see no reason why it couldn’t be applied by the Regional Medical Programs to persons in whom appear four or five or six of the cardinal indices of high lability. Dr. Lixorr. Do you provide these to all of your patients? Voice. We provide it at the time of annual periodic examination. My name is Webb and I am a colonel in the U.S. Air Force. Dr. Epwarps. Your point is that people should carry their last electro- cardiogram around with them and use that as a baseline in the event of a question of change. Voice. This is quite possible. It is not expensive. It’s quite easy to carry out. If this were embossed on an ad- dressograph card which had the per- son’s essential data embossed on the other side, it would really facilitate his admission to the hospital. Dr. Fox. I think one commentary is this: Dr. Robert Grant used to say our criteria for the electrocardiog- raphy is comparable to saying all men 76 of normal height range between 5 feet and 7 feet 7 inches or something. We have very slack criteria and the use of something of this sort immediately makes much more sensitive our ap- preciation of change. Dr. Epwarps. Dr. Likoff, would you care to comment on this point of the base line electrocardiogram? Dr. Lixorr. I am not really cer- tain where this discussion has drifted, nor to what purpose. Is it implied that it is difficult for a patient with overt symptoms to be admitted to a hospital or is it implied there is some difficulty in the emergency station or first care of this patient becoming confused as to what is wrong? Actually, this is the crux or the nexus of the whole problem. If this in truth is so in your region, then clearly some identification of a pa- tient who might get into trouble would be worthwhile, but then would statistical analysis, itself worthwhile, be necessary proportionately because there are a number of people without any warning signs whatever who get into deep trouble almost immediately. I can’t really see this is a pertinent point unless one can establish that this sort of thing goes on routinely throughout the country. I rather doubt it. Voice. Perhaps the time has come for the panel to begin to discuss the detection and treatment of coronary heart disease via excreise. Dr. Likorr. Do you ask such a question because you envision such a project? Vorcr. I am aware that we have a vogue for this. I think the vogue is fairly well documented and certainly it is accepted by a large number of cardiologists. The problem is how to prevent or how to make our spectator sport-conscious public more aware of the fact that perhaps they would do themselves more good if they in- dulged in it a bit themselves. Dr. Epwarps. Are you speaking against Sunday professional football? T think it really is amazing the num- ber of people who sit themselves down on a Sunday afternoon watching when they could be doing something possibly to better their health. Voice. We have been _ talking about the detection of coronary dis- ease. I asked the question for the panel to discuss the role of exercise of a practical sort that might help. Dr. Epwarps. Dr. Moses, would you care to say something about exer- cise as a practical matter in coronary disease? Dr. Moses. I can’t speak to it authoritatively from the point of view of diagnosis, but I think Dr. Likoff or Dr. Fox might. I can say that there is now ample data that the regular exerciser, the person who as part of his daily habit either at work or at play engages in significant physical exercise, this person is less vulnerable to the catastrophic heart attack. He probably is not any less vulnerable to heart attack but is less vulnerable to a catastrophe. I think the first part of the man’s question had to do with exercise and the diagnosing, and I think I am not qualified to answer that. Dr. Likoff may well like to com- ment or Dr. Fox. Dr. Lixorr. This is the type of area, the inquiry into this problem, the advancement of knowledge, with which I think, the Regional Medical Program must engage itself if it is to be an effective type of program throughout this country, because the answer regarding exercise both diag- nostically and therapeutically is un- known. There are again many concepts in this regard and precious little truth. As far as exercise for diagnosis is con- cerned, it is stated by the most astute among us that the physician taking a careful history and performing a careful examination can diagnose the onset of coronary artery disease in all but about 20 percent of the candi- dates or potential inquiries that come to his office. Secondly, if exercise were performed as a method of clarifying the 20 percent that he cannot put his finger on, 20 percent of that base figure—20 percent of 20 percent— would be salvaged by the more so- phisticated exercise tolerance studies. Now, this is an overview. There are proponents and there are antago- nists to this view, but I think it’s a reasonably fair one. In all likelihood, from the diagnostic standpoint, ex- ercise cannot do much for you unless you are interested in physiological parameters and detail of what careful bedside techniques are apt to do. In terms of. therapy there is be- ginning to be an accumulation of fact to indicate that the performance of a cardiac patient exercised through a Icisurely routine is greatly improved. However, the likelihood is apparently that he dies on the same designated date, only he dies in bettcr condition. Dr. Epwarps. Dr. Fox, would you care to comment on exercise? Dr. Fox. Only, I don’t think we have the data today to indicate when, but I certainly agree when he dies he will have died having led a more active and we hope more rewarding life. Voice. I think this is very pertinent because I think the thing that bothers most practicing physicians is the re- focus and reemphasis on the post- coronary management of their pa- tient. In other words, paticnts are told about the value of exercise and so are doctors, but this has not ade- quately been clarified; so I think there does remain a great deal of confusion. Now, there are some fairly good studies that have been done. Many are now in progress trying to more carefully delineate how much exer- cise can be imposed in the rehalbili- tative phase of post inyocardial in- farction and I think the Regional Medical Program should involve it- self in these studies and do a better job of both professional and public education at this point. We have to remember for many years we have preached the philoso- phy of intensive bed rest and treat- ment of coronary patients with kid gloves, so now we are in fact chang- ing and reversing this position. As a matter of fact, there have been some excellent papers published which would indicate that the role of anti- coagulants really reflects the fact we have now modified the care of the cor- onary patient to introduce the exer- cise Component; so in effect we have introduced another variable in evalu- ating, for example, anticoagulation procedures. Dr. Fox’s group, Iam cer- tainly sure, is very much interested in this; and if the Heart Association also is interested, we perhaps ought to de- velop some good guidelines which would be based on sound exper- imental data such as is available with the help of physicians in making sounder decisions in this matter. I think there are possibly some legal compliance cases regarding these matters about which the doctor is also concerned. Dr. Epwarps. I think you are qualificd to answer this question which [| would like to put to you. What is your attitude about a formal work evaluation of the patient who has recovered and is considering re- turning to work? Voce. I think this has been one of the key interesting foci of the Heart Association. We have helped with governmental agencies to sponsor and support work evaluation tests. We fecl i’s a highly important thing to de- velop. We would like the practicing physician to know the availability of these units so that he could help sup- port his patients. Of course, exercise evaluation is part of this program. I think that any time you introduce a program of ex- ercise in an individual who has had a myocardial infarction this has to be done under fairly carefully and pre- scribed circumstances. It’s not some- thing you can do haphazardly, and you cannot say that everyone is going to be treated the same; so I think this area deserves a great deal of con- sideration, particularly in view of the rather significant switch in our phil- osophy of the care of the patient with myocardial infarction. Dr. Epwarps. I will agree we haven’t even begun to scratch the surface. I think we should have ques- tions from someone who hasn’t spoken. Voice. The question is to Dr. Fox and perhaps the other members as well. Can you try to briefly summarize what we know about the economics and effectiveness of coronary units in relation to the population served for the 50-bed hospital, 200-bed hospi- tal, so forth. Dr. Epwarps. Do you understand the question? Dr. Fox. I believe I do, but T wish you hadn’t asked it because it reveals my ignorance; I am sorry to say there are no data that really tell us the an- swer to your question. Part of the question I think is: Is it worthwhile to set up a unit which is dedicated to the relatively unique care of coronary patients in smaller hospitals? And this is an area of great interest that has not yet been fully explored, but it would appear when you get below the average acute hospital size of 100 beds you run lower than 100 infarctions as diagnosed on exit, either dead or alive. If you then spread this patient pop- ulation over the number of beds that can be maintained effectively in the cost-benefit sense by the two com- petent people that are considered necessary for resuscitative efforts, you will come up with a very disadvan- tageous personnel-to-patient ratio; and, therefore, in these smaller hos- pitals it seems important to try to put together a combined unit either with intensive care of other sorts, the post- surgical recovery room, back of the emergency room, in which patients in the area of trauma and such are cared for by the same personnel, but where there is a reasonable degree of isolation, particularly acoustical iso- lation of the coronary patient so he isn’t kept anxious as a result of the hustle and bustle attending the care of other sorts. Much must be done. The Congress - recognized this and gave moneys which are in the RMP budget this year specifically to explore small hos- pital and other facility coronary care efforts, for which a brochure of ex- planatory text has been issued by the RMP office. Voice. I saw something in the Springfield, Mo., coronary care unit which impressed me very much. They have developed something which merits consideration; that is, the reha- bilitation of the postinfarction situa- tion. After the patient has gone through the I.C.C.U., he comes out 77 aa and then he progresses into a reha- bilitative phase and there is the op- portunity where you can begin to induce the philosophy of exercise to the patient or begin to talk to the patient about restructuring his living in regard to diet and other things which are going to greatly influence his way of life in the future. I think we probably ought to pay serious attention to this thing because I think it does offer a good way to restructure the life of a postcoronary patient. Dr. Epwarps. We realize in clos- ing we haven’t really gotten very far. We have estimated that 20 million Americans right now have heart dis- ease and a year from now a million of them will have died. We have major areas of challenge. Our biggest challenge is in the area of athero- sclerosis and coronary heart disease. One very important point that has not been discussed very much in the past which is bound to be a subject for the future over and over again is the patient who thinks he is well and might be dead within the next half hour from coronary disease. The acute death occurring in perhaps a quarter of a million people a year out- side of the hospital emphasizes how important a practical problem this is to determine the identification of the individual and to provide facilities to prevent the catastrophe. We have had just a few words about rehabilitation and recognize that if our economy is to remain stable with this tremendous weight of 78 coronary patients in the population, extensive efforts in development of appropriate rehabilitation must be undertaken. PANEL DISCUSSION ON— CANCER Panel: Sidney Farber, M.D. (Chairman) President-Elect, American Cancer Society and Director of Research Children’s Cancer Research Foundation Boston, Mass. Michael J. Brennan, M.D. Scientific and Medical Director Michigan Cancer Foundation Detroit, Mich. Juan del Regato, M.D. Director, Penrose Cancer Hospital Colorado Springs, Colo. Kenneth M. Endicott, M.D. Director, National Cancer Institute National Institutes of Health Guy F. Robbins, M.D. Director of Planning Memorial Hospital for Cancer and Allied Discases New York, NY. r. Farper. It has been a year D since the last mecting of the Regional Medical Programs. A great deal of experience has been gathered by many groups throughout the coun- try, and it seemed to the division that the time was ripe to discuss some of the questions of cancer more specifi- cally. I am going to ask Dr. Michael J. Brennan, Professor of Medicine at Wayne State University, to begin. Dr. BRENNAN. I have been asked to talk about the Regional Medical Pro- gram in Michigan and the needs of this program in cancer in the light of the studies that we have been in- volved in for the past several months. Now, in the State of Michigan, we have divided the State into three sub- regions. The total population of the State is around 8 million and there are 4 million in the metropolitan area which is composed of four counties— Wayne, Macomb, Oakland, and Monroe. The great problem with the disease is it is concentrated in the metropolitan areas because they are where the population is. When we started off, we had the idea that our biggest difficulty was with the delivery of care to what are called the disadvantaged urban pop- ulations. We have 6,000 deaths from cancer a year in the metropolitan re- gion. This is about one out of every 50 people that die in this country of the disease. If we take it that some 30) percent of our population is in Harrington's poverty classification and disadvan- taged in one way or another, and that the stage at which people present themselves for the treatment of can- cer in this group is much more far ad- vanced than it is in the people going to private physicians, then one would think that a very large saving in lives could be accomplished by simply rais- ing the level of care available to these people to that available to the portion of the population which can afford to go to private physicians and be treated in private hospitals. However, if one corrects for the fact that a great number of these categorically indigent people are peo- ple over 65, living on social security and retirernent income, then it de- velops that our optimism about the effect of widespread programs of de- tection among. the poor will be too sanguine. My calculations would indicate, and I won’t go into them in detail here, that we would be able to save somewhere around 450 more lives a year if we gave to this indigent popu- lation the same attention that we give to the paying population, in the large hospitals where we have the best medical talent and facilities available to us. Now, why don’t we pick up a much larger margin of control if we man- age greatly to improve the medical surveillance over somewhere in the order of 30 percent of our popula- tion? The reason is that the distribu- tion of cases, according to disease site, is so far different in the private hos- pital group than it is in the county hospital group. The county hospital group is at a disadvantage in terms of the fact that they are older people and more of their mortality from cancer is with kinds of neoplasia for which we do not at the present time possess any effective system of therapy and control. This disappointing fact of the mat- ter brought home, after I had realized it, something which I noted for the first time in the report of the Presi- dent’s Commission on Heart Disease, Cancer, and Stroke. While a great deal was called for in the way of edu- cational facilities, research facilities, specialized hospital facilities, training of chemothcrapists and so on, there didn’t seem to be any general realiza- tion that until we arrive at the time where we have a significant major technological improvement in our ability to handle this discase—par- ticularly in that portion of the popu- lation over 65 in which 50 percent of the disease is concentrated—until that time comes, we have to face up to it that around 60 percent of peo- ple who have this diagnosis made— this includes all cases, skin and else- where—are going to die of cancer. Studies on our service at Henry Ford Hospital, which is a large cancer chemotherapeutic and medical man- agement service, showed that in the last year of life, the median length of time required in hospital for the full polliation utilization of the radiologi- cal, neurosurgical, surgical, chemo- therapeutic, and medical maneuvers which to our best judgment were needed for the help of these patients was 45 days in the last year of life. Multiply that times 6,000 people dying of the disease, and you can get an idea of how many hospital bed days you require. It turns out that, for the management of the late pa- tient, we need somewhere in the order of 1,000 hospital beds and an out- patient visiting service with a capac- ity of 1,500 patients per week. Now, of course, these people are being cared for in one way or an- other at the present time, often shamefully and often times far below the level at which we should be able to help them. But, in terms of inte- grated facilities for the management of disseminated cancer, we only have at most in the Detroit metropolitan area 200 beds that would qualify for such a designation in terms of the kind of men who are in charge of them and in terms of the kind of fa- cilities and skills available to those men and within those institutions for the management of this kind of dis- ease. It seems to me, therefore, that the most greatly needed development for the Regional Medical Programs in the context of our existing situation (not the situation we hope for 5 or 10 years from now, but our existing situation) is the development of an extended-care type of facility suitable for the management of patients un- der chemotherapy, under radiother- apy, under medical management for disseminated cancer. These institu- tions need not be as expensive nor as heavily staffed as the conventional hospital. They ought to be satellite to the general hospital and ought to have a ready flow back and forth of patients according to need. Unless we create them, we may find ourselves in a situation where we don’t have room in the gencral hospitals for the care of acute illness. All of these things flow out of a sociological change which has hap- pened in our society. The large fam- ily structure has disappeared. We are dealing with the unit family structure. In people past 65, this unit family structure often consists of two per- sons, both of whom are afflicted with one or another form of chronic illness or disability. To talk about bas- ing cancer care on home care pro- grams under these circumstances is to talk about having to provide nursing service and practical nursing service in homes all over the city, in homes which are small, which don’t have resources to help with the care of these seriously ill people. We have to realize that we must find ways to make up for all of those things which the extended family structure did in the past for the elderly and for the sick—~all those kinds of support, loans and physical assistance, nursing as- sistance, transportation, help with shopping, all of these things. In the cancer patient and in the stroke patient—and these two diseases are very much alike in what they im- pose in these regards—these diffi- culties are severe, protracted, and be- yond the reach of any unit family structure to deal with. We must, therefore, develop institutional or- ganizations which respond to needs which we cannot think of as being primarily or solely medical, but which are medicosocial. Dr, Farner. The second speaker, Dr. Juan del Regato, is director of the Penrose Cancer Hospital in Colo- 79 rado Springs. He is a member of the National Advisory Cancer Council and is known to all of you, not only for his preeminence in the field of radiotherapy, but also for his broad philosophy of patient care, diagnosis, and research in the field of cancer. Dr. pet Recaro. As you know, I am a therapeutic radiologist, al- though my interest in cancer is wide. For the purposes of this session, I should concentrate on the particular aspects that are involved in the re- sponse to the needs that you might find in the field and the actual possi- bilities of solution. Radiotherapy is only second in importance to surgery in the treatment of cancer. ' We feel that it is not enough, of course, in order to create the possi- bilities of fruitful curative treatment as well as palliative treatment with radiotherapy, to just acquire the equipment. As we have repeatedly said the skill has to be there first before the equipment comes, and the equipment is only a very small part of the whole business. To begin with, in our own concept, one cannot do adequate radiotherapy in any place unless there is a com- prehensive care of cancer available in that particular place. That implies competent diagnostic facilities, com- petent cancer surgery in the various specialties, competent tumor pa- thology, which is an item often disre- garded. We do not treat the patho- logic report; we treat the pathologic entity. And a pathologic report is sometimes at variance with the truth. 80 There should be also, of course, in such a center cancer chemotherapy and other ancillary services such as rehabilitation, followup facilities, et cetera. Unless these circumstances are fulfilled, it is not likely that anybody in an isolated place is going to do adequate radiotherapy just simply be- cause he has the equipment. And even if he were skilled, he needs all of these other conditions to have been fulfilled in order that he can do ade- quate radiotherapy. But to give you an idea, assuming that we are already in a position where we have decided where the center is going to be, there are two approaches for you in the field—the one is to reinforce the centers that are already there. And the second one is creating new centers. Well, the first one is, of course, easier. It may not be geographically satisfactory, but it is much easier. Now, we figure that a major center will need at least one radiotherapeutic unit for every 300 new patients per year, one high-voltage or cobalt unit, and one or two other radiotherapeutic units such as roentgen therapy of con- ventional voltage. And then, there should be also availability of radium and superficial radiotherapy equip- ment. This is a minimum for every 300 new patients at the major center. This equipment will require addi- tional supporting facilities such as transverse tomography, dressing rooms, followup examination rooms, treatment planning simulators in order to diminish the time that is misused in trying to study the patients within the room where the main unit is. There is, of course, need for minor surgical suites and all of this kind of thing that goes along with such a center. Machine shops are usually necessary, accessory to departments of radiotherapy, because of all the minor different things that have to be built to treat patients adequately. And, of course, 1 wouldn’t pass by the obvious need for physicists in any such center and specialized dostuetrists or special technologists, techiietiuns, nurses, et cetera, without which one cannot think about having an ade- quate center for radiotherapy. Now, it is obvious that there are certain indications of radiotherapy that could be taken care of without all of that, but the point that we are thinking about is a center that is re- sponsible for, respondent to, all of the needs with which we might be presented, all of the possibilities, not a selected group. The selectivity might come at the secondary centers level where the people in charge might de- cide to take up only certain problems that can be managed at this level and then transfer the others to the major centers. That is a question of logistics in which I cannot nor am I com- petent to go. My emphasis has to be upon the fact that whenever you contemplate radiotherapy, as Dr. Endicott already indicated yesterday in his brilliant ad- dress, we probably have already too many cobalt units in the country; what we need is people who know how to handle them. The cobalt will not do the job. It is the skill and the facilities, the ancillary facilities that go with the department of radio- therapy, that are needed. And these, of course, are not easily acquired. There is a total of 300 well-quali- fied and specifically trained radio- therapists in the country—exactly 299—for the entire country. A great deal of the radiotherapy will have to continue to be done for some time by menowho are willing and are capable of doimy both radiodiagnosis and radiotherapy since we do not have, nor can expect to have, in the near fu- ture a sufficient amount of radio- therapists. We need easily cight to 10 times as many as we have at the pres- ent time. And the number of men in the training of therapeutic radiology is rather reduced. It is of the order of 50 to 60 in the entire Nation. That yields, at most, some 20 new radio- therapists per year. This is really a very small amount of new radiother- apists for such a large country with such great needs. This presents, I am certain—and I am not trying to make it worse, but rather make it evident—a very seri- ous problem to envisage. It isn’t easily solved, but it is obvious that the so- lution of the problem is not neces- sarily to buy the equipment or to will this no longer a problem. It is a problem and will continue to be a problem. Now, from our point of view, out- side of the ficld of radiotherapy, we have lived just long enough to know that it is a tragedy to put a tremen- dous effort in the early diagnosis of patients only to see them mistreated or neglected afterwards. If we under- take any such thing as a regional smears project for the diagnosis of cancer of the cervix before it has be- come an infiltrating cancer, the im- portant thing is that the patients that are found to have carcinoma in situ receive adequate treatment or the pa- tients that are found in that process that have already early iafillrating carcinomas receive adequate treat. ment. It is not because it is early that it is easier to treat it. In fact, it requires a greater skill sometimes to do the job even though the patient is early. ‘The same thing applies to such things as cancer of the breast. Whether the diagnosis is done in every doctor's of- fice, as it should be, or whether it is done in special cancer centers like our own, a great number of early cancers of the breast can be found, and they can be found by young physicians who are specially trained to palpate thor- oughly the breasts of all women in followup examinations. We have a large clinical followup examination of thousands of patients that were treated for minor things like basal cell carcinomas of the tip of the nose whom we have followed now for periods of 15 to 20 years. All patients are properly examined an- nually when they come for their fol- lowup examination and this yields a considerable number of cancers of the breast among the women and cancer of the prostate and of the colon among men. In our hospital, in one year in which we made a record of it, a whole third of the patients with can- cer of the breast who were operated in our hospital were women who had cancer of the breast discovered by a resident in traiing when the women were not aware that they had any- thing the matter with them. That is when it is fruitful, of course, to dis- cover cancer and to treat it, But it would be too bad to discover a num- ber of early cancers of the breasts and have someone do a simple mastec- tomy on them. This is the time to do really adequate surgery, and this is the thing that I think is worth emphasizing. Dr. Farser. The third speaker is responsible for the largest program in the world today—the National Can- cer Institute. Dr. Ennicott. I thought today I might talk a little bit about some of the problems of operating a can- cer center because we have sort of a cancer center. Perhaps it is a little on the long-haired side because it is primarily research oriented, but it comprises many of the features of so-called excellence which I think medical schools and university-based cancer centers would want. It is part of a more general facility in which many diseases are studied. So it is not really a cancer hospital, although we have separate wards. Most of the specialities that might be concerned 81 with the treatment and diagnosis of cancer are represented and most of them have separate wards of their own. It is concerned primarily with treatment and research on therapy of advanced disease, but it also includes substantial leavening of studies of the abnormal physiology and biochemis- try of the disease and something which I regard as very important— we insist on the right of our physi- cians to admit patients with other diseases and to carry out studies in other areas. Now, | think this is something very important in keeping first-rate men working in the management of ad- vanced cancer. They have to have some outlet, some psychological out- let, especially the younger ones, or they simply can’t take it. They can’t face those patients, especially chil- dren, day in, day out, unless they have some variety in the diet. Our group requires what many would consider to be excessive sup- port in terms of laboratory facilities. Part of these laboratory facilities are directly related to what they are do- ing in patients, but even more is re- quired to do the research they want to do which is not directly patient re- lated. And I am sure that it is nec- essary to provide this if you are going to get first-rate men and keep them on the job. We have 250 beds. Of those, 150 are in the clinical center in Bethesda, and they are all research beds. We have another 100 beds in the Public Health Service Hospital in Baltimore, 82 and only a portion of these are re- search beds. The beds are expensive. They are much too expensive for patients who are ambulatory. And we have long since developed arrangements with local motels for patients who are taken care of in the outpatient fa- cility and live in motels. This is es- pecially helpful in dealing with chil- dren, especially children with acute leukemia. We have beds enough to bring them in when they really re- quire intensive care, but for the most part, they are cared for in the out- patient facility. To do this adequately, obviously, requires more than the ordinary out- patient facilitics. One has to analyze the kind of thing that is going to be done in this facility and prepare for it. Now, I am convinced that many of the medical schools, medical centers, that are going to be involved in this program over a period of years can attract and kcep the kind of men you are going to need to do the educa- tional job, the consultation job, the central referral job, if you will provide research beds, some laboratories, and a good ambulatory care arrangement of some sort. Mike Brennan has talked about one possibility. I have mentioned the use of motels. Perhaps we might get Dr. Farber to mention how he handles this same problem, especially with children. Dr. Farper. The final formal pres- entation will be given by Dr. Guy Robbins, the Director of Planning at the Memorial Hospital for Cancer and Allied Diseases in New York City. Dr. Roszins. I have found that working in the vineyards which are being irrigated and nurtured by the Regional Medical Program is really one of the most stimulating activities that I have been involved in. I found early—I am trying to speak as a sur- geon—that one of the greatest things that one had to do was to take the Billy Graham approach, not the Billy Sunday approach. My father was a Methodist minister down in southern Indiana. We used to have these men and women come in to save souls. This basically was the utilization of a technique which would get souls out of the Baptist and Christian Church into the Methodist Church. And I remember as a small boy one of these characters coming to town and taking me out to get a soda. Right away, I was suspicious because, having dealt with a lot of ministers, they usually didn’t give very much away. So I said to Mrs. Barr—first, I drank the soda—“Why did you do this?” She said, “Guy, I am here to help your father. Now, sometimes during my first evening, things don’t go just right, and I want you to get one of your friends, and when I am giving my plea, if things don’t go right, I will give you a sign, and you come on down the aisle.” And I will never forget to my dy- ing day as I pulled this other little ragamuffin out into the aisle and went down there, this woman said, “And a little child shall lead them.” But, you know, you do have to take some sort of an approach to all of these things and look for techniques and for ways of communicating that will present your objective. And as you know, with many of Billy Sun- day’s converts, they stopped near the local bar to celebrate their salvation on the way home and that was it. But I think that from what I have seen, the team that has been devel- oped here is taking the Billy Graham approach. And this is a tough thing for surgeons to do because, you know, we are pretty egotistical, and most of us, I think, really shy a little clear of cancer because somchow or another it is woven into our philosophy that you do something like a hernia, and it gets all done, and that’s fine. But if you take care of a cancer patient and there is a recurrence and there are all these family problems and everything else, you sort of look at it as a defcat of your own. To try and develop among surgeons and_ those working with surgeons an intradis- ciplinary approach to look at the patient as a whole, a person, this is tough. But there are more and more peo- ple that are doing this. And certainly, it falls within the philosophy of the way of life that I think can be clearly defined as Americanism. I have been very fortunate to have been involved with the Cancer Com- mission of the College of Surgeons for a number of years, and with Murray Copeland and Lee Clark and many of the other people I see here in the room I am part of a team that is working with the regional medical group. And I can tell you we are 100 percent behind the program, and we are not too far behind, either. We are right in there with it. oe Many of you may or may not know about our regionalization program. We had a tumor registry program. It has been going for a long time. And under John Klein, Lee Clark, and Murray Copeland, we decided to do an audit on this just to see how good it was. This started about 5 or cn 6 years ago. We found out a lot of things that you are finding—things that we thought were all right. Well, instead of shaking a nasty finger and saying, “It is no good; get rid of it,” we got together to try to do something about it. The first thing we did was to broaden our cancer com- mission to get this intradisciplinary activity on the road. We have repre- sentatives from general practice, pathology, radiology, radiation ther- apy, and general medicine. We also have entwined in this practicing sur- geons all over the country and are succeeding in getting them to look at this problem—the way of helping people get along, utilize what we have, throw away some of the things that are bad. But we have found there are very few things that are bad; it is Just the way that they are used. I am sure that you will find extra man- power if you will utilize these men that are all over the country now. There are 200 of them. Many of them are in the program now, but there are some that would like to be part and parcel of this. We have found that our tumor registries are a good way of evaluating how things are going. However, we have found one thing that we were terribly lacking in. We have had all kinds of support at the local level and certainly at the national level from Mary Switzer and her group in voca- tional rehabilitation. It is great to diagnose a patient. It is great to treat him right. But the trouble is so often that that is where our treatment has stopped. All of us in this room believe that you should do everything to get a person back into the socioeconomic swing of things, but what are you do- ing about it? There are ways, We used to say, “Well, the laws are no good; we can’t help a cancer patient 83 i SAARC as EE ES until five years.” There are ways to take care of that. I wish you could see the way New Jersey’s DVA works with the State, the Federal people, and with the pa- tients in the hospitals. They are doing a great job. New York is coming along, too. This takes a lot of Billy Graham approach, though. You can’t do this overnight. One of the most interesting and en- lightening meetings I ever went to was one that Dr. Smith down in Jer- sey fielded. They had 500 practicing physicians in the middle of the week listening to the problems involved with getting the aid that is available at the community level, and it was great. And there are going to be more of those meetings. They were a little surprised, as a matter of fact, how good a turnout it was. But they had spent a lot of time disseminating information about this, utilizing the many, many forms of communication. These are the things that we have got to do. We have got to get the people that may even be considered by some as just too busy making a living, but if you give them just the slightest notion that you want their ideas and you want them to help get this thing on the road, it works. And, of course, this is the heart of the whole Regional Medical Program. And it is a sermon that everyone is preaching that is working in this group. There is another thing I think that is awfully important for surgeons to do, and some of us are doing it, but 84 I don’t think near enough of us are— and that is finding the time to help in the lay education program. There are parts of this country now where pa- tients come in, and they are too far advanced even to consider as possibly being a cure. There are parts of this country where everybody has a radio, 70 percent of them have televisions, but in the local newspapers there is nothing on health. And on the tele- vision and in the radio programs, there is nothing on health. I think we need some comic books and things of this type. Because if people can be sold, if you can sell a population cig- arettes, why can’t you sell health pre- vention against these diseases? We have worked hard, and a lot of money has been spent. But there cer- tainly must be something more we can do. And I have found that if you put a surgeon on his guard to try to get him motivated, if you get this fel- low going, he is almost as big a terror in this sort of thing as he is in the operating room. Dr, ANprews, Neil Andrews, Ohio State University. When I was in Tuc- son at the AMA meeting, I had the opportunity to talk to Clif Mount and Bradigan about a program that is be- ing done—and I think you alluded to this Just a moment ago, by a num- ber of organizations, including the College of Surgeons, the American Cancer Socicty, College of Chest Surgeons and others—in cancer reg- istries if I remember correctly. Could you give us a progress report on that? Dr. Roszins. There are two pro- grams, I think, to which you might be alluding. One is the tumor registry program which has been going on for 30 years. We believe that if you are going to evaluate how a patient is doing or has done or how you as a physician are working, there should be some records kept. Now, just to take the names and numbers and age and site and stage and so on, that’s great. But if you just put that in a repository and never utilize it, it doesn’t make any sense. And we have found administrations don’t like to spend money on some- thing that their staff doesn’t use. One of our main efforts through the regionalization program has been to try to get these records used in teaching exercises and in self-evalua- tion. I was asked to go to a 500-bed hospital in Westchester and give a talk on breast cancer. And I said I would love doing it, but I wouldn’t go unless they had one of their men give their experience in what has been done and then I would be glad to dis- cuss things. Well, one of their men went into the tumor registry, and he found, al- though they had had several hundred breast cancers, primary cases, out- patients that they had operated, they didn’t have a single one that had lived 3 years. And this man gave the 5-year survivals at the national level with negative nodes and positive nodes. When I spoke [ gave the usual del- inition of a specialist. Then I said, “Tere are my slides; T ant not going to use them. I am not going to show them. He has told the whole story, and I think it is up to you fel- lows to do a self-analysis and find what is wrong. Is it your followup or is it that a lot of you are doing slip- shod operations and modified simple mastectomies?” I didn’t know if I were going to get out of the room or not, but two or three people came up to me and said, “This is what we have needed for a long time.” And then I found there had been two or three people who had been trying to do this. They had put this particular hospital on notice that if they didn’t get a clinical program along with their tumor reg- istry, we weren’t going to okay their tumor registry. We feel keeping rec- ords and not using them is not good. The second part is the study that we have been designated to do on looking into a number of hospital ac- tivities to see if we can get ideas as to how they are doing things in the management of cancer patients. We will have a large bulk of information that can be passed on. That is the Warren Cole Commit- tee that is doing this work in con- junction with all the specialists, in- cluding those in the Acadamy of Gen- eral Practice. In no way are we charged to set up standards. We are finding out a lot of things that are most interesting. In one hospital, we found they have wonderful hori- vontal communications, but the social service worker had never met the man who was in charge of the cancer pro- gram for that hospital. And the social service worker had 16 master’s degree social service workers working with her. This particular chief of the social service department had been in this hospital since 1952. We also found that, although they didn’t have a rehabilitation program and that the social service workers didn’t actually know anything about what they were doing, the orthopods were doing a fantastically good job. Those on medicine and those in the nursing arca and those in the so- cial service department said, “gee, we had better work together; we look sort of silly.” All horizontal communi- cations, no vertical communications. Now, coming up with data of this type is not going to change the way medicine is practiced, but I think that it will make people utilize what they have. We have found that there are some hospitals who do not have an X-ray therapy department. But they have a regional arrangement so that their patients are getting excellent care. And certainly, we wouldn’t say this was bad. Dr. Farrer. At this time, I would like to call on Dr. Margaret Sloan to say something more about the Amer- ican College of Surgeons’ relationship with the division of Regional Medical Programs. Dr. Stoan. I would like to com- ment a little bit on what Dr. Robbins has just said and to set in proper perspective this activity which is now known as the Warren Cole Committee. Section 907 of our legislation says that the Surgeon General shall estab- lish and maintain a list or lists of med- ical facilities in the country staffed and equipped to provide the latest advances in the diagnosis and treat- ment of heart disease, cancer, and stroke, and to serve as training situa- tions in these diseases. It further says that the Surgeon General, in carrying out this activity, shall from time to time turn to ap- propriate national professional or- ganizations in the country. The division, in trying to deter- mine how to respond to this part of the legislation, decided that as an in- itial step, it would be appropriate to consult with the national professional organizations of the country. We are thoroughly appreciative of the great sensitivity of the medical profession toward federally imposed standards, and we do not propose to develop federally imposed standards through this activity. Knowing that the American Col- lege of Surgeons had already estab- lished the Cancer Commission, which included in its membership repre- sentatives of all the professional or- ganizations in the country most closely involved in the diagnosis and treatment of cancer, we turned to the American College of Surgeons and asked their help in this undertaking. The Cancer Commission includes representatives of the American Col- lege of Surgeons, the American Med- ical Association, the American Academy of General Practice, all the surgical specialties, the American College of Radiology, the American College of Pathologists, and others. And we have negotiated a contract with the American College of Sur- geons to consider this field, to con- sider what should really be present in a medical facility which is going to do the kind of job we would all like to sce in the diagnosis and treatment of cancer. When these criteria, as we are call- ing them, or guidelines are available in the field of cancer, which we ex- pect will happen sometime next sum- mer, we propose to make them avail- able to hospitals all over the country for their own internal guidance and to program coordinators and mem- bers of their staffs in the Regional Medical Programs. Through the availability of these guidelines, we hope it will be easier to identify the gaps in the diagnosis and treatment of cancer, in the capa- bility of a region to carry out good cancer diagnosis and treatment. This will be a guideline, both to hospitals in their development as better in- stitutions for the future and a guide to Regional Medical Programs in try- ing to develop regionally the capa- bility they will need to perform ade- quately in this area. 1 believe that we have been very fortunate in persuading Dr. Warren Cole, who is known to all of you and has the respect of all of you, to chair the committee, representing all these professional organizations, which is struggling with this problem. They have developed a list of such guide- lines. They are now testing them as to their feasibility in actual visits to various types of hospitals around the country. And if this works well and productively in the field of cancer, we propose to undertake similar ac- tivities in the field of heart disease and stroke, Dr. Cotuns: Collins from North- western Ohio. I happen to be a path- ologist in a community hospital pro- viding service in pathology to several small community hospitals—let’s say from 50 beds up. I have been im- pressed with the fact that in the smaller community hospitals, | cer- tainly in my area, there has been no long-term followup of cancer pa- tients. Perhaps in a surgeon’s own personal experience, he has followed therm, but to my knowledge, there has been no collective experience. These cases may move from community to community. With this background in my, let’s say, puzzlement about how to work out a proper followup situation, I wonder if a regionwide tumor regis- try isn’t the answer. Most hospital tumor registries I have been familiar with have been as Dr. Robbins has already cited—dead. The material goes into a file and nobody ever looks at it. And I am very much disillusioned with the hospital tumor beds. I was very much impressed with Dr. Smart’s presentation on the Salt Lake City, and I think it might be the an- swer. I don’t know. 85 Dr. Roppins. You are a great straightman for Dr. Smart, and I am another of his straightmen and so is Andy Mayer of the College of Sur- _ geons and so is Murray Copeland. We think this man has come closer to a workable sort of a regional tumor registry than anyone else that we know. And this is primarily because of one thing: He is doing quality con- trols and really working with the local hospital and its staff and giving them prestige and also giving them a prod- uct that they can use and understand. Mr. Chairman, maybe Dr. Smart might want to comment. Dr. Smart: I believe that one of the most important things that we can do in improving the quality of cancer care at the present time is to follow the lead of the American Can- cer Society and the American College of Surgeons in trying to make these hospital tumor registries really effec- tive. A tremendous amount of work has gone into the gathering of this data. And if we can induce physicians to followup their patients regularly . . . By “regularly,” I mean every 6 months, preferably. I think it depends a little bit upon the type of malig- nancy they have, but they need to be followed. Now I think a tumor registry must have a mechanism for relieving the tremendous amount of secretarial work. The problem at the present time in the community hospital tu- mor registry is this: A tremendous number of patients, tremendous num- 86 ber of variables, lots of different kinds of cancer, all different types of exist- ence as far as survival is concerned, and yet, the secretary is not a statis- tician, she is not a physician, and even the physician is not a statistician and is unable to deal with the tre- mendous number of facets. How can the American College of Surgeons or the Regional Medical Program or any other program sim- plify this tremendous number of facets? I think a meaningful com- puter program can actually service a great number of hospitals as individ- ual hospitals and yet correlate the statistics that come from the health departments. It can account for all the deaths and immediately update all the registries simultaneously. It can pick up the patient that moves from one hospital to another or from one doctor to another. It can simul- taneously, then, update the registry which will send out automated letters to doctors to remind them, at 6-month intervals, of certain patients. And, not only that, I believe that it is im- portant also to be able to have some kind of action arm so that, if the patient is lost to that physician, we have some ethical way of approach- ing that patient. And in our particular area, we have tried to develop an action arm through the public health depart- ment where we can utilize the public health nurses actually to visit the pa- tient with the permission of the physi- cian and say, “How is it that you haven’t been going to your physician for a checkup? We feel that it is im- portant that you do so. And if you are unhappy with him, let’s find an- other one.” And I am anxious to sec the Ameri- can College of Surgeons in particular try not only to establish these cancer registries, but in some way to see if we can’t develop a mechanism by which we can give them an individual hospital automated followup. I think for about $50 a year that most community hospital registries could get a report of the survival curves on all their patients, listings of all their patients, and a listing to each individual physician of the patients that he has been following for that year. I think it could be done cheaply. I think it could be done effectively. And I think that these tumor reg- istries which they have been pushing could actually be made to be a very effective tool in education and in re- search, as well as in saving patients’ lives through followup. Dr. Anprews. Dr. Farber, if I may just comment to my colleague from Lima, the department of health of Ohio State did until about 3 years ago maintain a central cancer registry. Unfortunately, this was un- available as regards followup mate- rials. So it was disbanded, and we at Ohio State now are attempting to put together an automated program such as Dr. Smart has stated so that we can make this available through- out our region as we have developed it. Dr. Wiipar. Wilbar, West Vir- ginia. I can’t help but compare, as I listen here, the heart program and the cancer program. They run into difficulty in that in the heart pro- gram, there is a cardiologist who is the captain of the team; in the cancer program, there isn’t any captain of the team. Many specialists are inter- ested in cancer. When it comes to getting adequate examination for cancer of the large bowel, I think one of the troubles is that the internist, the surgeon, the proctologist, the pathologist, the gen- eral practitioner, are interested, but nobody has the whole interest. The public health person is interested. Maybe this is a shot from the blue, but we have specialties that deal with a very narrow part of medicine. Per- haps plastic surgery is one example. There is no specialty board for on- cology or tumors, for cancer. Perhaps there should be such as we have for cardiology. I wonder what the pane! would think of that. I know it is sort of per- haps a new idea. Dr. BRENNAN: The American So- ciety for Clinical Oncology was formed approximately 3 or 4 years ago. One of the problems which im- mediately came up following the or- ganization of that society, whosc membership consisted largely of men who had been active in clinical re- search as opposed purely to the care of cancer patients, was an impetus on the part of the group toward the formation of a subspecialty board in oncology. . Well, I have found myself opposed to this idea. As a hematologist, | never found it necessary. The Ameri- can Society for Hematology suc- ceeded in doing all that we wanted it to do for us or we wanted to do for hematologists without going the route of the subspecialty board. However, this does not detract from the fact that there must be a captain of the team in every institu- tion. He should be, I suppose, in an old Latin way of expressing it, primus inter pares, the chairman or head of a group of equals, who con- sultatively deal with the management problem of the patient. As we know from all human affairs, there must exist a last place of responsibility and decision. Now, who that man should be will depend upon the staff of the institution itself. In some cases, it will be a surgeon who has a long and wide-based interest in cancer man- agement. In others, it will be a radi- ologist. We have the Penrose Hospital captain sitting right next to us here. In other places, it will be an internist. Our problem is that we don’t real- ize the degree to which American medical institutions, the whole ap- paratus, has been around the problem of acute illness. And yet, we now are tying in stroke and cancer (I exclude heart from this problem) to deal with chronic illness in this acute care framework. And the whole apparatus has to be changed to fit chronic illness. We have hurt ourselves with the idea that there are social needs and 292-414 O—68——-7 medical needs. Actually, there are only personal needs—needs of indi- vidual persons who are part of a social matrix the entire integrity of which is disrupted when the personal needs of individual members are not met. In chronic illness, it is very obvious and clear that we have to respond in an altogether different way than we have before. We have to go out- side the ranks of medicine as such to do this. These are not simply medical problems; they are also problems that require the skills of sociologists and social workers, the whole range of helping professions. And we need captains for these teams, but I don’t think that we can identify them in terms of their medical specialities. We can’t identify them in terms of where they came from in training. We can only identify them in terms of where they stand in competence, in interest and in concern at a particular time. Dr. pet Recaro. I would like to introduce a consideration in which I think all of you will have an interest. Tt is a fact that you would have easily confirmed that this country has a lesser number of cancer hospitals today than it had 30 years ago. And the reason is that the concept of a cancer hospital in this country has been a total, full-time staff type of approach to the treatment of cancer, with which the American medical profession as a whole doesn’t go along very well. So this has been limited for the most part to the treatment of in- digents or to outstanding research institutions. I would like to point out to all of you the fact that there is a different approach which we undertook 20 years ago, and that now is being adopted in certain other areas than ours. It is the small cancer hospital in association with a large general hospital, the cancer hospital utilizing all of the advantages of the special institution and nevertheless utilizing the talents and facilities that are already there. This is worthy of consideration in practically any city in the United States of any size because you already have talents there that can be used and do not need to be displaced in order to start a unit of cancer ap- proach that will involve all of the skills that are necessary in pathology as well as in radiotherapy, chemo- therapy, ct cetera. Dr. Daviss: Dr. Davies, Memphis. I would like to address this question to Dr. Brennan. In making an appeal for an extended care facility, you pointed out that there are some 6,000 deaths from cancer in Detroit a year and that only 450 lives could be saved if you went the route of early detec- tion and increased facilities for early diagnosis. Doing a little arithmetic, since you said that the deaths come to about one out of 50 deaths in the country, I get a figure ‘of some 7,000 people, lives, that could be saved in the coun- try, which J think is a fairly sizable number. Dr. Brennan. I believe that you could increase the salvage rate, the ultimate salvage rate, in cancer by using optimally the available detec- tion facilities, not by 450, but by closer to 1,000 a year in the Detroit metropolitan area. My point was that if we brought up the level of accessi- bility of care and the quality of care for the indigent to that which holds presently for the nonindigent popula- tion in America today, we would save only 450. Now, I don’t believe that the pri- vate profession is utilizing detection methodology in an optimal way. And I agrce with you, we need to look to detection and find intelligent ways of doing this. We have experience with a can- cer detection clinic which is 20 years old and which examines approxi- mately 8,000 patients a year. And we know very well what the yield of these examinations can be. But one has to think in terms of priorities, I believe, too. And the overwhelming and crushing problem that is in front of us today is that, because we insist semantically in separating out social and medical needs and writing insur- ance programs for one and not for the other, we are ending up with a wastage of hospital facilities, a de- moralization of the profession and the discouragement and despair of many patients and their families simply because we can’t make the sociomedical product we need for chronically ill people in acute care institutions. Let us try to understand, for ex- ample, why a doctor keeps his patient 87 in the hospital when he isn’t actively treating him any more. Why have so many of us over-used the Blue Cross? It is not because we are careless about the Blue Cross; it is because, in many instances, we recognize that the hos- pital is the only existing acceptable facility in which, in the totality of this patient’s situation, we can reasonably say he should stay. This is a great problem. Dr. Srorry. Storey, Philadelphia. I would like to ask a question tat is related to the discussion that has just gone on, but I would specifically like to ask it of Dr. Smart. Specifically, it is whether or not you consider it practical to make cancer a reportable disease in any given region. What I have in mind with that is that we don’t have too much difficulty getting information on mortality and we are able to get morbidity statistics through tumor registries of hospitals which have tumor registries, but we have great difficulty in finding out what the true incidence of any form of cancer is and what the prevalence of the disease is. And we also have great difficulty in finding out what the stage of cancer is in any given community at the time that it is diagnosed. It seems to me this is critical in- formation, and we have got to be able to get this. And we have dis- cussed the possibility of the mech- anism of making cancer a reportable disease as being a way of getting at this kind of information, but the gen- eral feeling among our people is that 88 this is impossible; you would never be able to get the health care system at several levels at which it functions to cooperate in such a program. Dr. Smart. Dr. Baylor of the Na- tional Cancer Institute is presently undertaking, again, beginning in January 1969, a 3-year study of ten cities and of two States to try to de- termine the incidence by having every physician pick up every single case within that area. Now, how much the need is to do that in all areas of the country, I am uncertain. But I would say that in Utah and also in Montana and also in Idaho, it is a reportable disease, and they are getting reporting of about 10 percent of the cases. And the reason that they are getting reporting of only 10 percent of the cases is be- cause they aren’t giving anything back to the physician. They are re- questing more and more work of him, but they are giving nothing back in return. And the answer is that the reports have simply been filed on a desk in the health department and nothing has ever been done with them. The only incidence figures they have ever come out with are the incidence fig- ures that have come from the Cancer Society where they say 285 patients per 100,000 are going to develop a malignancy. We took the approach of hiring eight medical students and sending them out so survey all of the hospitals of the State. We went into every rec- ord room; we pulled every record, beginning with January 1966, up to the present time. We did get as close as we could, but we still didn’t go to the practicing physician’s office. This was a very efficient method, and we were able to survey in a pe- ried of 8 weeks 41 hospitals in the State of Utah and 36 hospitals in the State of Wyoming with eight medical students in a period of 8 weeks. That is one way of getting at this thing. Wyoming different proach, "Phey said, “What we ought to do is make it a law.” And they just passed the law in Wyoming that all pathologists must send a duplicate report of the histology of every case of malignancy to the State health department. And in the last 3 months, even though it has been a reportable disease by physicians for several years, in the last 3 or 4 months, they have picked up more cancer cases than they have in the entire 3 years previous. And that is a pretty efficient way of doing it. Dr. Farzer. If you will permit me to make a few concluding remarks. First, I do want to acknowledge the distinguished leadership which Dr. Robert Marston has given to his staff and to the country in this very great and important program. It is one of the most important moves, I believe, in the history of medicine in this country. We are grateful to him and to the splendid staff that he has brought to work with him in this important program. We are grateful to our panelists here for their contributions to the look oa ape problems of cancer in the Regional Program. I think it is quite clear to you that all of us will leave this room somewhat dissatished because there are so many problems that we would like to have discussed. If we can con- vey this to Dr. Marston, perhaps we can have another session in the not too distant future with much more time allotted for the discussion of many other problems which are con- cerned with cancer in the Restonal Programs. ‘There are a few points F would like to make here because I think they are of some importance to our work which will go on before the next conference. Mention was made by Dr. Brennan of that important segment of the population which is less favored than others. Of course, we are all deeply concerned in seeing to it that every man, woman, and child in the coun- try has access to as fine methods of cancer diagnosis detection and diag- nosis and then treatment, and finally rehabilitation, as any other man, woman, and child in the country. But I would emphasize that if we did no more than carry on the kind of cancer diagnosis and treatment available today to patients who are in the favored group able to pay,.we would not be doing our job. There are two more jobs to be done. The first is to see to it that every- one, including the private patient, receives everything that medicine, sur- gery, and laboratory science has to offer today for their prolongation of life and hopefully for their cure. I have figured and I am willing to de- fend these statistics, that if we applied everything that is known today to every patient in the country, includ- ing those in favorable economic cir- cumstances and those who have no private doctors at all, we could save 100,000 patients this year of the 300,000 who are going to die of cancer. I think this should be our imme- diate goal in the Regional Programs. We must be certain that when we initiate these programs, we must not permit Gresham’s law of economics to operate. We must not have poor work pushing out good work in an attempt to spread this to everyone. We must raise the standard for pri- vate patients as well as for those who are less favored. I think there are a few delusions under which we have operated in the past. One is that every doctor's office is a cancer detection center. That is impossible. We must not impose that load upon a general practitioner, who is not equipped by training or with the proper instrumentation or with the proper hospital backup, to accept the responsibility of telling a given person that he has or has not evi- dence of cancer. To follow this along, Iam glad that this was brought out by Dr. Robbins that no one doctor can take care of any one patient with cancer. There never was a time when any one doctor could do that. This team approach is essential. It is a much abused term. I have used another term—the conception of total care of the patient which brings in everyone, every discipline, that might be of aid to the patient. I was pleased with this question about who is the leader of the team. The leader could be any one of the specialists mentioned and one more. There is one speciality that could be added, Dr. Brennan. There was a man named James Ewing, and there was a man named Dusty Rhoads; both of them were pathologists, and they were leaders. What is important is that in this interdisciplinary ap- proach to the entire problem of can- cer treatment and cancer research, there must be someone who is highly skilled .in his own discipline, who by his nature and interests has a broad view of the entire field of cancer and awareness of what it means to achieve goals of prevention and goals of cure. That man can come from any dis- cipline. We must not permit any of the rules of craft unionism or the spe- cialty boards to determine who will be the leader of a group interested in the patient with cancer. We have to go back, not only to the hospital, but to the medical school to bring into the medical school the word “oncology” as an honorable term, representing a pur- suit that brings in people from every discipline represented on the faculty of the medical school. And such a division of oncology in a medical school must be so created that it will not interfere with the development of the disciplines of biochemistry or in- ternal medicine or surgery or pathol- ogy. It should detract from none of them, but bring additional strength to every one of these disciplines. If we do that in every medical school, we will turn out doctors who are already accustomed to an inter- disciplinary approach no matter what field the new doctor may enter. I would say one final word here. We have gone through a period of discussion of continuing education, a matter of tremendous importance. We have also gone through a period of data collection, planning, and study. There is no question that this is a field of great importance. But these are supporting structures of the program that will lead us to the final goal of these Regional Medical Pro- grams. That is the care of the patient. We must get to the patient as rapidly as possible without waiting for 5 or 10 years of study and planning. We must help them and we must help the continuing education peo- ple. But with knowledge and re- sources of medicine in this country today, we can apply what is known by those who are more expert, more ex- perienced, in cancer than those who have not worked in the field, to every patient of every doctor in the country and to every person who is sick with cancer, whether he has a doctor or not. T would urge that we push ahead with planning which leads to the care of the patient. That’s the goal, and that’s what the Regional Medical Programs were created for. We must not be content with years and years of application to the base upon which we are going to build because there is so much that is known today that we can use for the benefit of those who do not have what is known to those who are most expert in this field. I would hope that we will have in the near future another confer- ence of those interested in the prob- lems of cancer related to the Regional Medical Programs, and that we will talk about more specific programs which can be instituted today and which hopefully will have been in- stituted by those of us who are here today to report on at the next confer- ence. 89 PANEL DISCUSSION ON— STROKE Panel: Nemat Borhani, M.D. (Chairman) Professor of Internal Medicine and Chairman, Department of Community Health University of California School of Medicine Davis, Calif. Clark H. Millikan, M.D. Consultant in Neurology Mayo Clinic Rochester, Minn. James F. Toole, M.D. Professor and Chairman Department of Neurology Bowman Gray School of Medicine Winston-Salem, N.C. William A. Spencer, M.D. Director, Texas Institute for Rehabilitation and Research Houston, Tex. Richard L. Masland, M.D. Director, National Institute of Neurological Diseases and Blindness National Institutes of Health R. Boruant. The first item that we will cover this morning is the epidemiology and early detection of cerebrovascular diseases in the United States. Disorders of the cerebral circula- tion, grouped together under the category of Cerebrovascular Diseases 90 (ICD 330-334), rank third among leading causes of death in the United States; they are outranked only by arteriosclerotic heart disease and malignant neoplasms. In 1965, a total of 201,057 persons died of cerebrovascular diseases, a rate of 104 per 100,000 population. The age-specific death rate increases with age, from 15.4 per 100,000 in the age group 35 to 44 to 430 per 100,000 in the age group 65 to 74 and 1322.2 per 100,000 in the age group 75 to 84. Death rates also vary among the races and between the two sexes, 96.3 for white males, 108 for white females, 113.5 for nonwhite males and 115.9 for nonwhite females. Cerebrovascular diseases impose a multibillion dollar burden on the Na- tion’s economy each year. The most recent data from the National Center for Health Statistics indicate that in 1962 the loss from the labor force reached 177,700 man-years at a cost of $701.8 million. The direct and in- direct estimated cost of stroke in 1962 amounted to $1,147 million. Nearly 50 percent of the direct cost of $211.6 million was for hospital care; more than half of the indirect cost or $468 million was associated with morbidity from cerebrovascular diseases. The analysis of mortality data re- veals that there exists a marked clustering in mortality from cerebro- vascular diseases within the United States. The highest rates are found in the South Central and South Atlantic States and the lowest rates are in the Southwestern and Mountain States. It should be noted that the geo- graphic clustering of cerebrovascular disease mortality in the United States does not, in general, conform to geo- graphic distribution of mortality from arteriosclerotic heart disease. The findings of the recently con- ducted National Cooperative Study on Mortality from Cerebrovascular Disease indicate that the observed geographic variations in mortality are real and not due to statistical arti- facts. More specifically, analysis of the death certificates for white males and females, age 45 to 69, from nine areas of the United States, representing high, intermediate, and low reported cerebrovascular disease death rates, showed that the difference in rates do not seem to be due to: 1. Coding differences in selec- tion of the underlying cause of death on certificates that list cere- brovascular disease diagnosis, 2. Differences in certification practices by coroners or medical examiners, 3. Use of vague terminology, and 4, Large number of deaths at- tributed to cerebrovascular disease in nursing homes and outside of hospitals. The findings of this study bring to focus the need for a comprchensive morbidity study to further explore the reasons for the geographic differences in mortality. Unfortunately, not enough infor- mation is available on incidence of cerebrovascular disease in general populations. Those data which are available are difficult to compare. The Middlesex County, Conn., study reported an annual incidence rate of 2.3 per 1,000 population of all ages. This incidence rate increased tremendously with age, from 4.1 per 1,000 in the age group 55 to 64 to 50 per 1,000 in the age group 85 and over. In Framingham, Mass., among 5,106 men and women aged 30 to 62 years who were found to be free of both coronary heart disease and cere- brovascular disease during the initial examination, there occurred 90 cases of cerebrovascular diseases in 12 years of observation, an incidence rate of less than 2 per 1,000 per year. In Framingham, thrombotic brain in- farction was by far the most common type of cerebrovascular disease, ac- counting for 63 percent of all such events. Hemorrhage into the brain was the least common (4 percent), but most lethal type of cerebrovascu- lar discase. As far as prevalence of cerebro- vascular disease is concerned, the available data leave much to be de- sired. By and large it is believed that total prevalence of this disease in the United States is between 1 and 2 million, It should be emphasized that: accurate data on prevalence of cerebrovascular disease are not avail- able and are much needed. In summary, the available data suggest that there is no appreciable sex differential in cerebrovascular disease, that Negroes experience rnore cerebral and subarachnoid hemor- rhage than Caucasians, that increas- ing age and blood pressure are clearly related to the development of cerebrovascular disease, that hyper- cholesterolemia is associated with the risk of developing this disease only in the age group 30 to 49, and not thereafter and that there is some evidence relating cigarette smoking to cerebrovascular disease. Major deficits in our knowledge of the occurrence and the nature of cerebrovascular disease are evident. Many aspects of the epidemiology of cerebrovascular disease need urgent systematic studies. Furthermore, as was reported by the President's Com- mission on Heart Disease, Cancer, and Stroke, many fundamental prob- lems of physiology, pathology, neurol- ogy, neuropathology, circulatory dy- namics, and blood clotting, to name only a few, need to be studied with respect to development of cerebro- vascular diseases. If intelligent programs aiming at the prevention and contro] of cerebro- vascular disease are.to be established, it is vital to: 1. Be able to distinguish be- tween various types of cerebrovas- cular disease and their precursors, 2. Know accurately the mor- tality and case fatality of the various types of untreated cerebro- vascular disease, 3. Ascertain the true incidence and prevalence as well as the magnitude of disability resulting from each type, and 4. Accurately assess existing therapeutic and rehabilitative re- sources and measures, as they may alter the natural history of various types of this disease in the com- munity. Once cerebrovascular disease has become manifest, its treatment is es- sentially limited to either surgical procedures, or acute supportive medi- cations. Also with modern medicine, many patients anticipating cerebro- vascular disease can be treated effec- tively to avert catastrophe; and, among those who have suffered severe attack, treatment can reduce or pre- vent chronic disability. It is commonly believed that all new and modern techniques of therapy and rehabilita- tion could, and indeed would, pro- vide benefit to the patient, when in- telligently applied. What is not known, however, is information re- garding utilization of current knowl- edge in the medical community and how judiciously these measures ‘are being applied to the cerebrovascular disease patient population as a whole. Indeed, questions arise as to how effectively the medical community is utilizing the information already available with respect to cerebrovas- cular diseases. Are the high risk in- dividuals being identified and to what extent the risk being altered? Are ade- quate diagnostic procedures and fa- cilities being utilized? To what ex- tent have current advances in the field become known to the practicing physician? What rehabilitation serv- ices are available, are they adequate, and how are they being utilized? It is evident that there is a great need for basic reliable information to be collected. This must be done be- fore any meaningful preventive or control measure could be applied. To me, these questions pretty well chart the way for the activities of the Re- gional Medical Programs throughout the country. I think we can leave the epidemiol- ogy at this point and hear from our distinguished panel. The first mem- ber of the panel who is going to dis- cuss the subject of various aspects of management of the acute phase of cerebrovascular disease is Dr. Clark Millikan. Dr. Mituxan. If we start with the presumption that the Regional Medi- cal Program is going to attempt to do something about stroke patients, it seems wise at least to discuss the matrix into which we may mold the stroke setting. I am going to begin in terms of personnel and facilities because, after all, the core issue has to do with the kinds of people that are going to address themselves to the individual care of individual stroke patients, or the prevention of stroke in individ- uals, plus facilities, meaning all of the physical components, the two molded together into an organizational com- plex which might in this instance be called the RMP approach to the stroke program. So we start also with the presump- tion that for a given region there will be centers of excellence, or a center of excellence, which must interrelate in terms of the original law to all por- tions and all communitics and all persons of the region. I am going to start with the theoretically optimum center setting to demonstrate the complexity of the problem we are talking about, what kinds of persons or disciplines should be represented as far as the center is concerned. Now, the word “should” was used advisedly. This is in a sense a theoreti- cal concept, and you will see not many fulfill the criteria as the criteria are elaborated. Here is a list: One, Neurology. Now, neurology might handle EEG, brain scans, and encephalography in a given setting, but often different personnel will be involved with some of those items. Two, Neuroradiology, for contrast studies. In some instances this in- volves scanning, or they handle echo, or may not, of course. Three, Medicine, including Cardi- ology, the inspection, diagnosis, and therapy of hypertension, and hema- tology in reference to blood constitu- ents. Now we have the business of the high hemoglobin raising its head, and. what the meaning of this is going to be remains to be seen; obviously the diagnosis and long-term care of diabetes. Four, Surgery, vascular and neuro- surgery. Although there has been 91 considerable emphasis on the surgery of occlusive disease in the cervical portions of the cerebral circulation, we must reflect that differential diag- nosis obviously includes other condi- tions inside the head, and when we get to the subject of hemorrhage, whether subarachnoid or intracere- bral, we have a situation that falls into the province of the neuro- surgeon. In some settings the neuro- surgeon has become accomplished at doing peripheral vascular surgery. So number four is surgery. The next one is Rehabilitation. And in the setting of the research center the whole concept of rehabil- 92 itation may have to be subdivided, as far as personnel is concerned—physi- cal medicine, speech, and language pathology. Nursing, and all the supporting structures that go around nursing, either in terms of prevention, prog- nosing stroke, or the completed stroke setting—this kind of personnel ob- viously is mandatory to the setting. The next one I have put down is Social Service. The kind of personnel necded to the return of an individual to the community, the interrelation- ships between the cost structure of the patient and the patient’s family—all of this must be worked out through persons involved in the social setting of a particular patient’s problem. Number eight, Clinical Pathology. This is the type of professional in- dividual who heads the backup laboratory services which are manda- tory for the research, training, and the actual practical care of patients in this setting. Now, recall I am discussing the most sophisticated of patients’ setting, the center, the hub of the wheel. Clinical pathology, and here we see individuals who must in some instances look after brain scans, and others must of course take care of the clot lysis phases of the problem; chemistry in general, and in certain instances, tissue pathology. I have put down the next one as the general area of Secretarial. This is the kind of supporting personnel that is mandatory to the filling out of the various kinds of forms, transcrib- ing reports, et cetcra. We go on to number 10, Neuro- pathology. Then I put Epidemiology. We are talking about the center now, for the study of the impact of the disorder on the community, the collection and analysis of data in reference to the spread of it and its possible meanings. Number 12, Neuro-ophthalmology. Number 13, Neuropsychology. Number (4, for this center kind of business, Computer Methodology. It is fairly obvious as we get further in- to the 20th century that the use of computer technology and method- ology is becoming a part of our every- day life. Number 15 is a collection of items under so-called Basic Science, and here is experimental pathology, phy- sics, mathematics, electronics, neuro- chemistry—a whole host of different kinds of people who well may need to be involved in the mix of research in- vestigation at the level of the cere- brovascular research center. And finally, 16. I have put down other administrative types of persons having to do with Fiscal Arrange- ments, the accomplishment of the attaining of various kinds of space, its remodeling, and that sort of thing. You see how ridiculous this is in terms of taking care of Mr. Average American with a stroke. As Dr. Endi- cott said yesterday, $25 million for one cancer center that can handle a few hundred patients is not a realistic look at the problem of cancer in the United States. So let’s change our view a bit and say what is possible in a county com- munity in Illinois, or in Missouri or in Florida, outside the immediate setting of the great medical center. We might look at it from a dif- ferent standpoint and say if we take the temporal profile of cerebrovascu- lar disease where can we make an impact as we begin to structure or- ganizational matrices for an attack on cerebrovascular disease? Well, of course, as Dr. Masland emphasized yesterday, we turn to the matter of prevention and what kinds of personnel might be involved in a community in screening and attempt- ing to do something about preven- tion, and what kind of physical facil- ity is necessary. I have written down here that one of the key issues sooner or later must be that a physician be in the mix who knows something about the brain. For the moment let’s temporarily discard the concept of the formal disciplinary distinction. There have been argu- ments among some of us at times about what kind of a discipline- oriented physician could really know something significant about the brain, but it has been a belief of some of us that we can train individuals in short- term training experience to at least become knowledgeable of some of the practical aspects and, theoretically, every physician should have this knowledge, or should have some abil- ity in this regard, updated from time to time by continuing education tech- niques. So that some sort of physician, whether called formally and board- certified in neurology is not the issue at the moment. In the first place, it is not possible for all the cornmmunitics. Dr. Masland, how many are cer- tified in neurology now? Dr. Mastanp. About 1,200. Dr. Miuurkan: Close to 1,500. You get the complexity of the prob- lem and the impossibility of the prob- lem in terms of distributing these people to make even administrative contact with every citizen in the United States. The matter of the surgery at the so-called minimum level is an impor- tant matter. We start with some kind of individual who knows something about the brain—this may be an in- ternist, this may be a man in general medicine who has had some special training experience-——and if we are going to discuss practical prevention in terms of screening, then action, we have to get action. Before closing I want to. make a comment about this. We have to get inclusion of someone who knows something about vascular surgery, whether titled a ncurosurgeon or a general surgeon with special training in vascular surgery. I want to make a plea before clos- ing~-I don’t know whether I will get strenuous objection from the panel or the audience or not. I want to make a plea that we do not construct matrices for the approach to the pre- vention of stroke in which we put vascular surgeons in an isolated set- ting to do the whole job. I think that as we see referred problem patients, that one of the commonest sources of problem patients come from settings where there has been a very, very vigorous surgical operative approach to the clotted arteries in the neck by people who have not yet had their lifetime medical experience enriched by finding out anything about the brain. And I personally believe that it is highly important that this sur- very not only be conducted by in- dividuals who are technically expert at handling the problems of vascular surgery, but who are working in con- junction, consultation, and full com- munication with some kind of person who knows something about the brain. Perhaps we will have an oppor- tunity later on to come back to further discussion of the matrix be- cause there is a great deal more to be said about this. Dr. Bornant. Dr. James Toole will talk about intracranial hemorrhage. Dr. Toois. Those of you who are experts will have to bear with me while I give you what I would con- sider a basic talk on hemorrhage within the head. Intracranial hemor- rhage within the head occurs when an artery, a capillary, or a vein rup- tures, allowing blood to spill into the surrounding tissues. Depending upon the site of the rupture, this spillage may result in the accumulation of a blood clot which can act as a mass compressing and displacing the adja- cent structures and tissues and/or spasm of the arterial tree in which the rupture occurs, and lastly a reac- tion to the blood itself as in the chem- ical meningitis which occurs when there is a subarachnoid hemorrhage. Vessels may rupture because the walls are weakened by disease, occasionally, because the intraluminal pressure is excessive, or because of trauma which tears the vessels. In many instances two, or even three, of these factors may occur in combination with one another. Whether the resulting clot enlarges depends upon many factors, only two of which are the clotting mechanism and the site of the bleeding. In some locations, bleeding seems to stop more quickly than others, and obviously if the clotting is abnormal, as in leu- kemia, or in a patient on anticoagu- lants, the bleeding may continue, when it would cease in normals. Even though head injury rep- resents a major cause of intracranial bleeding, I have decided today to con- sider only bleeding due to disease of the vessels, so-called spontaneous hemorrhage, with a very occasional allusion to the traumatic injuries which are such a great problem as causes of hemorrhage. As mentioned earlier, bleeding may be arterial, capillary, or venous. Ar- terial blood, being under higher pressure, usually results in more mas- sive bleeding with a more rapid evolu- tion of events than does capillary or venous bleeding—obviously with some exceptions. Hemorrhage can occur from any site or from any artery or vein within the head—for example, vessels may rupture into the pituitary gland but some vessels rup- ture more frequently and as a result some structures are involved more often than others. Again I want to emphasize that I am addressing this talk to those of you who have not studied the anat- omy of the skull, the meninges, or brain. First, I would like for you to con- sider the venous anatomy of the brain. (Slide) You can see that the brain is covered by meninges, the dura 93 mater, the arachnoid, and the pia mater. Outside the dura you can see the middle meningeal artery and vein. Rupture of one or the other of these two vessels causes epidural hema- toma-—almost always the result of trauma to the overlying skull. At times a barely preceptible skull frac- ture causes rupture of artery or vein, with the rapid accumulation of a blood clot, which presses on the brain like a tumor. Evacuation of the blood clot removes the tumor and ligation of the vessels cures the patient, but delay even for an hour or two may be fatal. Beneath the dura is the pia-arach- noid and between them are veins which, when ruptured, result in sub- dural hematoma, which is another mass lesion within the head caused by a blood clot. Bleeding in this instance is almost always venous so that the evolution of events is usually more chronic, often with insidiously pro- gressive signs and symptoms. (Slide) Here is an example of an accumulation of blood clots beside the temporal lobe. You can see that it presses up on the brain, displacing the structures which are ordinarily in the midline and resulting in displace- ment of the hemisphere and compres- sion of the midbrain which ultimately caused the patient’s death. (Slide) The next form of intra- cranial hemorrhage which we will discuss briefly is the subarachnoid hemorrhage. In this disease, bleeding occurs within the pia-arachnoid and blood flows freely through the cere- 94 bral spinal fluid, up over the hemi- spheres and down around the brain stem into the spinal theca. Local blood clots accumulate, and this can act as a mass lesion, but most of the systemic signs are secondary to the reaction to blood in the cerebral spinal fluid. This results in acute headache, stiff neck, and change in level of consciousness. About half of the patients with subarachnoid have a ruptured aneurysm. The others are of unknown cause. Most aneurysms arise from the arterial circle of Willis or the arteries which feed or arise from it. Aneu- rysms are thought to be congenital and to be the result of herniations of intima through congenital defects in the media. This herniation may be brought about by clevation in. sys- temic arterial libad pressure. Unfortunately, the development of an aneurysm cannot be anticipated. They hardly ever produce localizing signs or symptoms which one could utilize in mass screening programs to decide whether or not one might eventually have a subarachnoid hem- orrhage. However, in the majority of people who have ruptured ancurysms, hypertension is found, which gives some hope that control of hyperten- sion might result in reduced fre- quency of this disaster. The next type of hemorrhage that I would like to discuss is hypertensive intercerebral hemorrhage. Recall that we have just discussed aneurysms of the circle of Willis and the major arteries at the base of the brain. There is another type of aneurysm which seems to develop in patients with sus- tained hypertension. These are micro- aneurysms which occur in the arteri- oles which penetrate the substance of the brain. These aneurysms are micro- scopic in size and appear to be a tortuosity of vessels, beads of out- pouching. In some cases, these micro- aneurysms rupture and produce an intracerebral hemorrhage which de- stroys the parenchyma of the brain. Most people have felt there is very little to be done about these clots once the rupture has occurred, for it de- stroys structures, many of which are vital to normal function. Most occur in the region of the internal capsule, or in the thalamus—areas of the brain which are both very difficult for the neurosurgeon to approach. The point to emphasize about all of these forms of intracranial hemor- rhage is that all are better prevented than treated. Identification of pa- tients who might suffer subarachnoid or intracerebral hemorrhage from either form of aneurysm is partly the identification of hypertensive patients and it is hoped that the control of hypertension would reduce the inci- dence of these tragic diseases. The traumatic forms of hemorrhage—epi- dural and subdural hematomata—are also better prevented than treated. In summary, the most common forms of intracranial hemorrhage are those secondary to trauma to the head and hypertensive extracerebral hemorrhage. Each of these can be prevented at least in part, and the therapy for each is dependent upon having a properly trained group of people available, as was discussed by Dr. Millikan, with adequate equip- ment for the rapid management and initiation of the steps necessary to re- lieve the condition. Dr. Boruant. Dr. William Spencer ‘will talk about the various.aspects of rehabilitation in stroke. Dr. Spencer. I approached my part of this perhaps a little differently. We might entitle it “A Tale of a Noncategorical. Approach to a Cate- gorical Problem,’ because I think there is some question in your minds on the relationship of rehabilitation to RMP, either as physicians or as administrators or as people concerned with the administration of Regional Medical Programs. What is the relationship of rehabil- itation as a method of patient man- agement to these various categorical problems? I suppose stroke is prob- ably the most evident one, simply be- cause the person with a completed stroke very often has problems of mobility or movement, and it is in the disturbances of movement that physical rehabilitation, at least in a medical sense, has had great utility and development. Unfortunately, however, this leaves in your mind a residue which is not consistent with what is happening in rehabilitation medicine, and that. is a realization that rehabilitation offers a way of planning for the manage- ment of an individual so that on the one hand it is possible to limit the de- velopment of those conditions that will lead to his inability to function in a life responsibility, and on the other hand there are developing pro- cedures and precise methods for better, more integrated use of a variety of health services, health serv- ices which help the individual achieve life adjustment. There is another trend in rehabili- tation which has particular impor- tance to Regional Medical Programs, and that is: We are becoming aware more and more of the anticipatory elements of care of the individual. The movement of early care which considers the individual from a point of view of disability potential, from a point of view of the impact of his characteristics as a person, his living situation, his natural life space upon what happens to him in terms of sur- vival and in terms of prognosis. This is something we have to be concerned with right from the very beginning. Most of you probably think of re- habilitation as a “Humpty-Dumpty” operation, which is to put Humpty- Dumpty back together again after you have a catastrophic dissolution of every aspect of human behavior—a physical, personal, psychological, emotional, social, economic catastro- phe. This is the way rehabilitation es- tablished itself in medicine. That was the meaning of the so-called third phase of medicine, and I think, too, perhaps this is the reason that reha- bilitation was usually considered late in the course of disease and disability and didn’t fit into the neat cate- gories—disease categories, we are discussing. What are the trends in this field? These suggest that aspect of rcha- bilitation as a model of extended care which has as its focus ultimately not only personal life adjustment but management of those conditions which will threaten the life of the individual and his ability to adapt and adjust. First, in stroke we are seeing an im- proved ability to predict stroke prone- ness, as we have heard, by advances in the quality of the mathemathical predictive models, as they are called, that are being developed for estimat- ing the likelihood of these conditions. I think this will improve increasingly in the near future so that right away we will be forced into having a pro- cess or a procedure to care for people who have a high risk of increased lia- bility to these conditions. Let me illustrate what I mean. On the one hand, in society we have pro- posed advanced automated health screening. Now, RMP is one of our few possible solutions to having a pro- cedure or process to do something about those discovered once we identify the people who have in- creased risk. It is one thing to know it is going to happen. It is another thing to be prepared to do something about it, and I suspect that people believe we are giving attention to the latter more than the former, that they will assume we will do better diag- noses and hope that this is matched by an adequate backup of care. In the rehabilitation context, what this means is that we are seeing im- proved ability to prognose what will happen to an individual as a conse- quence of stroke in the totality of his situation. We are learning better how to say whether the realistic outcome is going to be cure through natural recovery or improvement through usage of some definitive medical or surgical procedure, or whether it is likely that with a comprehensive and extended program of a highly inten- sive kind we can help this individual to adapt and adjust to nonresolvable neuroanatomical impairments. For- tunately these may not be paralleled by identical functional impairments, because the brain is so plastic. Alter- natively we may predict whether maintenance of life, just simply sus- tenance of life is all that is going to happen, or whether there will be a continuing regression and dissolution of the person. This is very important to know. Al- though we don’t presently have these distinctions in those aspects of mor- bidity statistics, these should be the basis for our planning and our basis of deciding what can we do at a local community level or for us to con- sider at a central level of organization of health services. The implication of such studies is going to have tre- mendous impact on the organizational structure of health services. Offsetting disability must be added to medical care as a part of the acute care process. The acute care process has to have built in procedures to an- ticipate the consequences of the long- term situation, to a greater extent in stroke perhaps than in any other condition. We have learned from studies of ideally healthy men, simply immobi- lized under bed-rest circumstances, that there is rapid deterioration of the physiological capacity to adapt to the physical environment, and indeed even to the psychological environ- ment. Irregardless of the pathology, the consequences of our circumstances of care, if they produce inactivity, im- mobility, and deprivation of sensory and motor input or experiences, problems will be created which we call the immobilization syndrome— leading to the disabilities which are equally as great and devastating as the original disease process and these can be offset. The impact of this on care is that the reorganization of community hos- pital services to prevent disability, to prevent the effects of immobility and inactivity is an essential, realizable, early ingredient of what we can do in our RMP programs. We should put this up as a requirement of a satis- factory operational stroke program if we are going to make an impact on the complete stroke situation. The next thing that this will do is to force us into a posture of having to define better triage and prediction of those who will benefit from intensive rehabilitative services and those who will be adequately managed and can benefit from available community service. We just have to face up to 95 this because there are not enough pro- fessionals for restorative services. There are only 600 physiatrists. There are probably fewer people than that with any substantial training and con- cern about this rehabilitation manage- ment process in other specialities. The next thing is that we are seeing an evolution of institutionalization in rehab medicine. If you define broadly “institutionalization,” it is the organi- zation of collective human effort in a physical setting. In rehabilitation, this is essential, because if you need the assistances of many professions and many disciplines you have to inte- grate and coordinate what they do around the patient’s needs, and as he changes. This means that the institutional pattern of the intensive care, ex- tended care of the severely disabled, is going to increase in the future rather than decrease if these accruing numbers are to be diminished. Some kind of model of relationships has to be developed between these institu- tional resources and the classic com- munity resources of the hospital. I don’t think there are enough pro- fessional people or that there is enough money to model intensive re- habilitation centers in every commun- ity hospital as we have done with surgical suites. Not for a long time. Therefore, the teaching function of these specialized resources has to ex- pand out of proportion unfortunately to the research and the care activities that they are doing if we are going to mount any kind of a program that 96 will affect greater life adjustment suc- cess of the stroke person. Finally, I think we are seeing a de- mand for a high rate of application of research findings in this evaluative prognostic process, and in this or- ganizational aspect of care. The bar- riers are on the one hand that ad- vances in molecular biology are less applicable to this situation of opti- mizing and providing better health care than we had hoped in our original planning in bridging the gap between research and its application. Paralleling a reorganization of health care services for stroke and other problems that have produced ex- tended needs for care is the require- ment that we must very rapidly understand these organizational fea- tures through health services research. This has not had in any sense the attention it needs, if we are going to be in a position to have good alterna- tives to suggest to one another. And I mean to one another, as J hope we will find out what every group is doing in rehab aspects of comprehen- sive patient management. In conclusion, I think that rehabili- tation medicine in some elements, par- ticularly in the processes of evaluation of disturbed human function and in development of knowledge about how to understand adaptive behavior of the human in the situation of disease, particularly these chronic conditions, will offer to you in Regional Medical Programs a useful teaching and dem- onstrational model of comprehensive and extended care which we see as our distant goal and yet a realizable goal for our citizens who have stroke, in- cluding ourselves. Dr. Borwant. I will ask Dr. Mas- land to emphasize and expand on what he presented yesterday in terms of resources and activities throughout the country in the field of stroke. Dr. MasLanp. Just to recapitulate briefly: I have urged that, recogniz- ing that we must start with limited programs, our ultimate objective should be a total program for stroke. Such a program comprises, first, facilities for the recognition of the stroke-prone individual, and for pre- ventive measures applied to such in- dividuals, highlighting particularly those with hypertension, with diabetes and with certain biochemical abnor- malities. I mentioned yesterday that evidences of vascular disease may be observed in conjunctiva, and it has been mentioned today that a high level of hemoglobin appears to be found more commonly in the stroke- prone individual. Secondly, we need centers for the sophisticated diagnosis of the stroke patient and centers within which there can be applied the modern sur- gical and medical methods of treat- ment of the acutely ill patient. Next we must provide for prompt mobilization and effective remedia- tion in an effort to achieve the maxi- mum restoration of function in the stroke-disabled individual. Finally we have the long-term problem of the life adjustment of such individuals, whether this is to be ac- complished at home, in the local community, or ultimately in the long- term Care institution. We have indicated the resources which the institute has deveoped for this. I should point out that, as Dr. Millikan has so ably outlined, the neurologist per se is only one member of a much broader team. Somehow, however, there must be brought to bear on the stroke problem, especially at the phase of diagnosis and acute therapy, the capabilities of individ- uals who have knowledge and under- standing of the function and symp- tomatology of the nervous system. Fig. 1)* Here is our list of stroke research centers. Some of them are rather specialized: Berkeley Center is primarily working with the epidemiology of stroke. The Baltimore Center is also pri- marily epidemiology. The center in Boston is concen- trating on the management of aphasia. The others, I think, are dealing with one or another aspect of the clinical characteristics of stroke. (Fig. 2)* These are individual re- search projects. These we have indi- cated only to point out that here are individuals who have an interest in some aspect of the stroke problem. However, many of these are of a fundamental research nature, and they may have little relevance to the practical problem of dealing with the stroke patient. *See pages 60-65. (Fig. 3)* Vhis shows the centers where there is a study of the sub- arachnoid hemorrhage and cranial aneurysms. And wou will no- tice in each of these maps there is a disturbing paucity of activity west of the Mississippt. (Fig. 4)* Here is the cooperative study of the value of hypotensive agents in the prevention of stroke. This is a study in which a group of patients with hypertension are man- aged. They are being given hypo- tensive agents to see whether they will in fact reduce the frequency of stroke. We are hopeful that this will prove to be the case. (Fig. 5)* This is the study sup- ported by the Heart Institute, focused primarily on the surgical management of stroke through surgery of the in- tracranial arteries. It is now a random study in which some are treated sur- gically and some medically. (Fig.6)* I should have mentioned yesterday that there are two types of training programs, We do have seven programs specifically directed toward the problem of stroke. Most of these are general neurological training cen- ters whose men will certainly be knowledgeable and helpful regarding the differential diagnosis and treat- ment of stroke. I also failed to mention yesterday two important elements in this pro- gram of training. Within several of our stroke research centers we have recruited nurses who are skillful in intra- neurological nursing, and in collab- oration with the Bureau of Health *See pages 60-65. Manpower, fellowships are being pro- vided for nurses to be trained in ncu- rological nursing within these centers. If you want to have some nurses trained in the specifics of neurological nursing, the Bureau of Health Man- power can be helpful. The officials to contact are Dr. Jessie M. Scott, Di- rector, Division of Nursing, Bureau of Health Manpower, or Dr. Faye Abdellah, Chief, Research Grants Branch, Division of Nursing. Secondly, within our training pro- grams, a number of centers are pro- viding special postgraduate training, in the management of stroke. If you have a man in your community who wants to become more expert in the diagnosis and management of stroke, he can receive a 3- or 6-month or 1-year fellowship—in effect, a resi- dency—within which he can receive special training in the problem of stroke. Dr. Boruant. I would like to open the floor to discussion and questions. Dr. Heustis. A. E. Heustis, Mich- igan. The panel has told us about the things we might expect in the larger centers. But I have a hypothetical case, gentlemen, a community of 100,000, a good cadre of board-spe- cialized internists and surgeons and no neurologists, an orthopedic sur- geon with a yen toward rehabilita- tion, a special part of a hospital with an interest in rehabilitation, What really can this place do, both for the physicians in the community and for the physicians in the surrounding area and for patients, from a real practical standpoint? Dr. Toor. One thing I would point out to you is the guide for set- ting up a stroke program which has just been distributed by the American Heart Association. Dr. Millikan, Chairman of the Council on cerebro- vascular disease, and a variety of ex- perts have worked to put together a manual for just such a community as you describe: How to mobilize community activity, what to do, whom to recruit, and how to get some action started. This is called “A Guide for Affiliates and Chapters in the Stroke Program.” Dr. Mituxan. I would like to get in on that hypothetical question. Was one of the conditions no neurologist? Dr. Heustis. No neurologist. Dr. Mitiixan. I would put in a strong plug, then, for having some person in the grouping, that you did presume would go some place for some short-term training experience, specifically referable to stroke. I don’t know how other members of the panel would feel about this. I would guess that an internist- type individual might be the one. 1 wouldn’t want to fully earmark this as a disciplinary requirement. Some individual might be selected for 3, 6 months of experience on an active stroke demonstration unit or an active stroke service. Then that person could become the leader for developing the on-going activity in your community of 100,000. Dr. Masianp. In a community of 100,000 there would be a tremendous opportunity for such an individual who had received even that rather modest amount of additional com- petence. You might even consider taking two people—a medically ori- ented and a surgically oriented per- son. Training programs are available for each within which, in a relatively brief period of time of practical ex- perience, they can become knowl- edgeable in the newest methods of diagnosis and management. Stipends are available to make it possible for a person to do this without a com- plete financial loss. Dr. Hunt. Hunt, Virginia. I think many neurologists in many communi- ties, because of the magnitude of the problem, are really unwilling to be- gin the task. Where can be a focal point? Or what is a good focal point where the neurologist in the com- munity can begin to approach the problem without this total commit- ment? Dr. SPENCER. Well, what was pro- posed in the question before was what can be done in a community hospital which has some array of specialists, and which has some interest, appar- ently, in looking at the problem of stroke in that community. On the one hand, a great deal of attention has been given to how you would build up the diagnostic capa- bility for this group. And I agrce that with short-term training, the most interested and susceptible phy- sician and physicians may be cap- 97 St tured to do this kind of functional evaluation and comprehensive pa- tient management planning and guidance. But I think the problem is--what emphasis should the diagnostic train- ing or educational experience have? Should it be in respect to triage or sorting of those people that will re- quire very elaborate and complex sur- gical procedures, for instance, versus those that can be probably quite well managed in that institution itself? Now, I think you have to there- fore assess each individual institu- tion’s capabilities as well as their goals in coming up with a plan of education which is acceptable to the people in- volved. J think you have also. got to parallel this with a functional evalua- tion unit in a community hospital di- rected by a physician, perhaps part- time, in a community, a practicing physician who is supported and trained for a period of perhaps a month in an intensive rehabilitation center so he learns the methodology of functional evaluation. Probably you will find a physical therapist in that hospital, and develop such an evaluation unit as a support- ive service to the physicians and to the hospital so you can begin the triage process. Dr, Mitiixan. The question had to do with how to get going in a com- munity. I would like to suggest as soon as you get home you get going on this; and this does not require elaborate personnel. There is a neat cross-over—hypertension as a cross- 98 ing bond between heart and stroke. I would suggest that you can whomp up the hypertension bit and get a screening program going. You are probably aware of the activities of one Joseph Wilber, who has had an interesting expérience in Atlanta in a smaller community in the south- east, where they have done a hyper- tension screening. This is now re- ported in the literature. The idea being to find out those individuals in the community who have hyperten- sion and to get them into the hands of their local physicians without changing the whole format of prac- tice in that situation. We all realize, even if you have a neurologist, individuals vary in terms of their professional disease-oriented interest, and you may or may not have someone who is considerably in- terested in the problem of stroke, or someone who has a bit of time. But if you use a larger item such as hyper- tension—and I am relating this now to prevention and screening—why, you can begin a program with ex- isting personnel, training laymen and other individuals to do screen- ing as far as blood pressure observa- tion is concerned, the initial taking of blood pressure, and get something going. Dr. Evans. I would like to address this question to Dr. Spencer. Bill, I would suspect that there are more people in the home and other insti- tutions—-not in hospitals—the kind you are talking about—so would you address yourself to the role of nurs- ing, social work, visiting nurses asso- ciations and community health orga- nizations, their involvement? This is not just a hospital situation. Dr. Spencer. I was going to say, the third element that you definitely could consider is what we would call out-of-hospital extended care. And here the visiting nurse associations— in a community of that size I will bet there is one or Dr. Evans. Probably four. Dr. Spencer. All right, four. Un- fortunately, what has happened in these is that the physician is not ex- perienced in how to use them, so it is not a part of his treatment decision making. But capability, with proper planning for this functional evalua- tion and the inclusion of community agencies in this planning process around individual patients, should allow the development of proper us- age of such things as can be done. And there are many things which can be done in the home setting also. But I think the problem is what he said— how do you get this going? I sug- gested that concept of evaluation units. Physicians are familiar with and accept laboratories, heart sta- tions, and things of this sort. Can we sneak in consideration for function and have it under a physician, so you can have physician-to-physician re- ferral of consultation? Then you may gradually introduce the other disci- plines that are concerned with com- prehensive patient management, that exist and are continually telling us, “Our problem is lack of optimal tim- ing of physician referral.” Dr. Evans. And continued super- vision. Dr. Spencer. J think realistically, too, we have to look at the adequacy of our various care sponsors’ methods of reimbursement for services to allow this to happen. Dr. Boruant I see in the audience we have Dr. Carroll Quinlan, who is the chief of the Stroke Control program. Dr. Quintan. I am sure many of you are familiar with the Heart Dis- ease Control program. For those of you who are not, we are an operating branch of the National Center. for Chronic Disease, and we have re- cently changed our name to Heart Disease and Stroke Control program, more or less to emphasize our interest in the problem of stroke. It might seem confusing to you who perhaps are new in Regional Pro- grams, how we may differ from the National Institutes of Health. The Institutes by and large, as Dr. Mas- land pointed out, are working in the area of fundamental basic research. Our laboratory by and large is the community. We are working in the same areas in which you are working. Our purpose is to do research and development on ways to put to work those discoveries made by the Insti- tutes and other areas of fundamental research. There are certain activities in which we are presently engaged, in which I think perhaps you might have a direct interest. We are at the present time inaugu- rating a national system of stroke registries. We are doing this for sev- eral different reasons. One, we are interested in the nature and extent of the stroke problem. This, as you know, is very poorly defined, both na- tionally and locally, and I would commend the idea of a stroke registry to each one of you, because it seems to me that if you are not aware in your own region of the nature and the extent of the stroke problem, it is going to be a very difficult one to attack. Now, as pointed out by Dr. Lilienfeld yesterday, registries have a number of different purposes, and very valuable ones. First of all, they are most important in planning and programing. Secondly, they are a very good instrument for manage- ment. And thirdly, and perhaps most importantly, they are very important in evaluating the effect of your program, All of you are beginning to start community programs. I think that it is well to sound a note of caution, and that is this---that sooner or later, per- haps in several years, you are going to be called upon to justify your pro- gram, and I think if you have in- augurated this, and know the nature and extent of the problem, you will be able to sce what effect your pro- gram has had, We are working in a number of other different areas. We work by contract and by assignees. In our ex- hibit upstairs we outlined in written form the various activities in which we engage. We would be very happy to work with any of you in your region in planning in any way that we can. Dr. Sparkman. Would Dr. Mas- land comment on the nurse training programs, please? Dr. Mastanp. This is a new pro- gram which is just getting underway. Several of the stroke clinical research centers have very competent nursing staffs. We have felt that these people who are recruited and maintained primarily to support the research ac- tivities should also be made available for the training of other nurses in the techniques and problems of neurological nursing. In order to ac- complish this we have established a collaboration. with the Bureau of Health Manpower, which is provid- ing fellowships for nurses to receive training in a well-organized training program of the stroke research cen- ters. The place for you to contact would be the Bureau of Health Man- power. Dr. So.oway. Dr. Faye Abdellah would be the one to contact on this. Dr, Levin. David Levin, Central New York Advisory Board, School of Social Work. I wanted to make an observation that all of the changes that are taking place which we see here, social and rehabilitation services divisions, in terms of welfare plan- ning, will mean that you have a re- source in the communities. One of the questions I would like to address to Dr. Millikan and Dr. Spencer 1s how you can really involve the kind of planning that is taking place on a local level, because each of the social workers in the public agency now will have bracketed into its name every- thing that comes from Washington and from the State office of rehabilita- tion. There is a tremendous army of helpers, and I was wondering about your experience, or your proposals— how to involve them? Dr. Spencer. People get involved best around an effort to solve a prob- lem which is of larger scope than any one of them can handle. I didn’t get to detail further this concept of a functional evaluation unit in a hospi- tal. It certainly should include the vocational counselor and the welfare worker from that community hospi- tal concerned with these kinds of problems. The evaluation process and the commitment process, which has to follow up what services are go- ing to be committed by whom, is the place for their participation. Again, the problem is how you get this into our system of medical care under the physician’s direction and coordination and integration. This is preciscly what he is not trained to do. So all you can do is try to use this evaluative consultative device or something that is familiar to the doctor. The diag- nostic evaluative process which ex- pands his activities and which in- cludes in terms of human function, including social function, may give him real help around a real patient that is his responsibility and produce the desired result. Then the next thing that may be practical is to back up these func- tional units with live communication links with the resources that can give the more sophisticated decision sup- portive service, at least to help the staff in these units to define the patient that is beyond their scope of management. That is going to require two-way video and -audio linkages. This isn’t as expensive as people think. On a line-of-sight basis we can do it now for $4,000 per terminal, and we have done it experimentally. I am talking about two-way video and two-way audio. It can be done now. There are al- ready networks for visual com- munication developing rapidly by industry and by national educational television. We have even got a satellite kicked out by NASA which the Inter- national Radio Relay League built. We don’t have anything like this in medicine for medical care and scien- tific communication which is ridic- ulous in the space age. If you support these community institutions as, already, experiments are showing you can, with two-way communication assistance, so that when they have problems, they have somebody to see and talk to, present their problems to, then you have the beginning of next element in educa- tion. I think this is a valid concept. We know at least that there is real interest in it on the part of the com- munity hospitals. And the other thing, as Dr. Evans pointed out, being realistic in terms 99 of the problem, the first is to identify the resources we have got by real, indepth analysis of communities other than our own, like this hypothetical community of 100,000. You may be astounded as to what is there in care resources, and their susceptibility and willingness to change. The problem is we haven’t produced or demonstrated visibly enough successful examples or methods, organizational methods, and of procedures which these people can use and need that they haven't been trained in. I assure you, assessment of func- tions in the interpretive sense is not simple. I can give you a specific in- stance. If you get a vital capacity value expressed as a percent normal of lung capacity, what does it mean in terms of that patient’s ability to tolerate the energy expenditure of his natural life activities? Is it a siwnifi- cantly deviated measurement or not? That is what I mean by functional evaluation. You have to interpret measurements in terms of individual functional capacities, and the pa- tient’s demands. That is not trivial, but this can be done. This is what the doctor is interested in as an antidote to the laboratory measurement explo- sion and the patient will benefit. Dr. Too.rz. One aspect which hasn’t been mentioned, and I just throw it out, is education of the fam- ily into being involved. We are talk- ing about our provision of care to this passive person and his passive family. My attitude is involvement of the family and mobilization of members 100 of it to provide as much of what we have been talking about as possible. And a huge emphasis has to be placed upon the methods by which the people are taught. Also, another aspect of this that I have been interested in is redesign of the home. Very seldom docs a physician or other interested person actually go into the patient’s home and sec him in his own setting. These two aspects we should not forget. Perhaps the most practical thing is such a simple thing as a good architect or someone who knows how to make a person mobile and produc- tive in his own home. Dr. Boruant. I think that we can summarize today’s session: There are two issues which were em- phasized, and they are not mutually exclusive, First of all, as is evident, there is a great need for basic, reliable in- formation on the magnitude of the problem and the resources available in the community for systematic plan- ning of effective programs of preven- tion and control of the cerebrovas- cular diseases. And secondly, there is a need for a systematic application of our knowl- edge and resources in terms of pre- paration of the community and build- ing on the resources already in existence in various communities. T think that these two issues pretty well chart the way for the Regional Medical Programs throughout the country. I would like to emphasize that we should not go on and develop stroke programs without really taking our time and spending as much time as needed—and this will differ from community to community and from region to region—to learn what is really needed in our region. I think it is essential that we spend enough time and develop a systematic program activity that we know exactly, be it in the hypothetical community of 100,000 that Dr. Heustis mentioned or whatever region we are working in. What are the resources really available? What is the nature of the problem in that community? And what kind of prevention, control and rehabilitation program is already in existence there that we can build on? Nobody can tackle this problem alone. No program can do it alone. And, as you heard yesterday and today, there are many Federal Gov- ernment programs, State programs, and I am sure, local programs that are already in existence. There are many people in various disciplines of health already doing various ac- tivities in this particular field. There are organizations, voluntary health organizations, and official organiza- tions, public agencies, that are doing certain things. J think it is incumbent upon us to bring these things into focus in the region where we would like to de- velop a program for stroke, and to take advantage of the resources. and funds available. Two specific questions have really bothered me for a long time, and I hope that the Regional Medical Pro- grams will direct themselves to an- swering these questions. T mentioned already, in the introductory remarks I made, the variations in the geo- graphic mortality of stroke in various States in the country. We are planning to pursue further activities with the support from NINDB, NHI, Heart and Stroke Control, and the Re- gional Medical Programs and all the various Federal Government agencies that can help us, to chart some kind of a program to finally learn about the nature of the disease throughout the country. Finally, I think in every region it is important for us to learn what the proportion is of the stroke cases who never get to the hospital. Dr. Spencer put it at something around 80 percent. TE think it is very important, if we are really talking about controling cerebrovascular disease. controlling death, and morbidity from this dis- ease, that we must know, because if we concentrate in our hospitals and centers, and these patients never get to the hospital, then we are just losing the battle before it is started. Secondly, we must know about the nature of the problem. I think again this must be done on the regional basis, and I can guarantee you that the national data on the epidemiology will provide useful data and, al- though they can be helpful, they will not be as helpful as the kind of data that you will collect in your own re- sion, because national data will differ from place to place. I think it is very important for us to develop a systematic program of surveillance—call it registry or what- ever you want—a program which will tell the people in charge of the region of the nature of stroke in that region, the incidence, the prevalence, the socioeconomic classes of victims, the age groups, and race groups and all the various characteristics, that so tremendously affect the outcome of this disease in various parts of the country. I would think that there is a tre- mendous opportunity for the Re- gional Medical Programs to bind all existing programs together, and to build on them a true program of con- trol so that the people will benefit. And IJ arn sure this will be done. 101 292-414 O—6S——-S GROUP DISCUSSIONS ON .... HEALTH MANPOWER—REVIEW OF COMMISSION REPORT REGIONALIZATION URBAN PROBLEMS RELATED FEDERAL PROGRAMS HEALTH SERVICES RESEARCH CONTINUING EDUCATION AND TRAINING, FOR WHAT? DATA COLLECTION AND REGISTRIES HOSPITALS COMMUNITY INVOLVEMENT OPERATIONAL PROGRAM DEVELOPMENT The group discussions, held simultaneously on Wednesday and Thursday, January 17 and 18, 1968, involved panelists who represented various aspects of the subject areas covered. These sessions were scheduled to provide conferees the opportunity to voice their own ideas and exchange thoughts in each of the 10 topics of common interest. The reports that follow were written by members of the staff of the division of Regional Medical Programs, who attended and recorded each of the sessions. To preserve the flavor of the group discussions as they developed, the content and singular style of each report have been maintained essentially as submitted by the recorder. GROUP DISCUSSION TOPIC A: “HEALTH MANPOWER-— REVIEW OF COMMISSION REPORT” Discussants: James C. Cain, M.D. (Moderator) Consultant in Medicine The Mayo Clinic Rochester, Minn. Leonard Fenninger, M.D. Director, Bureau of Health Manpower Public Health Service C. H. William Ruhe, M.D. Director, Division of Medical Education American Medical Association Chicago, Ill. A.N. Taylor, Ph. D. Dean, School of Related Health Services Chicago Medical School Chicago, Ill. Dwight Wilbur, M.D. President-Elect American Medical Association San Francisco, Calif. Recorder: Veronica L. Conley, Ph. D. Education Specialist Division of Regional Medical Programs He discussant reviewed those aspects of the “Report of the National Advisory Commission on 104 Health Manpower” of pertinence to his specific area of interest and expertise. Dr. Dwight Wilbur discussed four issues covered in the Report-—the supply of physicians, relicensure of health professionals, forcign physi- cians, and peer review. Dr. Wilbur supported the recommendation that the numbers of medical schools and of students should be increased. He agreed that Federal funds toward the support of medical education are de- sirable, provided the expansion in numbers is accompanied: by improve- ment in the quality of educational programs. On the issue of relicensure of health professionals, a highly controversial one over a period of years, it was noted that the Report recommended that relicensure be further considered by appropriate organizations and agencies. The public seems to gen- erally support the concept of relicen- sure as a guarantee of good quality care. A review of current State Licensing Board procedures was stressed as essential since health man- power is a national asset, and mobility between States should be assured through reciprocity. Dr. Wilbur stressed that the responsibility for and authority over foreign physicians should reside in educational institutions. These physi- cians, he said, should be required to have the same qualifications and pass exams comparable to U.S. physicians. The importance of peer review at the local level was emphasized. The American Medical Association and other medical societies have assumed responsibility for the general improve- ment of the quality of medical edu- cation. The public is generally un- aware of the extent to which the peer review process is already underway. Research is needed to formulate cri- teria by which physicians’ perform- ance and patient care can be measured. Dr. Ruhe commented on two points in regard to financial support for students. The need for some sup- port of aimedical education is now generally accepted. Complete sup- port by the Federal Government of medical education is supported by some as a means of bringing in stu- dents from the lower economic levels of society. This isa controversial issuc which current statistics fail to sup- port. The implied criticism of the medical curriculum in the Report is not justified in view of the constant review and change in the curriculum conducted by medical educators. Re- licensure has been discussed sporad- ically since 1932. The emphasis should be on motivation of physicians through appropriate continuing ed- ucation efforts to improve their practice. Only then should relicen- sure be seriously considered. In regard to the Report, Dr. Taylor stated that the title implies equal consideration of all health pro- fessionals when in fact it is devoted primarily to physicians. The recom- mendation that education of health personnel be assumed by universities is questioned in view of the current trend by these institutions to remove the education of such professionals from their curricula. Dr. Fenninger commented that the Report addressed itself to the need to improve the health of in- dividuals and of patients as the rea- son for a system of care and health services. The public has demands and expectations of services by health personnel beyond what can be sup- plied. The Report pointed to long- and short-term issues which include quality and quantity ef care, use of skills, public education, and increase in resources. During the question and answer period there was lively discussion on such issues as Regional Medical Pro- grams and their peer review mech- anism, the improvement of medical education through the programs. criteria to judge quality of medical practice, and the determination of medical manpower needs and better utilization of manpower. GROUP DISCUSSION TOPIC B: “REGIONALIZATION” Discussants: Lester Breslow, M.D. (Moderator) Professor of Health Administration and Chairman, Health Services Division, School of Public Health University of California at Los Angeles Los Angeles, Calif. Walter J. McNerney Executive Director Blue Cross Association Chicago, Ill. William R. Willard, M.D. Vice President Uniwersity of Kentucky Medical Center Lexington, Ky. Recorder: Roland L. Peterson Chief, Planning Branch Division of Regional Medical Programs he discussion addressed itself to the questions: What is regionali- zation? What problems does it pose? How can it be achieved? Regionalization was defined by Ir. Willard as implying linkages among health resources and as a process of getting people involved and appro- | priate planning begun. The functional aspect of regionali- zation was particularly stressed. It was pointed out that there might be different bases of regionalization for differing purposes. Dr. Sparkman said that “regions” for patient care and continuing education well might differ. Even patient care might re- quire different “regions,” as in the case of acute coronary care versus cancer therapy. While the functional aspect was clearly recognized, others emphasized that geography and peo- ple are fundamental to regionaliza- tion. Mr. McNerncy pointed out that there had been many failures in re- gionalization. The resistance to re- gionalization was historical and widespread, and included libraries and schools. Speaking from his own experience, he cited the reasons for the failure of an attempt in the past at regionalization of hospitals in up- per Michigan. Some of these reasons were: Attitudinal—Too often the insti- tutions involved in regionalization were more interested in autonomy and building up their own strength as an alternate to linking together with others. Economic.—There were no incen- tives. Administrative-—The administra- tive underpinnings were ad hoc and incidental rather than continuing and substantial. Speaking from the audience, Dr. Charles Lewis of the Kansas Program, saw the principal problem of region- alization as one of social enginering. He was seconded by Mr. McNerney, 105 ‘te who pointed out that little is known about the social engineering and ad- ministrative aspects of regionaliza- tion. The medical center, he observed, is essentially an authoritarian setting. Regionalization will require negotia- tion and compromise and entering the realm of “brutal politics.” Dr. Breslow felt that involvement might prove to be the solution. He noted that getting the nontechnicians and nonprofessionals to come to grips with the problem is perhaps neces- sary, since the former have too many vested and embedded interests. Mr. McNerney felt that regional- ization must take into account com- munity needs and must have structure. Successful regionalization requires a delicate balance of the two. Dr. Breslow was optimistic about the future for health regionalization. He based this on— greater experience in this regard, particularly with regard to area- wide health facilities planning; a greater commitment to the con- cept of and need for regionaliza- tion. At the time of the passage of Hill-Burton, there were a few farsighted individuals but little widespread commitment; physicians and others, and not just hospitals, are now involved. He cited the number of practitioners who had become involved in Re- gional Medical Programs; a greater public understanding for the need of regionalization; 106 increasingly sophisticated technol- ogy. Dr. Willard said that if medical centers and other institutions see Re- gional Medical Programs only as an opportunity or additional resource to do some things they have always wanted to do, then neither Regional Medical Programs nor regionalization will be successful. GROUP DISCUSSION TOPIC C: “URBAN PROBLEMS” Discussants: Paul Ward (Moderator) Executive Director California Committee on Regional Medical Programs San Francisco, Calif. Roger O. Egeberg, M.D. Dean, School of Medicine University of Southern California Los Angeles, Calif. Frank Lloyd, M.D. Director of Research Methodist Hospital of Indiana Indianapolis, Ind. Anne R. Somers Industrial Relations Section Princeton University Princeton, N_J. Ray E. Trussell, M.D. Director, School of Public Health and Administrative Medicine Columbia University New York, N.Y. Recorder: Stephen J. Ackerman Associate Director for Planning and Evaluation Division of Regional Medical Programs he moderator, Mr. Paul Ward, opened the session by pointing out the distinct differences betwecn rural and urban areas in the solution of the problem of delivery of quality health care to people, and defining the purpose of the session as focusing on the contributions that Regional Medical Programs can make to the solution of the urban problem. The following are highlights of comments by the panel members: Mrs. Anne Somers: The medical establishment has both the opportunity and responsi- bility to make significant contribu- tions to the solution of the problem of urban health. We know more of the internal channels of the heart vessels on the one hand, and the canals on the planet Venus on the other, than we do about the back alleys of our ghettos. Special aspects of urban problems in New Jersey are: Increasing immigration of rural poor from the South to city ghet- tos. Outmigration of physicians. Vacuum of leadership in academic medicine. The great potential and promise of Regional Medical Programs— “to build a bridge of service be- tween science and the people.” Hopeful developments in New Jersey : The organization of the Depart- ment of Community Affairs un- der leadership of Paul Ylvisaker, which little by little is translat- ing pangs of conscience about the needs of the inner city into substantive action. Emergence of interests and leader- ship action from academic medi- cine through the stimulation and organization of Regional Medi- cal Programs. Specific move in New Jersey to have its program develop leadership in communitywide planning for de- livery of quality medical care by bringing together the leadership of the medical establishment with the leadership of the urban community, including the inner city, through the cooperation of the Department of Community Affairs. Dr. Roger Egeberg: The need for emphasis on availa- bility of care rather than a priority of concern for quality. The need to change the focus from the provider’s standpoint to that of the consumer’s, and to change the patterns so that the services are pro- vided as the people want them and can really use them. Regional Medical Programs must be concerned with regionalization, subregionalization, sub-subregionali- zation, and perhaps, sub-sub-subre- gionalization, in order to fit the care to the needs of the persons to be served, rather than force people into the mold of the producers. All of the concepts about develop- ment of new systems of care and the use of new types of paramedical and subprofessional health personnel are within the scope of the programs, where resides responsibility to use them in finding the solutions to these problems. Dr. Frank Lloyd: Regional Medical Programs can do well by helping to plan a compre- hensive program with the delivery of services in the urban areas. By excluding Negro physicians from hospital privileges, and from educational programs in the health professions (Indiana freshman class has two), the leadership potential of Negro health professionals in the solution of these urban health care problems is removed. It is of prime urgency that these deficiencies be reversed. We are wasting health manpower by making mandatory unnecessary training. Unskilled personnel can be trained to do health jobs but it must come from bottom up. Paul Ward: To secure the desired changes in the delivery of health care and the utilization of nonprofessional health aides, etc., requires the application of strong pressure behind the division of Regional Medical Programs in Washington and State, regional, and local health officials in the field. The built-in resistance of multiple vested interests makes progressive action un- likely without such firm counter- pressure. Dr. Ray E. Trussell: Problems in urban areas are much greater and must get a good deal of publicity if persons with fiscal control are to react. Regional Medical Programs can make a contribution to overcome lack of understanding on urban problems through participation of the scientific community which can provide scien- tific data to help public officials. Neither. Regional Medical Pro- grams nor any other program can bridge the gap between need and service without major public decisions about what can be done. Some problems and questions raised in floor discussion were: How can ideas and information be gotten from people in the ghet- tos and how can those people be in- volved in planning? Recognizing the need to involve the underprivileged consumer, how can leadership be developed among these groups? The problem of Negro rejection of Negro professional leadership puts these people in the uncomfort- able position of being needed but not wanted. With regard to the Piel Com- mission Report in New York which tended to preserve two care sys- tems, one for the poor and one for the others, the problem of the po- litical realities of an existing large body of civil service employment forces continues in city hospitals. The problem continues of. se- curing professional acceptance of the use of subprofessional health personnel in positions of responsi- bility. How can Regional Medical Pro- grams help underprivileged physi- cians without staff privileges be- come part of the system? 107 ee eee ee re GROUP DISCUSSION TOPIC D: “RELATED FEDERAL PROGRAMS” Discussants: Daniel I. Zwick (Moderator) Associate Director for Program Management Health Services Office Community Action Program Office of Economic Opportunity James H. Cavanaugh, Ph. D. Director, Office of Comprehensive Health Planning Office of the Surgeon General Public Health Service Donald R. Chadwick, M.D. Director, National Center for Chronic Disease Control Bureau of Disease Prevention and Environmental Control Public Health Service Carruth Wagner, M.D. Director, Bureau of Health Services Public Health Service Eugene Veverka Division of Medical Care Administration Bureau of Health Services Public Uealth Service Recorder: Leroy G. Goldman Program Policy Specialist Division of Regional Medical Programs 108 Er discussant briefly described the principal programs and ac- tivities of the agency he represented, and went on to discuss the relation- ship between that agency and Re- gional Medical Programs. Regarding the programs of the Di- vision of Medical Care Administra- tion, Dr. Veverka emphasized that the division and Regional Medical Programs shared the same goal of bringing the best possible care to everyone in necd in the most effective and efficient manner. The division, he noted, is cooperating with the Department of Housing and Urban Development in the provision of mortgage loans for group practice facilities. Additionally, the division is concerned with both health man- power and facility needs, and hopes to dovetail these concerns with the activ- ities of Regional Medical Programs in these same areas. Dr. Cavanaugh described the five major areas of the Comprehensive Health Planning legislation (Public Law 89-749) and reported on its progress to date. The first three seg- ments of this legislation deal prin- cipally with State and areawide health planning. These include for- mula grants to States for compre- hensive health planning, — project grants for local and arcawide health planning, and project grants for training, studics, and demonstrations of health planning. The final two seg- ments deal with the provision of health services through both the for- mula and project grant mechanisms on a noncategorical basis. Dr. Chadwick described the role of the National Center for Chronic Dis- case Control as being of most impor- tance in the transition between activities of the categorical institutes of the National Institutes of Health and the operational activities of Re- gional Medical Programs. As such, its role has been one of demonstrat- ing the efficacy of newly developed techniques based upon the growth of hiomedical knowledge. Dr. Waener described the Bureau of Health Services as the focal point for the organization and delivery of health services. It, therefore, — is concerned with the development of self-organizing processes to effect this organization and delivery which in- clude the planning process, consul- tation, and certain. certification procedures. Mr. Zwick in describing the Neigh- borhood Health Center program of the Office of Economic Opportunity highhghted the relationships between that program and Regional Medical Programs. Specifically, he noted, it is the poor who suffer the most as a result of the gap between knowledge and application. Additionally, he described the common interest of both programs in developing alter- native piodels in the organization and delivery of health services. During the question and answer portion of the session, the principal focus was on the relationships be- tween Regional Medical Programs and the Comprehensive Health Planning Program, particularly at the local-regional level. Several persons reported on .the developing | ex- perience in different parts of the country im implementing these twa programs in concert. GROUP DISCUSSION TOPIC E: “THEALTIE SERVICES RESEARCIL? Discussants: Paul Sanazaro, M.D. (Moderator) Director, Division of Education Association of American Medical Colle ges Evanston, Il. Morris E. Collen, M.D. Director, Department of Medical Methods Research The Permanente Medical Group Oakland, Calif. Caldwell B. Esselstyn, M.D. Associate Director New York Metropolitan Regional Medical Program New York, N.Y. John Thompson Professor of Public Health and Director, Program in Hospital Administration Yale University Medical School New Haven, Conn. John Williamson, M.D. Division of Medical Care and Hospitals The Johns Hopkins University School of Hygiene and Public Health Baltimore, Md. Recorder: Richard F. Manegold, M.D. Associate Director for Program Development and Research Division of Regional Medical Programs he discussion of this panel fell into the following five general areas, and were discussed in_ this framework: Essential nature of health services research. The inherent problems and strat- egy of data collection. The problems of evaluation. A consideration of the priorities in establishing areas for research. The special problems and op- portunities in health service re- search presented by Regional Medical Programs. Health services research.—The components of health services re- search have been identified by Dr. Kerr White as descriptive, analytical, experimental, and evaluative. The initial stage is reportorial and de- scribes the ‘health system” as it exists. The analytical phase depends upon establishing hypotheses and then ap- propriate data collection. The ex- perimental phase, one which pres- ently is largely undeveloped, depends on testing models and manipulating variables. Finally, evaluation, which although not research per se, is in- herent in research and requires methodologies. Health services research was briefly differentiated from operation re- search and operations research. Operation research depends on the collection of specific data for estab- lishing policy and management deci- sion. Operations research and _ its component systems analysis depends upon the development of a mathe- matical model and appropriate ma- nipulation. Health services research is apphed research involving a variety of medical and social disciplines and the application of all manner of methodologies to the complex prob- lems of health care. Data collection.—Major problems in health services relate to data col- lection. These problems include ac- quisition, availability or sources, com- prehensiveness, validity, timeliness, and use. Clearly, the quantitation of health services research depends on the validity and comprehensiveness of the data base. A data base has five character- istics: It must be comprehensive; it must relate to reality; it must be timely; it must be available; and it Mra 109 must be used. For the most part, available data are not comprehensive. Thus, although there are data on the incidence of diseases (so many/pop- ulation) there is only fragmentary information on “service time.” (“Service time” is information on the number of patients in the health sys- tem with a given condition.) Our present data lack, therefore, is in- formation on prevalence. Evaluation.—-Evaluation poses spe- cial problems. What should be eval- uated? What can reasonably be eval- uated? What are the regional respon- sibilities in evaluation and what are the national responsibilities? In many instances end result evaluation cannot be the measure. Regional Medical Programs deals basically with chronic diseases that will not promptly yield to changes in management. Further, because of the annual increments in the population at risk gross mortality and morbidity statistics may not show significant changes. Evaluation is a two stage process. First criteria must be established and then a professional judgment must be made. Were the criteria attained? In these terms evaluation can be established on the basis of expert judgment of what should be the ex- pected mortality, the morbidity, and the cure rate. A comparison between expectation and reality then leads to an examination of the realities of the expectations, the deficiencies in health care, or both. 110 Although long-term evaluative goals pose time difficulties, intermedi- ate goals can be set. These include measures of better resource alloca- tion, better utilizations, improved and more relevant educational programs. Conventional wisdom may be used to bridge the science service gap. Clearly, not all “latest” advances are advances and some plainly are not feasible. Many “new” procedures do not stand the test of use. Others, “heart transplants” for instance, clearly are not when first developed feasible for the system. Thus, con- ventional wisdom can dictate to some degree what should be and can then be measured, evaluated. Research priorities —Certain areas in the health field will yield greater results in the health service field. Some population groups, usually upper middle class, now have good health care services. Conversely, the poor and many rural areas do not have adequate health care. Thus, priorities for research in these areas of health care offer obvious prompt payoffs. Special opportunities for health service research.—Regional Medical Programs, by involving the various components of the health system, offer special research advantages. Health service objectives may be es- tablished; cducational and service programs designed to serve these ends; finally, evaluation can test the effectiveness of the innovation. Regional Medical Programs offer to the health service researcher a lab- oratory. They inherently tend to stimulate both the proper questions and the quest for the solutions. GROUP DISCUSSION TOPIC F: “CONTINUING EDUCATION AND TRAINING, FOR WHAT?” Discussants: Patrick B. Storey, M.D. (Moderator) Professor and Chairman Department of Community Medicine Hahnemann Medical College Philadelphia, Pa. Luther Christman, Ph. D. Dean, School of Nursing Vanderbilt University Nashuille, Tenn. George E. Miller, M.D. Director, Office of Research in Medical Education University of Illinois Chicago, Ill. A. N. Taylor, Ph. D. Dean, School of Related Health Services Chicago Medical School Chicago, Til. Recorder: Alexander M. Schmidt, M.D. Chief, Continuing Education and Training Branch Division of Regional Medical Programs r. Storey opened with a very brief statement listing the pur- pose of Regional Medical Programs: To improve medical services in a re- gion and link them to patients; the Conference-Workshop: To allow a comparison of notes among Regional Medical Programs representatives; and the Discussion Groups: To help cach other with specific problems of making continuing education efforts relevant to program goals. Dr. Storey asked if anyone had a problem for discussion of the group; there was an instantaneous and vigorous demand for the floor. The next hour and a half plus was occupied by an exchange among re- source persons and attendees, num- bering more than 100 and filling the room beyond its seating capacity. The following summary of questions and discussions reflect that exchange: Q. Dr. Miller has said we already had enough continuing education, and that we didn’t need any more. What did he mean? A. (Dr. Miller) I have said we have enough information. We arc drowning in information. What we need is not more information or ways of disseminating the information, but a method of establishing priorities of what a physician needs. We must help a learner (physician, etc.) to want, then obtain, and then use what he actually needs. This is the major issue. Studies have been done as to what a physician thinks he needs, or what he wants; but such are, by and large, invalid, as they are based on his own opinion. This often represents what he is comfortable about, or even what he knows alreacly. Some attempts have been made to help a physician discover for himself what he actually needs. Examples: AMA national plan, etc. What is needed is educational diagnosis, and not treatment (more courses). We have entirely too much treatment. Q. Gan a physician (or other) teach himself? What is the role of teaching machines, TV tape, etc.? A. The problem with self-instruc- tion is that one tends to study what he is most comfortable with. Also, his objectives are too often inappropri- ate. If a golfer wants to improve his score, he can read and work out by himself, but he will get little or no better, and maybe worse. He must get professional help from a golf pro. Self-education in medicine is the same, in a way. At some point a pro- fessional educator must help set ob- jectives, and help one to decide what he is really missing, and what he there- fore really needs. ‘To accomplish this, the student must reveal his igno- rance—this is often a painful process. TV tape is like a book, and we have books now. The problem is really what the content should be. Q. How, then, is one to motivate a physician (or other) to learn? (About three-quarters of the discus- sion revolved around this one point, motivation. ) A. Motivation is tied to need. If one discovers what he really needs, motivation should not be too great a problem. We use what is known about the learning process all too little (psy- chology of learning, etc.). Like the golfer, who gets from a golf pro what he needs and applies it immediately to his benefit, medical education should give to a physician what he needs, when he needs it, in a conven- ient way and at a convenient time, in a palatable form. It (the content) must have the characteristic of being applicable to what the learner does, and applicable the next day. One major problem now is with basic medical education. The medical student spends time in a series of closed systems, each with a finite end point, usually with some sort of exam passed at the end. The practice of a profession is open-ended, without the built-in motivations of exams, etc. Therefore, the medical student must be indoctrinated from the beginning of his medical education to be a self- motivated learner. He must be taught to use the various self teaching aids available like books, TV tape, etc. What makes us think that our prac- titioners know how to use these things now, just because Regional Medical Programs can buy thern and put them out for use? Medical students should be taught to be critical self-learners, perhaps by the process of evaluating what their professors believe and know. It is commonly said that the medi- cal school atmosphere of peer judg- ment is healthy and should be taken out to the community. But the fallacy here is that while the academic sur- geon may accept the give-and-take regarding surgery, he gets pretty ir- ritated about being questioned about biochemistry. The validity of aca- demic peer judgment and its applica- bility outside the school need study. _The experience of the American College of Physicians with the phy- sician’s self-inventory would suggest that physicians aren’t reluctant to find out about themselves, at least if they are fairly sure there is no built-in penalty. Any doctor really wants to do what he does well, or at least as well as his peers. Perhaps the physician is over- worked and tired, and a bit disillu- sioned. Q. Does the system interfere? A. Yes, indeed. First of all, most of the medical system, especially the ad- ministrative system, is 19th century. This interferes with everything. Secondly, role perceptions interfere all the time. A study of patient care was done at the University of Illinois (Dr. Miller) and it was found that role perceptions and misperceptions effectively blocked team-oriented ed- ucational efforts. The doctor always had to lead the team, a nurse couldn’t do this or that, etc. Yet, team teaching, based on the care of a patient, is probably vital. Too little of this is done any place, and probably must be begun in med- ical schools. But if the “For what?” is for the care of the patient, then the education must be centered there, and the real needs must be the patient needs, and this must be the orienta- tion, not what a physician wants or what a teacher wants to teach. Lil GROUP DISCUSSIONS TOPIC G: ‘DATA COLLECTION AND REGISTRIES” Discussants: Abraham M. Lilienfeld, M.D. (Moderator) Professor and Chairman Department of Chronic Diseases The Johns Hopkins University School of Hygiene and Public Health Baltimore, Md. James F. King, Jr. Office of Program Planning and Evaluation Office of the Surgeon General Public Health Service Andrew Mayer, M.D. Assistant Director American College of Surgeons Chicago, Ill. John E. Wennberg, M.D. Program Coordinator Northern New England Regional Medical Program Burlington, Vt. Recorder: Maurice E. Odoroff Assistant to the Director for Health Data Division of Regional Medical Programs he panel organized its discus- sion around the following three areas: The use of 1970 census data 112 as a basis for planning; the use of can- cer registries for planning and evalu- ation; and data collection for use in evaluation. Use of 1970 census data for Re- gional Medical Program planning.— The Census Bureau is now testing its procedure in New Haven, Conn., in preparation for gathering 1970 cen- sus data. This presents an opportu- nity to obtain information useful for regional medical purposes by ag- gregating small areas’ data for such relevant items as the demographic characteristics and socioeconomic data. There are three general uses of these census data: Use for defining population and their characteristics to isolate con- centration of problems amenable to special social research. These data also permit determining the political jurisdiction. It permits matching health data to census data and thus record linkage between health data and social and economic characteris- tics as a basis for providing service. It permits selecting special samples to do intensive studies by matching information from local sources between health agencies and with other local data, such as housing, economic characteristics and social unrest. Use of registries for planning and evaluation —Cancer registries are a tool for planned data collection on a continuing basis. The primary objec- tive of a cancer registry is improved patient care. The registry must meet this criteria or else it is worthless. The two major types of cancer registries are hospital-based registries and population-based central registries. The aim of the hospital-based registry is followup of cancer patients, defined as returning for examination to dis- cover possible spread to new sites or for concurrent disease. The central registry is epidemiologic in emphasis aimed at determining incidence and prevalence and survival rates for can- cor patients, Concern was expressed with the trend within the Regional Medical Programs for establishing central registries. The concentration needs to be at the local level because a central registry is no better than the quality of data received from hospital-based registries. Moreover, there needs to be considerable motivation at the local level for good quality data to be achieved. Data collection for evaluation — Evaluation was defined as evaluation of medical care to determine gaps in medical care; evaluation of Regional Medical Programs in terms of stated program objectives and how they are met; and evaluation of projects. Evaluation is essentially a value judgment and relates to criteria de- veloped for these objectives. Objec- tives are expressed in terms of evaluation procedures. The art of evaluation involves discovery of indi- cators or measures which allow their assessment. These requirements pre- sent difficulties in defining objectives in terms susceptible to analytic assess- ment because objectives must be ex- pressed in terms of mortality and morbidity and efficiency of medical care. The major problem is to find or develop indicators which sufficiently measure morbidity. The problem of measuring morbidity is further com- plicated by the fact that certain dis- cases give rise to several morbid conditions. The development of in- clusive indicators require a scheme for specific Ineastrcnment and a scheme for quan- fying and evaluating one condition against the other, and the develop- ment of a summary set of indicators of ‘net morbidity.” The requirements to define the types, amounts, and interrelationship of morbidity is a major problem in- volving a research effort beyond the capacity of Regional Medical Programs. Mortality and efficiency of medical care are more casily measured. The failure to develop a full set of indica- tors for morbid states implies that the complete set of issues involved in the objectives of the program are not con- sidered in the analysis. GROUP DISCUSSION TOPIC H: “HOSPITALS” Discussants: D. Eugene Sibery (Moderator) Executive Director Greater Detroit Area Hospital Council Detroit, Mich. Pearl R. Fisher, R.N. Administrator Thayer Hospital Waterville, Maine John W. Kauffman Administrator Princeton Hospital Princeton, N.J. Edward H. Noroian Executive Director Presbyterian University Hospital Pitisburgh, Pa. Recorder: Richard ¥. Manegold, M.D. Associate Director for Program Development and Research Division of Regional Medical Programs E mphasis in the discussion was first placed on the basic purpose of Regional Medical Programs. Follow- ing this, attention was directed to the changing role of hospitals in health care and the hospitals’ unique advantages for fulfilling this role. With this background, a consensus developed, although there were dis- senters, that in general hospital ad- ministrators as a profession were not sufficiently involved in the programs in their regions. Consideration was given to the proper methods for in- volvement of hospitals and the proper involvement of hospital administra- tors in Regional Medical Programs at the regional and national level. The following are directions the discussions went and areas they covered: The goal of the program is to improve patient care through cooperative arrangements. These arrangements will, if effective, change the behavior of the provid- ers of care, and thereby the goal of the program will be approached. The hospital is the major com- munity institution with the poten- tial of focusing the energies of the provider of care. Hospitals, in this sense, have changed their percep- tions from episodic care to com- munity and comprehensive care. For this latter role hospitals have unique strengths. These strengths are several-fold. First, the hospital represents one of the community’s major resources for organized and _ personalized health care. As such, there is neces- sarily a community concern. There is, if not always the reality, at least the potential for professional, paramedical, and health educa- tion. There is, also, the experience in organizing the providers of care into effective teams. There is the 113 economic focus for developing the necessary resources. Finally, in the hospital administrator, himself, there is the management compe- tence experience in developing plans and putting them into opera- tion. In spite of these significant re- sources, the participants were gen- erally concerned that hospital ad- ministrators were seemingly only marginally involved. Several strate- gies for involvement were suggested. These included the development of local advisory groups as in Georgia and the coincident need to develop areawide planning councils. One somewhat thorny problem re- lated to institutional vested interest arose. On the one hand, some agreed that these interests should be diluted for the total community concern. New mechanisms of financing using for- mulas for reasonable cost and charges will mitigate some of the competitive forces. On the other hand, several urged that vested interests were in- deed the source of institutional and professional excellence. At best, one could hope to coordinate these inter- ests but should hesitate to dampen them. Finally, the poor attendance at the Conference-Workshop and the discus- sion itself were discussed. The fact was that fewer than 2 percent of the total conferees at the meeting were hospi- tal administrators. Recognition was given.to the fact that greater attend- ance at both the panel discussion and the Conference might be proper. 114 Equal recognition was given that the reasons for this seemingly poor at- tendance might be explored. If, in- deed, the low census of hospital administrators was symptomatic of in- adequate involvement of administra- tors, correction of the causes would strengthen Regional Medical Pro- grams. In closing the session, the interest of the division in establishing greater liaison with national and State orga- nizations representing hospitals was voiced and noted. GROUP DISCUSSION TOPIC I: “COMMUNITY INVOLVEMENT” Discussants: Robert M. Cunningham, Jr. (Moderator) Editor Modern Hospital Magazine Chicago, Ill. Alan C. Davis Science Editor American Cancer Society New York, N.Y. Howard Ennes, M.P.H. Assistant Vice President for Community Services and Health Education The Equitable Life Assurance Society New York, N.Y. Pierre C. Fraley Director of Information Greater Delaware Valley Regional Medical Program Philadelphia, Pa. Marc J. Musser, M.D. Program Coordinator North Carolina Regional Medical Program Durham, N.C. Recorder: Edward M. Friedlander Assistant to the Director for Communications and Public Information Division of Regional Medical Programs I' being generally agreed that com- munity or consumer involvement is indispensable to success in promo. tion of a Regional Medical Program, the following issues rapidly emerged in the group’s discussion : Community involvement for what? Community involvement of whom? Who is the consumer? Patients or physicians? Do the community representatives really represent the consumers? The difficulty of identifying quali- fied lay leaders. The difficulty of explaining what Regional Medical Programs are. Howard Ennes asked for “con- sumer modulation,” later translated as “community health citizenship” in application. “The times,” Ennes said, “demand intensified ‘consumer mod- ulation’ of health care activities, in- cluding those related to goal-setting, resource allocation, priorities deter- mination . . . in short, all aspects of the delivery of health services, Cheir costs, and related community de- cisionmaking.” Health care programs for the community must pass a “4—A test, he said. “Are they: Appropriate, Avail- able, Accessible, Acceptable?” “T suggest,” said Ennes, “the ur- gent need for a nationwide partner- ship to create a concept of ‘com- munity health citizenship’—an effort to be joined in by governmental! and private sectors, by professional and lay groups, by all levels of activity— Federal, State, local.” The object would be to focus on the responsibility of the individual to know and make the most of himself, to utilize health services, and to participate con- structively in community health de- cisionmaking. In this direction, “we have (literally) done next to nothing.” Pierre C, Fraley introduced the “for what?” Fraley pointed out that “the means need to justify and accom- plish the desired end.” Fraley cited the example of Pap smear testing in New York City. Whether the free screening station was installed in a midtown department store or moved up to Harlem, it tended to attract the same intelligent, highly motivated, not-so-poor class of women, mainly white and mainly Jewish. He sug- gested that the goals of community involvement should be to increase knowledge, to change attitudes or motivation, and to change behavior. Describing “the successful applica- tion of a public information program” in the “State of Franklin,” a seven- county rural area in southwest North Carolina, Dr. Marc J. Musser empha- sized the “right man” principle in ob- taining community involvement. “The initial public information program was carried on by virtually one man, on a_ person-to-person basis,” said Musser. “This man is a psychologist and member of the fac- ulty of Western Caroline University at Cullowhee. .. . It was clear to him that the seven counties... working together, could do far more to solve their mutual problems than each county working independently. His personal interest and drive were contagious among the various area leaders, and . . . he worked success- fully with them in establishing the State of Franklin Health Council, Inc. . . . the first organized health planning group.” This effort pre- ceded the North Carolina Regional Medical Program, and _ involved 4,000 persons in seminars on commu- nity health problems. Alan C. Davis, discussing the dif- ficulty of explaining what a Regional Medical Program is, described it as the first public program in the health care field to involve the practicing physician. Davis warned against bringing in professionals only: “It’s the consumers we are ultimately aiming at,” and advised against su- perimposing concepts or set standards from on high, “Let the people do it.” In the discussion, Fraley, joined by Dr. Stanley W. Olson from the aud- ience, protested the assumption that the patient is the consumer in Re- gional Medical Programs. “The phy- sician is the consumer,” said Fraley. Olson pointed out that Regional Medical Programs emphasize work- ing through established groups and does not provide direct service to con- sumers, i.e., patients. From the audience, Dr. Henry T. Clark discussed the problem of iden- tifying quality in lay leaders. “Those who may get involved often have no knowledge of the processes involved in community organization and ac- tion,” he said. A New Jersey discussant pointed out that the chosen representatives do not necessarily represent the actual consumers. Musser put in a plug for the political science book, “Rulers and Ruled,” as a good source of informa- tion on the nature and complexities of forming working relationships be- tween what someone called, “Us and all them.” From her experience with promo- tion of citizens’ health groups in west- ern Pennsylvania, Sister M. Ferdi- nand advised: “At their first meeting, they don’t know what they want. Let them get rid of their frustrations. Then you have them involved.” Whether Regional Medical Pro- grams are designed to help patients or help doctors help patients, there seemed to be no disagreement with the unidentified voice from the back of the room: “The program will be judged by improvement in medical care.” GROUP DISCUSSION TOPIC J: “OPERATIONAL PROGRAM DEVELOPMENT” Discussants: Charles E. Lewis, M.D. (Moderator) Program Coordinator Kansas Regional Medical Program Kansas City, Kans. C. Hilmon Castle, M.D. Program Coordinator Intermountain Regional Medical Program Salt Lake City, Utah T. A. Duckworth Chairman, Regional Advisory Group Wisconsin Regional Medical Program Wausau, Wis. Albert E. Heustis, M.D. Program Coordinator Michigan Regional Medical Program East Lansing, Mich. Donal R. Sparkman, M.D. Program Coordinator Washington-Alaska Regional Medical Program Seattle, Wash. Recorder: Richard B. Stephenson, M.D. Associate Director for Operations Division of Regional Medical Programs r I ‘he discussion was opened by the panel participants briefly review- ing their own regional experiences 115 with developing operational status. The meeting was then thrown open for general questions and discussion. The general area of how to handle both the generation and review of op- erational proposals was discussed from several aspects, beginning with the involvement of letal action groups of various kinds through dif- fering levels of technical or scientific review to final regional advisory group action. Although there was considerable variation in the detailed approach, there was general agree- ment as to the overall methodology of handling and the necessity of in- volvement at the different levels. The relationship of planning to op- erational activities was explored from several different angles. The ques- tion was raised as to whether plan- ning should be directed primarily toward regionalization or toward the categorical objectives of improving care of health disease, cancer, stroke, and related diseases. It was agreed that planning should do both, but that the primary thrust was toward the concept of regionalization as the way in which to accomplish the cate- gorical objectives, with the spin-off of a general upgrading of health care being both desirable and inevitable. Reemphasized in a number of dif- ferent ways was the importance of a continued strong planning activity as a program moves into an opera- tional phase together with recognition of the greater flexibility inherent in the operational grant as contrasted with the purely planning grant. 116 There was also general recognition of the importance of acquiring either a critical mass or of reaching a criti- cal point in the planning process to- gether with the need for concomi- tant evaluation as an ongoing part of planning. Additional points touched on in- cluded the usefulness of the fruits of previous planning activities such as Hill-Burton and similar activities; the desirability of involving early in the planning process persons with ex- pertise outside the medical profession itself; and the fact that the regions as identified for the purposes of initial planning grants would in fact be made to regions and not to indivi- vidual institutions within the region. Finally, it was reemphasized that “there were many roads to Rome,” and that it was neither the intent nor the desire at either the local or the national level for there to be uniform- ity or conformity to some master scheme for regions to become opera- tional, but that diversity and flexi- bility were clearly in order. A NONPROFESSIONAL LOOKS AT Irving J. Lewis REGIONAL MEDICAL PROGRAMS REMARKS Honorable Melvin R. Laird 117 A NONPROFESSIONAL LOOKS AT REGIONAL MEDICAL PROGRAMS Irving J. Lewis Deputy Assistant Director Bureau of the Budget Office of the President am pleased to have this opportu- nity to be at the Conference- Workshop on Regional Medical Pro- grams. I always welcome an occasion to show to an unbelieving public that the men in the Budget Bureau do not wear green eye shades or sit upon high stools in their counting houses. In a recent talk at this same hotel, Dr. Ivan Bennett, Deputy Director of the Office of Science and Technology and one of my principal mentors in the health field, described us in these words: “Some of you, I know, have had experience with the Bureau of the Budget, where, since the multiple- crack system does not exist and there are no fissures that allow for pene- tration of local interests into national policy decisions to influence decision- making and allocation of resources, one has recourse only to putting to- gether a balanced, persuasive, and factual argument. It is with real re- spect and admiration that I say that here are the beady-eyed, hard-nosed skeptics, receptive to opinion but de- manding iron-clad factual details—a 118 demand which for me, and indeed, all of my colleagues who have been ex- posed to it in depth, has meant a re- orientation of thinking, a new level of objectivity, and above all, a last- ing respect for a much-maligned and little understood executive agency.” I quote Ivan at length so that I may publicly accept his compliments while at the same time deny that we are beady-eyed, and hope that we are better understood as a result of his efforts. Also, despite our passion for anonymity, we now find that the stage on which Federal programs are played has become so vast that we do have to allow for a few occasions which permit us to see local interests at work, or, as we say at the Bureau, the real world. For it is to help in shaping this real world that presi- dential goals, policies, purposes, and proposals are eventually fused into what is termed “the program of the President.” It is the translation of that program into dollar terms which leads usin the Budget Bureau to pur- sue the facts, to question the purposes of programs, to analyze—alas, all too imperfectly—their costs and benefits, so that the decisionmaker—in our case, the President—can look at al- ternatives and evaluate relative pay- offs from different kinds of public in- vestments. As availability of public funds for public purposes becomes tighter, the need for questioning is heightened. Our thirst for knowledge is quickened as we understand that when budget decisions are made we are affecting not only your hard-earned personal income but also the way in which society utilizes its people and its natural or physical resources, and the services or social purposes which these resources produce. The alloca- tion process is never ending—the larger the Federal budget the greater the responsibility that Government assumes to channel and direct its re- sources according to rational choices. { have no crystal ball to tell me how large the level of Federal spending will be or ought to be. I would only be speculating, and I would be es- pecially speculative if I engaged in the game of “what if we had no Viet- nam?” The level will remain high, however, and the competition for the dollars increasingly acute. This acute competition means that we in the Budget Bureau must concern our- selves with the goals and objectives and the hoped-for results of health and other programs. We try to refuse to go along with the proposals that ‘shoot from the hip. What I am saying is that while we in the Budget Bureau have no special wisdom or formulas for sorting out our budgetary goals and priorities, the President wants his program to be tuned to the problems of our society and the need for developing solutions to those problems. He wants his final choices to be not only good choices, but better than other pro- posals to accomplish the same end, and to show better returns for the same investment of public funds. To be sure, the budgetary process is neither clear cut nor infallible, and, as I have indicated, our analytical techniques are still probably not as solid as we would like. Still, I hope you will accept that this budgetary effort is no simple ac- counting task, but one in which after we fall back exhausted—incidentally, that will occur for 1969 very shortly— we have helped the President find a balance first, among the national goals of national security, foreign af- fairs, education, health, abolition of poverty, environmental quality, rec- reation, housing, transportation, sci- ence and technology, and so on; and second, among the programs most likely in action to give him progress toward these goals. There is never enough to go around, and it is little wonder that Maurice Stans, Presi- dent Eisenhower's last budget direc- tor, called budgeting the uniform dis- tribution of dissatisfactions. There is ample room to demon- strate that the worth of social investment is subject to qualifiable assessment. There is rather a wide- spread effort today in the Government to produce these assessments, going under such names as systems analysis or program planning and budgeting. Thus, investment in education is said to be more than socially “good”—we | say it is economically productive, and we can even say by how much. We can, by better analysis, show that the rehabilitation of the handicapped is not only socially useful but eco- nomically advantageous. In medical science, similar reasoning can and has been applied to show favorable cost/benefit ratios---for example, it has been done in studies in the Department of Health, Education, and Welfare of the health of the poor and the health of children. But let me quickly hasten to dis- abuse you of any idea that budgeting and its associated decisionmaking is strictly for budget professionals. This is no system of push buttons or whirring magnetic tapes. Public pol- icy is still made in the political arena, and it is in this arena that the budg- etary decisions are made. A better grasp of the role of public expenditures in creating social asscts does not by itself tell us when to spend or how much to spend. Our pluralistic society responds to pluralistic de- mands whether they are supported by a dispassionate array of facts and figures or not. Many human needs clamor for passionate attention, and many problems cry out for solutions as ucelected areas of public concern, Certainly, our planning and: analyti- cal capability is not great enough to have given us in so short a time rationality to develop our present array of Federal human resource pro- grams. About 459 such programs are described in the annual catalog of Federal assistance programs pro- duced by the OMice of Economic Op- portunity. I commend this catalog to your attention. It may help you not only to find out whether there is a grant program to finance your favorite project, but it will also rather and cost/effectivencss 292-414 O—68——-9 forcibly impress upon you the sweep of Government activity in the social field. ‘The use of the phrase “human re- sources” has become fashionable in today’s intellectual parlance, but I think it signifies that the programs grouped under this banner constitute a new type of governmental effort, not to be compared with social legis- lation of the past—either the New Freedom of Wilson or the New Deal of Roosevelt. That legislation—fair labor standards, child labor laws, food and.drug controls, unemployment in- surance, social security, to mention a few—reflected a simpler social philos- ophy that Government should pro- vide a basic underpinning by interdicting various behavior patterns or by providing certain minimum in- come quarantees. Today, the revolu- tion of rising expectations in the less developed world is paralleled by un- rest in our own society, and Govern- ment is responding by provision of services on a very broad front. The 89th Congress alone produced 21 new health programs, 17 new educational programs, 15 new economic develop- ment programs, 12 new programs to mect problems of cities, and four new manpower programs. From our carly days, we Americans have been a “practical” people. And so our society tends to bring into being human resource programs that are targeted to specific action areas. These may be categories of disease or specific population groups, and—I may add—are too often controlled by MR. LEWIS the professional specialists. Too often, the professional insists on assump- tions, approaches, programs, or tech- nology of universal applicability. Lest we “dehumanize” human resource programs, may I stress that the pri- mary focus of Government in man- aging this array of programs ought to be on the individual no matter who he is—underprivileged, poor, aged, migrant, veteran, child, mother, non- white, retarded, rural, uneducated, or other statutory category. These programs, and I include Re- gional Medical Programs, have cre- ated a new dimension for Federal management and for relations with the private sector and State and local governments. Unfortunately, for those who approach governmental re- lations simply, no one has contrived a simple formula for the execution of these programs. On the contrary, we have adopted, probably not always consciously, the approach of prag- matic experimentation. There is not always time to wait for the perfect solution. So, we grope toward it, ac- cepting some risks. We place a high premium on close cooperation and a flow of information among equals, and, above all, we are willing to see institutional change come about in many forms. We have had to try to move more and more decisionmaking out into the field, recognizing that co- ordination of programs cannot all be achieved by Federal action. The bene- fits of decentralization, however, must be accompanied by the costs of anom- alies, diversity, inconsistency, and even downright error. But deep- rooted social and economic problems are complex in nature and cannot be. attacked by simple-minded, single- shot approaches. In his report to the President and the Congress on Regional Medical Programs, the Surgeon General set forth at length a number of issues and problems which face the Regional Mcdical Programs. Some derive from characteristics of the general health setting in this country-—for example, its essentially voluntary and private nature, the magnitude and complex- ity of what is often termed a $43 bil- lion industry, manpower limitations, and rising medical costs. Others relate 119 to the law itself—definition of a re- gion, significance of disease categories, use of advisory groups, dissemination of information relating to advances in diagnosis and treatment, and others. In time, these and other issues will be dealt with in the public, executive, and legislative forum. But, as I see Regional Medical Programs in the context that I discussed earlier—our problem of allocating resources of men, money, and materials—its prime worth to our society will be in its ca- pacity for improvement of our sys- tem—or systems—of medical care for the people served. Let me stress the word “medical” because too often in the past in this country we have used “health” as a euphemism for medical in view of our unwillingness to con- front on a public level the problems of medical care. By now it is established that Gov- ernment has set its face in the direc- tion of tackling the problem of assur- ing to all its citizens the access and availability of high quality medical care. I regard as idle the discussion whether we mean such care is a right, like public education, or a privilege. The goal is clear, and if we are serious about it, we must constantly make painful choices as to where we will put our moneys and equally painful decisions on how to arrange our in- stitutions. I do not anticipate that we will experience major trade-offs in Gov- ernment spending between previously well-funded activities that were of less 120 public controversy—such as _bio- medical research and academic science—— and new activities designed to finance and make available the medical knowledge we have. How- ever, it is also clear that extremely high on the health agenda is the dis- tribution of our medical knowledge— what we call the organization and delivery problem. I think that it is in solving this problem and in bringing medica] care to people that the Re- gional Medical Programs potential lies. Medicare and medicaid alone ac- count for over $8 billion of the Federal expenditures of $15 billion for health programs. They have virtu- ally eliminated financial barriers for the aged and have made it possible for poor and near-poor in_ three- fourths of our States to receive an increasing volume of medical services. These landmark laws of 1965 are ac- companied by others in maternal and child health. Tronically, many people—and es- pecially medical professionals—are troubled over this outpouring of Federal funds to diminish the fi- nancial burden of paying for medical care, and they are rightly troubled, because with demand for medical care now effective, as the economists say, the pressure is on the profession to deliver. In addition, of course, there is the vocalized but as yet not effective demand of citizens not yet covered—for example, the disabled, the migrants, or the rural and urban poor not eligible for medicaid. None of us needs to be an economist to know that when more funds are poured into the arena for purchase, the selling system must be more ef- ficient or its supply must be enlarged or the infusion of funds may simply be eaten up by price inflation. Debate continues—and I am no expert— on the extent to which medicare con- tributed to rising medical costs, but the rising costs are with us and there- fore spur us to examine our system of medical care. Many speak of Regional Medical Programs as a unifying focus for the health resources of a region, linking patient, physician, hospital, and medical centers to provide the latest advances of knowledge to the people in this region. But health functions are a continuum, and Regional Medical Programs will have to con- sider the problems of distribution, cost and organization of health care. I would think that, because of the tremendous scope of heart disease, cancer, stroke, and related diseases, the task of improving organization and delivery of medical care through Regional Medical Programs has to be viewed in the context of comprehen- sive health services and not in a nar- rowly based disease approach. This task will have, in the long run, serious implications for medical cen- ters and medical schools. The com- fort of biomedical research and in- dividual case treatment or teaching may be replaced for many by the rag- ing controversies over medical care costs, doctors’ fees, etc. “Interesting medicine” may become not disease- oriented, but the area of organizing the system of care. Of course, another impact, still only seen in general terms, will be seen in the need for production of more doctors faster. The President’s Health Manpower Commission recommended that we develop economic incentives to make this possible. Oliver Cope wrote somewhat despairingly of this prob- lem of medical education a few months ago in Harper’s Magazine. I would hope that in time we could overcome his despair by responding to the prod of the Commission. Through the National Center for Health Services Research and Devel- opment, Regional Medical Programs will get invaluable assists through a rising level of supporting investiga- tions and experiments. Another significant actor on the scene is the “Partnership for Health,” and I guess we still have to establish with more clarity how we want this experiment to tie in with Regional Medical Pro- grams. There is a tendency to regard this program as just another State support program. This is an error in judgment, and you will find that it is regarded here in Washington as a pilot program of some significance. It is a major breakthrough in changing the proclivities of professionals and their executive and legislative sup- porters to opt for narrowly-based categorical programs. There is a seri- ous effort afoot in this town to create more manageable packages which permit the local private and public MY UR aw DP we sector to act decisively while preserv- ing the right of the Federal Govern- ment to cstablish priorities of na- tional significance. In the Budget Bureau we have read with considerable interest the Sur- geon General's priority statement for Partnership for Health issued in No- vember. This priority statement is very topical, and I suggest that it has great meaning for many of you. This statement establishes three budget priorities that are relevant to Re- gional Medical Programs: First: The requirement for corn- prehensive health care, directed to individuals and families, not dis- €ases ; Second: Improvement of the health status of the indigent; and Third: Use and training of neighborhood residents and in- volvement of neighborhood resi- dents in planning and implementa- tion of health projects. I would only bore you were I to recite statistics about the health status of the poor. The evidence of unusual disease and high prevalence of ill health identifies them as a high- risk population. While the middle and upper classes in this opulent society have a malaise and uncertainty about their own lives, the health status of the poor is part and parcel of that complex called poverty which is much greater than just lack of in- come. It is what Colin McLeod, in his recent AAMC address, eloquently called “the lack of hope that one can ever rise beyond the despair of being forever a hewer of wood and a drawer of water; it is the despair of being un- able to aspire to the expression of his potential as a human being; it is the despair of having no future except that of mean survival in misery loaded enclaves surrounded by an opulent society.” There has now been mounted in the Office of Economic Opportunity a program by the “medical radicals,” as Marion Sanders calls them, of Neighborhood Health Centers. To- day, 46 centers are in operation or to be funded, and medical schools at all levels are in the business. This is more than an incidental change in attitude. It is recognition that the Na- tion’s health business lies in making medical care available to all, and the role of medical schools and centers is crucial in this. May I, as a layman, suggest that heart, stroke, cancer, and related diseases—significantly related or not—will be found among the poor in the neighborhood health cen- ters. Undoubtedly, many medical schools are or will be deeply involved in both Regional Medical Programs. and neighborhood centers and both programs should profit from each other. If Iam right that Regional Medi- cal Programs has not been sufficiently concerned thus far with the problems of the poor, I can extend this lack of concern to the cities generally. Not that I ignore the rural poor. The Breathitt Commission reminds us most forcibly that urban poverty has deep roots in rural poverty. But the crisis of the cities is a hunnan resources crisis and the cities are where we will find most starkly the poverty of which Colin McLeod spoke. For too long our society has in- vested resources in only the physical aspects of the city, but the Model Cities program is ample testimony that human and social needs are the dominant theme today. Sixty-three cities have been selected for first generation grants under this top priority program, designed to im- prove the quality of urban life, de- clared by Congress to be the most critical domestic problem facing the United States. These 63 cities now have the initiative by law to develop programs for selected neighborhoods so as to remove or arrest blight and decay, to make marked progress in reducing social and educational clis- advantages, ill health, underemploy- ment, and enforced idleness, and to provide educational, health, and social services necessary to serve the poor in the Model City area. You should be aware that this is a pro- gram run through the Department of Housing and Urban Development, but that HUD places primary reliance on other agencies for evaluating the human resources program proposals of these Model Cities plans. The Model Cities program, born in the inspiration of a few, dealing with the institutional arthritis of Federal, State, and local bureaucracies and frustrated by the professionalism in health, education, and welfare, may yet turn out to be our boldest experi- ment. Regional Medical Programs trics to develop, on the basis of local initiative, new institutions and tech- niques to solve health problems. In a sense, Model. Cities is Regional Medical Programs writ large upon the total human resources scene. The Model Cities program has an- other lesson for Regional Medical - Programs—the necessity of citizen participation in program develop- ment and his access to the decision- making process. There are many roles which we can attempt to define as being logical and effective for the private citizen in health affairs. Hos- pital trustee or planning body mem- ber are obvious roles. Not so obvious and perhaps somewhat more nebu- lous is the role of the private citizen as a member of the board of direc- tors of a regional medical program. I know many of you are thinking about this role of the citizen which, incidentally, would parallel the con- sumer representation found in the Partnership for Health program. In any case, the nonprofessional role in planning a regional medical program warrants expansion and the com- munity members, to play this role, will have the responsibility for asking a number of unpleasant questions about the quality of the medical care in a region, the availability and acces- sibility of comprehensive health serv- ices, or the usefulness of Regional Medical Programs in inhibiting the rate of cost increase in medical care. May I suggest, however, that there is another consumer role which must 121 be considered. It is an inevitable role if human resources programs are to reach the people whom they are de- signed to serve. I am speaking here of the citizen in the neighborhood who will not be satisfied with past patterns of consumer representation, but wishes rather through neighborhood organizations to make his views known. The requirement of partici- pation of the citizens in the neighbor- hood in determining the programs which serve them is found increas- ingly in Federal law, Model Cities and Office of Economic Opportunity being only highlight examples. The prescription of the participation may vary in differing statutes as may its administration in practice. But one thing is certain: The voice of the citizen consumer will be heard at the grassroots level in the deliberations affecting his future. The need of community involve- ment and citizen participation is un- familiar to the medical profession, which has survived a long time in this country under the slogan, “You are the doctor.” But Paul Ylvisaker very astutely pointed out at last year’s conference in this hotel that the Regional Medical Programs has too narrow a professional base, and he stated that, if the health professions do not become consumer oriented, “within 2 years your medical schools will be picketed by a combination of the American Mayors Federation and CORE. And I wonder,” he said, “if your medical faculties are ready for that experience.” 122 Not too long ago Public Broadcast Laboratories televised the sharply polarized views of the police and the militant Black Power advocates re- garding law enforcement by police. It was a fairly chilling experience for the advocates of moderation. But I found provocatively thoughtful the minister from Atlanta who calmly told a nationwide audience that all our social, education, and health ef- forts were hampered by an essentially negative attitude of Americans to- ward the poor and the Negro. If we expect human resources programs, including Regional Medical Pro- grams, to realize their investment po- tential to serve human beings, the professional’s attitude must be one that not only permits him to help the poor and Negro, as he did in the past eras of social legislation, but also motivates him to urge their involve- ment and give them access to the de- cisionmaking process. That is our goal in Model Cities, Office of Eco- nomic Opportunity, and Partnership for Health. It should be no less in Regional Medical Programs. May I thank you for this op- portunity to be present at this Con- ference, and wish you well in your endeavors. REMARKS Honorable Melvin R. Laird Member, U.S. House of Representatives State of Wisconsin came here to learn, and I have been listening to the morning ses- sions with a great deal of interest. It is true that I have served on the Health, Education, and Wel- fare Appropriations Committee ever since this department was created, working very closely with the gentle- man on the other side of the aisle, John Fogarty, who was my closest and dearest friend in the Congress. We had a very great association together for some 16 years. T know that he would be proud of the progress that the Regional Medi- cal Program has made ina very short period of time. And the fine report on this conference which I was privi- leged to hear from you, Doctor, I think speaks well for this program. When we made the first appropri- ation for this program, of course, we were concerned about the delivery of the research benefits which we had funded at an ever increasing rate for a period of some 12 to 13 years, the delivery of these research benefits and research findings to a limited num- ber in the medical manpower field. But the purpose of this program was to sec that medical services in the hands of a very limited medical man- power group could get to patients in the various regions of our country and the use of this medical manpower could be a fuller use, fuller utiliza- lion, more effective. Because, as we went forward into the future, we could see that it wasn’t just a question of doctor shortages, but it was a question of shortages in every arca of medical manpower. And the Regional Program could move in the direction of making bet- ter usc of the limited supply which we had on hand and which we fore- HONORABLE MR. LAIRD saw for the decades of the seventies and eighties. And I think the progress that has been made that has come from these discussions and your report, Dr. Coggeshall, on the work that has gone on here at this conference shows that this prograni is finally getting started. It has got a long way to go, but at least, you are defining the problem. * % * 123 “atl APPENDICES . > PND ow . CONFERENCE-WORKSHOP PROGRAM COORDINATORS’ STEERING COMMITTEE REGISTERED PARTICIPANTS REVIEW COMMITTEE AND NATIONAL ADVISORY COUNCIL DIVISION STAFF REGIONAL MEDICAL PROGRAMS PUBLIC LAW 89-239 REGULATIONS APPENDIX 1 CONFERENCE-WORKSHOP PROGRAM THEME: ISSUES FOR REGIONAL MEDICAL PROGRAMS IN THE IMPROVEMENT OF HEALTH CARE WEDNESDAY, JANUARY 17 8am. REGISTRATION Concourse FOCUS ON THE ISSUES 8:30-10:30 am. PLENARY SESSION International Ballroom West Chairman: STANLEY W. OLSON, M.D., Chairman, Coordinators’ Steering Committee and Coordinator, Tennessee Mid-South Regional Medical Program Quality and Availability of Health Care for Heart Disease, Cancer, Stroke, and Related Diseases in the Future as Related to: e Science and Service CARLETON CHAPMAN, M.D., Dean, Dartmouth Medical School, Hanover, N.H. « Regionalization LESTER BRESLOW, M.D., Professor of Health Administration and Chief, Division of Health Services, UCLA School of Public Health Los Angeles, Calif. « Development of Personal Health Service DWIGHT L. WILBUR, M.D., President-Elect, American Medical Association, San Francisco, Calif. ll am~-12 Noon PLENARY SESSION (continucd) International Ballroom West Quality and Availability of Health Care for Heart Disease, Cancer, Stroke, and Related Diseases in the Future as Related to: e The Population Chairman: ROGER ©. EGEBERG, M.)., Dean, School of Medicine, University of Southern Clatifornia, Los Angeles, Calif. 126 Panel: RAY E. TRUSSELL, M.D., Director, School of Public Health and Administrative Medicine, Columbia University, New York, N.Y. FRANK P. LLOYD, M.D., Director, Medical Research, Methodist Hospital, Indianapolis, Ind. AMOS JOHNSON, M.D. Garland, N.C. Terrace 12 Noon-6 p.m. DEMONSTRATIONS—EXHIBITS Special demonstrations and exhibits which reflect regional and other related activities have been arranged and will be opened and manned during this period. See Appendix A of this printed program for listing of demonstrations and exhibits and their locations. 1:30-3:30 p.m. SERIES I--PAPERS ON REGIONAL ACTIVITIES AND IDEAS Selected 15-minutes papers presenting highlights of regional activities and ideas now being developed in the regions will be presented on the following schedule in adjacent rooms permitting and encouraging conferees to develop a preselected schedule so that they can move from room to room at 20-minute intervals to hear those papers in which they have the most related interest: Starting lime Meeting rooms on concourse level 1:30 Papers | 7 13 19 25 30B 1:50 Papers 2 8 14 20 26 30C: 2:10 Papers 3 9 15 21 27 " 2:30 Papers 4 10 16 22 28 " 2:50 Papers 5 1] 17 23 29 ” 3:10 Papers 6 12 18 24 30A ” See appendix B for detailed listing of papers, speakers and room location. 3:45-5:15 p.m. SESSION I—DISCUSSION GROUPS Insofar as possible, discussion subjects are related to preceding papers and in some cases paper presenters are included as discussants. TOPIC A “Health Manpower—The Commission Report” TOPIC B “Regionalization” TOPEG CG “Urban Problems?’ “POPRPECH DD Related Bederal Proprsinas” “POPEC, FS ealth Serviees Research” See Appendix C for listing of participants and room location. ce es in THURSDAY, JANUARY 18 REGIONAL MEDICAL PROGRAMS INTO ACTION 8:30-10 arm. PLENARY SESSION International Ballroom West Chairman: ROBERT G. LINDEE, Co-Chairman, Conference-Workshop on Regional Medical Programs, Assistant Dean, Stanford University School of Medicine, Palo Alto, Calif. Division of Regional Medical Programs Reports on: © Progress and Issues ROBERT Q. MARSTON, M.D., Associate Director, National Institutes of Health, and Director, Division of Regional Medical Programs. * A New Emphasis ALEXANDER M. SCHMIDT, M.D. (presenter), Chief, Continuing Education and Training Branch, Division of Regional Medical Programs. <2 RICHARD F. MANEGOLD, M.D., Associate Director for Program Development and Research, Division of Regional Medical Programs. e Operations Research ROBERT BUCHER, M.D. (presenter), Dean, Temple University School of Medicine and Consultant to the Division of Regional Medical Programs. JACK HALL, M.D., Director of Medical Education, Methodist Hospital, Indianapolis, Ind., and Consultant to the Division of Regional Medical Programs. HERBERT P. GALLIHER, Jr., Ph. D., Professor of Industrial Engineering, University of Michigan, and Consultant to the Division of Regional Medical Programs. MAURICE E. ODOROFF, Assistant to the Director for Health Data, Division of Regional Medical Programs. 10:30-12:30 p.m. PLENARY SESSION (continued) Chairman: JOHN A. GRONVALL, M.D., Co-Chairman, Conference-Workshop on Regional Medical Programs, Associate Director and Associate Dean, University of Mississippi Medical Center, Jackson, Miss. A National View of New Developments in: International Ballroom West ® Tleart Disease DONALD S. FREDRICKSON, M.D., Director, National Heart Institute, National Institutes of Health. © Cancer KENNETH M. ENDICOTT, M.D., Director, National Cancer Institute, National Institutes of Health. ® Stroke RICHARD L. MASLAND, M.D., Director, National Institute of Neurological Diseases and Blindness, National Institutes of Health. 12:30-6 pm. DEMONSTRATIONS—EXIIIBITS Terrace Special demonstrations and exhibits which reflect regional and other related activities have been arranged and will be opened and manned during this period. See Appendix A of this printed program for listing of demonstrations and exhibits and their locations. 127 :30-3:30 p.m. - NAL ACTIVITIES AND 1:30-3:30 pm. SERIES II—PAPERS ON REGIO 3:45-5:15 p.m. SESSION II—DISCUSSION GROUPS : IDEAS E : : Insofar as possible, discussion subjects are related to preceding papers and in some A Selected 15-minute papers presenting highlights of regional activities and ideas now cases paper presenters are included as discussants. a being developed in the regions will be presented on the following schedule in adjacent “ . : a + : rooms permitting and encouraging conferees to develop a preselected schedule so that Tore 7 Bonn eule Fdueation and ‘Training, For What? they can move from room to room at 20-minute intervals to hear those papers in which TOPIC H “Hospitals” cn egistries they have the most related interest: TOPIC I “Cormmunity Involvement” Starting TOPIC J “Operational Program Development” lime Meeting rooms on concourse level See A dix C for listi ‘ . 4 1 . t t t tion. 1-30 Papers 3] 37 43 49 55 ee Appendix C for listing of participants and room location 1:50 Papers 32 38 44 50 56 2:10 Papers 33 39 45 51 57 2:30 Papers 34 40 46 52 58 2:50 Papers 35 41 47 53 59 FRIDAY, JANUARY 19 3:10 Papers 36 42 48 54 60 See Appendix B for detailed listing of papers, speakers and room location. 8:30-10 a.m. PANEL DISCUSSIONS To permit the conferees to relate the presentations on Heart Disease, Cancer, and Stroke given at the Plenary Session on Thursday morning, and participate in a dis- cussion of their relationship to Regional Medical Programs, three concurrent panels are scheduled: HEART DISEASE Linceln Room Chairman: JESSE EDWARDS, M.D., President, American Heart Association, Charles T. Miller Hospital, St. Paul, Minn. Panel: THEODORE COOPER, M.D., Associate Director, National Heart Institute, National Institutes of Health. SAMUEL M. FOX IN, M.D., Chief, Heart Disease Control Program, National Center for Chronic Disease Control, Bureau of Disease Prevention and Environmental Control. WILLIAM LIKOFF, M.D., President, American College of Cardiology, Hahnemann Medical College, Philadelphia, Pa. CAMPBELL MOSES, MD, Medical Director, American Heart Association, New York, N.Y. 128 re 9 id s- Is Tt CANCER Chairman: Panel: Thoroughbred Room SIDNEY FARBER, M.D., President-Elect, American Cancer Society and Director of Research, Children’s Cancer Research Foundation, Boston, Mass. MICHAEL J. BRENNAN, M.D., Scientific and Medical Director, Michigan Cancer Foundation, Detroit, Mich. JUAN DEL REGATO, M.D., Director, Penrose Cancer Hospital, Colorado Springs, Colo. KENNETH M. ENDICOTT, M.D., Director, National Cancer Institute, National Institutes of Health. GUY F. ROBBINS, M.D., Director of Planning, Memorial Hospital for Cancer and Allied Diseases, New York, N.Y. STROKE Chairman: Panel: Hemisphere Room NEMAT BORHANI, M.D., Professor of Internal Medicine and Chairman, Department of Community Health, University of California School of Medicine, Davis, Calif. RICHARD L. MASLAND, M.D., Director, National Institute of Neurological Diseases and Blindness, National Institutes of Health. CLARK H. MILLIKAN, M.D., Consultant in Neurology, Mayo Clinic, Rochester, Minn. WILLIAM A. SPENCER, M.D., Director, Texas Institute for Rehabilitation and Research, Tlouston, ‘Tex. JAMES TOOLE, M.D., Professor and Chairman, Department of Neurology, Bowman Gray School of Medicine, Winston-Salem, N.C. SUMMING UP AND LOOKING AHEAD 10:30 a.m.-12 Noon PLENARY SESSION International Ballroom West Chairman: PAUL D. WARD, Incoming Chairman, Coordinators’ Steering Committee, and Coordinator, California Regional Medical Program. e Conference-Workshop Summary of Issues LOWELL T. COGGESHALL, M.D., Vice President Emeritus, University of Chicago. e Address by . IRVING LEWIS, Deputy Assistant Director, Bureau of the Budget, Office of the President. e Closing Remarks by . PHILIP R. LEE, M.D., Assistant Secretary for Health and Scientific Affairs, U.S. Department of Health, Education, and Welfare. 12 Noon ADJOURNMENT APPENDIX A LISTING OF DEMONSTRATIONS AND EXHIBITS WEDNESDAY, JANUARY 17, 1968 THURSDAY, JANUARY 18, 1968 12 Noon-6 p.m. DEMONSTRATIONS—EXHIBITS Special demonstrations and exhibits which reflect regional and other related activitics have been arranged and will be opened and manned during this period. The following list indicating location on Terrace Level or in Park Suite Rooms includes number or letter of exhibit, the name of the exhibitor, and some descriptive information on each exhibit. 129 TERRACE LEVEL [Exhibit No.] and exhibitor [1] Greater Delaware Valley Regional Medical Program Description and (exhibit contact) Maps and charts depict the need and method for subregionalization of a “mega-region.” (Mr. Ward Bentley) {Exhibit No.] and exhibitor [8-9] Rochester Regional Medical Program in Conjunction With the Heart Disease Control Program of National Center For Chronic Disease Control Description and (exhibit contact) Models of various available types of coronary care units, including that in operation in this Regional Program. (Mrs. Jane Hansen) [2] Western New York Regional Medical Program A 4-panel display of how a region is acting to improve patient care. (Mr. Anthony Zerbo) [3] Missouri Regional Medical Program A dual display. One includes photographic panels illustrating various operational projects now under- way in this region. The other is a scale model of the comprehensive medical care facility now being built in Smithville, Mo., the site of one project. (Miss Annette Eberley) [4] Tennessee Mid-South Regional Medical Program 3-panel display of nursing care showing how efforts of physicians and nurses for superior care can be achieved by vertical organization as opposed to the fragmenting effects of horizontal organization. (Dr. Stanley Olson) [5] North Carolina Regional Medical Program and Commission on Professional and Hospital Activities A cooperative exhibit indicating data on acute coro- nary occlusion from 44 hospitals in North Carolina. (Dr. Virgil Slee) [6] Colorado-Wyoming Regional Medical Program A dual exhibit. One section is an exhibit which indi- cates development of this program. Combined with this will be a videotape presentation showing how this program plans to use videotape units for con- tinuing education. (Mr. Robert Vestal) [7] Heart Disease Control Program of National Center For Chronic Disease Control A dual exhibit. One is a descriptive display of the type of work done in the Standardization and Reference Laboratories of this program and location of the laboratories participating in standardization pro- grams for drugs used in treatment of heart disease. The other is a display of computer analysis of electrocardiograms. (Dr. Gerald Cooper) [10] Cancer Control Program of National Center For Chronic Disease Control Entitled “Stop Oral Cancer,” this visual exhibit high- lights special forms of detection and treatment of this type of cancer. (Dr. Richard L. Hayes) (11) Rehabilitation Services Administration A 4-panel display describing the services of vocational rehabilitation. (Mr. Tom Brubeck) (12) National Heart Institute of the National Institutes of Health Detailing some related programs of the Institute, this exhibit will emphasize its coronary drug project to evaluate lipid-lowering drugs in acute coronary disease. (Mr. Donald Bradley) {13] Washington-Alaska Regional Medical Program An exhibit designed to explain this program and by a special device provide the opportunity to identify the mortality rate in the three categorical diseases in the various parts of the State of Washington and compare them. Also included is an arrhythmia simulator which permits physicians to test them- selves in diagnosis and treatment of acute cardiac problems. (Mrs. Marion Johnson) [14] North Carolina Regional Medical Program in Conjunc- tion With the National Institute of Neurological Diseases and Blindness of the National Institutes of Health An exhibit detailing the stroke control program now underway at the Bowman-Gray School of Medicine. (Dr. James Toole) [15] Intermountain Regional Medical Program A 7-part exhibit including a description of this program; description of use of highly portable videotape recording system; illustration of this region’s effort to establish a “regenerative” con- tinuing education program; examples of organiza- tional planning; visualization of importance of two types of data collection; and demonstration of scope and method of this Region’s two-way radio network. (Mr. Charles Akerlow) 130 MISSOURI REGIONAL {Exhibit No.] and exhibitor Description and (exhibit contact) [16] National Institute of Ncuro- logical Diseases and Blindness of the National Institutes of Health Exhibit consists of information and a map indicating the location of Stroke Kesearch Center, Training Programs and Aneurysm Studies established and underway throughout the country. (Mr. Robert Hinkel) [17] National Canccr Institute of the National Institutes of Plealth An exhibit demonstrating the activities and location of Cancer Research Centers and Clinical Cancer ‘Training Centers established and underway through- out the country. (Mrs. Pauline Wall) [18] Bureau of Health Manpower A 3-panel exhibit describing the organization, function and activity of this Bureau and its relationship to the delivery of health care. (Mr. Wayne M. Bard) [19] American Cancer Society A visual display of professional educational printed materials related to various types of cancer. (Mr. Walter James) [20] Chronic Respiratory Disease Control Program of the National Center for Chronic Disease Control Materials describing diagnosis, treatment, and related activities in emphysema and chronic bronchitis will be displayed and available. (Mrs. Shelic Lengel) [Exhibit No.] and exhibitor Description and (exhibit contact) (21] American Heart Association Materials detailing the activities of this Association as they relate to Regional Medical Programs and an example of how a State association is working with one Regional Medical Program will be available in this exhibit area. (Miss Placide Schriever) [22] Iowa Regional Medical Program Diagrams showing interrelationship between this pro- gram and health planning groups in the region. (Dr. Willard A. Krehl) [23] Louisiana Regional Medical Propram Display includes original drawings for slide presenta- tion describing the development and activities: of this program. (Dr. J. A. Sabatier) [24] Office of Program Planning of the Surgeon General This exhibit of maps developed by computer shows census data by small geographic area for possible use in Regional Medical Program planning. (Mr. James King, Jr.) (25] Mountain States Regional Medical Program A visual description of the usc of questionnaires to gain planning information and data from the region for usc in developing this program. (Dr. Alfred Popma) [26] West Virginia Regional Medical Program A visual explanation of initial activities and people concerned in the development of the planning phase of this program. (Dr. C. L. Wilbar) [27] Division of Medical Care Administration of the Bureau of Health Services A 3-panel exhibit visualizing automated multiphasic screening ranging from patients themselves to the use of the computer. (Miss Grace Osgood) [28] American Medical Association Exhibit visualizes the areas of responsibility, available resources, and other health organizations that should be involved with Regional Medical Programs. (Dr. Howard Doan) [29] Division of Regional Medical Programs The standard exhibit currently being used at large national meetings and a newly developed smaller easily transportable and usable replica to be made available for smaller local, area, and regional meetings on request. (Mr. Frank Karel IIT) 131 [Exhibit No.] and exhibitor Description and (exhibit contact) [Exhibit letter] room exhibitor Description and (exhibit contact) [30] Veterans Administration [31] Michigan Regional Medical Program This exhibit visualizes the long-range VA hospital replacement and relocation program, providing some idea of future facilities that should be included in regional planning. (Mr. Howard Armstrong) Describing ‘‘Project Echo” (Evidence for Community Health Organization), this exhibit visually details an on-going environmental appraisal and inter- views to assess current health status and needs of the population of this region. (Mrs. Betty Tableman) PARK SUITE ROOMS [Exhibit letter] room exhibitor Description and (exhibit contact) [A] Bancroft Room California Regional Medical Program Display portion portrays the development of this pro- gram in the new University of California School of Medicine at Davis. The demonstration section shows the medical television programs being carried out at the University of California, Los Angeles. (Harry O. Bain and Dr. Donald Brayton) [B] Chevy Chase Room Kansas Regional Medical Program Specially selected slide presentation of elements of this program designed to be used to inform and encourage cooperation of various groups within this region. (Dr. Charles Lewis) (C] Chevy Chase Room Oklahoma Regional Medical Program A demonstration of the U.S. Air Force Computer- Based Worldwide System for Continuing Medical Education—as adapted to the Oklahoma program. (Col. Owen G. Birtwistle) (D] DuPont Room Greater Delaware Valley Regional Medical Program A presentation of the systems analysis approach to planning as utilized in this region. TO BE PRE- SENTED ON THURSDAY ONLY. (Dr. G. Angelides) [E] Edison Room Wisconsin Regional Medical Program 132 (1) The display portion shows the screening: meehsaniagn used in this proprani as a basis for decision making on clements of operational! programs. (2) ‘Che demon- stration portion covers the Dial Access Medical Library Service now in operation in this region. (Mr. Roy Ragatz) ([F] Farragut Room National Library of Medicine A demonstration of the medical television system in operation from the Audiovisual Center of the National Library of Medicine in Atlanta to affiliated hospitals in various parts of the city. (Mr. John Argyle King) [G] Jackson Room National Naval Medical Center A demonstration of the development and use of audiovisual materials in medical education. (Ensign T. Galbreath) {H] Kalorama Room Clinical Center of the National Institutes of Health A 15-minute film demonstrating the automated computerized clinical laboratory of the clinical center and the possible application of such a system to hospitals on a regional basis. TO BE GIVEN ONLY AT 3 P.M. WEDNESDAY AND THURS- DAY. (Dr. George Z. Williams and Dr. John Otis) {I] Independence Room Division of Nursing of Bureau of Health Manpower Preliminary information and cxamples of instruc- tional systems for training nurses for’ intensive coronary Care units and open heart surgery. Based upon educational projects sponsored by the Division of Nursing at Presbyterian-University of Pennsyl- vania Hospital by Dr. Laurence Meltzer and at Ohio State University by Rita Chow. (Miss Florence Reynolds) APPENDIX B LISTING OF 15-MINUTE PAPERS ON REGIONAL ACTIVITIES AND IDEAS PAPERS BY ASSIGNED NUMBER WEDNESDAY, JANUARY 17, 1968 Paper No. Tithe, author, and (repsion) Tame and location 1 “Health Evaluation Studies Utilizing a Multiphasic Sereen- 1:30 p-m. ing Center Operating in Cooperation with a Comprehen- Lincoln Room sive Health Care Program for Persons in an Urban Poverty East Area.” LLOYD ELAM, M.D. (Tennessee Mid-South) Paper Paper No. Title, author, and (region) Time and location No. Title, author, and (region) Time and location 2 “Provision of Optimum Clinical Laboratory Services for 1:50 p.m. 16 “Complementary Relationship Between Iowa Regional 2:30 p.m. 3,000,000 People’? DAVID SELEIGSON, M.D. (CGon- Lincoln Room Medical Program-—-Comprehensive Ifealth Planning and Military necticut) Last Voluntary Comprehensive Ilealth Planning: A Necessary Room 3 “Biochemical Sereening in Missouri.” JAMES T. PACKER, 2:10 p.m. Accomplishment.” JOHN C. BARTLETT, M.A., LL.B. M.D. and HUBERT J. VAN PEENEN, M.D. (Missouri) Lincoln Room (Lowa) East 17 “Problems in Developing the Role of Medical Schools in 2:50 p.m. 4 “A Regional Utilization, Patient Information and Statistics 2:30 p.m. a Regional Medical Program.” VINCENT dePAUL Military System.” JOHN D. THOMPSON (Connecticut) Lincoln Room LARKIN, M.D. (New York Metropolitan) Room East 18 “The Role of a School of Public Health in.a Developing 3:10 p.m. 5 “Flanner House Multiphasic Sereening Program.” HAR- 2:50 p.m. Regional Medical Program.” EDWARD COHART, Military VEY FEIGENBAUM, M.D. (Indiana) Lincoln Room M.D, (Connecticut) Room East 19 “‘Watts-Willowbrook Regional Medical Program.” 1:30 p.m. 6 “Experiment to Test and Implement a Model of Patient 3:10 p.m. DONALD J. BRAYTON, M.D. (California) Hemisphere Care in Hospitals.” LUTHER CHRISTMAN, PH. D. Lincoln Room Room . (Tennessee Mid-South) East 20 “Council of Regional Planning Directors and Administra- 1:50 p.m. 7 “The Use of a Multi-Media Approach to Enhance the Learn- 1:30 p.m. tors.” JOSEPH J. MASON, JR. (Alabama) Hemisphere ing of Health Science Personnel.” WILLIAM G._ Lincoln Room Room COOPER, M.D. (Colorado-Wyoming) West 21 “Development of Relationship Between the Medical As- 2:10 p.m. 8 “Use of a Telephone Network for Continuing Education.” 1:50 p.m. sociation of the State of Alabama and the Alabama Hemisphere RICHARD H. LYONS, M.D. (Central New York) Lincoln Room Regional Medical Program.” J. O. FINNEY, M.D. Room West (Alabama) 9 “Communication Research Unit”? WILLIAM STEPHEN- 2:10 p.m. 22 “The Sub-Regional Concept and Liaison Staff.” WILLIAM 2:30 p.m. SON (Missouri) Lincoln Room C. SPRING, JR., M.D. and WARD BENTLEY (Greater Hemisphere West Delaware Valley) Room 10 “Community Information Coordinator.” WARD L. 2:30 p.m. 23 “The Delineation of Sub-Regional Health Service Areas 2:50 p.m. OLIVER, M.D. (Albany, N.Y.) Lincoln Room as a Basic Step in Regional Medical Planning.” CONRAD Hemisphere West SEIPP, M.D. (Connecticut) Room I “Development of Receptive Attitudes Toward New Ideas.” 2:50 p-m. 24 “Regional Advisory Group and Review Process.” 3:10 p.m. JOHN S. GILSON, M.D, (Intermountain) Lincoln Room CHARLES E. LEWIS, M.D. (Kansas) Hemisphere West , Room € ae 2, » . 12 OL F WARD CC. iorsiay Core Poverty Areas. Fe Fe oo 1 25 “A Proposed Circuit Postgraduate Program in Heart Disease, 1:30 p.m. : a West n ’ Cancer, Stroke and Related Diseases in the Oregon Thoroughbred hh a Region.” M. ROBERTS GROVER, M.D. (Oregon) Room 13 “The Role of the Voluntary Health Agencies in the Regional 1:30 p.m. . « . . to de Medical Program in Iowa.” WILLARD A. KREHL, Military 26 The Information and Education Resource Support Unit. “ee om a M.D. (Iowa) Room JOHN N. LEIN, M.D. (Washington-Alaska) Thoroug re 14 “Small Community Planning.” TASKER K. ROBINETTE = 1:50 p.m. / — oo . . . (Washington-Alaska) Military 27 ‘Unusual Programs for Continuing Education of Physicians 2:10 p.m. Room at Grassroots Level.” C. L. WILBAR, JR., M.D. (West Thoroughbred - . . Virgini Roo 15 “Coordination of Comprehensive Health Planning and 2:10 p.m. irginia) m Regional Medical Program Activities in Western Penn- Military 28 “Community-Centered Continuing Medical Education.” 2:30 p.m. sylvania, 1967.” E. WAYNE MARTZ, M.D. and Room C. HILMON CASTLE, M.D. (Internmoutain) Thoroughbred Room HOWARD HOUGH (Western Pennsylvania) 133 Paper No. Title, author, and (regior) Time and 29 “Survey of Continuing Education of the Physicians in 2:50 p.m. Metropolitan Washington.” THOMAS W. MATTINGLY, Thoroughbred : M.D., LEONARD CHIAZZE, JR., SC.D., and MAL Room q XAVIER (Metropolitan Washington, D.C.) : 30A ‘Approaches to Evaluation of a Regional Medical Program.” 3:10 p.m. 7 CALDWELL B. ESSELSTYN, M.D. (New York Metro- Thoroughbred politan) ‘Room 30B ‘Systems Approach to Planning.” ANGELO P. ANGEL- 1:30 p.m. IDES, M.D., LARRY McGOWAN, M.D., ARTHUR DuPont STANKOVICH (Greater Delaware Valley) Room 30C “Informal Discussion on Systems Analysis.” HERBERT P. 1:50 p.m. GALLIHER, JR., PH. D. (Professor, University of DuPont Michigan) Room 134 PAPERS BY ASSIGNED NUMBER THURSDAY, JANUARY 18, 1968 Paper No. Title, author, and (region) Time and location 3] “A Study of Physician Office Practice in the Connecticut 1:30 p.m. Region.” DONALD RIEDEL, PH. D. and ORVAN W. Lincoln Room HESS, M.D. (Connecticut) East 32 “Consumer Health Care Survey.” LAWRENCE J. SHARP, 1:50 p.m. PH. D. (Washington-Alaska) Lincoln Room East 33 “Continuum of Long Term Care in a Local Health Service 2:10 p.m. Area.” E. RICHARD WEINERMAN, M.D. (Connecti- Lincoln Room cut) East 34 “Involvement of Local Hospitals in the Regional Medical 2:30 p.m. Program by the Appointment of Local Hospital Advisory Lincoln Room Groups.” J. GORDON BARROW, M.D. (Georgia) East 35 “The Regional Medical Program as a Means of Increasing 2:50 p.m. the Morale of the Family Doctor”? ROGER BOST, M.D. Lincoln Room (Arkansas) East 36 “Community Hospital Learning Centers.” FRANK M. 3:10 p.m. WOOLSEY, JR., M.D. (Albany, N.Y.) Lincoln Room East 37 “Experiences with a Stroke Care Demonstration Unit.” 1:30 p.m. ROBERT R. SMITIT, M.D. (Mississippi) Jefferson Room East 38 “System for Clinical Data Collection and Analysis in 1:50 p.m. Patients with Acute Myocardial Infarction.” C. HILMON Jefferson Room CASTLE, M.D. (Intermountain) East 39 “Cost Benefit Analysis”? JOHN E. WENNBERG, M.D. 2:10 p.m. (Northern New England) Jefferson Room Fast 40 “Comprchensive Cardiovascular Care Unit.” GLENN O. 2:30 p.in. TURNER, M.D., CECIL R. AUNER, M.D. and JOHN Jefferson Room J. McKINSEY, M.D. (Missouri) East 41 “Dataphone EKG Consultation: A Model for Extension of 2:50 p.m. Medical Center Services to Community Hospitals.” Jefferson Room JOHN B. HERMANN (Nebraska-South Dakota) East 42 “Experience with the WARMP Mock-up Coronary Care 3:10 p.m. Unit.” STEPHEN YARNALL, M.D. (Washington- Jefferson Room Alaska) East 43 “Nursing in the Regional Medical Programs-Alliance for 1:30 p.m. Better Patient Care”? HESTER THURSTON (Kansas) Military Room Paper Paper No. Title, author, and (regior) Time and No. Title, author, and (regior) Time and 44 “Continuing Nursing Education Using University Hospital 1:50 p.m. 58 “Cancer Training and Continuing Education and Com- 2:30 p.m. Nursing Service Training Facilities.” (Mrs.) MARGARET Military puterized Tumor Registry.” CHARLES SMART, M.D. Thoroughbred SOVIE (Central New York) Room (Intermountain) Room 45 “Health Manpower Survey of Western New York.” Harry 2:10 p.m. 59 “Assurance of Adequate Therapy Following Detection of 2:50 p.m. A. SULTZ, JOHN FORTUNE, JOSEPH FELDMAN, Military Cervical Carcinoma”? JOHN B. PHILLIPS, M.D. Thoroughbred SPERO MOUTSATSOS (Western New York) Room (Albany, N.Y.) Room 46 “Guest Resident Program.” GEORGE ROBERTSON, 2:30 p.m. 60 “Coordinating High Energy Radiation Therapy for 35 3:10 p.m. M.D. (Maine) Military General Hospitals.” JOHN IVES €Connecticut) Thoroughbred Room Room 47 “Continuing Education Performance Deficits.” CLEMENT 2:50 p.m. BROWN, M.D. (Greater Delaware Valley) Military Room PAPERS BY TIME AND LOCATION OF PRESENTATION 48 “Skeleton Program in Continuing Education and Clinical 3:10 p.m. Research.” WILLIAM H. McBEATH, M.D. (Ohio Military WEDNESDAY, JANUARY 17, 1968 Valley) Room 49 “An Experimental Model in Organization of a Regional 1:30 p.m. yop: . ope . Paper - Medical Program.” RICHARD F. HAGLUND (Inter- Hemisphere Starting time Fille, author, and (region) No. Location mountain) Room 50 “Multi-Project Planning.” WILLIAM R. THOMPSON 1:50 p.m. 1:30 p.m. “Health Evaluation Studies Utilizing a 1 Lincoln Room (Washington-Alaska) Hemisphere Multiphasic Screening Center Operating East Room in Cooperation with a Comprehensive é “ : : Health Care Program for Persons in an St A Systems Approach to Regional Medical Program Plan- 2:10 p.m. 3 se : - > . : Urban Poverty Area.” LLOYD ELAM, ning.” DAVID H. GUSTAFSON, PH. D. (Wisconsin) Hemisphere M.D. (Tennessee Mid-South) Room ~ ne « . . “The Use of a Multi-Media Approach to 7 Lincoln Room 52 Development of a Regional Medical Program Data Source 2:30 p.m. Enhance the Learning of Health Science West Book.” LOUISE BELL (Western Pennsylvania) Hemisphere Personnel? WILLIAM G. COOPER, Room M.D. (Colorado-Wyoming) 13 “Clinical Data Collection with a Purpose.” HOMER 2:50 p.m. “The Role of the Voluntary Health Agencies 13 Military WARNER, M.D. (Intermountain) Hemisphere in the Regional Medical Program in Room Room Towa.” WILLARD A. KREHL, M.D. 54 “The Design and Dissemination of Data Collecting Instru- 3:10 p.m. (Iowa) ments.” LAURA G. LARSON, R.N. (Mountain States) Hemisphere “Watts-Willowbrook Regional Medical Pro- 19 Hemisphere Room gram.” DONALD J. BRAYTON, M.D. Room 35 “A Cooperative Project for the Care of Cancer Patients by 1:30 p.m. (California) Memorial Hospital for Cancer and Allied Diseases.” Thoroughbred “ cul : A Proposed Circuit Postgraduate Program 25 Thoroughbred GUY F. ROBBINS, M.D. (New York Metropolitan) Room in Heart Disease, Cancer, Stroke, and Re- Room 56 “Cooperative Community Health Program.” EDWARD 1:50 p.m. lated Diseases in the Oregon Region.” M. L. BURNS, M.D. (Northwestern Ohio) Thoroughbred ROBERTS GROVER, M.D. (Oregon) Room “Systems Approach to Planning.” ANGELO 30B Dupont 57 “Community Cancer Coordinator.” WILLIAM P. NEL- 2:10 p.m. P. ANGELIDES, M.D., LARRY Me- Room SON, M.D. (Albany, N.Y.) Thoroughbred GOWAN, M.D., ARTHUR STANKO- Room VICH (Greater Delaware Valley) 292-414 O—68——-10 135 Starting lime 1:50 p.m. 2:10 p.m. 136 Title, author, and (region) “Provision of Optimum Clinical Laboratory Services for 3,000,000 People.” DAVID SELIGSON, M.D. (Connecticut) “Use of a Telephone Network for Continuing Education”? RICHARD TU. LYONS, M.T. (Central New York) “Small Community Planning.” TASKER K. ROBINETTE (Washington-Alaska) “Council of Regional Planning Directors and Administrators.” JOSEPH J. MASON, JR. (Alabama) “The Information and Education Resource Support Unit.” JOHN N. LEIN, M.D. (Washington-Alaska) “Tnformal Discussion on Systems Analysis.” HERBERT P. GALLINER, JR., PH. D. Professor, University of Michigan “Biochemical Screening in Missouri.” JAMES | T. PACKER, M.D. and HUBERT J. VAN PEENEN, M.D. (Missouri) “Communication Research Unit.” WILLIAM STEPHENSON (Missouri) “Coordination of Comprehensive Health Planning and Regional Medical Program Activities in Western Pennsylvania, 1967.” E. WAYNE MARTZ, M.D. and LIOWARD HOUGHIL (Western Pennsyl- vaniit) “Development — of Relationship Between the Medical Association of the State of Alabama and the Alabama Regional Mcdical Program.” J. O. FINNEY, M.D. (Alabama) “Unusual for Continuing Ed- ueation of Physicians at Grassroots Level? C1. WILBAR, JR., M.D. (West Virginia) Programs 306 24 Location Lincoln Room 2:30 p.m. East Lincoln Room West Military Room }1emisphere Room Thoroughbred Room Dupont Room Lincoln Room East 2:50 pam. Lincoln Room West Military Room Hemisphere Room ‘Thoroughbred Root Starting time Title, author, and (region) “A Regional Utilization, Patient Informa- tion and Statistics System.’ JOHN D. THOMPSON (Connecticut) “Community Information Coordinator.” WARD L. OLIVER, M.D. (Albany, N.Y.) “Complementary Relationship Between Towa Regional Medical Program— compre~ hensive Tlealth Planning and Voluntary Comprehensive Health Planning: A Neces- sary Accomplishment.” JOHN C. BART- LETT, M.A., LL. B. (lowa) “The Sub-Regional Concept and Liaison Staff.” WILLIAM G. SPRING, JR. M.D. and WARD BENTLEY (Greater Delaware Valley) *Community-Centered Continuing Medical Education.” C. HILMON CASTLE, M.D. (intermountain) “Planner House Multiphasic Screening Pro- gram.” HARVEY FEIGENBAUM, M.D. (Indiana) “Development of Receptive Attitudes ‘To- ward New [deas.? JOLIN S. GILSON, M.D. (Intermountain) “Problems in Developing the Role of Medical Schools in a Regional Medical Program.” VINCENTE dePAUL LARKIN, M.D. (New York Metropolitan ) “Phe Delineation of Sub-Regional Health Service Areas as a Basic Step in Regional Medical Planning.” CONRAD SETPP, MT. (Connecticut) “Survey of Continuing Education of the Physicians in Metropolitan Washington.” THOMAS Wo MATTINGLY, M.D... LEONARD CHIAZZE, JR. SC.D.. and MAL XAVIER (Metropolitan Woash- ington, 1.0.) Paper No. 4 16 28 Location Lincoln Room East Lincoln Room West Military Room Hemisphere Room ‘Thoroughbred Room Lincoln Room Bast Lincoln Room West Military Room Hlenusphere Room ‘Phoroughbred Room Paper Paper Starling lime Title, author, and (region) No. Location Starting time Title, author, and (region) Na. Location 3:10 p.m. “Experiment to Test and Tmplement a 6 Lincoln Room 1:50 p.m. “Consumer Health Care Survey.” LAW- 32 Lincoln Room Model of Patient) Care in Efospitals.” Bast RENCE J. SHARP, PH.D. (Washington- East LUTHER CHRISTMAN, PH. D. (Pen- Alaska) nesscc Mid-South) “System for Clinical Data Collection and 38 Jefferson Room “The Impact of RMP on Hard Core Pov- 12 Lincoln Room Analysis in Patients with Acute Myocar- East erty Areas.” PAUL D. WARD (Cali- West dial Infarction.” C. HILMON CASTLE, fornia) M.D. (Intermountain) “The Role of a School of Public Health ina 18 Military “Continuing Nursing Education Using Uni-+ 44 Military Room Developing Regional Medical Program.” Room versity Hospital Nursing Service Training EDWARD COHART, M.D. (Connec- Facilities”? (Mrs.) MARGARET SOVIE ticut) (Central New York) “Regional Advisory Group and Review 24 Hemisphere “Multi-Project Planning.” WILLIAM R. 50 Hemisphere (ances) CHARLES E. LEWIS, M.D. Room THOMPSON (Washington-Alaska) Room ansas “ i i Ith P 2 T “Approaches to Evaluation of a Regional 30A Thoroughbred ae aera Community pean “(Nowth- i Reroughbred Medical Program.” CALDWELL B. Room western Ohio) oa ESSELSTYN, M.D. (New York Metro- politan) 2:10 p.m. “Continuum of Long-Term Care in a Local 33 Lincoln Room Health Service Area.’ E. RICHARD East PAPERS BY TIME AND LOCATION OF PRESENTATION WEINERMAN, M.D. (Connecticut) “Cost Benefit Analysis.” JOHN E. WENN- 39 Jefferson Room THURSDAY, JANUARY 18, 1968 BERG, M.D. (Northern New England) East P “Health Manpower Survey of Western New 45 Military Starting lime Title, author, and (region) Ne. Location York.” HARRY A. SULTZ, JOHN FOR- Koon , , TUNE, JOSEPH FELDMAN, and SPERO MOUTSATSOS (Western New 1:30 p.m. “A Study of Physician Office Practice inthe 31 Lincoln Room York) Feet cut Ree AN. emt oenreee East ““A Systems Approach to Regional Medical 51 Hemisphere Feel an . we Program Planning.” DAVID H. GUSTAF- Room (Connecticut) SON, M.D. (Wisconsin) “Experiences with a Stroke Care De stra 37 ‘fferson Room ee ont? ROBERT ke SMITIL, MLD. Jen ron moom “Community Cancer Coordinator.” WIL- 57 Thoroughbred (Mississippi LIAM P. NELSON, M.D. (Albany, Room Pi) — . . a. New York) ‘Nursing in the Regional Medical Programs- 43 Military Room Alliance for Better Patient Care.” HESTER 2:30 p.m. “Involvement of Local Hospitals in the 34 Lincoln Room THURSTON (Kansas) Regional Medical Program by the Ap- East “An Experimental Model in Organizationof 49 Hemisphere pointment of Local Hospital Advisory a Regional Medical Program.” RICHARD Room Groups. J. GORDON BARROW, M.D. F. HAGLUND (Intermountain) (Georgia) “A Cooperative Project for the Care of Can- 55 Thoroughbred “Comprehensive Cardiovascular Care Unit.” 40 Jefferson Room cer Patients by Memorial Hospital for Room GLENN O. TURNER, M.D., CECIL R. East Cancer and Allied Diseases.” GUY F. ROBBINS, M.D. (New York Metropolitan) AUNER, M.D., and JOHN J. McKINSEY, M.D. (Missouri) 137 Paper APPENDIX C LISTING OF PARTICIPANTS AND LOCATION OF DISCUSSION GROUPS Starting time Title, author, and (region) No. Location 2:30 p.m. “Guest Resident Program.” GEORGE 46 Military ROBERTSON, M.D. (Maine) Room “Development of a Regional Medical Pro- 52 Hemisphere gram Data Source Book.” LOUISE BELL Room (Western Pennsylvania) “Cancer Training and Continuing Educa- 58 Thoroughbred ‘OPIC A tion and Computerized Tumor Registry.” Room TOP CHARLES SMART, M.D. (Intermoun- Moderator: tain) 2:50 p.m. “The Regional Medical Program as a Means 35 Lincoln Room of Increasing the Morale of the Family East Doctor.” ROGER BOST, M.D. (Ar- Discussants: kansas) “Dataphone EKG Consultation: A Model 41 Jefferson Room for Extension of Medical Center Services East to Community Hospitals.’ JOHN B. HERMANN (Nebraska-South Dakota) “Continuing Education Performance Defi- 47 Military cits”? CLEMENT BROWN, M.D. Room (Greater Delaware Valley) “Clinical Data Collection with a Purpose.” 53 Hemisphere HOMER WARNER, M.D. (Intermoun- Room tain) “Assurance of Adequate Therapy Following 59 Thoroughbred Detection of Cervical Carcinoma.” JOHN Room B. PHILLIPS, M.D. (Albany, New York) 3:10 p.m. “Experience with the WARMP Mock-up 42 Jefferson Room Coronary Care Unit.”” STEPHEN YARN- East ALL, M.D. (Washington-Alaska) Recorder: “Community Hospital Learning Centers.” 36 Lincoln Reom FRANK M. WOOLSEY, JR., M.D. East (Albany, New York) “Skeleton Program in Continuing Educa- 48 Military Room tion and Clinical Research.” WILLIAM H. McBEATH, M.D. (Ohio Valley) “The Design and Dissemination of Data 54 Hemisphere Collecting Instruments.” LAURA G. Room LARSON, R. N. (Mountain States) “Coordinating [gh Energy Radiation Therapy for 35 General Hospitals.” JOHN IVES (Connecticut) 60 WEDNESDAY, JANUARY 17 SESSION I-—DISCUSSION GROUPS 3:45-5:15 p.m. ‘Thoroughbred Room 138 Lincoln Room East “Tealth Manpower—Review of Commission Report” *JAMES C. CAIN, M.D., Consultant in Medicine, The Mayo Clinic, Rochester, Minn. LEONARD FENNINGER, M.D., Director, Bureau of Health Manpower, Public Health Service. ELEANOR LAMBERTSON, ED.D., Director, Division of Nursing Education, Teachers’ College, Columbia University, New York, N.Y. Cc. H. WILLIAM RUHE, M.D., Director, Division of Medical Education, American Medical Association, Chicago, Ill. *DWIGHT WILBUR, M.D., President-Elect, American Medical Association, San Francisco, Calif. CECILIA CONRATH, Assistant to Chief, Continuing Education and Training Branch, Division of Regional Medical Programs. * Members of the National Advisory Commisston on Health Manpower. TOPICB Moderator: Discussants : Recorder: Military Room “Regionalization” TOPIC C ROBERT SIGMOND, Moderator: Executive Director, Hospital Planning Association of Allegheny County, Pittsburgh, Pa. LESTER BRESLOW, M.D., Discussants: Professor of Health Administration and Chairman, Health Services Division, School of Public Health, University of California at Los Angeles, Los Angeles, Calif. WALTER J. McNERNEY, Exccutive Director, Blue Cross Association, Chicago, Ill. WILLIAM R. WILLARD, M.D., Vice President, University of Kentucky Medical Center, Lexington, Ky. ROLAND PETERSON, Chief, Planning Branch, Division of Regional Medical Programs. Recorder: Lincoln Room West “Urban Problems” PAUL WARD, Executive Director, California Committee on Regional Medical Programs, San Francisco, Calif. ROGER O. EGEBERG, M.D., Dean, School of Medicine, University of Southern California, Los Angeles, Calif. FRANK LLOYD, M.D., Director of Research, Methodist Hospital of Indiana, Indianapolis, Ind. ANNE R. SOMERS, Industrial Relations Section, Princeton University, Princeton, N.J. RAY TRUSSELL, M.D., Director, School of Public Health and Administrative Medicine, Columbia University, New York, N.Y. STEPHEN ACKERMAN, Associate Director for Planning and Evaluation, Division of Regional Medical Programs. 139 TOPIC D Moderator: Discussants: Recorder: 140 Hemisphere Room “Related Federal Programs” TOPIC E DANIEL IL. ZWICK, Associate Director for Program Management, Health Services Office, Community Action Program, Office of Economic Opportunity. JOHN W. CASHMAN, M.D., Director, Division of Medical Care Administration, Bureau of Health Services, Public Health Service. JAMES 11. CAVANAUGH, PIE D., Director, Office of Comprehensive Health Planning, Office of the Surgeon General, Public Health Service. DONALD R. CHADWICK, M.D., Director, National Center for Chronic Disease Control, Bureau of Disease Prevention and Environmental Control Public Health Service. CARRUTH WAGNER, M.T)., Director, Burcau of Efealth Services, Public Health Service. LEROY GOLDMAN, Program Policy Specialist, Division of Regional Medical Programs. Moderator: Recorder: Discussants: Thoroughbred Room “Health Services Research” PAUL SANAZARO, M.D., Director, Division of Education, Association of American Medical Colleges, Evanston, HI. MORRIS E. COLLEN, M.D., Director, Department of Medical Methods Research, The Permanente Medical Group, Oakland, Calif. CALDWELL BL ESSELSTYN, M.D., Associate Director, New York Metropolitan Regional Medical Program, New York, N.Y. JOHN THOMPSON, Professor of Public Health and Director, Program in Hospital Administration, School of Public Health, Yale University, New Haven, Conn. JOEIN WILLIAMSON, M.D., Division of Medical Care and Hospitals, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Md. RICHARD MANEGOLD, M.D., Associate Director for Program Development and Research, Division of Regional Medical Programs. THURSDAY, JANUARY 18 SESSION II—DISCUSSION GROUPS 3:45-5:15 p.m. TOPIC F Moderator: Discussants: Recorder: Jefferson Room East “Continuing Education and ‘Training, For What?” TOPIC G PATTRECGK BO STORUIY, MoD, Professor ciel Ch vv, Departinent of Counmmoity Mecheie, Hahnemann Medical College, Philadelphia, Pa. LUTHER CHRISTMAN, Ph. D., Dean, School of Nursing, Vanderbilt University, Nashville, ‘Penn. GEORGE E. MILLER, M.D., Director, Office of Research in Medical Education, University of [inois, Chicago, IH. A.N. TAYLOR, Ph. D., Dean, School of Related Health Services, Chicago Medical School, Chicago, III. ALEXANDER M. SCHMIDT, M.D., Chief, Continuing Education and Training Branch, Division of Regional Medical Programs. Recorder: Moderator: Discussants: Thoroughbred Room “Mata Collection and Registries” ABRALIAM M. LILDPENEPR.LD, MLD., Professor and Cliaivaisin, Departinent of Chronic Diseases, School of Ilygicne and Public Health, Johns Hopkins University, Baltimore, Md. JAMES F. KING, JR., Office of Program Planning and Evaluation, Office of the Surgeon General, Public. Health Service. ANDREW MAYER, M.D., Assistant Director, American College. of Surgeons, Chicago, Ill. HARVEY SMITH. Ph. D., Director, Research, Survey and Evaluation, University of North Carolina, Chapel Hill, N.C. JOHN E. WENNBERG, M.D., Coordinator, Northern New England Regional Medical Program, Burlington, Vt. MAURICE E. ODOROFF, Assistant to the Director for Health Data, Division of Regional Medical Programs. 141 TOPIC H Moderator: Discussants: Recorder: Military Room “Hospitals” D. EUGENE SIBERY, Executive Director, Greater Detroit Area Hospital Council, Detroit, Mich. PEARL FISHER, R.N., Administrator, Thayer Hospital, Waterville, Maine. JOHN W. KAUFFMAN, Administrator, Princeton Hospital, Princeton, N.J. EDWARD H. NOROIAN, Executive Director, Presbyterian University Hospital, Pittsburgh, Pa. RICHARD MANEGOLD, M.D., Associate Director for Program Development and Research, Division of Regional Medical Programs. TOPICI Moderator: Discussants: Recorder: 142 Hemisphere Room “Community Involvement” ROBERT M. CUNNINGHAM, JR., Editor, Modern Hospital Magazine, Chicago, Ill. ALAN C. DAVIS, Science Editor, American Cancer Society, New York, N.Y. HOWARD ENNES, M.P.H., Assistant Vice President for Community Services and Health Education, The Equitable Life Assurance Society, New York, N.Y. PIERRE C. FRALEY, Director of Information, Greater Delaware Valley Regional Medical Program, Philadelphia, Pa. MARC J. MUSSER, M.D., Coordinator, North Carolina Regional Medical Program, Durham, N.C. EDWARD M. FRIEDLANDER, Assistant to the Director for Communications and Public Information. Division of Regional Medical Programs. TOPIC J Moderator: Discussants: Recorder: Lincoln Room East “Operational Program Development” CHARLES E. LEWIS, M.D., Coordinator, Kansas Regional Medical Program, Kansas City, Kans. C. HILMON CASTLE, M.D., Coordinator, Intermountain Regional Medical Program, Salt Lake City, Utah. T. A, DUCKWORTH, Chairman, Regional Advisory Group, Wisconsin Regional Medical Program, Wausau, Wis. ALBERT E. HEUSTIS, M.D., Coordinator, Michigan Regional Medical Program, East Lansing, Mich. DONAL R. SPARKMAN, M.D., Coordinator, Washington-Alaska Regional Medical Program, Seattle, Wash. RICHARD STEPHENSON, M.D., Associate Director for Operations, Division of Regional Medical Programs. APPENDIX 2 COORDINATORS’ STEERING COMMITTEE REGIONAL MEDICAL PROGRAMS J. MINOTT STICKNEY, M.D., Program Coordinator, Northlands Regional Medical Program, Rochester, Minn. PAUL D. WARD, Program Coordinator, California Regional Medical Program, San Francisco, Calif. STANLEY W. OLSON, M.D., (Chairman) Program Coordinator, Tennessee Mid-South Regional Medical Program Professor of Medicine, Vanderbilt University, Nashville, Tenn. C. HILMON CASTLE, M.D., Program Coordinator, Intermountain Regional Medical Program, Associate Dean and Chairman, Department of Postgraduate Education, University of Utah, Salt Lake City, Utah. JAMES. T. HOWELL, M.D., Member, National Advisory Council on Regional Medical Programs, Executive Director, Henry Ford Hospital, Detroit, Mich. MARC J. MUSSER, M_D., Program Coordinator, North Carolina Regional Medical Program, Durham, N.C. WILLIAM C. SPRING, JR., M.D., Program Coordinator, Greater Delaware Valley Regional Medical Program, Wynnewood, Pa. APPENDIX 3 REGISTERED CONFERENCE PARTICIPANTS ABDELLAH, Dr. Faye G. Chief, Research Grants Branch Division of Nursing Public Health Service ADAMS, Wright, M.D. Executive Director IHinois Regional Medical Program AKERLOW, Charles W. Director, Media Services Intermountain Regional Medical Program ALEXANDER, Chauncey A. Assistant Director for Program Development—-Area IV University of California, Los Angeles California Regional Medical Program ALLRED, J. D., M.D. Assistant Coordinator Maryland Regional Medical Program AMOS, James R., M.D. State Health Department of North Dakota North Dakota Regional Medical Program ANDERSON, Elmer A., M.D. Medical Director John Wesley Hospital Los Angeles County Department of Hospitals ANDERSON, H. William Assistant Director Arkansas Regional Medical Program ANDERSON, Ivan D. Director of Research Kansas Blue Cross-Blue Shield Kansas Regional Medical Program ANDERSON, Otis L., M.D. Assistant Manager Washington, D.C., Office of American Medical Association ANDERSON, Philip C., M.D. Special Assistant to the Director National Institutes of Health ANDREWS, Neil C., M.D. Coordinator Ohio Valley Regional Medical Program ANGELIDES, Angelo P., M.D. Director of Medical Education The Lankenau Hospital of Philadelphia Greater Delaware Valley Regional Medical Program ARBONA, Guillermo, M.D. Professor of Preventive Medicine and Public Health School of Medicine University of Puerto Rico AREND, William P., M.D. Medical Consultant Heart Disease Control Program Public Health Service ARRINGTON, Clifton W., M.D. Meharry Medical College Mid-South Tennessee Regional Medical Program ARTZ, Invelda M. Nurse Consultant Heart Disease Control Program Public Health Service ASTON, Lydia S. Public Health Advisor Regional Medical Program West Virginia University Medical Center ATCHLEY, William A., M.D. Assistant Area Coordinator California Regional Medical Program University of California School of Medicine ATTIS, Bari Information Specialist National Institute of Neurological Diseases and Blindness National Institutes of Health BACASTOW, Merle S., M.D. President Medical Care Development, Inc. Maine Regional Medical Program 143 BAILEY, David R. Program Analyst Program Planning and Evaluation Office of the Surgeon General Public Health Service BAIN, H. O. Community Relations, California (Davis) Regional Medical Program University of California at Davis BAKER, John G. Public Relations Counsel Wisconsin Regional Medical Program BARD, Wayne M. Information Officer Bureau of Health Manpower Public Health Service BARNES, Donald R. Medical Systems Development Laboratory Heart Disease Control Program National Center for Chronic Disease Control Public Health Service BARNHART, Gilbert R., M.D. Bureau of Health Services Public Health Service BARR, Daniel M. University of Missouri School of Medicine BARROW, J. Gordon, M.D. Director Georgia Regional Medical Program BARTLETT, John C. Assistant Program Coordinator Iowa Regional Medical Program BASALYGA, R. G., M.D. Chief, Program Development Section Heart Discase and Stroke Control Program Public Health Service BATES, Barbara, M.D. Rochester (New York) Regional Medical Program 144 BATES, Roswell P., D.O. Executive Director Maine Osteopathic Association Regional Advisory Group Maine Regional Medical Program BAUMGARTNER, Leona Professor of Social Medicine Harvard Medical School BEASLEY, Steven E. Science Writer National Institute of Neurological Diseases and Blindness National Institutes of Health BECHILL, William D. Commissioner Administration on Aging Social and Rehabilitation Service U.S. Department of Health, Education, and Welfare BEDWELL, Maj. Gen. T. C., Jr. Director of Staff Assistant Secretary of Defense Health and Medical BELL, Louise M. Research Associate Western Pennsylvania Regional Medical Program BENJAMIN, Clement Assistant Chief Educational Studies Section National Medical Audiovisual Center Atlanta, Ga. BENTLEY, Ward Chief, Area Liaison Greater Delaware Valley Regional Medical Program BERNSTEIN, Arthur, M.D. Cardiac Program New Jersey Regional Medical Program BERNSTEIN, Lionel, M.D. Acting Assistant Chief Medical Director for Research and Education Veterans Administration and Development BERRY, Albert G. Instructor Department of Oral Pathology Meharry Medical College BERSON, Robert C., M.D. Executive Director Association of American Medical Colleges BINGHAM, Fletcher H. Assistant Director Council of Teaching Hospitals Association of American Medical Colleges BIRCH, Larry H., M.D. Program Director Michigan Regional Medical Program BLACK, Louis A., M.D. Assistant Program Coordinator Northwestern Ohio Regional Medical Program BLAKE, Thomas M. Coordinator for Fleart Mississippi Regional Medical Program BLAKEY, Thelma M. ‘Health Educator American Cancer Society BLASINGAME, J. T., Jr., M.D. Member Advisory Group Georgia Regional Medical Program BLAZER, Mrs. Rexford S. Vice Chairman, Regional Advisory Group Ohio Valley Regional Medical Program BLESS, Stuart R., M.D. Assistant Chief, Coronary Section Heart Disease Control Program National Center for Chronic Disease Control U.S. Department of Health, Education, and Welfare BLOOM, Charlotte Information Specialist Bureau of Health Manpower Public Health Service BOHANNON, Richard L., M.D. Former Surgeon General U.S, Air Force BOQUIST, William Information Coordinator California Regional Medical Program BORHANI, Nemat O., M.D. Professor of Medicine and Chairman, Department of Community Health School of Medicine University of California at Davis BORLAND, Jack Manager, Services Department Smith, Kline and French Laboratories BOST, Howard L., Ph. D. Ohio Valley Regional Medical Program Assistant Vice President for Program and Policy Planning University of Kentucky BOST, Roger B., M.D. Director Arkansas Regional Medical Program BOUCHARD, Richard E., M.D. Assistant Professor of Medicine University of Vermont Director of Coronary Care Program Northern New England Regional Medical Program BOWMAN, C. W. Program Representative South Carolina Regional Medical Program BOYDEN, George M. Chairman, Education Committee New Mexico Regional Medical Program BOYLE, Richard E., M.D. Department of Continuing Education Colorado-Wyoming Regional Medical Program . BRAUNSTEIN, Norman W. Public Health Advisor Chronic Respiratory Disease Program Public Health Service BRAWNER, Donald L. Chairman, Tulsa Subregional Committee Oklahoma Regional Medical Program BRAYTON, Donald, M.D. Coordinator—Area IV University of California at Los Angeles California Regional Medical Program BRENNAN, Michael J., M.D. President, Michigan Cancer Foundation Professional Advisory Committee on Cancer Regional Advisory Board Michigan Regional Medical Program BRESLOW, Lester, M.D. Professor of Health Administration Chairman, Health Services Division School of Public Health University of California at Los Angeles BRICKER, Sandra Editorial Assistant Ohio Valley Regional Medical Program BRINKLEY, Sterling B., M.D. Chief Medical Officer Rehabilitation Services Administration U.S. Department of Health, Education, and Welfare BROIDA, Joel H. Physical Therapy Consultant Heart Disease and Stroke Control Program Public Health Service BROOKS, Fredrica Public Relations Director New York Metropolitan Regional Medical Program BROWN, Charles E., M.D. President Charles Drew Medical Society California Regional Medical Program BROWN, Charles R. Administrative Assistant Indiana University Medical Center BROWN, Clement R., Jr., M.D. Director of Medical Education Chestnut Hill Hospital Greater Delaware Valley Regional Medical Program BROWNING, Levi M., M.D. Coordinator for Alaska Washington-Alaska Regional Medical Program BRUCE, Dr. Harry Chief, Manpower and Education Division of Dental Health Public Health Service BRYAN, James E. Executive Secretary American Federation for Clinical Research BUCCI, Barbara Echols Research Assistant The Johns Hopkins University Department of Medical Care Hospitals BUCHER, Robert, M.D. Dean, Temple University School of Medicine BURK, Lloyd B., Jr., M.D. Metropolitan Washington, D.C. Regional Advisory Group BURNEY, Anita W., M.P.H. Health Services Advisor U.S. Department of Housing and Urban Development BURNS, Edward L., M.D. Chairman, Regional Advisory Group Northwestern Ohio Regional Medical Program BURTON, Marvin H. Physician Education Coordinator New Jersey Regional Medical Program BUTLER, Josephine Washington, D.C., Tuberculosis Association BYRON, T. X., M.D. Medical Representative Postgraduate Programs California Regional Medical Program CAIN, James C., M.D. Consultant in Medicine The Mayo Clinic CALDWELL, Charles W. Director, Program Development and Ficld Services Iowa Regional Medical Program CALDWELL, Dale Director of Information Oregon Regional Medical Program CALLAHAN, Thomas E. Regional Advisory Group Western Pennsylvania Regional Medical Program CAMPBELL, Guy D., M.D. Coordinator Mississippi Regional Medical Program CANNON, Wilson P., Jr. Chairman, Regional Advisory Group Hawaii Regional Medical Program Senior Vice President Bank of Hawaii CARPENTER, Robert R., M.D. Institutional Liaison Officer Baylor University College of Medicine CARSON, Bruce F. Chief, Legislative Reference and Liaison Branch Office of Program Planning National Institutes of Health CASELEY, Donald J., M.D. Vice Chairman, Regional Advisory Group Tilinois Regional Medical Program Medical Director and Associate Dean University of Illinois Hospitals CASTLE, C. Hilmon, M.D. Program Coordinator Intermountain Regional Medical Program CAVANAUGH, James H., Ph. D. Director of Comprehensive Health Planning Office of the Surgeon General Public Health Service CAZORT, Ralph J., M.D. Dean Meharry Medical College CHADWICK, Donald R., M.D. Director, National Center for Chronic Disease Control Bureau of Disease Prevention and Environmental Control Public Health Service CHAMBERS, J. W., M.D. Program Coordinator Georgia Regional Medical Program CHAMBLISS, Cleveland R. Office of Program Planning Office of the Director National Institutes of Health CHAPMAN, Carleton B., M.D. Dean Dartmouth University Medical School CHASE, Beatrice A. Director, Services Community Planning for Nursing National League for Nursing CHATTERJEE, Manu, M.D. Program Coordinator Maine Regional Medical Program CHRISTMAN, Dr. Luther Dean, School of Nursing Vanderbilt University CICARELLI, Sara Marie President-Elect American Society of Medical Technologists CLAMMER, George R., M.D. Associate Coordinator for the State of Pennsylvania Greater Delaware Valley Regional Medical Program CLARK, Henry T., Jr., M.D. Program Coordinator Connecticut Regional Medical Program CLARK, John Kapp, M.D. Chief, Regional Medical Program Activi- ties University of Pennsylvania CLARK, Sister M. Ferdinand Chairman, Subcommittee on Community Involvement Regional Medical Program of Western Pennsylvania Administrator of Mercy Hospital of Pittsburgh CLEMENT, Edward C. Administrative Services Department North Carolina Regional Medical Program 145 COBB, Alton B., M.D. Chairman, Regional Advisory Group Mississippi Regional Medical Program Director, Division of Chronic Illness State Board of Health COGGESHALL, Lowell T., M.D. Vice President University of Chicago COHART, Edward M., M.D. Professor of Public Health Yale University Department of Epidemi- ology and Public Health COHN, Roy, M.D. Chairman, Stanford—Area ITI Regional Medical Programs Stanford University Medical Center COLE, Clifford H., M.D. Chief, Neurological and Sensory Disease Control Program Public Health Service COLEMAN, James Walker, IIT Program Representative South Carolina Regional Medical Program Medical College of South Carolina COLLEN, Morris E., M.D. Director, Department of Medical Methods Research The Permanente Medical Group COLLINS, William T., M.D. Secretary, Regional Advisory Group Northwestern Ohio Regional Medical Program Lima Memorial Hospital COMBS, Robert C., M.D. Area Director, Irvine—Area VIII California Regional Medical Program CONNOLLY, Eleanor C. Consultant National Tuberculosis Association CONNOLLY, John T. Staff Coordinator, Program Development New York Metropolitan Regional Medical Program 146 COOK, Ernest W., Ph. D. Medical Care and Education Foundation Rhode Island Regional Medical Program COOLEY, George W. Medical Society of the District of Columbia COOPER, Gerald R., M.D. Chief, Heart Disease Control Standardi- zation Laboratory National Communicable Disease Center in Atlanta COOPER, Henry R., M.D. Member, Regional Advisory Group Florida Regional Medical Program COOPER, Theodore, M.D. Associate Director National Heart Institute National Institutes of Health COOPER, William G., M.D. Director, Unit Teaching Laboratories University of Colorado Mcdical Center COPELAND, Murray M., M.D. Associate Director M.D. Anderson Medical Hospital and Tumor Institute Texas Medical Center CORNELY, Paul B., M.D. Head, Department of Preventive Medicine Howard University CRAYTOR, Josephine K., R.N. Rochester (New York) Regional Medical Program University of Rochester CREVASSE, Lamar, M.D. North Central Florida Subarea Coordinator Florida Regional Medical Program College of Medicine University of Florida CRISPELL, Kenneth R., M.D. Member, Executive Committee Virginia Regional Medical Program Dean, University of Virginia Medical School CROCKETT, Charles L., Jr., M.D. Consultant, Continuing Education and Regional! Planning Virginia Regional Medical Program Roanoke Memorial Hospital CROSS, Edward B., M.D. Chief, Adult Heart Control Section Heart Disease Control Program Public Health Service CROSWHITE, Margaret D. Office of Communication Alabama Regional Medical Program CROUCH, Boyden L. Coordinator of Communications and Continuing Education Arizona Regional Medical Program Research Assistant, University of Arizona School of Medicine CROW, Harry R. Sales Manager Wilson Gill, Incorporated CROW, Richard S., M.D. Medical Officer National Center for Chronic Disease Control Public Health Service CUGLIANI, Anne Staff Coordinator, Data and Research New York Metropolitan Regional Medical Program CULBERTSON, James W., M.D. Program Coordinator Memphis Regional Medical Program CUNNINGHAM, Robert M., Jr. Editor, Modern Hospital Magazine Chicago, III. DAITZ, Bernard D., M.D. Special Assistant to the Chief Division of Medical Care Administration Public Heaith Service DANFORTH, William H., M.D. Vice Chancellor for Medical Affairs Washington University, St. Louis Program Coordinator Bi-State Regional Medical Program DAVID, Wilfred, M.D. Deputy Director National Center for Chronic Disease Control Bureau of Disease Prevention and Environmental Control Public Health Service DAVIES, Dean F., M.D. Memphis Regional Medical Program DAVIS, Alan C. Science Editor American Cancer Society DAVIS, Burnet M., M.D. Research and Training Division National Library of Medicine Public Health Service DEAN, C. Robert, M.D. Associate Regional Health Director— Region II New York Metropolitan Regional Medical Program DEARING, W. Palmer, M.D. Executive Director Group Health Association of America, Inc. DeBAKEY, Michael E., M.D. Professor and Chairman, Department of Surgery College of Medicine, Baylor University Division of Regional Medical Programs Advisory Council DeGRASSE, Richard V. Program Manager Northern New England Regional Medical Program Del GUERCIO, Marie T., R.N. Health Education Coordinator New Jersey Regional Medical Program Del REGATO, Juan A., M.D. Director, Penrose Cancer Hospital of Colorado Springs National Advisory Cancer Council DeMARIA, William J., M.D. Director, Continuing Education North Carolina Regional Medical Program DENTON, Harrict A. Editor Public Health Service U.S. Department of Health, Education, and Welfare DIEFENBACH, Viron L., D.D.S. Director, Division of Dental Health Public Health Service DIETZ, J. Herbert, Jr., M.D. Consultant in Rehabilitation Medicine New York University Medical Center and Memorial Hospital Center DOAN, Howard W., M.D. Director Colorado-Wyoming Regional Medical Program DRISCOLL, Dr. Edward J. Associate Director for Extramural Programs National Institute of Dental Research American Society of Oral Surgeons DuBEAU, Normand Assistant Director, Information and Com- munications Missouri Regional Medical Program DUCKWORTH, T. A. Chairman, Regional Advisory Group Wisconsin Regional Medical Program Employers Insurance of Wausau DUKE, Arnold Planning Assistant Oklahoma Regional Medical Program EASTWOOD, Richard T., Ph.D. Executive Vice President Texas Medical Center, Inc. EBERLY, Annette Assistant to the Assistant Director for Public Education Information Missouri Regional Medical Program ECKBERG, Dwain L., M.D. Scientist Administrator Division of Research Facilities and Resources National Institutes of Health EDDINGER, John W. Director of Information Maryland Regional Medical Program EDEN, Raymond L. California Regional Medical Program Regional Advisory Group Executive Director, California Heart Association EDWARDS, Jesse E., M.D. President American Heart Association Charles T. Miller Hospital EGEBERG, Roger O., M.D. Dean University of Southern California School of Medicine EHRLICH, Frank Chief, Budget Management, Section I Financial Management Branch Office of Administrative Management National Institutes of Health ELAM, Lloyd, M.D. President Mcharry Medical College ELDER, Jerry O. Assistant Director, Survey and Planning Oregon Regional Medical Program ELLWOOD, Paul M., Jr., M.D. Executive Director American Rehabilitation Foundation ENDICOTT, Kenneth M., M.D. Director National Cancer Institute National Institutes of Health ENNES, Howard, M.P.H. Assistant Vice President Equitable Life Assurance Society ERICKSON, Frederick K. Acting Director Division of Allied Health Manpower Bureau of Health Manpower Public Health Service ESCOVITZ, Gerald H., M.D. Acting Chief, Continuing Branch Division of Physician Manpower Bureau of Health Manpower Public Health Service ESSELSTYN, Caldwell B., M.D. Associate Director New York Metropolitan Regional Medical Program ESTES, E. Harvey, Jr., M.D. Director, Community Health Sciences Duke University Medical Center ETHRIDGE, Clayton B., M.D. Chairman, Regional Advisory Group Associate Dean, George Washington University Hospital EVANS, Lester, M.D. Associate Director (Education) Connecticut Regional Medical Program EVANS, Lloyd, M.D. Office of the Dean, College of Medicine Ohio State University EYMANN, Carolyn Information Services Kansas Regional Medical Program FAHS, Ivan J., Ph. D. Medical Sociologist Minnesota Regional Medical Program FALK, Leslie A., M.D. Tennessee Mid-South Regional Medical Program Chairman, Health Meharry Medical College FARBER, Sidney, M.D. President-Elect American Cancer Society Director of Research Children’s Cancer Research Foundation FAUBER, John, D.D.S. Secretary, Council on Hospital Dental Service American Dental Association FAZEKAS, Joseph F. New Mexico Regional Medical Program Education Department of Community FEARN, James A. Ficld Representative Susquehanna Valley Regional Medical Program FEIGENBAUM, Harvey, M.D. Indiana Regional Medical Program Associate Professor Indiana University Medical Center FENNINGER, Leonard D., M.D. Director Bureau of Health Manpower Public Health Service FETTER, Franklin C., M.D. : South Carolina Regional Medical Program Dean, Medical College of South Carolina FIELDS, Cleo Rochester, New York Regional Medical Program Heart Disease and Stroke Control Program Public Health Service FINNEY, J. O., M.D. Associate Director Alabama Regional Medical Program FISHER, F. David, M.D. Office of the Dean College of Medicine Ohio State University FISHER, Pearl R., R.N. Administrator Thayer Hospital of Waterville, Maine FISK, Shirley C., M.D. New York Metropolitan Regional Medical Program Columbia University College of Physicians and Surgeons FITZ, Reginald, M.D. Program Coordinator New Mexico Regional Medical Program Dean, School of Medicine University of New Mexico FLAGLER, Philip B. Service Manager Smith, Kline and French Laboratories 147 FLANDERS, Sarah E., M.D. Assistant Visiting Physician Goldwater Memorial Hospital New York University Medical Center FLANNAGAN, William H. Member, Executive Committee on Regional Medical Programs Roanoke Memorial Hospitals FLEISHER, Daniel S., M.D. Associate Professor of Pediatrics Temple University School of Medicine FLEMING, George M., Ed.D. Director/Coordinator, Allied Health Texas Regional Mcdical Program Methodist Hospital Baylor University College of Medicine FLORIN, Alvin A., M.D. Acting Coordinator New Jersey Regional Medical Program FOLEY, Joseph M., M.D. Coordinator of Postgraduate Medical Education and Professor of Neurology Case Western Reserve University School of Medicine FOLLMER, Hugh C., M.D. Associate Director for Nevada Mountain States Regional Medical Program FORBES, Charles M. Vice President Memorial Sloan-Kettering Cancer Center FORDHAM, Robert A. Coordinator of Federal Programs University of Vermont FOX, Samuel M., III, M.D. Chief, Heart Disease Control Program National Center for Chronic Disease Bureau of Disease Prevention and Environmental Control Public Health Service FRALEY, Pierre C. Director of Information Greater Delaware Valley Regional Medical Program 148 FRANCIS, John O'S. Executive Office of the President Bureau of the Budget FREDRICKSON, Donald S., M.D. Director, National Heart Institute National Institutes of Health FRIEDRICH, Rudolph H., D.D.S. Chairman, Department of Oral Surgery Columbia University American Society of Oral Surgeons Chairman, Committee on Regional Medical Programs FULLARTON, Jane Evalyn Assistant Chief, Legislative Branch Office of Program Planning National Institutes of TTealth GAINES, Barbara, R.N. Assistant Director Continuing Education Oregon Regional Medical Program GALLIHER, Herbert P., Jr., Ph. D. Professor of Industrial Engineering The University of Michigan GANZ, Aaron, D.DS. Chief, Program Planning Office National Institute of Dental Research National Institutes of Health GARCIA-PALMIERI, Mario R., M.D. Professor of Medicine School of Medicine University of Puerto Rico GARVEY, Henry T. Information Officer Heart Disease and Stroke Control Program Public Health Service GETZ, Richard R. Executive Director Medical Television Network GILLESPIE, Guy T., M.D. Cancer Coordinator Mississippi Regional Medical Program University Medical Center GILLESPIE, John W. Planning Officer Alabama Regional Medical Program GILSON, John. S., M.D. Associate Coordinator Intermountain Regional Medical Program University of Utah Medical Center GLOVER, Homer B. Area Liaison Officer Greater Delaware Valley Regional Medical Program GOLDSMITH, Katherine L. Assistant Director-—Area VIII California Regional Medical Program GOODHART, Robert S., M.D. Coordinator, New York Academy of Medicine New York Metropolitan Regional Medical Program GOTO, Unoji, M.D. Chairman, Heart Advisory Committee President, Hawaii Heart Association GOTTOVI, Daniel, M.D. Medical Consultant Heart Disease and Stroke Control Pro- gram Public Health Service GRABER, Mrs. Joe Bales Special Assistant to Director Bureau of Disease Prevention and Environmental Control Public Health Service GRAEBER, Fred O., M.D. Assistant Director of the Idaho Study Mountain States Regional Medical Program GRAHAM, William D., M.D. Deputy Director Hawaii Regional Medical Program - Leahi Hospital, Honolulu GRANDON, Raymond C., M.D. Chairman, Regional Advisory Group Susquehanna Valley Regional Medical Program GRANING, Harold M., M.D. Assistant Surgeon General Public Health Service GREEN, Jerome G., M.D. Associate Director for Extramural Programs National Heart Institute National! Institutes of Health GREENE, Charles R., M.D. Coordinator, Downstate Medical Center State University of New York New York Metropolitan Regional Medical Program GRIFFITH, John H. Research Associate Commission on Professional and Hospital Activities GRIZZLE, Claude O., M.D. Director, Wyoming Division Mountain States Regional Medical Pro- gram GRONVALL, John A., M.D. Associate Director and Associate Dean University of Utah Medical Center Co-Chairman, Coordinators’ Steering Committee Conference-Workshop on Regional Medi- cal Programs GROVER, M. Roberts, Jr., M.D. Program Coordinator Oregon Regional Medical Program GRUBB, Donald A. Assistant Program Coordinator Northwestern Ohio Regional Medical Program GUSTAFSON, David H., Ph. D. Planning Coordinator Wisconsin Regional Medical Program GUTHRIE, Eugene H., M.D. Associate Surgeon General Public Health Service HAGLUND, Richard F. Program Manager Intermountain Regional Medical Program University of Utah Medical Center HAGOOD, William J., Jr., M.D. Speaker, Congress of Delegates American Academy of General Practice Member, Executive Committee Virginia Regional Medical Program HALL, Jack, M.D. Director of Medical Education Methodist Hospital, Indianapolis HAMMERSLEY, Don W., M.D. Chief, Professional Service American Psychiatric Association HAMPTON, H. Phillip, M.D. Chairman, Executive Committee Florida Regional Medical Program HANSEN, Jane Information Specialist Heart Disease and Stroke Control Program Public Health Service HAPPEL, Rederick Assistant Coordinator Greater Delaware. Valley Regional Medical Program HARDIN, Neal H. Head, Continuing Education and Health Professions Oklahoma Regional Medical Program HARE, Edgar Delaware Liaison Representative Greater Delaware Valicy Regional Medical Program HARRIS, John H., Sr., M.D. Chairman, Special Board Committee Susquehanna Valley Regional Medical Program HARRISON, Donald C., M.D. Chairman, Subcommittee on Heart Disease Stanford—Area IIT California Regional Medical Program HARTFORD, Thomas J., M.D. Vice President, Area Medical Programs American Cancer Society, Inc. HARVEL, Alvin E. Assistant Representative for Regional Organization : Office of the Surgeon General Public Health Service HARWOOD, Theodore H., M.D. Program Coordinator North Dakota Regional Medical Program HASEGAWA, Masato M., M.D. Senior Member, Steering Committee Hawaii Regional Medical Program HATCH, Charles L. Field Representative Susquehanna Valley Regional Medical Program HATCH, Thomas D. Executive Officer Division of Allied Health Manpower Bureau of Health Manpower Public Health Service HAYES, Donald M., M.D. Assistant Professor of Medicine Bowman Gray School of Medicine HAYES, John J. Director, Hospital Division North Carolina Regional Medical Pro- gram HAYES, Richard L., M.D. Assistant to Chief Cancer Control Program National Center for Chronic Disease Control Public Health Service HAYES, Robert H., M.D. Associate Coordinator Nebraska-South Dakota Regional Medical Program HELLER, William M., Ph.D Director, Department of Scientific Services American Society of Hospital Pharmacists HELLMAN, Louis P., M.D. Program Planning and Evaluation Maryland Regional Medical Program University of Maryland School of Medicine HENDRYSON, Irvin E., M.D. Associate Director New Mexico Regional Medical Program HENNESSEY, Florence D., R.N. Chief, Nursing Service Veterans Administration Hospital Member, Regional Advisory Group Ohio Valley Regional Medical Program HENNINGS, Arthur G. Member, Regional Advisory Group Steering Committee Coordinator, University Health Center of Pittsburgh HENRY, Barbara Whitmore Arca Liaison Officer Greater Delaware Valley Regional Medical Program HERMANN, John B. Planning Director, The Creighton University Associate Coordinator Nebraska-South Dakota Regional Medical Program HEUSTIS, Albert E., M.D. Director Michigan Association for Regional Medical Programs, Inc. HILDEBRAND, Paul R., M.D. Program Coordinator Colorado-Wyoming Regional Medical Program HILL, David B. Professor of Community Medicine University of Vermont HINE, Maynard K. Chairman, Research Committee American Dental Association American Association of Dental Schools HINKEL, Robert Information Specialist National Institute of Neurological Dis- eases and Blindness National Institutes of Health HISCOCK, Wilham McC. Deputy Director Office of Program Planning and Evalua- tion Office of the Surgeon General Public Health Service HOHMAN, Robert J. Executive Secretary American Heart Association Program Planning Committee Northlands Regional Medical Program HOHMANN, Thomas C., M.D. Chairman, Regional Advisory Group Subcommittee on Stroke Western Pennsylvania Regional Medical Program HOLBROOK, Ward C. Executive Director, Health and Welfare State of Utah HOLLAND, Charles.D. Assistant Director West Virginia Regional Medical Program HOLLOMAN, John L., M.D. Past President National Medical Association Member, Regional Advisory Group New York Metropolitan Regional Medical Program HOLMBERG, R. Hopkins, Ph. D. Director Health Systems Science Division American Rehabilitation Foundation HONICKER, Franklin, Jr. Liaison Officer Greater Delaware Valley Regional Medical Program HORENSTEIN,Simon, M.D. Associate Professor of Neurology Case Western Reserve University HORTON, Odell Director of Hospitals and Health Services City of Memphis HOUGH, Howard E. Associate Director for Community Involvement Western Pennsylvania Regional Medical Program HUBBARD, William N., Jr., M.D. Dean, School of Medicine University of Michigan — Chairman, Regional Advisory Group Virginia Regional Medical Program HUBER, Warren V., M.D. Metropolitan Washington, D.C. Regional Medical Program 149 HUDSON, Charles R. Assistant to the Coordinator Mississippi Regional Medical Program HUGHES, Gerald E. Secretary for Meetings American Academy of Pediatrics HUNT, Andrew D., Jr., M.D. Michigan Regional Medical Program Dean, College of Human Medicine Michigan State University HUNT, William B., Jr., MD. Chairman, Medical School Committee University of Virginia Hospital Virginia Regional Medical Program HUNTER, Oscar B., Jr., M.D. President College of American Pathologists HUSTON, Samuel R. Associate Director for Institutional Affairs Northern New England Regional Medical Program HUTCHISON, Dorothy J., R.N. Chairman, Nursing Committee Wisconsin Regional Medical Program INGALL, John R. F., M.D. Program Director Western New York Regional Medical Program INGERSOLL, Ralph, Ph. D. Director of Research in Medical Education Ohio State University College of Medicine IVES, John E. Director University of Connecticut, McCook Hospital JANEWAY, Richard, M.D. Assistant Professor of Neurology Program Administrator, Cerebral Vascular Research Unit Bowman Gray School of Medicine JEFFERS, James R. Coordinator, Economics Section Iowa Regional Medical Program 150 JENSEN, John L. Art Director Department of Communication Services University of Kansas Medical Center JOHNSON, Amos N., M.D. Garland, N.C. JOHNSON, Marion H. Director of Communications Washington-Alaska Regional Medical Program JOHNSON, Robert O., M.D. Assistant Regional Coordinator Wisconsin Regional Medical Program Cancer Study Group University of Wisconsin KAISER, Raymond F., M.D. Deputy Regional Health Director Region [X—San Francisco Public Health Service KASSEL, Henry W., M.D. Regional Health Director Region VITI-——-Denver Public Health Service KAUFFMAN, John W. Administrator Princeton Hospital KEAIRNES, Harold W., M.D. Assistant Coordinator for Research and Evaluation University of Kansas Medical Center KELLER, Martin D., M.D. Office of the Dean Department of Preventive Medicine Ohio State University KELSO, John H. Executive Officer Public Health Service KEMP, Maregucrite W. Staff Assistant, Information Office Bureatoof Tealth Manpower Pubhe Elealth Service KENNEDY, Paul K. Department of Planning and Coordinatien Alabama Regional Medical Program KENNER, Harris M., M.D. Assistant Director, Preventive Programs Section Heart Disease Control Program Public Health Service KENNEY, Howard W., M.D. Medical Director, John A. Andrew Hos- pital ‘Tuskegee Institute KENNEY, John A., Jr., M.D. Professor and Head Division of Dermatology Howard University College of Medicine Metropolitan Washington, D.C. Regional Medical Program KENRICK, Margaret, M.D. Delegate American Academy of Physical Medicine and Rehabilitation KING, James C., M.D. Associate Regional Health Director (Chicago) Bureau of Health Services Public Health Service KING, James F., Jr. Public Health Analyst Office of Program Planning and Evaluation Office of the Surgeon General Public Health Service KISSICK, William L., M.D. Director Office of Program Planning and Evaluation Office of the Surgeon Gencral Public Health Service KITCHING, William M. Field Services Consultant Adult Health Protection Branch Division of Medical Care Administration Bureau of Health Services Publie Health Service KNEK, Charles W., Jr. Office of Public Relations and Communications South Carolina Regional Medical Program KNOX, Van W.,, II Research Analyst . Health Economics Research Section Smith, Kline and French Laboratories KORNFELD, Jack P. Director of Data Analysis Washington-Alaska Regional Medical Program KOWALEWSKI, Edward J., M.D. National Review Committee American Academy of General Practice KRAMER, M.A. Field Representative American Medical Association KREHL, Willard A., M.D. Program Coordinator Towa Regional Medical Program Director, University Hospitals University of lowa KRYSTYNAK, Leonard F. Research Assistant University of Michigan KUMMER, Theodore G. Special Projects Administrator Smith, Kline and French Laboratories KUTTNER, Dena Exhibit Officer Cancer Control Program Public Health Service LAGACE, Arthur E., Jr. Health Administration Specialist Colorado-Wyoming Regional Medical Program LAMBORN, Emiley Director of State-Federal Relations National Rehabilitation Association LARKIN, Vincent dePaul Director New York Metropolitan Regional Medical Program LARSON, Carol M. Nursing Consultant—-Coronary Care Heart Disease Control Program Public Health Service LARSON, Laura G., R.N. Associate Director Mountain States Program LAWRENCE, Clifton F., Ph. D. Associate Secretary American Speech and Hearing Association LAWTON, Robert P. Associate Dean Yale University School of Medicine LAYTON, Margaret National Cancer Institute National Institutes of Health LEARNARD, William E. Associate Director Health and Welfare Activities Smith, Kline and French Laboratories LEE, Lyndon E., Jr., M.D. Director of Surgical Service Chief, Extra Veterans Administration Research Veterans Administration LEE, Dr. Marina D. Chief, Medical Division Science Information Exchange Smithsonian Institution LEE, W. Boyd Dental Consultant Cancer Control Program National Center for Chronic Disease Control Public Health Service LEEDS, Dr. Alice A. Special Consultant on Comprehensive Planning National Institute of Mental Health Public Health Service LEIN, John N., M.D. Associate Dean University of Washington School of Medicine LEVINE, Dr. David L. Associate Dean, School of Social Work Syracuse University Regional Medical 292-414 O—-68——11 LEWIS, Charles E., M.D. Coordinator Kansas Regional Medical Program LEWIS, Irving J. Deputy Assistant Director Bureau of the Budget Office of the President LEWIS, Sandra E. Executive Assistant to the Director Northern New England Regional Medical Program . LIKOFF, William, M.D. President, American College of Cardiology Hahnemann Medical College and Hospital LILIENFELD, Abraham M., M.D. Professor and Chairman Department of Chronic Diseases . Johns Hopkins University. School of Hygiene and Public Health LINDEE, Robert G., M.D. Assistant Dean Stanford University School of Medicine LINDSLEY, George A., M.P.H. Assistant Executive Director Illinois Regional Medical Program LLOYD, Frank P., M.D. Director of Research Methodist Hospital of Indiana LOBUE, A. J., M.D. Member, Regional Advisory Group California Regional Medical Program LOGSDON, D. N., M.D. Chief, Professional Service Section Division of Medical Care Administration Public Health Service LUKEMEYER, George T. Program Coordinator Indiana Regional Medical Program Associate Dean, Indiana University School of Medicine LUMMIS, Wilbur S., Jr., M.D. Deputy Director Hawaii State Department of Health LYLE, Carl B., Jr., M.D... Associate Professor of Medicine University of North Carolina School of Medicine LYNCH, George Audio-Visual Coordinator Bowman Gray School of Medicine LYNCH, Richard V., Jr., M.D. President, West Virginia State Medical Association Chairman, Regional Advisory Group West Virginia Regional Medical Program McBEATH, William H., M.D. Program Coordinator Ohio Valley Regional Medical Program McCALL, Charles B., M.D. Associate Professor University of Tennessee College of Medicine McCARTHY, Dr. Thomas Office of the Director Bureau of Health Services Chief, Grants Review Branch Public Health Service McCONNELL, Thomas S., M.D. New Mexico Regional Medical Program School of Medicine University of New Mexico McCORMICK, Calvin Senior Project Coordinator Kidde Construction, Inc. McCUNE, William S., M.D. President Medical Society of the District of Columbia McDANIEL, Valeta K. National Communicable Disease Center Heart Disease Control Standardization Laboratory Public Health Service McDONALD, Byron A. Systems Engineering Consultant Northern New England Regional Medical Program McFADDEN, Catherine L. Heart Disease Control Program Public Health Service McGILL, Ifenry C., Jr, M.D. Institutional Coordinator Texas Regional Medical Program McGOWAN, Larry, M.D. Greater Delaware Valley Regional Medical Program McKENZIE, Richard B. Program Coordinator Susquehanna Valley Regional Medical Program McLAUGHLIN, Margaret Chief Nurse Officer Public Health Service McNERNEY, Walter J. President Blue Cross Association, Inc. McNULTY, Matthew F., Jr. Director, Council of Teaching Hospitals Associate Director, Association. of Amer- ican Medical Colleges McPHAIL, Frank L., M.D. Director, Montana Region Mountain States Regional Medical Pro- gram MACER, Dan J. Director Veterans Administration Hospital Chairman, Regional Advisory Group Western Pennsylvania Regional Medical Program MacLAGGAN, James, M.D. Vice Chairman California Regional Advisory Group MACON, N. Don Planning Director Texas Regional Medical Program Program Coordinator for University of Texas MAGRAVW, Richard Assistant Director Bureau of Health Services Public Health Service 151 MAMITIYA, Richard, M.D. Leahi Hospital Hawaii Regional Medical Program MARKEY, William A. Deputy Director, USC—Area V California Regional Medical Program University of Southern California School of Medicine MARTIN, Samuel P., M.D. Program Coordinator Florida Regional Medical Program Provost, J. Hillis Miller Medical Center MARTZ, E. Wayne, M.D. Associate Director, Continuing Education Western Pennsylvania Regional Medical Program MARTZ, Dr. Helen E. Staff Assistant for Planning Medical Assistance Administration Social and Rehabilitation Service Public Health Service MARY, Charles C., Jr., M.D. Associate Director Charity Hospital of New Orleans MASLAND, Richard L., M.D. Director National Institute of Neurological Dis- eases and Blindness National Institutes of Health MASON, Joseph J., Jr. Associate Director for Administration Alabama Regional Medical Program MASSEY, Dr. Robert U. Lovelace Foundation for Medical Educa- tion and Research New Mexico Regional Medical Program MATOREN, Gary M. Associate Coordinator New Jersey Regional Medical Program MATTINGLY, Thomas W., M.D. Program Coordinator Metropolitan Washington, D.C., Regional Medical Program MAYER, Andrew, M.D. Assistant Director, Professional Activities American College of Surgeons 152 MAYER, William D., M.D. Dean and Director University of Missouri Medical Center MEEK, Peter G. Executive Director National Health Council MELICK, Dermont W., M.D. Program Coordinator Arizona Regional Medical Program University of Arizona College of Medicine MELTON, William K. Director of Education The American College of Radiology MERRITT, Betty L. Communications and Information Officer Georgia Regional Medical Program METCALFE, Robert M., M.D. Associate Director Tennessce Mid-South Regional Medical Program MEYER, Thomas C., M.D. Chairman, Postgraduate Education Com- mittee University of Wisconsin Medical School MILLER, George F., M.D. Director, Office of Research in Medical Education University of Ilinois College of Medicine Division of Regional Medical Programs National Review Committee MILLER, Winston R., M.D. Program Director Northlands Regional Medical Program MILLIKAN, Clark H., M.D. National Advisory Council on Regional Medical Programs Consultant in Neurology Mayo Clinic MITCHELL, Frank L., M.D. Deputy Chief, Office of Professional Serv- ices Division of Direct Health Services Bureau of Health Services Public Health Services MITCHELL, John A., M.D. President Charles L. Drew Society MIYAMOTO, Robert M., M.D. President Elect Hawaii Medical Association MOOLTEN, Sylvan E., M.D. Chairman, Task Force Committee on Medical Education Middlesex General Hospital in New Jersey MOORE, Charles W. Associate Coordinator, Administration and Institutions Kansas Regional Medical Program MOORE, George Deputy Regional Health Director Region 1!I1—Charlottesville Public Health Service MORGAN, Harold S., M.D. Program Coordinator Nebraska-South Dakota Regional Medical Program MORGAN, Robert J., M.D. Chairman, Regional Advisory Committee Nebraska-South Dakota Regional Medical Program MORRISSEY, Edward F. Assistant Director Connecticut Regional Medical Program MOSES, Campbell, M.D. Mcdical Director Amcrican Heart Association MOU, Thomas W., M.D. Assistant to the Coordinator Central New York Regional Medical Program MOUTSATSOS, Spero Project Director, Health Manpower Western New. York Regional Medical Program MULLER, Jane Assistant Director---Washington Office American Nurses Association MURBACH, Edwin R., M.D. Northwest District Chairman Northwestern Ohio Regional Medical Program MUSSER, Marc J., M.D. Executive Director North Carolina Regional Medical Program MYKYTEW, Marion, M.D. Assistant Coordinator Wisconsin Regional Medical Program Marquette School of Medicine NADEL, Eli M., M.D. Associate Dean St. Louis University School of Medicine NELLIGAN, William D. Executive Director American College of Cardiology NELSON, Kinloch, M.D. Program Coordinator Virginia Regional Medical Program Dean, Medical College of Virginia NELSON, William P., IEE, M.D. Professor of Postgraduate Medicine Albany Medical College NEMIR, Paul Director, Division of Graduate Medicine University of Pennsylvania NEWELL, Agnes M. Nursing Consultant Stroke Program Heart Disease Control Section Public Health Service NEWMAN, T. R. Administrative Officer Ohio Valley Regional Medical Program { NIGAGLIONI, Adan, M.D. Program Coordinator Regional Medical Program of Puerto Rico Chancellor, Medical Sciences University of Puerto Rice NILSON, George ‘T, Assistant Program Coordinator Maine Regional Medical Program NOROIAN, Edward H. Executive Director Presbyterian University Hospital Western Pennsylvania Regional Medical Program NORTON, Joseph A., M.D. President, Arkansas Medical Society Member, Regional Advisory Board Arkansas Regional Medical Program O'DOHERTY, Desmond 8., M.D. Chairman, Regional Advisory Committee Metropolitan Washington, D.C. Regional Medical Program Professor and Chairman, Department of Neurology Georgetown University Hospital OGDEN, Michael, M.D. Chief, Professional Assignment and Research Office of Program Services Division of Indian Health Public Health Service OLIVER, Ward L., M.D. Assistant Professor of Postgraduate Medicine Albany Medical College Albany, New York Regional Medical Pro- gram. OLSON, Edith V., R.N. Nursing Director Rochester (New York) Regional Medical Program OLSON, Stanley W., M.D. Director Tennessee Mid-South Regional Medical Program PACKER, James T., M.D. Associate Director Missouri Regional Medical Program University of Missouri Medical Center PAINTER, Robert C., M.D. North Dakota Regional Medical Prograin PALMOUTIST, Ernil B., MLD. Regional Health Director Region I[{[—Charlottesville Public Health Service PARELIUS, M. Ronald Oregon Regional Medical Program PARKER, Lorraine Assistant Director Communications and Information North Dakota Regional Medical Program PARKER, Ralph C., Jr., M.D. Program Coordinator Rochester (New York) Regional Medical Program PARKS, Raymond E., M.D. Associate Dean University of Mimai School of Medicine PARRETTE, Robert N. Physical Therapy Consultant Public Health Service PASCASIO, Anne, Ph. D. Associate Research Professor University of Pittsburgh Member, Division of Regional Medical Programs Review Committce PATE, James W., M.D. Chairman, Professional Committee Memphis Regional Medical Program Professor, University of Tennessee College of Medicine PATTERSON, John W., M.D. Dean University of Connecticut School of Medicine PAUL, Oglesby, M.D. Chairman, [Illinois Regional Group Professor of Medicine Passavant Memorial Hospital PAYNE, Ethel Nursing Consultant Heart Discase Control Program Public Health Service PAYNE, Gerald H. Chief, Adult Heart Preventive Programs Seetion Advisory Heart Disease and Stroke Control Pro- gram Public Health Service PAYNE, W. Faxon, M.D. Acting Director, Hopkinsville, Kentucky Area Tennessee Mid-South Regional Medical Program Jennie Stuart Memorial Hospital PEARSON, David A. Deputy Chief, Health Economics Branch Division of Medical Care Administration Bureau of Health Services Public Health Service PECHMANN, David K. Administrative Officer Virginia Regional Medical Program PECK, Cecil P. American Psychological Association Chief, Psychology Division Department of Medicine and Surgery Veterans Administration Central Office PEREZ, Eugene R., M.D. Program Director Virginia Regional Medical Program PERKINS, Miles L., M.D. Director Bureau of Medical Care Maine Department of Health and Wel- fare PERRY, Frank A., M.D. Coordinator for Meharry Medical College Tennessee Mid-South Regional Medical Program PERRY, Lowell W., M.D. Chief, Pediatric Section Heart Disease Control Program Public Health Service PETERS, Richard C. Assistant Coordinator Maryland Regional Medical Program PETERSON, John F., M.D. Director, Loma Linda Area talifornia Regional Medical Program Loma Linda University School of Medi- cine PEYERSON, Osler I, M.D. Associate Director Tri-State Regional Medical Program Harvard Medical School PETERSON, Stanley S., M.D. District Consultant Missouri Regional Medical Program Smith-Glyn-Callaway Clinic PETIT, Donald W., M.D. Director, USC--Area V California Regional Medical Program PHILLIPS, John B., M.D. Assistant Professor of Postgraduate Medicine Albany Medical College POLLEY, Donald B. Television Coordinator Bowman Gray School of Medicine POPMA, Alfred M., M.D. Program Director Mountain States Regional Medical Program POSKANZER, Charles N., Ph. D. Professor of Health Education State University of New York College at Cortland Central New York Regional Medical Program POTTER, Jacobus L., M.D. Coordinator New York University School of Medicine POTTER, John, M.D. Associate Professor of Surgery Georgetown University Hospital Metropolitan Washington, D.C., Regional Medical Program POWERS, Helen K. Chief, Health Occupations Education Bureau of Adult, Vocational and Library Programs Office of Education U.S. Department of Health, Education, and Welfare PRICE, Derck W. Survey Director University of California at San Diego Galifornia Regional Medical Program 153 spate atiaating QUINLAN, Carroll B., M.D. Deputy Chief Heart Disease and Stroke Control Program National Center for Chronic Disease Public Health Service RAKITA, Louis, M.D. Associate Professor of Medicine Cleveland Metropolitan General Hospital Western Reserve University RAMSEY, Lioyd H., M.D. Department of Medicine Vanderbilt University Tennessee Mid-South Regional Medical Program RANBERG, Robert A. Research Director Susquehanna Valley Regional Medical Program RAPAPORT, Elliot, M.D. Area Coordinator—Area I California Regional Medical Program Cardiopulmonary Laboratory San Francisco General Hospital READER, George G., M.D. Coordinator for Cornell Medical School New York Metropolitan Regional Medical Program Professor of Medicine REDING, Mary Josita Director, Executive Board American Association of Medical Record Librarians RENTHAL, Gerald, M.D. Director Joint Committee on Medical Care Education American Public Health Association REYNOLDS, Florence Chief, Information and Reference Services Division of Nursing Public Health Service 154 RICE, Walter G., M.D. Dean, School of Medicine Medical College of Georgia Georgia Regional Medical Program RICH, Susan, R.N. Assistant Director Survey and Planning Oregon Regional Medical Program RICHARDS, Carol Staff Assistant Carnegie Corporation of New York RICHES, Roger J. Assistant Operations Officer Heart Disease and Stroke Control Program Public Health Service RIDGES, J. Douglas, M.D. Medical Officer Medical Systems Development Laboratory National Center for Chronic Disease Control Public Health Service RIEDEL, Donald C., Ph. D. Associate Professor of Public Health Yale University Medical School RIKLI, Arthur E., M.D. Chief of Operations Missouri Regional Medical Program RINGLER, Robert L., Ph. D. Chief, Institutional Research Programs National Heart Institute National Institutes of Health ROBBINS, Guy F., M.D. Director of Planning Memorial Hospital for Cancer and Allied Diseases New York Metropolitan Regional Medical Program ROBBINS, Lewis C., M.D. Special Assistant to the Chief National Center for Chronic Disease Control Bureau of Disease Prevention and Environmental Control Public Health Service ROBERTO, Edward A. Administrator Brown County General Hospital Chairman, Committee on Community Hospitals Ohio Valley Regional Medical Program ROBERTS, Dean W., M.D. Chief, Regional Medical. Program Activities Hahnemann Medical College Greater Delaware Valley Regional Medical Program ROBERTS, Frank Administrative Assistant to the Director Louisiana Regional Medical Program ROBERTSON, George J., M.D. Medical Director Bingham Associates Fund ROBERTSON, Julius D., D.M.D. Institutional Liaison Texas Regional Medical Program ROBINETTE, Tasker K. Director, Health Care Planning Washington-Alaska Regional Medical Program ROBINS, Edith G. Information Officer Division of Medical Care Administration Public Health Service ROBINS, Morton Chief, Statistics and Analysis Program Heart Disease Control Program Public Health Service ROCK, James A., M.D. Vice Chairman, Regional Advisory Committee Western Pennsylvania Regional Medical Program Director, Laboratory Services Lee Hospital in Johnstown ROGATZ, Peter, M.D. Director, Long Island Jewish Hospital ROSS, Mabel, M.D. Regional Health Director Region I—Boston Public Health Service RUHE, C. H. William, M.D. Director, Division of Medical Education American Medical Association RUTH, William E., M.D. Representative Councilor American Thoracic Society SABATIER, Joseph A., Jr., M.D. Program Coordinator Louisiana Regional Medical Program SADLER, Alfred M., Jr., M.D. Office of the Director National Institutes of Health SADLER, Blair L. Program Analyst Office of the Director National Institutes of Health SAGEN, Oswald K., Ph. D. Assistant Director National Center for Health Statistics Public Health Service SANAZARO, Paul J., M.D. Director, Division of Education Association of American Medical Colleges SAPPENFIELD, Robert W., M.D. Assistant Director Louisiana Regional Medical Program SARACHEK, Norman S., M.D. Medical Consultant Heart Disease Control Program National Center for Chronic Disease Control Public Health Service SASULY, Richard Coordinator of Program Development California Regional Medical Program SCHACHTER, Joseph Statistician Heart Disease and Stroke Control Program Public Health Service SCHATZ, Irwin J., M.D. Wayne State University School | of Medicine Michigan Regional Medical Program SCHELLPEPER, William L. Nebraska-South Dakota Regional Medical Program | SCHIEVE, James F., M.D. Assistant Dean Office of Continuing Medical Education University of Cincinnati College of Medicine SCHMIDT, Roland E., M.D. Associate Professor of Pediatrics West Virginia University Medical Center SCHNAPER, H. W. Associate Director Alabama Regional Medical Program SCHNEIDER, Aleene Tumor Registry, Data Collection Bi-State Regional Medical Program SCHOOLMAN, Harold M., M.D. Director, Education Service Veterans Administration Central Office SCHOR, Stanley, M.D. Temple University School of Medicine Greater Delaware Valley Regional Medical Program SCOTT, Ralph M., M.D. Professor of Radiology University of Louisville Ohio Valley Regional Medical Program SEIPP, Conrad, Ph. D. Associate Director, Research and Evaluation Connecticut Regional Medical Program SELIGSON, David, M.D. Professor of Clinical Pathology Yale University School of Medicine SEMINGSON, Howard President, North Dakota Hospital Association Administrator, Trinity Hospital SHANHOLTZ, Mack I., M.D. State Health Commissioner Virginia State Department of Health Virginia Regional Medical Program SHARP, Lawrence J., Ph. D. Research Associate and Sociological Consultant Washington-Alaska Regional Medical Program SHELLEY, Roger Director of Public Relations Rutgers University Medical School SHIELDS, George 8., M.D. Associate Professor, Department of Internal Medicine Cincinnati General Hospital Ohio Valley Regional Medical Program SHINE, Patricia A. Director of Nursing Affairs Western New York Regional Medical Program SHOREY, Winston K., M.D. Program Coordinator Arkansas Regional Medical Program Dean, University of Arkansas School of Medicine SHULER, Virginia Special Assistant for Program Development Heart Disease and Stroke Control Program Public Health Service SIBERY, D. Hugene Executive Director Greater Detroit Area Hospital Council Michigan Regional Advisory Group SIDEL, James, M.D. Medical Consultant Heart Disease and Stroke Control Program Public Health Service SIDES, Jerry D., M. Set. Continuing Education for Paramedical Personnel Gunter Air Force Base, Alabama SIEBER, Harry F., Jr. Instructor, Temple University Medical School Greater Delaware Valley Regional Medical Program SIEBERT, Dennis F. Information Officer Heart Disease Control Program Public Health Service SILVER, David Director Diabetes Detection Program SKELLEY, Thomas J. Chief, Division of Disability Services Rehabilitation Services Administration U.S. Department of Health, Education, and Welfare SLEE, Virgil N., M.D. Director Commission on Professional and Hospital Activities SLEETH, Clark K., M.D. Dean, School of Medicine West Virginia University Medical Center SMART, Charles R., M.D. Intermountain Regional Medical Program University of Utah Medical Center SMITH, Patricia Ann Coordinator Planning for Library and Information Services Oklahoma Regional Medical Program SMITH, Robert, M.D. Stroke Coordinator Mississippi Regional Medical Program SMITH, Robert B. W., Col. US. Air Force Deputy Director of Professional Services Office of the Surgeon General SMITH, Robert R., M.D. Associate Director Georgia Regional Medical Program SMITH, Robert Ray Stroke Program Mississippi Regional Medical Program SMYTHE, Cheves M. Associate Director Association of American Medical College SOFFER, Alfred, M.D. Director, Scientific Activities American College of Chest Physicians SOLOWEY, Dr. Mathilde Chief, Program Projects and Clinical Center Grants Extramural Programs National Institute of Neurological Diseases and Blindness National Institutes of Health SOVIE, Margaret D. Director of Nursing Education State University Hospital Central New York Regional Medical Program SPARKMAN, Donal R., M.D. Program Coordinator Washington-Alaska Regional Medical Program SPARKS, Robert D., M.D. Assistant Director Louisiana Regional Medical Program SPENCER, William A., M.D. Texas Regional Advisory Group Director Texas Institute for Rehabilitation and Research SPICER, William S., M.D. Program Coordinator Maryland Regional Medical Program SPITLER, James D. Assistant Planning Director University of Texas Medical Branch Texas Regional Medical Program SPRING, William C., Jr., M.D. Program Coordinator Greater Delaware Regional Medical Program STANKOVICH, Arthur Director of Management, Systems The Lankenau Hospital Greater Delaware Valley Regional Medical Program STAPLETON, John F., M.D. Associate Dean and Professor Department of Medicine Georgetown University School of Medicine Heart Coordinator, Georgetown University Hospital STAUFFER, Lee D. Assistant Director Department of Continuing Medical Education Assistant Professor of Public Health University of Minnesota Medical School Information 155 STEARNS, Norman F., M.D. Acting Director Tri-State Regional Medical Program STEARNS, Perry, M.D. Assistant Coordinator Maryland Regional Medical Program STEINICKE, David G. Regional Medical Program Representative Michigan Commission on Professional and Hospital Activities STEPHENSON, Dr. William School of Journalism University of Missouri Project Director Missouri Regional Medical Program STEWART, Donald E., M.D. President, Minnesota Cancer Society Executive Committee, Northlands Regional Medical Program STICKNEY, J. Minott, M.D. Program Coordinator Northlands Regional Medical Program STITH, Marion C. Administrator C. 5S. Wilson Memorial Hospital of Johnson City, N.Y. STOKES, Joseph III, M.D. Coordinator, San Dicgo—Area VII California Regional Medical Program STONE, Lily M. American Cancer Society STONEHILL, Robert B., M.D. Program Director Indiana Regional Medical Program STORER, Edward H., M.D. Chairman, Cancer Committee Memphis Regional Medical Program Associate Professor University of Tennessee Medicine STOREY, Patrick B., M.D. Professor of Community Medicine Hahnemann Medical College Chairman, Task Force on Continuing Medical Education Greatcr Delaware Valley Regional Medi- cal Program College of 156 STRAUSS, William T., M.D. Assistant Professor of Postgraduate Medicine Albany Medical College Albany Regional Medical Program SUHRLAND, George, M.D. Department of Medicine Michigan State University SULLIVAN, Dean Washington, D.C., Office Smith Kline and French Laboratories SULLIVAN, James H. Assistant Coordinator Wisconsin Regional Medical Program SULLIVAN, W. Albert, M.D. Director Department of Continuing Medical Education University of Minnesota College of Medicine SULTYZ, Harry A. Associate Professor Department of Preventive Medicine State University of New York SUMMERALL, Charles P., III, M.D. Program Coordinator South Carolina Regional Medical Program SUTER, James T. Research Consultant Division of Hospital and Medical Facilities Public Health Service SUTHERLAND, John President John Sutherland Productions Los Angeles, Calif, SYPHAX, Oricanna C. Chief, Institutional Programs Section Division of Manpower Development and Training Office of Education U.S. Department of Health, Education, and Welfare TABLEMAN, Betty Planning and Administration Michigan Regional Medical Program TAPP, Jesse W., Jr., M.D. Associate Professor of Community Medicine University of Kentucky Institutional Coordinator Ohio Valley Regional Medical Program TAYLOR, A. N., Ph. D. Dean, School of Related Health Sciences University of Chicago Medical School TEWART, Braxton E. Program Associate New Jersey Regional Medical Program THELLIEMAN, Leslie C. Susquchanna Valley Regional Medical Program THOMAS, John F., M.D. Chairman, Regional Advisory Committee Texas Regional Medical Program THOMPSON, Dana Administrator Central Maine General Hospital THOMPSON, John D. Department of Epidemiology and Public Health Director, Program in Hospital Administration Yale University THOMPSON, Julia C. Director, Washington Office American Nurses Association THOMPSON, Spencer G., M.D. Associate Coordinator Texas Regional Medical Program THOMPSON, W. R. Director of Project Administration Washington-Alaska Revional Medical Program THORPE, Thomas Director, Communications and Public Information North Carolina Regional Medical Program THURSTON, Hester Assistant Coordinator for Nursing Kansas Regional Medical Program TITTLE, C. Robert, Jr., M.D. Program Coordinator Northwestern Ohio Regional Medical Program TOKARS, Jerome I., M.D. Buffalo (New York) Regional Medical Program TOLLMAN, James P., M.D. Program Director Nebraska-South Dakota Regional Medical Program University of Nebraska TOMPKINS, Robert G., M.D. Coordinator for Tulsa Area Oklahoma Regional Medical Program TOOLE, James F. Chairman, Neurology Department Bowman Gray Schoo! of Medicine TOOMIELY, Robert F. Director, Greenville General Hospital System South Carolina Regional Medical Program TORGERSON, Jean T. Chronic Respiratory Diseases Control Program National Center for Chronic Disease Control Public Health Service TOWNSEND, Thomas E., M.D. Chairman, Regional Advisory Board Arkansas Regional Medical Program TRENT, George F: Executive Assistant to the Director ‘Tennessee Midsouth Regional Medical Program TRUSSELL, Ray E., M.D. Associate Dean School of Public Health and Administrative Medicine Columbia University TUCKER, Norman Division of Physician Manpower Public Health Service TUDOR, W. J. Bi-State Regional Medical Program Southern [hnois University "FURENNE, Rover Social Work Consultant Atlanta Regional Office-—Region IV Public Health Service TURNER, Glenn O., M.D. Project and Medical Director Missouri Regional Medical Program TWISS, Maurine Communications Specialist University of Mississippi Medical Center ULLMAN, Alice Assistant Program Coordinator Cornell Medical College ULMER, Robert J., M.D. Member, Regional Advisory Group North Dakota Regional Medical Program UTTERBACK, Robert A., M.D. Professor, College of Medicine University of Tennessce Subcommittee on Stroke Memphis Regional Medical Program VAUN, William S., M.D. Director of Medical Mducation Monmouth Medical Center Greater Delaware Valley Regional Medical Program VESTAL, Robert, Tf Public Information Officer Colorada-Wyoming Regional Medical Programm VEVERKA, Eugene W., M.D. Assistant Director Division of Medical Care Administration Public Health Service VICKERSTAFF, Hugh Tennessee Mid-South Regional Medical Program VREELAND, Ellwynne M. Nurse Consultant Division of Nursing, Intramural Research Branch Bureau of Health Manpower Public Health Service VOLLAN, Douglas D., M.D. Coordinator, UC-Davis—-Area LI California Regional Medical Program WAGNER, Carruth J.. M.D. Director Bureau of Health Services Public Health Service WAKERLIN, George E., M.D. Director of Planning Missouri Regional Medical Program University of Missouri WALL, Pauline National Cancer Institute National Institutes of Health WARD, Paul D. Coordinator and Executive Director California Regional Medical Program WARLICK, William J. Project Director South Carolina Regional Medical Program WARNER, Homer R., M.D. Project Leader Intermountain Regional Medical Program Latter Day Saints Hospital WEBB, Dennis R. Field Services Consultant Division of Medical Care Administration Public Health Service WEBB, Hamilton, Col., USAF (MC) Assistant for Plans, Health and Medical Office of the Deputy Assistant Secretary of Defense U.S. Department of Defense WEEKS, William Administrative Assistant to the Associate Director New Mexico Regional Medical Program WEIL, Clifton C. Administrator Flint Goodrich Hospital of New Orleans WEINBERG, Harry B., M.D. Chairman, Regional Advisory Group lowa Regional Medical Program WEINERMAN, E. Richard, M.D. Professor of Medicine and Public Health Yale University Medical School WELD, Francis Minot, M.D. Medical Consultant Heart Discase Control Program Public Health Service WELLS, Benjamin B., M.D. Director Alabama Regional Medical Program WELTON, David G., M.D. President-Elect Medical Society of the State of North Carolina WENNBERG, John E., M.D. Program Coordinator Northern New England Regional Medical Program WEST, Kelly M., M.D. Director Oklahoma Regional Medical Program WESTLAKE, Robert E., M.D. Past President American Society of Internal Medicine WHALEY, Storm Vice President of Health Sciences University of Arkansas Medical Center WHIPPLE, Dr. Gerald Chairman, Tri-State Regional Advisory Council University Hospital, Boston WHITE, Charies H. Associate Director Ohio Regional Medical Program WHITMAN, Samucl, M.D. Associate. Dean School of Medicine Case Western Reserve University WILBAR, Charles L., Jr., M.D. Director West. Virginia Regional Medical Program WILBUR, Dwight, M.D. President-Elect American Medical Association WILKINS, Robert J. Associate Director Northlands Regional Medical Program WILLARD, William R., M.D. Vice President University of Kentucky Medical Center WILLIAMS, James D. Chief, Planning Assistance Section Office of Comprehensive Health Planning Public Health Service WILLIAMS, Robert G. W., Jr. Assistant for Personnel Office of the Deputy Assistant Secretary of Defense Health and Medical WILLIAMSON, John, M.D. Assistant Professor The Johns Hopkins University School of Hygiene and Public Health WITTEN, Carroll L., M.D. Chairman, Medical Practices Committee Ohio Valley Regional Medical Program WOOD, Courtney B., M.D., M.P.H. Coordinator, Mt. Sinai School of Medicine New York Metropolitan Regional Medical Program WOOD, Owen J. Sales Manager Video Engineering Company, Inc. Washington, D.C. WOOLSEY, Frank M., Jr., M.D. Program Coordinator Albany Regional Medical Program WRIGHT, Jane C., M.D. Coordinator for New York Medical College New York Metropolitan Regional Medical Program WU, Dr. S. Y. Professor of Economics University of Iowa WURZEL, Edward M., M.D. Executive Director American Association of Medical Clinics XAVIER, Mal Administrative Assistant Metropolitan Washington, D.C., Regional Medical Program 157 YAKEL, Ruth M. Executive Director The American Dietetic Association YARNALL, Stephen R., M.D. Director, Project Development Washington-Alaska Regional Program University of Washington Hospital YATES, William M. Administrative Assistant Tennessee Mid-South Regional Medical Program YOUNG, James R. Information Officer West Virginia. Regional Medical Program YUNG, E. V., M.D. Director, Survey and Planning Oregon Regional. Medical Program ZWICK, Daniel I. Associate Director of Program Management Office of Economic Opportunity Medical 158 APPENDIX 4 DIRECTORY OF REVIEW COMMITTEE AND NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS REGIONAL MEDICAL PROGRAMS REVIEW GOMMITTEE Kevin P. Bunnell, Ed. D. Associate Director Western Interstate Commission for Higher Education 30th Street Boulder, Colo, 80302 George James, M.D. Dean, Mount Sinai School of Medicine Fifth Avenue and East 100th Street New York, N.Y. 10029 Howard W. Kenney, M.D. Medical Director John A. Andrew Hospital Tuskegee Institute, Ala. 36088 Edward J. Kowalewski, M.D. Chairman, Committee of Environmental Medicine of the Academy of General Practice Akron, Pa. 17501 George E. Miller, M.D. Director, Office of Research in Medical Education College of Medicine University of Illinois Chicago, Ill. 60612 Philip M. Morse, Ph. D. Director Operations Research Center Massachusetts Institute of Technology Cambridge, Mass. 02139 Anne Pascasio, Ph. D. Assistant to the Vice President Health Professions University of Pittsburgh 443 Scaife Hall Pittsburgh, Pa. 15213 Samuel H. Proger, M.D. Physician-in-Chief Tufts-New England Medical Center Boston, Mass. 02111 David E. Rogers, M.D. Professor and Chairman Department of Medicine School of Medicine Vanderbilt University Nashville, Tenn. 37205 C. H. William Ruhe, M.D. Assistant Secretary Council on Medical Education American Medical Association 535 North Dearborn Street Chicago, I]. 60610 Robert J. Slater, M.D. President The Association for the Aid of Crippled Children 345 East 46th Street New York, N.Y. 10017 Mr. John D. Thompson Professor of Public Health and Director, Program in Hospital Administration Yale University Medical School New Haven, Conn. 06520 Executive Secretary Mrs. Martha L. Phillips Chief, Grants Review Branch Division of Regional Medical Programs National Institutes of Health Bethesda, Md. 20014 NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS Edwin L. Crosby, M.D. Director American Hospital Association Chicago, II]. 60611 Michael FE. DeBakey, M.D. Professor and Chairman Department of Surgery College of Medicine Baylor University Houston, Tex. 77025 Helen G. Edmonds, Ph. D. Dean, Graduate School North Carolina College P.O. Box 432 Durham, N.C. 27707 Bruce W. Everist, M.D. Chief of Pediatrics Green Clinic 709 South Vienna Street Ruston, La. 71270 John R. Hogness, M.D. Dean, School of Medicine University of Washington Seattle, Wash. 98105 James T. Howell, M.D. Executive Director Henry Ford Hospital Detroit, Mich. 48202 Clark H. Millikan, M.D. Consultant in Neurology Mayo Clinic Rochester, Minn. 55902 George E. Moore, M.D. Director, Public Health Research New York State Department of Health Roswell Park Memoria! Institute 666 Elm Street Buffalo, N.Y. 14203 Edmund D. Pellegrino, M.D. Vice President for the Health Sciences Director of the Medical Center State University of New York Stony Brook, N.Y. 11790 Alfred M. Popma, M.D. Director, Mountain States Regional Medical Program 525 West Jefferson Street Boise, Idaho 83702 Mack I. Shanholtz, M.D. State Health Commissioner State Department of Health Richmond, Va..23219 Ex Officio Member William H. Stewart, M.D. (Chairman) Surgeon General Public Health Service 9000 Rockville Pike Bethesda, Md. 20014 APPENDIX 5 DIRECTORY OF DIVISION OF REGIONAL MEDICAL PROGRAMS OFFICE OF THE DIRECTOR Immediate Office: Robert Q. Marston, M.D......... Director. Karl D. Yordy............... Deputy Director. Margaret H. Sloan, M.D... ..... Associate Director for Organizational Liaison. Maurice E. Odoroff.............- Assistant to Director for Health Data. Leroy G. Goldman............... Program Policy Specialist. Eva M. Handal................ Committee Management Officer. Elizabeth F. Fuller...........0.-.. Secretary to Director. Office of Executive Officer: Charles Hilsenroth............... Executive Officer. Nicholas G. Cavarocchi. . ...... Financial Management Officer. Robert L. Quave. ..........5.. Administrative Officer. Norman E. Prince, Jr ........... Personnel Officer. Anna V. Windsor.....:.......... Budget Analyst. Lorraine H. Hughes.............. Administrative Assistant. Mary J. McCormack............. Office Services Supervisor. Office of Communications and Public Information: Edward M. Friedlander........... Assistant to Director for Communications and Public Information. Frank Karel W1................. Public Information Officer. Judith J. Fleisher.......0........ Public Information Specialist. Ellen D, Carter.................. Public Information Specialist. Simone D. Biren................- Editor. OFFICE OF ASSOCIATE DIRECTOR FOR PLANNING AND EVALUATION Stephen J. Ackerman. ........... Associate Director for Planning and Evaluation. Planning Branch: Roland L. Peterson ...........-. Chief. Thomas Kinser.........:.....-5. Program Analyst. Theodore L. Koontz, Jr.......... Program Analyst. Lyman G. Van Nostrand......... Program Analyst. Evaluation Branch: Rhoda Abrams.................- Program Analyst. Arthur B. Hiatt, Jr.............. Program Analyst. Suzanne G. Paul................ Program Analyst. Laura J. Shouse................. Program Analyst. Mary A. Teller...............--- Program Anaylst. Edward S. Walsh................ Program Analyst. Statistics and Analysis Branch: Mary V. Geisbert..............-. Public Health Analyst. Loren D. Hellickson...........-.- Public Health Analyst. Leah Resnick. ........0...2.0055 Public Health Analyst. Jackie M. Rosenthal............. Statistical Assistant. OFFICE OF ASSOCIATE DIRECTOR FOR OPERATIONS Richard B. Stephenson, M.D...... Associate Director for Operations. Operations Staff: Ira R. Alpert... ........0...005. Operations Officer. Robert C. Anderson..........-.. Operations Officer. Vincent J. Carollo, M.D.......... Operations Officer. John R. Hamilton, HI, M.D...... Operations Officer. Robert M. O’Bryan, M.D........ Operations Officer. Alphonse Strachocki............. Operations Officer. Grants Management Branch: James Beattie. ......... 0.0.0.0. Chief. Thomas J. McNiff..............- Grants Management Officer. Gerald L. Teets. ................ Grants Management Officer. George F. Hinkle............-.-- Grants Management Officer. Arthur Curry... 0... .00...05 0.0055 Grants Management Specialist. Donald M. Fox..............0.- Grants Management Specialist. Grants Review Branch: Martha L. Phillips...-........... Chief. Grants Review Section: Peter A. Clepper.............0-. Public Health Advisor. Robert E. Jones...........-..--- Public Health Advisor. Patricia K. McDonald............ Public Health Advisor. Harold F. O'Flaherty. ........... Scientific Grants Assistant. Jessie F. Salazar.........---...-. Public Health Advisor. Grants Operations Section: Lorraine M. Kyttle............:.. Head. 159 OFFICE OF ASSOCIATE DIRECTOR FOR PROGRAM DEVELOPMENT AND RESEARCH Richard F. Manegold, M.D....... Associate Director for Program Development and Research. Continuing Education and Training Branch: Alexander M. Schmidt, M.D...... Chief. Phyllis E. Carnes, Ph.D.......... Education Specialist. Veronica L. Conley, Ph. D........ Education Specialist. Cecilia C. Conrath............... Assistant to Chief. David W. Golde, M.D.........,. Training Consultant. Frank L. Husted, Ph. D.......... Head, Education Research Group. Elsa J. Nelson................... Health Services Officer. Herbert O. Mathewson, M.D...... Training Consultant. Marjorie L. Morrill.............. Public Health Advisor. Rebecca R. Sadin............... Public Health Advisor. Sarah J. Silsbee... .....0........ Public Health Advisor. Jack J. Schneider, M.D.......-.. Training Consultant. Jehn C. Tapp, M.D.....0.0...... ‘Vraining Consultant. Charlotte F. Turner.............. Education and ‘Training Spccialist. Regional Health Services Branch: Philip A. Klieger, M.D........... Head, Clinical Programs Section, 160 APPENDIX 6 DIRECTORY OF REGIONAL MEDICAL PROGRAMS The Directory lists Regional Medical Programs for which planning or opera- tional grants have been awarded or which are in earlier stages of development. Regions were defined for planning pur- poses in the planning applications. State designations do not necessarily indicate that the regions are coterminous with State boundaries. The original definitions of the regions may be modified on the basis of experience. Awarded as of April 26, 1968. INDEX Region page ALABAMA (see also Tennessee Mid- South)... cece neces 162 Br eENe see Washington-Alaska. ANY ooo occ cc ccc cv ccecccveeeeeeees 162 ARIZONA eee eee eee e een tenets 162 ARKANSAS (see also Memphis).......... 162 BI TE eee cee ee inte esac 163 CALIFORNIA. 20 eee eee 163 CENTRAL NEW YORK..........:5........ 163 COLORADO-WYOMING.................. 163 CONNECTICUT....0.. 0 eee 164 DELAWARE VALLEY, see Greater Dela- ware Valley. BEOREIA Seeker eee eee eens GEORGIA... eee HAWAL. 00 cece nce ene eens IDAHO, see Intermountain;. Mountain ILLINOIS (see also Bi-State)............. 165 INDIANA (see also Ohio Valley).......... 165 INTERMOUNTAIN KENTUCKY, see Memphis; Ohio Valley; Tennessee Mid-South. LOUISIANA... eee eee 166 ect b eee ne eee e tenes 166 MARYLAND... .00. eee eee 167 MASSACHUSETTS, see Tri-State. MEMPHIS. ....... 00. c ee ee 167 METROPOLITAN WASHINGTON, D.C. 167 MICHIGAN. . 00.00... eee 167 MINNESOTA, see Northlands. MISSISSIPPI (see also Memphis)........ 168 MISSOURI (see also Bi-State: Memphis). 168 iets see Intermountain; Mountain tat MOUNTAIN STATES....000..00......06. 168 NEBRASKA-SOUTH DAKOTA............ i168 NEVADA, see Intermountain. NEW HAMPSHIRE, see Tri-State. Region page NEW JERSEY (see also Greater Delaware tee NEW MEXICO.) 169 NEW YORK, see Albany; Central New York; New York Metropolitan Area; Rochester; Western New York. NEW YORK METROPOLITAN AREA..... 169 NORTH BaLOTA bee eee eee eee aee 169 NORTH DAKOTA.....0. 0.0... eee eae 170 NORTHEASTERN OHIO... ee 170 NORTHERN NEW ENGLAND bebe eee eee 170 NORTHLANDS..... 0... eee 170 NORTHWESTERN OHIO................. 171 OHIO STATE (see also Northeastern maw Northwestern Ohio; Ohio Valley)... 171 OHIO VALLEY 171 OkLAHOM _ 171 EGON 172 PEN NSYLVANIA, see Greater Delaware Valley; Susquehanna Valley; Western Pennsylvania. PUERTO RICO... eee 172 RHODE ISLAND, see Tri-State. ROCHESTER SOUTH CAROLINA..........5... 172 at DAKOTA, see Nebrask. a SUSQUEHANNA VALLEY... 0. 173 TENNESSEE MID-SOUTH {see also Mem- phis) ence eee enna nee eee e eens 173 TEXAS... ec cece eee eens 173 TRISTATE. 2 ccc eee eee 173 UTAH, see Intermountain. VERMONT, see Northern New England. VIRGINIA... 0.02. 174 WASHINGTON-ALASKA. ... 2.00... 5 00 174 WASHINGTON, D.C., see Metropolitan Washington, D.C. WEST VIRGINIA (see also Ohio Valley)... 174 WESTERN INTERSTATE COMMISSION FOR HIGHER EDUCATION (WICHE), see Mountain States. WESTERN NEW YORK..............0005 WESTERN PENNSYLVANIA WISCONSIN............ 020005 WYOMING, see Colorado-Wyo mountain; Mountain States. al Name of Region Bi-State California Central New York Colorado-Wyoming Preliminary Planning Area Eastern Missouri and Southern California Syracuse, New York and 15 Colorado and Wyoming IMlinois surrounding counties Estimated Population 4,775,000 19,160,000 1,760,000 2,200,000 Coordinating Headquarters Washington University School of Medicine California Committee on Regional Medical Programs Upstate Medical Center, State University of New York at Syracuse University of Colorado Medical Center Program Coordinator William H. Danforth, M.D Vice Chancellor for Medical Affairs Washington University 660 South Euclid Avenue St. Louis, Mo. 63110 (tel: 314-361-6400, ext. 3013) Paul D. Ward Executive Director California Committee on Regional Medical Programs Room 304 655 Sutter Street San Francisco, Calif. 94102 (tel: 415-771-5432) Richard H. Lyons, M.D. Director, Regional Medical Program of Central New York 750 East Adams Street Room 1500 State University Hospital Syracuse, N.Y. 1321 (tel: 315-473-5600) Paul R. Hildebrand, M.D University of Colorado Medical Center 4200 East Ninth Avenue Denver, Colo, 80220 Program Director Howard W. Doan, M.D. . University of Colorado Medical Center 4200 East Ninth Avenue Denver, Colo, 80220 (tel; 303-394-7506) Chairman, Regional Advisory Group G. Duncan Bauman Business Manager St. Louis Globe-Democrat 710 North 12th Street St. Louis, Mo. 63101 Roger O. Egeberg, M.D. Dean, School of Medicine University of Southern California 2025 Zonal Avenue Los Angeles, Calif. 90033 Wilfred _W. Westerfetd, M.D. Acting President Upstate Medical Center 766 Irving Avenue Syracuse, N.Y. 13210 (tel: 315-473-4513) John J. Conger, Ph. Vice President for Medical Affairs and Dean, School of Medicine University of Colorado 4200 East Ninth Avenue Denver, Colo. 80220 Grantee Washington University School of Medicine California Medical Education and Research Foundation Research Foundation of State University of New York University of Colorado Medical Center Effective Starting Date of April 1, 1967 November 1, 1966 January 1, 1967 January 1, 1967 Planning Grant Amount of Planning Grant $603,965 $3 75,096 (1st year) $289,522 (1st year) $361,984 (1st year) $2,974,497 (2d year) $268,634 (2d year) $339, ‘605 (2d year) Effective Starting Date of Operational Grant Amount of Operational Grant 163 Name of Region Connecticut Florida Georgia Greater Delaware Valley Preliminary Planning Area Connecticut Florida Georgia Eastern Pennsylvania and portions of New Jersey and Delaware oe _ a ee ee __ Le ee ee Estimated Population 2,925,000 6,000,000 4,510,000 8,200,000 Coordinating Headquarters Yale University School of Medicine Florida Advisory Council, Inc. Medical Association of Georgia University City Science Center and University of Connecticut School of Medicine ee Oo — — a ae ee _ _ Program Coordinator Henry T. Clark, Jr., M.D. Samuel P. artin, M.D. J. WwW. Chambers, M.D. George Clamimer, M.D. Program Coordinator Provost, J. Hillis Miller Coordinator for Georgia Regional Wynnewood House Connecticut Regional Medical Medical Center Medical Program 300 East Lancaster Avenue Program University of Florida Medical Association of Georgia Wynnewood, Pa. 19096 272 George Street Gainesville, Fla. 32601 938 Peachtree Street NE. New Haven, Conn. 06510 Atlanta, Ga. 30309 (tel: 215-649-4100) (tel: 904-376-3211, ext. 5377) (tel: 203-776-6872) (tel: 404-876-7535) EE _ _ eee ee Program Director J. Gordon Barrow, M.D.” Director for Georgia Regional Medical Program Medical Association of Georgia 938 Peachtree Street N.E. Atlanta, Ga. 30309 eee re (tel: 404-875-0701) Chairman, Regional Arthur M. Rogers H. Phillip Hampton, M.D. Arthur P. Richardson, M.D. : Glen R. Leymaster, M.D. - Advisory Group Director of Traffic 1 Davis Boulevard Dean, School of Medicine Dean, Worman’s Medical College Scovill Manufacturing Company Tamipa, Fla. 33606 Emory University of Pennsylvania 99 Mill Street Atlanta, Ga. 30322 3300 Henry Avenue Waterbury, Conn. 06720 (tel: 813-253-0991) Philadelphia, Pa- 19 carat iecicine Florida Advisory Counc ne oe a ee Grantee Yale University School of Medicine Florida Advisory Council, Inc. Medical Association of Georgia University City Science Center or 066 __ ee _— _ _— ee SS _ Effective Starting Date July 1, 1966 November 1, 1967 January 1, 1967 April 1, 1967 of Planning Grant ee _ __ ee ee ae a eT ee Amount of $406,622 ost year) $240,000 $240,098 (1st year) $1,531,494 Planning Grant $338,513 2d year) $555,079 (20 year) ee a ee Effective Starting Date of Operational Grant Amount of Operational! Grant Operational Grann _—____— Oo __ 164 A Hy 4 z i Hi F B Name of Region Connecticut Florida Georgia Greater Delaware Valley Preliminary Planning Area Connecticut Florida Georgia Eastern Pennsylvania and portions of New Jersey and Delaware Estimated Population 2,925,000 6,000,000 4,510,000 8,200,000 Coordinating Headquarters Program Coordinator Yale University School of Medicine and University of Connecticut School of Medicine Henry T. Clark, Jr., M.D. Program Coordinator Connecticut Regional Medical Program 272 George Street New Haven, Conn. 06510 (tel: 203-776-6872) Florida Advisory Council, Inc. Samuel P. Martin, M.D. Provost, J. Hillis Miller Medical Center University of Florida Gainesville, Fla. 32601 (tel: 904-376-3211, ext. 5377) Medical Association of Georgia J. W. Chambers, M.D. | Coordinator for Georgia Regional Medical Program Medical Association of Georgia 938 Peachtree Street NE. Atlanta, Ga. 30309 (tel: 404-876-7535) University City Science Center George Clammer, M.D. Wynnewood House 300 East Lancaster Avenue Wynnewood, Pa. 19096 (tel: 215-649-4100) Program Director J. Gordon Barrow, M.D Director for Georgia Regional Medical Program Medical Association of Georgia 938 Peachtree Street N.E. Atlanta, Ga. 30309 (tel: 404-875-0701) Chairman, Regional Advisory Group Arthur M. Rogers Director of Traffic Scovill Manufacturing Company 99 Mill Street Waterbury, Conn. 06720 H. Phillip Hampton, M.D. 1 Davis Boulevard Tampa, Fla. 33606 (tel: 813-253-0991) Arthur P. Richardson, M.D. Dean, School of Medicine Emory University Atlanta, Ga. 30322 Glen R. Leymaster, M.D Dean, Woman’s Medical College of Pennsylvania 3300 Henry Avenue Philadelphia, Pa. 191 Grantee Yale University School of Medicine Florida Advisory Council, Inc. Medical Association of Georgia University City Science Center Effective Starting Date July 1, 1966 November 1, 1967 January 1, 1967 April 1, 1967 of Planning Grant Amount of $240,000 $1,531,494 Planning Grant $406,622 3st year) $338,513 (2d year) $240,098 3st year) $555,079 (2d year) Effective Starting Date of Operational Grant Amount of Operational Grant 164 Indiana Name of Region Hawaii Mlinois Intermountain Proliminary Planning Aroa linwat Iinois Indiana Utah, and portions of Wyoming, . Montana, idaho, and Nevada Estimated Population 740,000 10,895,000 5,000,000 2,220,000 Coordinating Headquarters Program Coordinator Program Director Chairman, Regional Advisory Group Grantee Effective Starting Date of Planning Grant Amount of Planning Grant Effective Starting Date of Operational Grant Amount of Operational Grant University of Hawaii College of Health Sciences Masato Hasegawa, M.D. Suite 105 Medical Arts Building 1010 South King Street Honolulu, Hawaii 96822 (tel: 808-944-8499) William D. Graham, M.D. Deputy Director Hawaii Regional Medical Program Lezhi Hospital Honolulu, Hawaii 96822 Wilson P. Cannon, Jr. Senior Vice President Bank of Hawaii P.O. Box 2900 Honolulu, Hawaii 96802 University of Hawaii College of Health Sciences July 1, 1966 Coordinating Committee of Medical ee and Teaching Hospitals of (Winois Leon 0. Jacobson, M.D. Dean of Biological Sciences Chairman, Coordinating Committee of Medical Schools and Teaching Hospitals of Illinois 950 East 59th Street Chicago, III. 60637 (tel: 312-MU4~6100) Wright R. Adams, M.D. Executive Director IHinois Regional Medical Program 122 South Michigan Avenue Suite 939 Chicago, Ill. 60603 (tel: 312-939-7307) Oglesby Paul, M.D. Professor of Medicine Northwestern University School of Medicine Passavant Hospital 303 East Superior Street Chicago, II]. 60611 (tel: 312-WH4-4200) University of Chicago July 1, 1967 Indiana University School of Medicine Robert B. Stonehill, M.D. Indiana University Medical Center 1100 West Michigan Street Indianapolis, Ind. 46207 (tel: 317-639-8492) George T. Lukemeyer, M.D. | Associate Dean, Indiana University School of Medicine Indiana University Medica! Center 1100 West Michigan Street Indianapolis, Ind. 46207 (tel: 317-639-8877) Indiana University Foundation January 1, 1967 University of Utah School of Medicine C. Hilmon Castie M.D. Associate Dean and Chairman Department of Postgraduate ducation University of Utah College of Medicine 50 North Medical Drive Sait Lake City, Utah 84112 (tel: 801-322-7901) Kenneth 8. Castleton, M.D. Dean, University of Utah College of Medicine ; University of Utah Medical Center Salt Lake City, Utah 84112 (tel: 801-322-7211, ext. 7201) University of Utah College of Medicine July 1, 1966 $194,771 "$108,006 (ust year) 2d year) $336,366 $384,750 ee year) $497,837 (2d year) $456,415 Se year) $363,524 (2d year) April 1, 1967 $2,038,123 (1st year) $2,215,234 (2d year) 165 Name of Region lowa Kansas Louisiana Maine Preliminary Planning Area lowa Kansas Louisiana Maine Estimated Population 2,755,000 2,275,000 3,660,000 975,000 Coordinating Headquarters Program Coordinator University of lowa College of Medicine Willard A. Krehl, M.D., Ph. D. 308 Metrose Avenue University of lowa lowa City, towa 52240 (tel: 319-353-4843) University of Kansas Medical Center Charles E. Lewis, M.D. Chairman, Department of Preventive Medicine and Community Health University of Kansas Medical Center 39th and Rainbow Boulevard Kansas City, Kans. 66103 (tel: 919-AD6-5252, ext. 271) Louisiana State Department of Hospitals E. Lee Agerton Director Louisiana State Department of Hospitals 655 North Fifth Street Baton Rouge, La. 70804 Medica! Care Development, inc. Manu Chatterjee, M.D. Program Coordinator Maine Regional Medica! Program 295 Water Street Augusta, Maine 04322 (tel: 207-622-7566) Program Director Chairman, Regional! Advisory Group Harry B. Weinberg, M.D. lowa Heart Association 1333 West Lombard Street Davenport, lowa 52804 George A. Wolf, Jr., M.D. Provost and Dean, School of Medicine University of Kansas Medical Center Rainbow Boulevard at 39th Street Kansas City, Kans. 66103 Joseph A. Sabatier, Jr., M.D. Program Coordinator Louisiana Regional Medical Program Claiborne Towers Roof 119 South Claiborne Avenue New Orleans, La. 70112 (tel: 504-522-5678) Charles B. Odom, M.D. Past President Louisiana State Medical Society 134 North 19th Street Baton Rouge, La. 70002 Merle S. Bacastow, M.D. President Medical Care Development, Inc Director of Medical Education Maine Medical Center Porttand, Maine 04102 Grantee Effective Starting Date of Planning Grant Amount of Planning Grant Effective Starting Date of Operational Grant Amount of Operational Grant 166 University of lowa College of Medicine December 1, 1966 ,348 (1st year) :591 (2d year) University of Kansas Medical Center July 1, 1966 $197,945 (ist year) $281,627 (2d year) June 1, 1967 $699,852 Louisiana State Department of Hospitals January 1, 1967 $490,448 (1st year) $454,445 (2d year) Medical! Care Development, Inc. May 1, 1967 $193,909 s year) $204,709 (2d year) Name of Region Preliminary Planning Area Estimated Population Coordinating Headquarters Program Coordinator Program Director Maryland Maryland 3,685,000 Steering Committee of the Regional Medical Program for Maryland William S. Spicer, Jr., M.D. Acting Coordinator Maryland Regional Medical Program 550 North Broadwa Baltimore, Md. 21205 (tel: 301-955-7444) Memphis Medical Region Western Tennessee, Northern Mississippi, and portions of Arkansas, Kentucky, and Missouri 2,425,000 Mid-South Medical Council for Com- prehensive Health Planning, Inc. James W. Culbertson, M.D. Professor and Cardiologist __ Department of Internal Medicine Coliege of Medicine University of Tennessee 858 Madison Avenue Memphis, Tenn, 38103 (tel: 901-JA6-8892, ext. 437) Metropolitan Washington, D.C. District of Columbia and contiguous counties in Maryland (2) and Virginia (2) 2,160,000 District of Columbia Medical Society Thomas W. Mattingly, M.D. Program Coordinator Metropolitan Washington, D.C. Regional Medical Program District of Columbia Medical Society 2007 Eye Street_N.W. Washington, D.C, 20006 (tel: 202-223-2230) Michigan Michigan 8,585,000 Michigan Association for Regional Medical Programs, Inc. Aibert E. Heustis, M.D. 1111 Michigan Avenue Suite 200 East Lansing, Mich. 48823 (tel: 517-351-0290) Chairman, Regional Advisory Group William J. Peeples, M.D. Commissioner Maryland State Department of Heaith 301 West Preston Street Baitimore, Md. 21201 Frank M. Norfleet Vice President Parts, Inc. 601 South Dudley Memphis, Tenn, 38104 Clayton Ethridge, M.D. Associate Dean, §chool of Medicine 901 23d Street N.W. Washington, D.C. 20037 William N. Hubbard, Jr., M.D. Dean, School of Medicine University of Michigan 1335 Catherine Street Ann Arbor, Mich. 48104 (tel: 313-764-8175) Grantee The Johns Hopkins University University of Tennessee College of District of Columbia Medical Society Michigan Association for Regional Medicine Medical Programs, Inc. Effective Starting Date January 1, 1967 April 1, 1967 January 1, 1967 June 1, 1967 of Planning Grant Amount of $173,119 $203,790 (1st year) $1,294,449 Planning Grant Effective Starting Date of Operational Grant Amount of Operational Grant $518,443 (1st year) $4 f 12,227 (2d year) $216,322 (2d year) March 1, 1968 $418,318 167 a Nebraska-South Dakota Name of Region Mississippi Missouri Mountain States Preliminary Planning Area Mississippi Missouri, exclusive of St, Louis aoe Montana, Nevada, and Nebraska and South Dakota yoming Estimated Population 2,350,000 4,605,000 2,160,000 2,110,000 Coordinating Headquarters Program Coordinator Program Director Chairman, Regional Advisory Group Grantee Effective Starting Date of Planning Grant Amount of Planning Grant Effective Starting Date of Operational Grant Amount of Operational Grant 168 University of Mississippi Medical Center Guy D. Campbell, M.D. Mississippi Regional Medical Program University of Mississippi Medical Center 2500 North State Street Jackson, Miss, 39216 (tel: 601-362-4411) Not identified University of Mississippi Medical Center July 1, 1967 $454,206 University of Missouri School of Medicine Vernon E. Wilson, M.D. Executive Director for Health Affairs University of Missouri Columbia, Mo. 65201 (tel: 314-449-2711) George E. Wakerlin, M.D. Director, Missouri Regional Medical Program Lewis Hall 406 Turner Avenue Columbia, Mo. 65301 (tel: 314~449-2711) Nathan J. Stark Group Vice President Operations Hallmark Cards, Inc. 25th and McGee Trafficway Kansas City, Mo. 64108 University of Missouri School of Medicine July 1, 1966 $398,556 st year) $324,254 (2d year) April 1, 1967 $2,887,903 (1st year) $3,484,039 (2d year) Western Interstate Commission for Higher Education Kevin P. Bunnell, Ed.D. Associate Director Western Interstate Commission for Higher Education University East Campus 30th Street Boulder, Colo, 80302 (tel: 303-443-2111, ext. 6342) Alfred M. Popma, M.D. Program Director Mountain States Regional Medical Program 525 West Jefferson Street Boise, Idaho 83702 {tel: 208-342-4666) George D. Humphrey, M.D. President Emeritus University of Wyoming P.O. Box 3067, University Station Laramie, Wyo. 82070 Western Interstate Commission for Higher Education November 1, 1966 $876,855 (1st year) $1,082,107 (2d year) March 1, 1968 $206,913 Nebraska State Medical Association Harold Morgan, M.D. Program Coordinator Nebraska-South Dakota Regional Medical Program 1408 Sharp Building Lincoln, Nebr. 68503 (tel: 402-432-5427) Robert J. Morgan, M.D. President Nebraska State Medical Association 916 West 10th Street Alliance, Nebr. 69301 Nebraska State Medical Association January 1, 1967 $350,339 (1st year) $349,367 (2d year) Name of Region New Jersey New Mexico New York Metropolitan Area North Carolina Preliminary Planning Area New Jersey New Mexico New York City and Westchester, North Carolina Nassau, and Suffolk Counties Estimated Population 7,000,000 1,005,000 11,480,000 5,030,000 Coordinating Headquarters New Jersey Joint Committee for Implementation of Public Law 89-239 University of New Mexico School of Medicine Associated Medical Schools of Greater New York Association for the North Carolina” Regional Medical Program Program Coordinator Alvin A. Florin, M.D. New Jersey Regional Medical Program 88 Ross Street East Orange, N.J. 07018 (tel: 201-675-1100) Reginald H. Fitz, M.D. Dean, School of Medicine University of New Mexico 900 Stanford Drive N.E. Albuquerque, N. Mex. 87106 (tel: 505-277-2321) Vincent de Paul Larkin, M.D. New York Academy of Medicine 2 East 103d Street New York, N.Y. 10029 (tel: 212-427-4100) Marc J. Musser, 4.0. Executive Director * North Carolina Regional Medical Program Teer House 4019 North Roxboro Road Ourham 704 N.C. (tel: 919-477-8685) Program Director Irvin E. Hendryson, M.D. University of New Mexico 900 Stanford Drive N.E. Albuquerque, N. Mex. 87106 Chairman, Regional Advisory Group Joseph R. Jehi, M.D. President The Medical Society of New Jersey 315 West State Street Trenton, N.J. 08618 Not identified Vernon Stutzman Regional Medical Program New York Academy of Medicine 2 East 103d Street New York, N.Y. 10029 George W. Paschal, Jr., M.D. President, Medical Society of State of North Carolina 1110 Wake Forest Road Raleigh, N.C. 27604 Grantee Foundation for the Advancement of Medical Education and Research in New Jersey University of New Mexico Associated Medical Schools of Greater New York Duke University Effective Starting Date July 1, 1967 October 1, 1966 June 1, 1967 July 1, 1966 of Planning Grant Amount of $297,466 $967,010 Pianning Grant $449,736 Oe year) $553,270 (2d year) $435,851 fist year) $773,674 (2d year) Effective Starting Date of Operational Grant March 1, 1968 Amount of Operational Grant $1,510,796 169 Name of Region North Dakota Northeastern Ohio Northern New England Northlands Preliminary Planning Area North Dakota 12 counties in Northeastern Ohio Vermont and three counties in Minnesota Northeastern New York Estimated Population 640,000 4,170,000 570,000 3,580,000 Coordinating Headquarters University of North Dakota Case Western Reserve University University of Vermont College of Minnesota State Medical Association Medicine Foundation Program Coordinator Theodore H. Harwood, M.D. Dean, School of Medicine University of North Dakota Grand Forks, N. Dak. 58201 (tel: 701-777-2514) Frederick C. Robbins, M.D. Dean, School of Medicine Case Western Reserve University 2107 Adelbert Road Cleveland, Ohio 44106 John E. Wennberg, M.D. Program Coordinator Northern New England Regional Medical Program University of Vermont College of Medicine 25 Colchester Avenue Burlington, Vt. 05401 (tel: 802-864-4511, ext. 244) Winston R. Miller, M.D. 375 Jackson Street Saint Paul,Minn, 55101 (tel: 612-224-4771) Program Director Willard Wright, M.D. Program Director North Dakota Regionas Medical Program 1600 University Avenue Grand Forks, N. Dak. 58201 Chairman, Regional Advisory Group Lee A. Christoferson, M.D. The Neuro-Psychiatric Institute 700 First Avenue South Fargo, N. Dak. 58102 Irvine H. Page, M.D. Consultant Emeritus Cleveland Clinic Division of Research 2050 East 93d Street Cleveland, Ohio 44106 Edward C. Andrews, M.D. Dean, College of Medicine University of Vermont 25 Colchester Avenue Burlington, Vt. 05401 Oo. L. Nelson, M.D. Chairman, Advisory Group Northlands Regional Medical Program 601 Medical Arts Building Minneapolis, Minn. 55402 Grantee North Dakota Medical Research Foundation Case Western Reserve University University of Vermont College of Medicine Minnesota State Medical Association Foundation Effective Starting Date of July 1, 1967 January 1, 1968 July 1, 1966 January 1, 1967 Planning Grant Amount of Planning Grant $188,010 $285,783 $316,186 Gist year) $370,904 (1st year) $702,504 (2d year) $529,250 (2d year) Effective Starting Date of Operational Grant Amount of Operational! Grant 170 Name of Region Preliminary Planning Area Estimated Population Coordinating Headquarters Program Coordinator Northwestern Ohio 20 counties in Northwestern Ohio 1,360,000 Medical College of Ohio at Toledo Cc. Robert Tittle, Jr., M.D. 2313 Madison Avenue Toledo, Ohio 43624 (tel: 419-248-6201) Ohio State Central and southern two-thirds of Ohio (61 counties, excluding Metropolitan Cincinnati area) 4,680,000 Ohio State University College of Medicine Neil C. Andrews, M.D. Assistant Dean, College of Medicine Ohio State University 410 West 10th Avenue Columbus, Ohio 43210 (tel: 614-293-5344) Ohio Valley Greater part of Kentucky and. contiguous parts of Ohio, Indiana, and West Virginia 6,000,000 Ohio Valley Regional Medical Program William H. McBeath, M.D. Director, Ohio Valley Regional Medical Program 1718 Alexandria Drive Lexington, Ky. 40508 (tel: 606-255-6684) Oklahoma Oklahoma 2,500,000 University of Oklahoma Medical Center Kelly West, M.D. Professor and Head, Department of Continuing Education : University of Oklahoma Medical Center 800 Northeast 13th Street Oklahoma City, Okla. 73104 (tel: 405-CE 2-8561) Program Director Chairman, Regional Advisory Group Grantee Edward L. Burns, M.D. Northwestern Ohio Regional Medical Program 2313 Madison Avenue Toledo, Ohio 43624 Medical College of Ohio at Toledo Richard L. Meiling, M.D. Dean, College of Medicine Ohio State University 410 West 10th Avenue Columbus, Ohio 43210 (tel: 614-293-5344) Ohio State University College of Medicine Louis Wozar President and General Manager Tait Manufacturing Company 500 Webster Street Dayton, Ohio 45404 (tel: 513-224-9871) The University of Kentucky Research Foundation James L. Dennis, M.D. Director and Dean University of Oklahoma Medical Center 800 Northeast 13th Street Oklahoma City, Okla. 73104 University of Okiahoma Medical Center 2d year) Effective Starting Date January 1, 1968 April 1, 1967 January 1, 1967 September 1, 1966 of Planning Grant Amount of $309,180 $126,182 $177,963 fast year) Planning Grant $346,760 {5 year) $407,238 (2d year) $282,100 Effective Starting Dato of Operational Grant Amount of Operational Grant 171 Loe) Name of Region Oregon Puerto Rico Rochester South Carolina Preliminary Planning Area Oregon Puerto Rico Rochester, New York and 11 South Carolina surrounding counties Estimated Population 2,000,000 2,670,000 1,270,000 2,600,000 Coordinating Headquarters University of Oregon Medical School University of Rochester School of Medicine and Dentistry Medical College of South Carolina Program Coordinator M. Roberts Grover, M.D. Director, Continuing Medical Education University of Oregon Medical School 181 Southwest Sam Jackson Park Road Portland, Oreg. 97201 (tel: 503-228-9181, ext. 519) A. Nigaglioni, M.D. Chancellor, School of Medicine University of Puerto Rico San Juan, P.R. 00905 (tel: 174-723-5210) Ralph C. Parker, Jr., M.D. Clinical Associate Professor of Medicine School of Medicine and Dentistry University of Rochester 260 Crittenden Boulevard Rochester, N.Y. 14620 (tel: 716-473-4400, ext. 3112) J.C. Chambers, M. Medica! College of South Carolina 55 Doughty Street Charleston, S.C. 29403 (tel: 803-723-9411) Program Director Chairman, Regional Advisory Group Herman A. Dickel, Member, Council of Medical Education Oregon Medical Association 511 Southwest 10th Avenue Portland, Oreg. 97205 Not identified Frank Hamlin Papec Machine Company Shortsvitle, N.Y. 14548 William M. McCord, M.D., Ph. D. President, Medical ‘College of South Carolina 80 Barre Street Charleston, S.C. 29401 Grantee University of Oregon Medical Schoo! University of Rochester School of Medicine and Dentistry Medical College of South Carolina Effective Starting Date of Planning Grant April 1, 1967 Application under review October 1, 1966 January 1, 1967 Amount of Planning Grant $219,168 (1st year) $231,125 (2d year) $306,985 te year) $318,286 (2d year) AA wr lst year ay yea Effective Starting Date of Operational Grant March 1, 1968 March 1, 1968 Amount of Operational Grant $221,191 $343,749 172 Name of Region Susquehanna Valley Tennessee Mid-South Texas Tri-State Preliminary Planning Area 27 counties in Central Pennsylvania Eastern and Central Tennessee and Texas Massachusetts, New Hampshire, contiguous parts of Southern and Rhode Island Kentucky and Northern Alabama ‘Estimated Population 2,140,000 2,700,000 10,875,000 7,010,000 Coordinating Headquarters Pennsylvania Medical Society Vanderbilt University School of Medicine and Meharry Medical College University of Texas Medical Care and Educational Foundation, Inc. Program Coordinator Richard B. McKenzie 3806 Market Street P.O. Box 541 Camp Hill, Pa. 17011 (tel: 717-761-3252) Stanley W. Olson, M.D. Professor of Medicine Vanderbilt University . Clinical Professor of Medicine Meharry Medical College 110 Baker Building 110 21st Street South Nashville, Tenn. 37203 (tel; 615-255-0692) Charles A. LeMaistre, M.D. Vice-Chancellor for Health Affairs Muiversity of Texas Main Building Austin, Tex. 78712 (tel; 512-GR 1-1434) Leona Baumgartner, M.D. Medical Care and Educational Foundation 22 The Fenway Boston, Mass. 02115 (tel: 617-262-3040) Program Director Spencer G. Thompson, M.D. Regional Medical Program of Texas Suite 724 , a Sealy-Smith Professional Building Galveston, Tex. 77550 (tel: 713-505-2425) Chairman, Regional Advisory Group Raymond C. Grandon, M.D. Secretary . Dauphin County Medical Society 131 State Street Harrisburg, Pa. 17101 Thomas P. Kennedy, Jr. President, Executive Committee Health and Hospital Planning Council Vanderbilt University Medical Center Hospital Board St. Thomas Hospital P.O. Box 449 Nashville, Tenn. 37203 John F. Thomas, M.D. Committee on Cancer Texas Medical Association 918 East 32d Street Austin, Tex. 78705 Mac V. Edds, Jr., Ph. D. Division of Medical Sciences Brown University President, Medical Care and Educational Foundation, Inc. 22 The Fenway Boston, Mass. 02115 Grantee Pennsylvania Medical Society Vanderbilt University University of Texas Medical Care and Educational Foundation, tc. Effective Starting Date June 1, 1967 July 1, 1966 July 1, 1966 December 1, 1967 of Planning Grant Amount of $263,530 1, $439,037 Planning Grant $265,841 fast year) $524,738 (2d year) $1,271,013 fast year) $1,577,612 (2d year) Effective Starting Date of Operational Grant February 1, 1968 Amount of Operational Grant $1,630,304 173 Western New York Name of Region Virginia Washington-Alaska West Virginia Preliminary Planning Area Virginia Washington and Alaska West Virginia Buffalo, New York and 7 surrounding counties Estimated Population 4,535,000 3,360,000 1,800,000 1,935,000 Coordinating Headquarters Program Coordinator Program Director Chairman, Reglonal Advisory Group Grantee Effective Starting Date of Planning Grant Amount of Planning Grant Effective Starting Date of Operational Grant Amount of Operational Grant Medical College of Virginia and University of Virginia School of Medicine Kinloch Nelson, M.D. Dean, Medical College of Virginia 1200 East Broad Street Richmond, Va. 23219 (tel: 703-M14~-9851) Eugene R. Perez, M.D. program Director Virginia Regional Medical Program Building, Suite 1025 460 East Main oasis Richmond, Va. 23219 {tel: 703-643-6631) Mack !. Shanholtz, M.D. State Commissioner of Health State Department of Heaith Bank and Governor Streets Richmond, Va. 23219 University of Virginia School of Medicine January 1, 1967 $545,454 University of Washington Schoo! of Medicine Donal R. Sparkman, M.D Associate Professor of Medicine School of Medicine University of Washington AA 312 Sere os Hospital Seattle, Wash. 9 (tel: 206-543-8540) Donal R. Sparkman, M.D. Associate Professor of Medicine School of Medicine University of Washington A312 University He Hospital Seattle, Wash. 9 (tel: 206-543-8540) University of Washington School of Medicine September 1, 1966 $266,248 &s year) $655,148 (2d year) February 1, 1968 $1,032,003 West Virginia University Medical Center Charles L. Wilbar, Jr., M.D. West Virginia Regional Medical Program West Virginia University Medical Center Morgantown, W. Va. 26506 (tel: 304-293-4511) Clark K. Sleeth, M.D. Dean, School of Medicine West Virginia University Medical Center Morgantown, W. Va. 26506 West Virginia University Medical Center January 1, 1967 $150,798 {3st year) $208,910 (2d year) ’ Schoo! of Medicine, State University of New York at Buffalo, in coopera- tion with the Health Organization of Western New York John R, F. ingal!l, M.D. Director, Regional Medical Program for Western New York School of Medicine, State University of New York at Buffalo Buffalo, N.Y. 14214 (tel: 716-833-2726, ext. 32, 50) William E. Chalecke, M.O. R.D. 2 Horton Road Jamestown, New York 14701 (tel: 716-483-1840) Douglas M. Surgenor, M.D. Dean, School of Medicine State University of New York at Buffalo 101 Capen Hal! Buffalo, N.Y. 14214 (tel: 716-831-2811) Research Foundation of the State University of New York December 1, 1966 $149,241 (1st year) $383,717 (2d year) March 1, 1968 $357,761 174 Name of Region Preliminary Planning Area Estimated Population Coordinating Headquarters Western Pennsylvania Pittsburgh, Pennsylvania and 28 surrounding counties 4,200,000 University Health Center of Pittsburg Wisconsin Wisconsin 4,190,000 Wisconsin Regional Medicat Program, Inc. Program Coordinator Program Director Francis S. Cheever, M.O. Dean, School of Medicine University of Pittsburgh M-~240 Scaife Hall 3550 Terrace Street Pittsburgh, Pa. 15213 (tel: 412-621-1006) John S. Hirschboeck, M.D. Wisconsin Regional Medical Program, Inc. 110 East Wisconsin Avenue Milwaukee, Wis. 53202 (tel: 414-272-3636) Chairman, Regional Advisory Group Dan J. Macer President, Veterans Administration Hospital University Drive Pittsburgh, Pa. 15240 T. A. Duckworth Senior Vice President Employers Insurance of Wausau 407 Grant Street Wausau, Wis. 54402 Grantee Effective Starting Date of Planning Grant Amount of Planning Grant Effective Starting Date of Operational Grant University Health Center of Pittsburg January 1, 1967 $340,556 (1st year) $326,765 (2d year) Wisconsin Regional Medical Program, Inc. September 1, 1966 $344,418 September 1, 1967 Amount of Operational Grant $630,149 175 APPENDIX 7 PUBLIC LAW 89-239 89TH CONGRESS, 8S. 596 OCTOBEN 6, 1965 AN ACT Heart Disease, Cancer, and Stroke Amend- ments of 1965 To amend the Public Health Service Act to assist in combating heart disease, cancer, stroke, and related diseases. Be it enacted by the Senate and IIouse of Representatives of the United States of America in Congress assembled, That this Act may be cited as the “Heart Disease, CANCER, STROKE, AND RELATED Sec. 2. The Public Health Service Act (42 U.S.C., ch. 6A} is amended by adding at the end thereof the following new title: “TITLE IX-—-EDUCATION, RESEARCH, TRAINING, AND DEMONSTRATIONS IN THE FIELDS OF HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES “Purposes “Sec. 800. The purposes of this title are-— “(a) Through grants, to encourage and assist in the establishment of regional co- operative arrangements among medical schools, research institutions, and hospitals for research and training (including con- tinuing education) and for related demon- strations of patient care in the fields of heart disease, cancer, stroke, and related diseases : “(b) To afford to the medical profession and the medical institutions of the Nation, through such cooperative arrangements, the opportunity of making available to their pa- tients the latest advances in the diagnosis and treatment of these diseases ; and “(c) By these means, to improve gen- erally the health manpower and facilities available to the Nation, and to accomplish these ends without interfering with the pat- terns, or the methods of financing, of pa- tient care or professional practice, or with 176 the administration of hospitals, and in co- operation with practicing physicians, medi- cal center officials, hospital administrators, and representatives from appropriate volun- tary health agencies, “Authorization of Appropriations “Sec. QOL. (a) There are authorized to be appropriated $50,000,000 for the fiscal year ending June 20, 1966, $90,000,000 for the fiscal year ending June 30, 1967, and $200,000,000, for the fiscal year ending June 30, 1968, for grants to assist public or non- profit private universities, medical schools, research institutions, and other public or nonprofit private institutions and agencies in planning, in conducting feasibility studies, and in operating pilot projects for the estab- lishment of regional medical programs of research, training, and demonstration activ- ities for carrying out the purposes of this title. Sums appropriated under this section for any fiscal year shall remain available for making such grants until the end of the fiscal year following the fiseal year for which the appropriation is made, “(b) A grant under this title shall be for part or all of the cost of the planning or other activities with respect to which the application is made, except that any such grant with respect to construction of, or provision of built-in (as determined in ac- eordance with regulations) equipment for, any facility may not exceed 90 per centum of the cost of such construction or equipment. “(e) Funds appropriated pursuant to this title shall not be available to pay the cost of hospital, medical, or other care of patients except to the extent it is, as determined in accordance with regulations, incident to those research, training, or demonstration activities which are encompassed by the purposes of this title. No patient shall be furnished hospital, medical, or other care at any facility incident to research, training, or demonstration activities carried out with funds appropriated pursuant to this title, unless he has been referred to such facility by a practicing physician. “Definitions “Sec. 902. For the purposes of this title— “(a) The term ‘regional medical program’ means a cooperative arrangement among a group of public or nonprofit private Institu- tions or ugencles engaged in research, train- ing, diagnosis, and treatment relating to heart disease, cancer, or stroke, and, at the option of the applicant, related disease or diseases; but only if such group--- “(1) is situated within a geopraphic grea, camposed of any part oor parts of any one or more States, whieh the Surgeon General determines, ino aceordinee with regulations, to be appropriate for carry- ing out the purposes of this title; “(2) consists of one or more medical centers, one Or more clinical research cen- ters, and one or more hospitals; and “(3) has in effect cooperative arrange- ments among its component units which the Surgeon General finds will be adequate for effectively earrying out the purposes of this title. “(b) The term ‘medical center’? means a medical school or other medical institution involved in postgraduate medical training and one or more hospitals atliated there- with for teaching, research, and demon- stration purposes. “(c) The term ‘clinical research conter’ means an institution (or part of an institu- tion) the primary function of which is re- search, training of specialists, and demon- strations and which, in connection therewith, provides specialized, high-quality diagnostic and treatment services for inpatients and outpatients. “(d) The term ‘hospital’ means a hospi- tal as defined in section 625(c) or other health facility in which local capability for diagnosis and treatment is supported and augmented by the program established un- der this title. “(e) The term ‘nonprofit’ as applied to any institution or agency means an institu- tion or agency which is owned and operated by one or more nonprofit corporations or associations no part of the net carnings of which inures, or may lawfully inure, to the benefit of any private sharcholder” or individual. “(f) "Phe . term alteration, major repair (to the extent per- mitted by regulations), remodeling and renovition of existing buildings (including initial equipment thereof), and replacement of obsolete, built-in) (as determined in ac- eordance with equipment of existing buildings. ‘construction’ includes regulations) “Grants for Planning “Sec. 903. the recommendation of a) The Surgeon General, upon the National