A
                                                                                                                                                                                                 \       @   I 'i
                            @RC)CEEDIN(3S:
                                                                                                                                                                                                                    VOLUME I


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                                                           PROCEEDINGS:

                                                                                      conference-
                                                                                          workshop
                                                                                                      on
                                                                                   REGIONAL
                                                                                      MEDICAL
                                                                                 PROGRAMS




           VOLUME I   Plenary Sessions o Panel
                      and Discussion Groups* Related
                      Background Information on
                      Conference-Workshop (Appendices)


          VOLUME 11   15-Minute Papers on Regional
                      Activities and Ideas











      JANUARY 17-19, 1968 0 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        1).N, tli,,                    of I)ocii7iietits. la.'. (;ov(@rTiin(@iitr 1'ritititig OfY'ice
                                                                                                                                                @@'zi@IiiiigLoii, 1).(!. 20402 - Ilri(!(! $1.50 (I)ztl)cr (,,Over)













                                                                     The     January     1968      Conference-   Committee  invited  all  regions  to   pre-     At   the   time   of   the    Conference-
                    PREFACE                                        Workshop   on   Regional    Medical    Pro-   sent  papers  on  regional  activities  and   Workshop,   many   of   the   54   existin,
                                                                   grams,  the  proceedings   of   which   are   ideas  to  submit  exhibits   which   could   reg'                 let'ng the'
                                                                                                                                                                  ions were comp   i           ir   opera-
                                                                   reproduced   in    these    two    volumes,   be  viewed   and   demonstrated;   and   to   tional  proposals.   The   meeting   served
                                                                   was  significant  in  origin,  content  and   participate  actively  in   panel   discus-   as a  catalyst,  so  that  at  the  present
                                                                   purpose,  and   marked   a   milestone   in   sions.  This  invitation  resulted  in  the   time    operational    applications    from
                                                                   the   development   of    Regional    Medi-   presentation  of  60   representative   pa-   a total of 24 of the reoions  have  eithei@
                                                                   cal Proarams.                                 pers  and  more  than  40  exhibits.  FLir-   been  approved   or   are   under   review.
                                                                     Growing  out  of   a   specific   request   thermore,    virtually    every     invited   The  i-nenibet-s  of  the  Stecrin<@  Coni-
                                                                   of  the  Program  Coordinators   at   their   speaker   accepted   the   opportunity   to   inittee  hav(,  expressed  their  satisfac-
                                                                   meeting  in   June   1967,   this   meeting   discuss  the  ma'or  issues  of  the   Con-   tion that  the  meeting  met  the  need.,,-
                                                                   was  planned   by   the   Steerin,,   Corn-   ference-Workshop.                             and  purposes  for   which   it   was   de-
                                                                   mittee   of    Coordinators    under    the     The  University  of   Mississippi   Mccl-   signed.  From  the   Division   standpoint.
                                                                   Chairmanship  of   Dr.   Stanley   W.   01-   ical  Center  and  the   Stanford   Univer-   the     Conference-NVorkshop     was      a
                                                                   son,    Program    Coordinator    of    the   sity  School  of  Medicine  kindly   grant-   major  source   of   substantive   informa-
                                                                   Tennessee    Mid-South    Regional     Med-   ed  leave  to  Dr.  John  A.  Gronvall  and   tion  concerning   progress   A@ithin   the
                                                                   ical  Program.  Its  purpose  was  to  pro-   Mr.   Robert   G.   Lindee,   respectively,   programs   which    was    invaluable    as
                                                                   vide  those  directly   involved   in   the   to   act   as    Conference-Workshop    Co-   testimony    before    the     Subcommittee
                                                                   development     of     Regional     Medical   chairmen.   These   two   men   established   on  Health  of  the  House  Interstate  and
                                                                   Programs    the    opportunity    to    ex-   and   directed   the   Conference    Office   Foreign     Commerce      Committee      on
                                                                   change   ideas   and   information    which   located  in  the   Division   of   Regional   March  26  and  27  in   support   of   the
                                                                   would  be  of  benefit   in   the   further   Medical   Programs    at    the    National   bill   to   make    necessary    amendments
                                                                   implementation   of   their   programs   at   Institutes  of   Health   in   the   months   and   to   extend   Public   Law    89-239.
                                                                   the  regional  level.  The  focus  was   on   preceding     the      Conference-Workshop.   Finally, and  most  important  of  all,  is
                                                                   what  Dr.  Lowell  T.  Coggeshall  in   his   Other   outside   consultants   who    con-   the  probability  that   this   Conference-
                                                                   summary   paper   called   "the    emerging   tributed  richly  to  the  success  of  the   Workshop  will   emerge   historically   as
                                                                   substance"  reflected   in   the   on-going   program   were    Mr.    Greer    Williams,   the  time  when  the  definition  of  oals,
                                                                   activities  in  the  regions,  particularly   who   worked   on   the   actual    publica   organizational     arrangements         and
                                                                   as  they  related  to  the  key  issues  of   tion of  these  Proceed'nas  from  the  re-   planninc,  turned   in   the   new   direc-
                                                                   this  program,  the  quality   and   avail-   ceipt of the first  abstract  until  publi-   tion  of  initial  operational   activities
                                                                   ability of  health  care  for  heart  clis-   cation,  and   Mr.   Greer   Hermetet   and   in the regions.
                                                                   case,   cancer,   stroke,    and    related   Mr.   John   Craner,   who   ,vorkcd   with      It  is  interesting  to  contrast  these
                                                                   diseases.                                     exhibitors   and   on    Conference    ai,-   facts with  those  of  the  first  Nationai
                                                                                                                                                               Conference on Regional -         1
                                                                      To  achieve  these  goals  the  Steering   rangements.                                                               %Ied'cal   Pro-
                                                                                                                                                                                                        iii











                         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  (PH
                         Publication  No.  t682)   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 Health,
                         tl??(l Dirt.,ctor, Diiii.vioit of
                         I?e,,Z'oizal Mc(lic(il 1'rt),,riz?tzs

                         March 31, 1968







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                                                                                                                                                                                  Page
                                                                                                             SUMMARY           OF           CONFERENCE-@VORKST-TOP           ON
                                                CONTENTS                                                     l@l-,"(,I()NAI, Ml,"I)I(@!Al,  lll@()(;I@AMS .........    ........
                                                                                                             Lowell T. Coggcsliall, 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 ..........................         I 0
                                                                                                                 Carleton Chapman, M.D.
                                                                                                                 REGIONALIZAT10N OF HEALTH SERVICE                      .......    1 5
                                                                                                                 Lester Breslow, M.D.
                                                                                                                 DEVELOPMENT           OF            PERSONAL            HEALTH
                                                                                                                 SERVICE              .........................................    19
                                                                                                                 Dwight L. Wilbur, M.D.
                                                                                                                 THE POPULATION         ..............................             24
                                                                                                                 Panel: Roger 0. 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 ..........................         34
                                                                                                                 Robert Q. Marston, M.D.
                                                                                                                 Karl D. Yordy
                                                                                                                 A NEW EMPHASIS                ................................    38
                                                                                                                 Alexander  M.   Schmidt,   M.D.
                                                                                                                 Richard  F.   Manegold,   M.D.
                                                                                                                 OPERATIONS           RESEARCH           AND            SYSTEMS
                                                                                                                 ANALYSIS             .........................................    41
                                                                                                                 Robert Bucher, M.D.
                                                                                                                 Jack Hall, M.D.
                                                                                                                 Herbert P. Galliher, Jr., Ph. D.
                                                                                                                 Maurice E. Odoroff

                                                                                                                                                                                   vu











                                                                                                  Page                                                                                               Page
                   A NATIONAL VIEW OF DEVELOPMENTS IN-                                                                    REGIONALIZATION                         ...............................    105
                       HEART             DISEASE ..................................               52                      Discussants: Lester Breslow, M.D. (Moderator)
                       Donald    S.    Fredrickson,    M.D.                                                                                Walter J. McNerney
                                                                                                                                           William R. Willard, M.D.
                       CANCER       ..................................                .......     55                      URBAN I"IZOBT,EMS           ........
                       Kenneth    M.     Endicott,     M.D.                                                               I)isctissiiits:  I'@itil W@ird (Mocl(@r;ttor)                              106
                       STROKE       ...........................................                   59                                       Roger 0. Egeberg, M.D.
                       Richard L. Masland, M.D.                                                                                            Frank Lloyd, M.D.
                                                                                                                                           Anne R. SorTiers
                   PANEL          DISCUSSIONS           ON-                                                                                Ray E. Trussell, M.D.
                       HEART             DISEASE ......   ...............    I    ...........     68                      RELATED          FEDERAL              PROGRAMS....              .......    108
                       Panel:    Jesse    Edwards,     M.D. (Chairman)                                                    Discussants:     Daniel Zwick (Moderator)
                                Samuel   M.   Fox    111,    M.D.                                                                          James H. Cavanaugh, Ph. D.
                                William    Likoff,     M.D.                                                                                Donald Chadwick, M.D.
                                Theodore Cooper, M.D.                                                                                      Carrutl-i Wagner, M.D.
                                Campbell Moses, M.D.                                                                                       Eugene Veverka
                       CANCER       ...........................................                   78                      HEALTH SERVICES RESEARCH                     ...............               109
                       Panel: Sidney Farber, M.D. (Chairman)                                                              Discussants: Paul Sanazaro, M.D. (Moderator)
                                Michael    J.    Brennan,    M.D.                                                                          Morris E. Collen, M.D.
                                Juan del Regato, M.D.                                                                                      Caldwell B. Esselstyn, M.D.
                                Kenneth M. Endicott, M.D.                                                                                  John Thompson
                                Guy F. Robbins, M.  .                                                                                      John Williamson, M.D.
                       STROKE       .......   .............................             .....     90                      CONTINUING         EDUCATION         AND         TRAINING,          FOR
                                                                                                                          WHAT?     ............................                  ...............    III
                       Panel: Neinat Borhani, M.D. (Chairman)                                                             Discussants: Patrick B. Stor@,, M.D. (Moderator)
                                Clark H. Millikan, M.D.                                                                                    Ltitlier Christman, Ph. D.
                                James   F.   Toole,    M.D.                                                                                George E. Miller
                                William    A.    Spencer,    M.D.                                                                          A. N. Taylor, Ph. D.
                                Richard    L.    Masland,    M.D.                                                         DATA COLLECTION ANI) REGISTRIES                             ...........    112
                   GROUP          DISCUSSIONS           ON-                                                               Discussants: Abraham M. Liliciife.Icl, M.D. (Moderator)
                                                                                                                                           James I,. Kiii(r, Jr.
                       HEALTH            MANPOWER-REVIEW             Ol,-             COMMIS-
                       SION  REPORT                      ....................................      104                                     Andrew Mayer, M.D.
                                                                                                                                           ,John E. Weiiiil)cr-, M.D.
                       Discussants: James C. Cain, M.D. (Moderator)                                                       uiosi,i,rAI,S    ........................................                  113
                                       Leonard                  M.]).
                                       C. H. @Villi@iiii l@tilic, M.D.                                                                     I)e@it-I l,'Islicr, l@.N.
                                       A.  N.  Taylor,  Ph.   1).                                                                          Jollll W.
                                       Dwight    Wilb@ir,    M.D.                                                                          EciNvarcl I-[. Not,oi@iii

                   viii








                                                                                          ]'age
                    COMMUNITY INVOLVEMENT                          ....................    114
                    I)isc@iss,ints: l@ol)(-rt M.  (,'iinninghiiii,,fr.  (Moderator)
                                  Aliti) (I. 1)@iv'ls
                                  [toward Eiiiies, M.1',Ii.
                                  l'ierre C. Fraley
                                  Marc J. Musser, M.D.
                    OPERATIONAL PROGRAM DEVELOPMENT                             .......    115
                    Disc@issants: Charles E. Lewis, M.D. (Moderator)
                                  C. Hiliiion Castle, M.D.
                                  '17. A. I)tAckwortla
                                  Albert E. Heustis, M.D.
                                  Donal R. Sparkmaii,M.D.
                A NONPROFESSIONAL LOOKS AT REGIONAL
                MEDICAL PROGRAMS              ...    ....    ...................     ..    118
                Irving J. Lewis
                REMARKS       ............        .....................................    122
                Honorable Melvin R. Laird

                APPENDICES

                    I - CONFEI@ENCE--%VOI@KSHOJI I'l@()GRAM                    ........    126
                    2.  COORDINATORS' STEERING COMMITTEE                          ....     143
                    3.  LISTING       Ol,'        REGISTEI@ED        I'AL@TICIPANTS   ...  143
                    4.  REVIEW            COMMITTEE            AND             NATIONAL
                         ADVISORY COUNCIL             .   ..     .....   .........         158
                    @5. DIRECTORY OF DIVISION STAFF,                      .............    159
                    6@  DIRECTORY            OF            REGIONAL             MEDICAL
                          PROGRAMS  -  - @ - @  @     .  ....  ...                         161
                    7.  PUBLIC LA@%'89-239..              ................        .....    176
                    8@  l@EGITLA'FIONS...                ......  I     ............        17@3











                                                                                                                                                                                          ix




















           SUMMARY OF CONFERENCE-WORKSHOP                    Lowell T. Coggeshall, M.D.
              ON REGIONAL MEDICAL PROGRAMS









                                                                   SUMMARY             OF              Larson  from   the   Mountain   States   Re-                    frame  of  reference  for  a   reaction   to                    reduce the costs  of  illness,  and  can  it
                                                                CONFERENCE-WORKSHOP                    ional  Medical  Program  has   so   intelli-                    the  Realonal   Medical   Pro-ram   that   I                    presci-%,e or restore the famllN,?
                                                                   ON             REGIONAL             'gently  pointed  out:  "Goals  are   essen-                    find I share              a  good   man@,   others.               This   pro-ram,   I   am   del'-   ted   to
                                                                                                                    I                                                                       1                                                 1                                   i,h
                                                     MEDICAL                  PROGRAMS                 tial  to  the   success   of   any   project                    It would be  itia(,ctirate  in  the  extreme                    find, prefers the experimental                   to   tile
                                                                                                                         one    fyets     @vliat     lie     wants     to   say   that   I   (-am(,   to   sneer    and    stav(@ci    exhortatory       method       of        health        pro,-
                                                                                                       because  no
                                                 Lowell    T,    Coggeshall,    M.D.                   until he knows what he wants."                                  to clieci-, but I did arrive at tl@iis  con-                    ress.  It  is  dividing  its  studN,                  popti-
                                                        Vice          President           Emeritus                                                                     ference    in    a    state    of    igiioran(,e    and    I    lation     into     three      -roups.      6,ic      N@-iii
                                                            University         of         Chica(,o     REGIONAL  ACTIVITIES                                            am    (roirig    a@%,av    mu(@ii     impressed     -,%@itli    deliver        comprehensive        care        in         a
                                                                                                       AND  IDEAS                                                      what   I    have    learned,    and    N@'Itli    a    great    neighborhood          health           center           plus
                                                                                                                                                                       deal     of     enthusiasm     for      the      I)ro,,ram's    multiphasic       screening        laboraton,        ser-,,-
                                                                                                         The  corpus          of      this      conference      is
                                               the       outset       of       this       meeting,                                                                     future.   I   will    trv    to    make    this    entliusi-    ices   to   one   group.   It   will   aix-c    onIN,    the
                                                                                                       found  in  the        60      reports      selected,      I
                                       ARobert        Marston         spoke         of         the                                                                     asiyi a little TI)OT-e, Sl)('.Cifi(@ later oil.                 scrcenlri,-    laboratory,    services     to     a     sec-
                                       C,                              11                              understand,       from        100        papers        sub-
                                       emera,ing   substance                of       the       Re-                                                                       Elam,    in    the    introclti(,tlori    to    his    re-    end    group.    And    it     will     save     a     third
                                                                                                       mitt(@ci.    Tli(@se    60     have.     been     presented
                                       -Iona]    Medical     Pro,,rain.     In     so     cloiii,,
                                                                                                                                                                       )ort,    point,,;    out    that    in    (.orltl,.Ist    to    lrotil)   for   control,    lca\@in,,,    it    to    obtain
                                                                                                       to  @,oii  in   tli(@   last   2   (lays   @in(l,   -,vicli     its                  (.xl)lol.;It,(),,    01,    (,@Ills(,s,    ti-@@L(lit'lotiil itic!(Il(,al              as    best    it
                                       he     made     r-nv     surnrniii(,-Lil)      task      so
                                                                                                       ast(Irilsliirl(@  speed,                       III      two
                                       TTIII(-IL  tll(@  (.@tsiet-  I)',,  providing,  III  C)rl(l                                                                                     @111(i ti(@;itfil(,Tlt of,                                                    of
                                       ino(l(@st  but  apt  little   I)Iit-.is(-,   tli(,   k(@@,-     bound  volumes  @in(I                         in     @,otir     AI I](.      I                   "li@is                                                                li@LS            (I(--
                                                                                                       Cilairs,  clav  by  dav  and  volume
                                       note for the entire proceedings.                                                                                      l@)y      only    i-ii(lim(,ntat,v    r(,s(,ai@(I]i     into     lionv    finecl       here       as       (Compassionate,        per-
                                       irl(@ tile                      )f It year af@                  VO]I]rTl('.                                                                                                                     sori@i.1,      (@oritiriiiiri(,,      faizillv-c)r-'ent(-(],
                                                                                                         I  will  @tcl(iress my  first fl(,
                                                             1                                                                                    '(@tlllg    "(!-                                                                     i@(@latiri,,  tli(@   patient   to   011(@   Clo(:tOl-   but
                                       vaguclv     recognized      the      form      of      tile                                                                     and Nvli(!tli(,i@ it riiakes iliticil
                                       program.    Now,     in     addition     to     form,     I     narks to      this    body    of     reports     (.@ntitled      lien   it   is."   I   le   points    out    -,%@liat    so    "' i %'I n,(,, film      specialist       ,roLip       reinforce-
                                                                                                       15-Minute       Pape?@.@       on       Re,lonal        Ac-                                                                               and        a         modern         teclinolo-'cal
                                                                                                                                                                                                                                       iiicnt                                               I
                                       find substance.                                                                                                                 i-nany  of   us   knoN%,,   but   not   all   of   us   call
                                         In       medical       science       and        practice-     tivities and Ideas. Since the              total       pro-     make    i@i-orousl@,    clear    -,@,heii    we    (go    to    backup.         Further,          the          participating
                                       health         care-the         ultimate          substance     gram,    both    in    its     planning     and     initial     the    White    Ilouse    or     Coii,,rcss'     for     the    I-riembci-s    of    the    coiiiiT-iunit@,    will    ha\@c
                                                                                                       operating    I)Iiases,    excltlsl%,c    of     a     short
                                       is        advancement        of        knowledge         or                                                                     moii(,v:  "Yet," he sa%,s,            "@ve      have      no    a    direct    -,-oice    in    IDolicN@makiii-    at    the
                                                                                                       leadtime,    is    hardly    i-nore     than     a     year
                                       method      that      makes       some       %%,orth@vlille                                                                     precise      knowledge      of      N%,Iictlic,r       corn-    center.
                                                                                                       old,   it   is   a   little   early    to    speak    about                                                                        This    is     but     one     example,,     and     per-
                                       difference   in   the    II-,,es    of    people.    'I'hat     results.     So,     quite     logically,      we      find     I)rchcnsive     medical     care      (,oul)lcd      N@@itli
                                       is,    what    we    as    members    of     the     health                                                                     modern     tccliiiolo,v     can     be     effective      in    hal)s       more       sophisticated       than        some,
                                                                                                       little    about    results    in     these     reports.
                                       professions       and       the        reat        American                                                                     improvin(,     the     health     of     our      citizens."    but    is    falrlv    typical    of    manv    other    re-
                                       public    look    for    is    to    be     found     under       Rather,     most      of      these      reports      run        In    this    frame    of     mind,     this     %@oltin-    'ional    efforts,    I    thin@-.     The     effort     is
                                                                                                       much   in    the    vein    of    the    one    from    the
                                       the         ton-nentln,,,         unforgiving,         one-                                                                     tary proram,  Yieadcluartei-ecl                      jointly    sober,      sensible,      and      devoid      of      ativ
                                                                                                       Tennessee       Mid-South       rc-ion,       as       pre-                                                        s     at-    claim       or       promise       o%7ert-tinnin-       tile
                                       word     label:     RESULTS.     If     we      do      not                                                                     at  Vanderbilt  and  Mefiai@t-v                   I
                                                                                                       senteci    1)@,    Llovcl    Elai-n     from     Melial-rN,                                                                            'denc(,             lncr
                                       have    in    hand    the    kind    of    --ood    results                                                                     ternl)tlii,,@    to    find     out     Nvhetlier     cotii-    e%,l         - oi-   dcf@   ,   i,calit@,.    It    is    an
                                                                                                 c     Medical     Colle(@c.     Let     me      ,-I%-e      NIon       reliensive,   fam'ly-oriented                        health    effort      in N,,,hicli  anv   of    Lis    in    clinical,
                                       we   %vant,    and    this    is    certainly    the    cas                                                                     p                          I
                                       in     heart     disease.     ('ancer.,     and     stroke,     enou(,Ii    of    the    sense    of     Elain's     report     care      in      a      neighborhood      health       cen-    academic,          and          scientific          medicine
                                       then   we   are   prone    to    speak    in    terms    of     to  make  inv         point       about        crner(riti(r     ter       coordinated       with        air        automated    would be proud            to     tak(,     part.     Indeed.
                                       PI"ONIISE.      I      (lo      not      i-nean       false     substance     and,     in      suni,      I)ro\-icle      a     1-nLiltiphasic       screenin,       laboratoi,        Nvill    I    think    it    is    an    approach    I'@'C     lia%-e
                                                                                                                                 1
                                       promise    in    this    instan(-(,.    I     mean     rea-                                                                     result     in     iiiil)ro\,ecl      moi-talitN@.      met'-    been                   foi-.    'I'lie    willingness     to
                                       sonable   liol)e,   for   cni-i(@liln,,   as   %%,ell    as                                                                     biclitv,     health     sci-%-I(,c     utilization,      and    c,,p@riiiient,      to  ti,%, and  risk              n@atl\C
                                                                                                                                                                                                             11
                                                                                                         *7'lie  60  reports  are  az,(zilabl@!  a,
                                       prolonging     life.     @\'Iiat     arc,     the     deals                                                                                                 lien(,       ilill)O\'Cr'lsllccl    results is a source of sheath                  in      these
                                                                                         I                     11       of       tire       Conference-Wor'ks,@,,;     health attitudes at               I
                                       we    seek    to    a(@(@oml)lisli"    As    l,aura     (;.     Proceedin,@.                                                    I)copl(@.      I-'tit-ther,      can      this      approach    I)ro(,raTlIS.

                                       2







 t                                                                                                             The    program    reports     reflected  the  program  of  the   Mountain   States
                                                                                                             both  a  wide  variety  of  plans  and  a  Regional   Medical   Program,    operated
                                                                                                             general sense of  progress  but,  because  by   an   organization    called    WICHE
                                                                                                             no one as yet  has  the  recipe  for  in-  (pronounced      "Whichy")-the      West-
                                                                                                             stant health, it was a  progress  of  ex-  ern  Interstate  Commission   on   Higher
                                                                                                             pectations  rather  than  of  realization  Education.  Here  is  a  region  covering
                                                                                                             in iyiost instances. In the  time  avail-  all  or  part   of   four   States-Idaho,
 a                                                                                                           a le I can  give  only  a  few  examples.  Montana,     Wyoming,     and     Nevada-
 s                                                                                                             As  Breslow  pointed  out,  the  grand-  an area  of  440,000  square  miles  with
                                                                                                             daddy   of   American   regional    medi-  only  2,100  physicians,   15,000   other
 e                                                                                                           cine  is  the  Bingham  Associates   Fund  health  professionals,  and   no   homing
                                                                                                             of   the   Tufts-New   England    Medical  institution, that is, no university  med-
                                                                                                             Center,  which  has  been  operating   in  ical center. Yet, I am  told,  this  pro-
                                                                                                             the  State  of  Maine  since  1932.  This  gram has  one  of  the  most  active  and
 t                                                                                                           program  still  flourishes,   now   under  enthusiastic   organizations   and    has
                                                                                                             Regional   Medical   Program    auspices.  found a cordial reception  in  the  medi-
 e
                                                                                                             It is pleasing to find that 'nnovat'
                                                                                                                                         I         ion  cal centers serving it  from  outside  of
                                                                                                             still flourishes,  too.  As  reported  by  the Mountain States region.
                                                                                                             George  Robertson,   a   guest   resident     Much  emphasis  has  been  placed   on
 t                                                                                                           program  has  been   placed   in   opera-  the  need  for  innovation  in  the   Re-
                                                                                                              on. Tufts  sends  residents  and  clini-
                                                                                                             ti                                         gional  Medical  Programs,  but   it   is
                                                                                                             cal  fellows  from  Boston  to  work   in  not  all  innovation  of   course.   Many
                                                                                                             selected  small  community  hospitals  of  of the principles  of  good  health  care
                                                                                                        @i   Maine.   These   postdoctoral    students  that  do  require  innovation  for  wider
 e
 e                                                                                                           go   to   Maine   as   teachers   without  and more effective  delivery  are  deeply
                                                                                                             diplomas.  They  cannot   be   used   for
                                                                                                                                                        rooted  in  the  traditions  of  medicine
                                                                                                      @i     routine  hospital  work   because   their  as  well   as   community   organization.
                                                                                                                  nce  is  discontinuous.  The   local
                                                                                                             prese                                      We  find  frequent   reference   to   the
                                                                                                             doctors do not think of the  guest  resi-
                                                                                                                                                        importance   of   "concern"   and    "in.
 s                                                                                                           cients as teachers so  much  as  channels  volvement"  and  at  one  point   Willard
                                                                                                             of  information  from  the  medical  cen-
 y                                                                                                                                                      A.  Krehl  wraps   the   matter   up   by
 c                                                                                                           ter.   They   seem   happy   to    learn,  stating:  "The  important  objective   is
 n                                                                                                           through  these  young  ii-ien,  how   the  concerned involvement."
 1,                                                                                                          professors   currently   handle   various              I
 e                                                                                                           problems. It seems  that  you  can  teach     Speaking  of  the  "educational  pack-
                                                                                                             an  old  dog  new  tricks,  provided  you  age,"  William  G.  Cooper   says:   "One
                                                                                                             know more  than  the  do-.  Put  a  nicer  of  the  major  overall   objectives   of
 0                                                                                                           way, it  always  has  been  possible  for  Regional  Medical  Programs  is  to   en-
 e                                                                                                           the old to learn from the young.           hance  the  learning   of   all   members
 c                                                                                                             We  find  another  kind  of  innovation  of the health care  team  in  order  that
                                                    DR. COGGESHALL                                           iiivolvln,- geography  and  logistics  in  they in turn  will  be  able  to  provide

                                                                                                                                                                                                3








                           medical   care   for   their    citizenry.    The   sion,   the   telephone,   and    so    on.    The      Vincent     Larkin,      from      the      New   ISSUES RELATING TO
                           'learner'  in  this  case  may   be   the   dc>c-   medical    and     nursing     professions     are   York      Metropolitan      Regional       Medical   QUALITY              AND              AVAILABILITY
                           tor,   the   nurse,   the    medical    technolo-   capitulatin-    quite    brightly    and    grace-   Program,      a      megalopolis      constituting   OF HEALTH CARE
                           gist,    the    physiotherapist,    other    mem-   fully,   it   appears,   to   the   offerings   of   one  of   the   largest   regions   in   the   Na-
                           bers  of  the  team   or   indeed   the   patient   the    visual     and     audio     communications   tion,   diverts    our    attention    from    the      Having   felt    mN,    first    responsibility
                           himself."                                           industries.    Yet    I    am     enchanted     to   limitations    of    the    average    practition-   ,%,as   to   do   Justice,   however   inadequate,
                             The    Albany    l@egional     Medical     Pro-   learn,    although    not    from     a     formal   er,   about   which   ,ve   hear   so   much,   to   to    the    Regional    Medical    Programs    in
                                                                                                                                                                                         action,  I  can  no@@,,   as   the   pro-ram   for
                           gram      approaches      continuing       educa-   paper,   that   a   network   of    small    rural   those   of   the   medical   schools,   so   often
                           tion   by   turning    the    tables    on    the   hospitals   in   the    southwestern    area    of   assumed    to    be    the    ideal    base    for   the    opening    session     suggested,     focus
                                                                                                                                                                                         on the issues, in summar@, fashion.
                           medical   center,    as    Frank    M.    Woolsey   North    Carolina    called    the    "State    of   regional medicine:
                           implies.  If   the   mountain,   that   is,   the   Franklin"   plans    to    resort    to    carrier      "On    closer    inspection    we    can    see      The   first    three    speakers    were    ex-
                           practicing    physician     in     the     commu-   pigeons    to    transport    laboratory    speci-   that  the   medical   school   falls   far   short   tremely  ,%,ell  chosen   for   a   diversity   of
                           nity,   will not    come    to    Albany    Medical mens    back    and     forth.     The     pigeons   of  being  able  to   play   this   central   role   viewpoint   and   as   con-,,ersel@@   it   turned
                           College    for    further    training,     Mahom-   can  carry   the   load.   But   for   transplant-   effectively.     Institutions      which      have   out   for   the   general   harmony    of    their
                                                      I                                           I   assiirn(@,   it   will   be                                                                                ti;tls, I  think,  th(,r(,
                           (,t, that is, tli(@  iTie(l'cal  c(@,i)ter,  will   able  li(@arts,                                      focused  on  tli(@  tr@@tiniii,,, of                 r(@ryiarks. On (@ssen
                           'IO  to  tli(!  ii!ountain.  'I'he  strategy   is   necessary    to    employ    falcons.    Actually,   students are asked  to  fo(-tis  oii  tli(!  1)@t-          not   discord   but   ,(,neral    a(,i-(@(,
                                                                                                                                                                                         iii(,nt, @-t N%'OTI(](,r to                  inc(,
                            coniniunltv     I)osl)ltal     learning     cen-   a   pigeon   homing    on    a    hospital    lab-                                                                                    )iit(@iiil)lat(! s'
                                                                                                                                    ti(jit;  faculties  wlil(@li   have   been   cl(,-
                           ters"  and  the   instrument   is   a   so-called   oratory   serving   smaller    institutions,    to   voted  to  the  eclu(-ation  Of   Tnedi(@al   stu-   they   I)ro'ecteci    the    disparate    inia(rcs
                           medical   'uke   box,   now   in   its   develop-   me,    expresses    the    very     essence     of   dents,    interns,    residents,    and    fellows   of  medical   clean,   public   health   official,
                                      i
                           mental  stage.  This   J'uke   box   plays   rec-   regionalization.                                     are    asked    to     instruct     practitioners,   and   medical    politician.    I    grant    that
                           ords  and   pr   'ects   pictures   of   whatever      But     Luther     Christman,      Dean      of   high   walls   which   were   erected   to    pro'   each    represents    a    -i-cat    deal     more
                                         Oi                                    the   School   of   Nursing   at   Vanderbilt,   a                                                            n   these   one-dim"'    ion    profiles    as
                           the   medical   center   is    pushing,    educa-                                                        tect   the   standards   of   the   ivory   towers   tha                       ens
                                                                                                                                                                                         anyone     Nvho     knows     Carleton      Cliap-
                           tionally    speaking.    The    basic     machine   sociologist,   sounds    a    warnin,    that    I   are    to    be    demolished    without    assur-
                                                                                                                     n
                           is   actually    a    commercial    j'uke    box,   can   appreciate,   from   a    career    lifetime   ance   that   the   standards    will    not    be   man,        Lester        Breslow,        and-most
                                                                                                                                                                                                    tly-Dw'ght         Wilbur         might
                           and    the    new    jargon     is     wonderful:   in   internal   medicine:                      Be-   lowered   and   the    ivory    towers    sullied;   pert,nen              I
                           "Dial    access    carousel    projectors    have   cause   messages   about    care    must    filter                                                                   I   speak   of   this   professor    of
                                                                                                                                    in short, the racing car is to         be     har-   protest.
                           been added,"                                        through     many     people,     the      messages   nessed to the plow."                                 medicine   as   a    medical    politician    only
                             We   find   a   great    deal    about    auto-   may    become     garbled     or     not     reach      Therein  lies   one   of   the   less   obvious   because   I   doubt   that   anyone    can    rise
                           mated    multiphasic     screening     at     the   their  target  at   all.   Much   time   must   be   but    more    difficult    problems    in     our   to     become     president-elect      of      the
                                                                                                                                                                                         American      Medical      Association       with-
                           rate  of  60  tests  a   minute   in   the   pro-   spent   scurrying   around   .   .   .   to    in-   heaven   -    and    -    earthmovincr    project,
                                                                                                                                                                                         out   engaging   in   the   politics   of    orga-
                           gram    reports,    and    a    heavy    emphasis   sure   that   everyone    is    infon-ned    about   otherwise     known     as     regional      med'-   nl,,d medicine.
                           on   the   familiar   subject    of    continuing   the    necessary    care     measures     for,each   cine.   I   can   speak   with    the    authority      Because    the    Regional     Medical     Pro-
                           medical    education.    I    am    pleased    to   patient.   Under   this    set    of    conditions   of   a   retired   dean   who   has    had    many     rams    now    seem     to     be     developin-
                           find     Margaret     Sovic     from     Syracuse   tli(@re  is   likelihood   of   many   errors   of   t-irics to Tyiov(,. his fa(-tiltv in the, clii-e(,-  explicitly   or   implicitly,   as    a    reason-
                           reporting    on    continuing    education     in   omission.   .   .    .    Thus,    patients    may                                                        able    and    acceptable    idea,     ancl     do
                                                                                                                                    tion    of    desirable    change,    soi-netirnes
                           nursing,   using    the    teaching    facilities   be   placed    in    some    'copardy    by    the                                                                                       the        American
                                                                                                          i                         finding   that    havin,    moved    these    I-s-   have the approval of
                                                                                                                                                                                  1
                           of   a   university   hospital   nursina    serv-   very  system  set   up   for   their   care."   It   tinguished   men   he    has    to    move    them   Medical    Association..    I    am    sure    the
                           ice.    Again,    as    throughout    the    pro-   warms   my   heart   to   find    a    sociologist   a(rain   at   a   later   time   and   over   tile   Realonal       Medical       Prouram's       coun-
                           aram,   @ve   find   a   resort   to   electronic   preaching   this   essential   point   of   first-    a ... e (,,round.                                   cils   and   staff   would   as    leave    for-et
                           communications        techn;-Iues,        televi-   class clinical i-neclicine.                                                                               the     i)ro(@ram's      rather      opportunistic

                           4





                       conception     and     bizarre      gestation,      l@tit    was that research  is serv'                                      Chapniai@i             denied  that           medical     shared     this     skepticism     until     the     last
                                                                                                                1         ice,    even     as                               I                       I                        I           I 1
                       Our                  @%ritli @t          of       history                  Fiji(]   patient   care    ;ti,(!    set,v-                 has  I';Ill(,Cl   to          tli(@  fruits      three  days.
                       tfi@it      s(-,h(ilars      can      hardly      abandon    1(:Cs.   There   is   r(@@illy   no    CILIirrel    here,     of  I)Ioiiieclic2il  i-es(-,at,(:Ii   to   tll(,@   I)a-        NNIlIbLir,      however,      was      more       San-
                       %v Lilolit  iiij);I-I.Ill(@lit of their                Of    'Ill(l his IS ;I ]II('(' NV@ly  Of'  1)1'011]Otlll@'                                                tli@it tti(- (I(,-               tl)otiL    Our    (-al)acity    foi-     social
                       free    inquiry,    (@oulci     not     leave     genesis                of  the   conflict   resLilLlii(l,   from         IIV('I-y Of  these  fruits  Iran  b(@(,ii  spotty.           @t(-.tioii   and    I)t-o@l,i-css    by    common    con-
                       (Itilt(,, alone.                                             tti(,-     ov(@renii)lias's     on     riicd'cal      re-     1-1(.- also justly    coiiti-@tcl'ctecl    the    coill-     sent.     He     recalled      that      "De      Tocquc-
                          Chapman     t-(-inark(@(I     that     Lli(@     (,na-    S@.Ll-(@li   at   the   exl)cns(.,   of   reaching    and     iiioii cliar,tl,c of it        1)(@tNvecii  lal)oi-a-        @rillc     identified     this     uiilqti,c     American
                       bling   legislation    was    I)c)x-n    "aini(.1    talk    patient service.                                              toi-y     discovery     and      ,tl)l)llcaLloii      in     ability    to    become     associated     A!ith     oth-
                       of     crisis     in      medicine,"      and      added,       Chapman        speculated         that         Federal     rnedi(@al   practice,    suggesting    that    if    the     crs    to    plan     and     operate     pro,rams     in
                       "There    has     been     so     much     talk     about    participation    in    the    creation    of    a    cli-     biomedical     researcher      has      aiiv      fault,     the      absence      of       central       Governmental
                       the    crisis     in     medicine     that     we     are    mate     favorable     to     research     is      trace-     it   is    that    "he    rushes    into    print    and     direction and control."
                       beginning     to     consider     all     the      shout-    able   to   the   career    officers    of    the    Pub-     sometimes      onto      the      television      screen        Here,   beyond   a    doubt,    is    the    key    to
                       in,,,-    -with    suspicion    instead    of     alarm."    lic    Health    Service;    in    this,     I     should     inu(@h      too      readily      and      uncritically"     the   future   success    or    failure    of    a    Re-
                       Wilbur,  reflecting on  oricin  a                             I          1       1                 1   1                      1          1  Is            I
                                                                     nd      in-    differ     with     him     by      amplifying      those     w     th     find'n,@      described      as      break-      tonal     Medical     Pro-ram     that      has      the
                       tent,     aareed     that     "in      many      respects    responsible     to     include     not     only      cru-     tliroughs.   So,   "it    is    small    Nvonder    that     singular  characteristic  of  bein-                   im-
                       this    act     is     quite     extraordinary."     Cer-    sading      Public      Health      Service      officers     both      physicians       and       laymen       become     posed    not    from    the    top    down    but     the
                       tanly    none    of    us    who    had    the     oppor-    but      health-minded      politicians      and      re-     bewildered       when       so        many        break-     bottom     up     and      therefore      leaves      the
                       tunity     to      read      the      DeBakey      report    search-minded         physicians         from         the     tliroughs      are       either       forgotten       or     distinct       impression       of       having        no
                       from     an     objective      position      can      ex-    medical      schools      and       research       insti-     proved wrong a year or two later."                           strong      and      inspired       leadership.       The
                       press      anything      but      pleasant       surprise    tutions.   As   a   matter    of    fact,    the    first        This      speaker      conceived      the       prob-     potential     genius     of     the      Division      of
                       that     the     heart     disease,      cancer,      and    sizable      medical       research       grants       to     lein    to    be    one    of    equal     access     to     l@c,,Ional    Medical     Programs     is     that     it
                                                                                    nonl)rof        institutions      and      their      in-     health   services   On   the   part    of    all    peo-     insists    that    the    ideas    and    the     'nitia-
                       stroke     I)ro,,ram     has      turned      out      so               it                                                                 I                                                                                           1
                              Whatever     ground      the      infant      lost    vestigators      (@amc      from       private       ph'-     ple,    and    concluded    that     tli(,     l@egional     tive, the organization and the                     stimu-
                       in     qi-icstionable      percentage      or      diffi-    lanthrop@,,        followed         by           national     Medical     Pro@ams     is     a     moderate,      evo-     lus,    come    from    the     grassroots,     so     to
                       cult    delivery,    it     has     been     made     ul)    voluntary        health        organizations.         The     lutionary      measure      designed      to       carry     speak.     There      are      some      students      of
                       hrou                                                                                                                                                                                    their fellow man and his motivat'
                       t      gh     skillful     legislation     and     admin-    Federal         Government         embraced          such     out     the     prophecy     that     public     dollars                                                          ions
                       istration,     as     well      as      being      demon-    support      after      World      War       11       and     spent   for   research   (,an   bi-iii,,,   us    better     who   regard   all   this   as    too    good    to    be
                       strated     in     the     emerging      substance      I    greatly augmented it.                                                                                                      true,    yet    as    far     as     the     arrangements
                       mentioned.    Due    in    part     to     the     infor-       Chapman        further         speculated         that     health.                                                      in     54      different      re      'onal      programs
                                                                                                                                                     'I'hose      who      believe       that       social                                   bm               I'D
                       mat'on       overkill       on       heart       disease,    the    "politics    of     the     research     cli@atc,"                                                                  have ,one it is true.
                                                                                                                                                  groul3s        with        lon@,-cstablished         and
                       cancer,   and    stroke    and    in    part    to    the    have      "ke])t      us      from      developing      a                                                                     WilbLir      praised       Dr.       Marston       and
                                                                                                                                                  \well-defined    self-iiiterests     are     al)t     to     It's   staff   for   "the    creation    of    a    local
                       slml)](.,    fact    that     planning     and     organ-    rnc(-.hanisrri     (@al)abl(@     of      looking      at     ,                                                             I                                 1
                                                                                                                                                  t)e  riion,cd   only   by   threats   oi,   by   I)rO"I-     and       regional       climate       which       en@en-
                                      'ke    the    public    as    dull,    the    the  health  problem  for  what                       ac-
                       1/.ation  stri                                                                                               it
                       l@e,,,]<)nal       Medical       Pro,,rarris        until    ttially   is:      A        tightly         interrelated,     ,,es   have    been    i-naclc    skeptical    of    the     dcrs      voluntary      cooperative      action       to
                       no%%@   have   not   had   much    of    a    story    to    enormously         complicated,         and         over-     OLITCOITIC    of    @t    I)i-o(,i,aiii    which     de-     iiiipi-o\,e     the      health      care      or--aniza-
                                                                                                                                                                                'D
                       tell.        Sl)cak'ng        perhaps        Yratultously    whelmin,,,Iy   important   unity."                   I-le     I)cnds,    by     direction     of     Con(,ress,     on     tional      patterns      and       delivery       svstem
                       foi-     regional     medicine,     I      would      say    pointed  out  that  we  as  yet  do                   not     voluntary      cooperation       of       pi-acticiii,,,     N,,,,Iilcli     currently     exist,"     and      latei@
                       the   story   is   ,ettin-   better   all    the    time.    have al'i  organizational  pattern                   that     doctors,       academic       i-necliciiac,       public     added,    "in    a    sense,    the     program     corn-
                       I airi much impressed with it.                               is     stron(,     enough     to     foster      balanced     authorities,     and     a     variety     of     others     bines   the    better    features    of    the    liberal
                          -Under    the    title,     "Science     and     Serv-    development        of         research,         teaching,     not      wholly      distiii'Llished      for      their     and     conservative     approaches     to     a     ere-
                       ice,"         Chapman's          primary          messacc    and practice.                                                 compatibility'.    I    must     admit     to     havin@     ative societv."

                                                                                                                                                                                                                                                                       5











                                         At     the     same     time,      Wilbur      spelled    also      mentioned       runaway       costs:       "The     HoNv    you    persuade    doctors     to     come     to    ity   of   care   theN,   are    I%@ln,a,    the    effi-
                                      ou,t     the     position     of     organized      medi-    tremendous      costs      involved       in       apply-     and    stay     in     small     towns.     One     (,ood    clency    of    their     Tllethods,     the     validity
                                      cine's        cooperation         in         unmistakable    in,   'ust    one    set    of    advances    in    medi-     way   is   to   be-in    with    a    coi-nmunitn,    at-    of  "felt  needs,"  or  the            number          If
                                                                                                       @ j
                                      terms.   It   is   well    known,    I    should    note,    cal      science,      namelv,      organ      transplan-     tractive     to     the     doctor's     wife.      AnN.-    persons      not      -etting       adequate       health
                                      that      physicians       and       hospitals       have    tation,    are    causinff    tol)    bud,et    officials     thin<,,   that   makes   life    tolerable    for    tile    care.
                                      credentials         and         qualifications         by    in     Federal     and     State      governments      to     doctor      also      licll)s.      Johnson       deinon-         The      suuestion      that      the      IZe,lonal
                                      which     they     attempt      to      assure      them-    burn      the      midnight      oil.      Ilow      fast     strated    himself    to     be     cluite     (@ornfort-    Medical      Pro,rams       offered       an       extra-
                                      selves     of     each     other's     competency     and    should    we     develol)     these     iie%v     I)roce-     able  @@,itti  tlic,,  idea   of   til-),,radiri,l@   the    ordinary  opportunity  to  pin                       down
                                      hope   to   insure   their   patients    of    a    hi,rh    dures      and      lioA,      can       economv       be     quality     of     the      practitioner's      services.    some    of    the    variables    in    mectinc,     man-
                                      quality    of    medical    care.    Since     a     poor    maintained?"                                                                                                               power     demands     and     thus     make     a     be-
                                      quality     of     care      is      sometimes      worse        We     must     hurry     on     without      answer-     DISCUSSION  GROUPS                                           ginnina         toward         solution          obtained
                                      than   none   at   all,   it   is   natural    for    in-    in', these questions.                                                                                                      ready     acceptance.     In     mv     own      opinion,
                                      telligent    patients     or     their     group     rep-        Ro-er    0.    EgebergA,Ishecl     to     give     no        A   kind    of    i-ougli    and    readv    @'alid'a-    the        organization,        distribution,         and
                                      resentatives-such        as        organized        labor    (rrounci    on    tYi(,-    need    for     excell(-n(@e,     tion   of   tli(,   choice   of   issues    and    points    more    effective    utilization     of     the     serv-
                                      or  welfare  a-enc'                                                                                                        pursue(]      by       tlic@       program       speakers    ices    of    health     professionals     is     equally
                                                                  ies-to       apply        the    but    pleaded     that     availability     of     serv-                                                                  I                               I         I
                                                                                                                                                                 came    out    of    the    discussion    -roui.)s.    In
                                      profession's      own      standards      to       obtain    ices    was    e-,,erv    bit     as     important     as                                             0                    as   important as, if it          does     not       have
                                      the    "best    medical    care."    There     is,     of                                                                  some      instances,          discussants          stated
                                                                                                   their quality.                                                                                                             higher  priority  over,           large         increases
                                      course, no -Uarantee.                                                                                                      their    problems        and        their        opinions    .
                                                      n                                                Ray     E.     Trussell     conceded     that     the                                                                  n the production of              doctors,         nurses,
                                         Wilbur  warned:                         If  R                                                                           TTIOI'(, forcefully    tll@ITI     tli(,     sl)(-al@ers.    '
                                                                                             MP    I)tjrsi.ilt of         cltiility (@@ir(, %vts                 'I'lils %%!as tli(-    Ias(@  in   tli(-   ,t-otil)   that   and otil(@rs.
                                      becomes    an    instrument     for     tli(!     (,stab-    (@oiisuiriir)g   irici    costly,    2Lri(.1    supported
                                      lishment      of      national       standards       with    Will)Llr's        position        against        national     I)oncl(,r(@(I   Lli@I)ail    2trid    related    I)rc)i)-    AT)NIINIS'I'l@i\'I'ION  OF
                                      the      coercive      compliance      compelled       by    standards      in      regional       medical       care,     ](,ms.  'I'lieli-  (@on(@ei-ii   tiicl   to   do   @vitli    REGIONAL  MEDICAL
                                      such    standards,     it     will     arouse     nation-                            0                                     the  difficulties  of  I)roinotin(r                 corn-
                                                                                                   yet   he   held   that   at   his   level    (the    city                                                      .  .        PROGRAMS
                                                                                                                                                                 munity         involvement         and         organizing
                                      wide     resistance     from      physicians,      insti-    of   New    York)    it    is    necessary    to    limit
                                      tutions,      and       allied       health       profes-    public     funds     to     medical     and      hospital     re(,ional        programs         in         metropolitan         Presentation    of    the     Re     ional     Medi-
                                                                                                                                                                                                                                                                   9
                                      sionals.    What    can     be     ained     by     coop-     ,,rvi(,es    that    i-n(!et     riiiniinuiyi     stand_     areas    contaiiiin',    a    @vicl(-     var'et@,     of    cal    Pro-rams    through    the     eyes     of     Bob
                                      ('r@-ttioil ilicl                                                                                                                               or.                                     M@it-stoll            III,, vt;lfl'  1)1,()Vi(l(.(]  ;III
                                                                                                                                                                 ov(",
                                      will            I)(. ]<)St if tli@. us(,  of                 to                   (',LI'(' to I)I'iV@tt(@ 1);Lti(!Ilts     ti(@IIS :Lll(l                                S('Ilo()IS,                   (I(@illoilstl-:Ittoll  of  tll(,   (li%,I-
                                                                                                                                                  ,,M                                           li(,@Litli  and
                                                           for   tile   moment   li(-S   (lot--    will  not satisfy tli(@ intent of I'                1)        fare   ageri(,les,   or   tii(@   like.    I    listened,    Siol .is   genius   for   di-a@@,in(,--   attention    not
                                      mant     in     Public      Law      89-239,      becomes    lie   said.   "There    has    to    be    an    improve-                                                                       tself   but   to    its    regions,    whence    all
                                      its        dominant         characteristic.','                                                                             and     heard     lively      discussion      but      no    to   I
                                                                                                   ment in service  .  .  .  ."                                                                                               thin-s    come    and    ivhere    all    things     hap-
                                         This      @vas      practical      advice on       how        Frank    P.    Lloyd     explored     the     tecl-l-     answers.
                                                                                                                                                                    In     these     discussions,     no     one     ques-    pen,    according     to     the     la@v.     In     all
                                      to    avoid    conjuring    up    old    devils,     such    niques     of     involvement      by      which      the                                                                       bability,  tho
                                      as     the     fear     of     "socialized     medicine."    cli,ialitN,     of     ni(,dic@al     care     can     be     tioned    the    existence    of    a    health    iyian-    pro                     se     listeners     who     con-
                                                                                                                                                                                      e,    nor    did    anyone     quite                that   the   stafrei-s   of   this    cli@,l-
                                         Breslo@v     touched     on     other     kinds     of    r'a'seci-for        example,        by         persuading     1)owei- shoi-ta,,
                                      problems      in       the       regionalization       of                                                                  know    what     to     do     about     it.     Particl-    sion     of     the      National      Institutes      of
                                                                                                   practitioners     to      give      routine      Pal)ani-
                                      health,    such    as     the     fact     that     those    (-olaou       smears.       Amos       Johnson,       the     pants    appeared    to     agree     that     no     one    Health   were   a    lot    less    interesting    tl-ian
                                      interested        in         environmental         health    articulate      encral      practitioner      from      a     knows      for      sure      how      many       doctors    the    people    from    the    field    A,ere     merely
                                      control      and       those       planning       patient    rural      North      Carolina       (Community       at-     and      other       health       professionals       the    uncompreliendina      of      the       devotion       of
                                      care      services      "have       remained       almost    tacked    the    issues    of    quality    and    avail-     country     needs,     inasmuch     as      there      is    Bob   and    his    stafT    to    the    concept    that
                                      entirely     oblivious     of     each     other,"     he    ability     from      still      another      standpoint:     presently    no    way    to    measure     the     qual-    leadership     must     come     fi@om     the      corn-

                                      6








           munity   or   region    and    not    from    Wash-    administering      the       Regional       Medical    tem,     and     the      educational      imperfec-
           ington bureaucracy.                                    Programs,     will     strive      to      preserve    tions  are  the   fabric   of   oui-   health   care
              It   was   a   lii@hli,ht   of    the    confer-    existing   centers   of    excellence    in    scl-    crisis.      The      new       emphasis       being
           crice,  from  iri@,  standpoint,   to   find   that    ence,    education,    and     service,     @vhlle,    placed   on    these    major    issues    by    Re-
           the   members   of   both    the    division    and    at   the   same   time,    working    with    State    gional    Medical    Programs    is    being     re-
           the   staffs    of    the    programs    themselves    and   local   forces,   evolve   a   system    that    flected     by     the     developing      resources
           were,   at   every   level,   persons   of   appar-    @vill  make  available   to   the   bulk   of   the    and energies of the prorrams."
           ent   high   caliber.   'I-he    observation    ex-    population    medical     services     that     are       It   is    significant    that    the    staffers
           tends   to   the   many    bright,    youn,    peo-    excellent    in    quality    and    adequate    in    speak    of    not    one     program     but     of
           ple    I    met.     The     analogy     of     the    cluantity-at   least    in    a    major    segment    "programs"    in    the     plural.     In     other
           Linl%,,ersity   came   to   mind;   the    institu-    of the diseases that plague us all."                   words,   Nve   have   borne   witness    in    these
           tion  is   precisely   as   strong   or   as   weak       I   have   little    doubt    that    his    ap-    three    days    to    the    emerging     substance
           as its faciiltv. 'J'al(-nt         plainly   %,Isl-    I-)roach    N@,oulcl    have    I)cc@n    extremely    of   54    "happenings,"    that    is,    54    Re-
           i)](. in til(@ (li@-l'iloll stiff ;in(] telex I-(.-    ])Iizzlltl", to .,oil)(! of tli(,              pro-    gloii-,tt  l'i-ogi-ains   now   in   existence.   In
            lo[) @l I(@oor.(I III;   ;I11( I t II(-i I'St; II                                                      ;II          Of LI)(! Old             @Lll,'Ilogy  Of   the
              ff   tli's    unusual    policy    ol    leader-                                                                                                            rc-
                     I                                            fohn           iit   of    the        I"Iockcfeller    Llir(@e-legged  stool  of  Leaching,
           shil)-someone       called       it       "creative    Foundation    or    Joe     Mountain     of     the    search,    and    service     to     patients,     I
           anarchy"-sun,lves      its      inherent       dis-    Public   Health   Service,   as   it    may    also    should   like   to   introduce   a   new   one    to
           advantages,   such    as    the    apparent    lack    perplex    some    of     the     advanced     stu-    fit   the'   occasion.    I    see    the    Federal
           of   aggressiveness    and    articulateness,    it    dents   of   social    systems    and    processes.    Government    as    the    hub    of     a     wheel
           will (@onstitLit(@  one  of  tli(@  ,r(,at  totir,;    litit  if   we   regard   tli(@   program   is   in    in  wlil(,Ii   the   sl)okes   are   reaching,   rc-
           (I(. form(,(. ;fl (11(@  History  of           ;t(l-                        iii@ly ;1,1'.,O ('Otl(@(!iV(!  It                S(@l-Vi(@(', ;III(] tll('  run  I)in(l-
             .  .                  (  ,             If]                                                                                                    I
           ftiiriistl,@iLloll.    I    I o I' (.,I I 1-y'                          sL@ii-tliiig    innovation.     It    '11,g   them   togctlici-   is   l@eg'oiial    Medi-
                                                      ,g  (jut    as  a                                    I                                      I
           the    effective    organization     and     opera-    has   the   great    virtue    of    keeping    the    cal Programs.
           tion   of   a   program   based   on   the   neces-    enterprise     well     removed      from      that
           sity   of    voluntary    cooperation    and    im-    battlefield   where   we   can   still   see    the
           plemented    by     letting     leadership     come    unburied     boncs     of     many     a     social
           from   the    outside    in    and    the    bottom    I)Ianner    and     social     reformcr-that     is
           up  is  difficult  to   get   used   to,   I   con-    the    battlefield    of    socialized    medicine.
           cede,    Once    one    appreciates     what     is      Alexander    M.    Schmidt,    chief    of    the
           happening,    however,    he    is     not     dis-    Continuinc,,      Education      and       Training
           I)osed   to   change   it,   but   becomes   rather    13ranch,   stims   up   the   situation   in   this
           intrigued   with   how   it    will    come    out.    articulate fashion:
           The     division     staff     otlienvise     gives      "The     challenges     faced     bv     Re,lonal
           (!\,e@,    (@%,idencc    of     bcin-     extremely    Vedical     Pro-rams     are      no@v      readily
           able.  'T'here  seems  to be       method        in    apparent   and,   while   great   in    size    and
           their madness.                                         scope,    are    rnatched    by    the    potential
             .%Iarston    (iiiot(,(l    his    chief,    James    foi-   solution   offered    bv    the    programs.
           @li;tillloll:
           t(,I@(.1      iliziii@,  di (-@rse geographic          l'isill"  (!Osts  of  (:are,  the  shortages,   the
           and    social    cir(7LIiristances,     NIH,     in    impersonalized      and       disjointed       sys-

                 292-414 0-@18---2                                                                                                                                                                                              7














                   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 0. Egeberg, M.D.
                                                                            Ray E. Trussell, M.D.
                                                                            Frank P. Lloyd, M.D.
                                                                            Amos Johnson, M.D.









                                      QUALITY             AND   one  of   the   others   for   special-usually   aspirations.  The  term  "research   in   the   How   does   society   produce   its   Curies,
                                AVAILABILITY               OF   defensive-purposes     but     the     preser-   service   of   mankind"   has   very   funda-   the  Floreys   ancl   Flemings,   the   Enders
                                     HEALTH              CARE   vation  of   independence   has   still   been   mental  meaning   despite   the   fact   that   and  Salks;  the  Eiiisteiiis,   the   13ohrs,
                           FOR         HEART         DISEASE,   paramount.    This,    contrary     to     the   it  has   become   so   hackneyed   and   its   and  the  Ferinis?  It  is  not,  in  our  own
                                CANCER,               STROKE,   views  of   some   roups,   has   not   always   context  so  restricted  that  it  rubs  many   bewildering   and   complex   day,   an    ac-
                                     AND              RELATED   been   a   bad   thing.   On   the   contrary,   of  us  the  wrong   way.   The   basic   re-   curate  answer   to   say   that   outstanding-r
                                 DISEASES       IN        THE   it  has  for  generations   been   a   reason-   searcher,  no   less   than   the   conscien-   and  giftecl  men  -,vlll   rise   to   promi-
                                                       FUTURE   able   modus   vivendi    tinder    which    a   tious   schoolteacher   or   medical    prac-   nenCC  no  matter   where   they   happen   to
                               AS         RELATED         TO-   great   deal   has   been   accomplished    if   titioner,   is   en-aged   in   rendering   a   be  born  and  live  out   their   lives.   We
                                                                we  persuade  ourselves  to  take   the   long   service  to  the  public.  He  may   succeed,   know,  of  course,  that  a  man  like   NVil-
                        SCIENCE          AND          SERVICE   view of it. But it  has,  at  the  same  time,   within  the  confines  of   his   laboratory,   liam Witherin,     Imade    his     methodical
                           Carleton    Clia[)tiiati,    M.]).   a] Solved   tli(-.   problem-   we   must   now  in iriipt-ovirig the lot  of  ryiillions;  or   c)l)s(@r%,atioris A,hll(- he wis engag(,(]  in
                                                                solve to (I(@V(@iol). We (7.11illot llo%v (,o    met,(, likely li(! will @i(@(7oiiil)lisli a     @.L busy                      ;tn(.1 fit-. did it
                  Dean,    Dartrnouth     Medical     Scliool                                             "I
                                         Hanover,        N.H.   our    separate,    independent    ways    and   less (Iranian(-, ol-)J'ective. But be is  en-   Without  @t   sl)rccl   Of   CtICOLir@gcriient
                                                                that,  to  my  mind,  is  one  of  the   chief   gaged  in  public  service  all   the   same.   from  His MajestN's        Government       or
                                                                things   the    Regional    Medical    Program   Unfortunately,     the     more      unobtru-   from  a  universitv.   Such   men   will   un-
                                                                law is all about.                                sively  he  works   and   the   more   remote   qliestionablv    appear    from    time     to
               -E)egional    Medical    Programs     is     a
                                                                                                                 his   research    area    from    immediately   time  even  though  the   climate   of   their
                     concept     that     was      concerned,   SCIENCE IS SERVICE                               discernible  need,  the  more  likely  he  is   time  is  one  of  indifference  to   investi-
               and   is   now   being    implemented,    amid                                                    to   be   regarded   as   a    supernumerary,   gative   effort.   But    it    happens    ex-
               talk of crisis in medicine.                         My     topic-Science     and     Service-is   a  parasite,  on  the  social  body.  Or   it   traordinarily   rarelv.   NN'c   kno@v    also
                                                                                                                          I
                  There  is  so   much   talk   today   about   a  very  appropriate   one   by   iTieans   of   may  be  assumed  that  if  he   works   part   that    phenomena     ilke     Leonardo     de
               the  crisis  in  medicine  that  we  are   be-   which   to    approach    today's    problems,   time  at  some  task  that  is  visibly   and   Vinci   have   sprung   up   from   time    to
               ginning   to   consider   all   the   shouting   although   I   know   in   advance   that   -L   immediately   useful   he    may    be    al-   time   in   what   seems   superficially    to
               ,,vith  suspicion   instead   of   alarm.   We   run the risk of being too diffuse
                                                                                                                 IoNved,  more   or   less   grudgingly,   the   be    the    most    unpromising     settlnos.
               are  becoming  so  used  to  talk  of   crises   coming  at  it  from   this   angle.   But   1   right  to  do  basic  research  on   a   lim-   Leonardo,  at  the  start,  had  little   more
               and  dire  predictions  that  @ve   are   get-   should  say  at  the   outset   that   if   we   ited basis.   In  other  situations,  '   the   than  a  proud  father   to   urge   him   on.
               ting   a   little   bored   with   the   whole   don't    approach     the     problem     dif-   investigator   is   viewed   with   tolerance   But  we  tend  to  forget  that  he  had   his
               thing.                                           fusely-or   at   least   in   general   terms-          0
                                                                                                                 because  he   is   obviously   capable;   but   patrons   in   his   formative   years@    men
                  But  there  is  a   crisis   in   medicine,   we  will  fail  to  reach  above  the  special   he  is  at  the  same  time   considered   to   like  Lorenso   di   Medici,   who   made   it
               misdefined   but   real,   one    which    has   privileges,   functions,    and    obligations   be  so  impractical  that  someone   in   au-   possible   for   him   to   Nvork    independ-
               been   gradually   gathering   force   for   a   our    individual    professional     callings   thority  must   tell   him   what   work   he   cntly   for   something   like    15    years.
               long  time.   All   three   aspects   of   our   impose  on  us.  And  we  will  fail  to  per-   can and cannot undertake.                       Whenever     extraordinary     talent      has
               profession-research,       practice,       and   ceive  the  elements  of  nobilitv  that   are                                                   flourished,  the  ambient  society   has   al-
               education-are   caught   up    in    it    and   inherent in the taxing and           gruelling   THE CREATIVE CLIMATE                            most  al@vavs  had  a  hand  in  it  by   ere-
               there  obviously  is   no   easy   resolution.   efTort that lies before us.
                                                                                                                                                                 ating,  one  wav  or  another,   a   favorable
                                                                   In  this  connection  I  sfiould  like   to     All these
               The   three    components    have    coexisted                                                                   views arc, in their        un-   climate.
               to  now,  each  leading  a  relatively   inde-   persuade  vou   that   science   is   service,   diluted forms, i-ossly wrona and          are      Today,    the patrons  of  rescai-cl-i  are
               pendent     existence     despite     overlaps   that  hoxvcver  basic   and   specialized   it   in  themselves  a  public   disservice.   The   malnlv   the   @reat   foundations   and   the
               here   and   there.   Each   component    has,   may  be,  its  relation,  immediate  or   dis-   question   no   one,   the   scientist    in-   Federal     Government,     acting     through
               from   time   to   time,   teamed   up    with   tant,   is   to   human   need,   hopes,   and   eluded, is really willing to face          is:  the universities. Quite  carIN@  in  the  life

               10







                                                                                                       of  the  American  republic,  our  univer-  cial forces,  as  well  as  about  science,
                                                                                                       sities attempted  on  their  own  to  pro-  had  to  point  out  the  need   for   such
                                                                                                        'de  a  limited  climate   for   research  a  climate  and  had,  at  the  same  time,
                                                                                                       vi
                                                                                                       (@1'e@itivity @is it was then  understood.  to be able to make  ti-ic  concept  politi-
                                                                                                       Our  (,ovcrniiieiit  at  first  liid   its  cally  acceptable.  It  was   and   remains
                                                                                                       hands  full   with   other   matters   and  a  subtle  and  tedious  process;  and  the
                                                                                                       took  no  direct  action  to  support  re-  key to success  was  and  is  a  convincing
                                                                                                       search but  in  Britain  the  identity  of  presentation to  the  public  and  to  leg-
                                                                                                       research   and   service    was    compre-  islators of the fact that  'in  the   short
                                                                                                       liended  relatively  early.  Victoria  had  term and in the  Ion-,  research  is  serv-
                                                                                                       been on the  throne  little  more  than  a  ice   and   must   not   be   defined   too
                                                                                                       decade  when  the  Parliai-nent  ave  sci-  narrowly.
                                                                                                       ientific creativity a  boost,  using  tax-     In  the  United  States,  Federal   par-
                                                                                                       payer's  money   for   the   purpose.   It  ticipation in the  creation  of  a  climate
                                                                                                       did it by setting up a system  of  grants-  favorable  to  research   in   the   health
                                                                                                       iii-aid to individual scientific  investi-  field  seems  to   have   come   not   from
                                                                                                       gators,  to   be   administered   by   the  our  great   research   societies-not   di-
                                                                                                       Royal  Society.  The  Society  itself  was  rectly  from  the  most  renowned  of   our
                                                                                                       a  bit  suspicious  of  the   governmcnt's  scientists-but   from   an   arm   of   the
                                                                                                       intent  but  the   system   was   accepted  Federal   Government   itself:   The   U.S.
                                                                                                       and  the  first  grants   were   made   in  Public  Health  Service.  The  effort   be-
                                                                                                       1850. Socially  and  politically,  it  was  gan about  the  turn  of  the  century  and
                                                                                                       a  monumental  event   in   the   En-lisli  the most  significant  step  was  taken  in
                                                                                                       speaking  world;  yet  one   can   sc@arch  1937,  when   the   National   Cancer   Act
                                                                                                       all  the  standard  authorities  on   Vic-  not  only  set   up   the   National   Can-
                                                                                                       torian Britain  and  find  hardly  a  men-  cer Institute  but  also  gave  the  Public
                                                                                                       tion  of  it.  The  scientists  themselves  Health   Service   authority   to    anvard
                                                                                                       failed  to  comprehend  the   social   im-   rants-in-aid  and   fellowships   to   in-
                                                                                                       portance   of    what    was    happening.  dependent  investigators   worl,-ina   out-
                                                                                                       They  may,  possibly,  have  been  a   bit  side  Federal  institutions.   The   subse-
                                                                                                       ashamed   of   it   and   they    grumbled  quent  evolution   of   the   system,   and
                                                                                                       about  threats  to   their   independence;  the   fundamental   features   which   have
                                                                                                       but, even  so,  they  accepted  the  funds  made  the   National   Institutes   as   we
                                                                                                       and went to work. No  one,  least  of  all  know   them   todiy   so    extraordinarily
                                                                                                       the scientists   seemed   to    understand  successful  were  the   work   of   percep-
                                                                                                       that the  creation  of  a  healthv  climate tive   and    dedicated    career    Public
                                                                                                       for that  form  of   public   service   we  Health Service officers.
                                                                                                       call  research  is  in  important   ineas-    The importance of  all  this  is,  I  be-
                                                                                                       Lit,c a i)oiitical i-riatter with  all  that       very   fundamental    indeed.    The
                                                                                                       that  entails.  Someone  who  is   kno",I-  politics  of  the  research  climate  is  a
                                              DR.CHAPMAN'                                              cdgeable  about  politics  and  other  so-  I)oorlv   understood    and    badlv    ne-

                                                                                                                                                                                          I  I

















                                                                                                                                                                                                                                                                   t
                   glected     academic     topic.     I     should     hope    fee                               'ng      ground      is    and    the     present     situation     so     blatantly     be      described       as       breakthroughs.       And
                                                                                    tive  common  meet
                   that     before     very     long     an      enlightened    quickly    established,    our     actions     in     the    bad,    that    only     revolution     will     suffice.     is    small     .@,onder     that     both     physicians
                   scientist,      perhaps      working      with      other    immediate       future       mav        do        nothing    But    these    -entlemen,    I    believe,    fail    to     and      laymen      become       be@@,ildere@       when
                   men    from     other     disciplines,     will     study    more    than    to    create    a     new     type     of    understand    that    revolution     is     a     process     so     manv     breakthroughs     are     either     for-
                   the     matter     exhaustively     and     that,      in    imbalance,      fully       as       unfortunate       as    Nvliich    injects     an     element     of     violence              or proved @vrong
                                                                                                                                                                                                           gottcn                              a   vear   or    t@vo
                   so    doing,    he    and     his     colleagues     will    the   ),-(,serlt   one,   in   wlilcfi   the   resear(@li    @iti(i disorder
                                                                                                                                                     I        I    into    a    Progressive    riiove-     later.   Sor-ne       of        them        unfortunately
                   put     all      these      forces-political,      scien-    climate     is     attenuated      while      one      or    ment     that     is     already      under@vay.      And     reach      the      bedside      almost       immediately
                   tific,        @ial-into        proper        perspective.    both   of   the   other    elements    is    built    up.    fully   as   often   as   not,   the   end   result    is     and     produce     results     of     which,      under-
                   Such   a    study    has    not,    to    date,    seemed    This,    some     of     my     colleagues     in     the    a     destructive     one      and      an      obscuring     standablv,     -,,erv     little     is      subsequently
                   very     important.     Had      it      been      other-    academic     woricl     are     saying,     is     f)r(--    of  nol)lf-  @tricl  n(,(@(@ss@ii-v   ,,,oils   @viii(@li                   'I'o    f@) t'
                                                                                                                                                                                                                                I  irii@tt("  "is  tll(@   flr(@-si-
                   @vise,    and    bid    the     very     ter-rii     "re-    (@isc,ly @vliat is  litl)l)criiii,,  aiicl  tli(@y  iriay    have   tli(@iiiselves   @lll-(,@icly;tr's(@n   by    evo-     (I(,iit's    Coriirnission    ozi    lfeart     I)jsease,
                   search      climate"      been       viewed       realis-    be   rigfit.   The   danger    of    creating    a    new    lutiozi.  But  the  least we          in     the     aca-     Cancer    and    Stroke     did     in     late     1964,
                   tically   instead   of    as    a    justification    for    imbalance   is   a    very    real    one.    The    un'-    demic   world    face,    as    ive    go    about    re-     that     the     researcher     is     revealing      his
                   emulating     across     the      board      the      ex-    fyiniz   force   of    the    future,    as    the    Re-    designing      our      methods       and       tailoring     findings    only    to    other    members     of     his
                   ample      and      method      of      the      medieval    gional       Medical       Program       law       recog-    or     expanding      our      total      product      to     own        particular        research         brotherhood
                   university     we     might     be      much      further    nizes,     will     probably     be     the      emerging    meet    the    Nat@ion's    needs,    is     a     degree     is,   I   think,    to    avoid    the    major    issue.
                   along.   It   would,   I    believe,    have    led    us    medical       center,       an       agglomerate       of    of     internal     dislocation      and      redistribu-     There    is    no    conspiracy    of     secrecy     in-
                   to     create     an      orderly      technique      for    hospitals,      medical      and      health       train-    tion     of     emphases.     The     Regional     Mecil-     volved.    But    it    is    quite    another     matter
                   self-examination        and         broad         projec-    ing      facilities,      community      health      cen-    cal     Program     law,     the     cynics      notwith-     to    point    out,    as     the     Commission     also
                   tion.                                                        ters       and       programs,        'and        varying    standing,     is     designed     to     minimize     the     did,     the     undeniable     fact      that      equal
                                                                                                                                                       Z,
                    But     the     influences     and     currents     that    amounts     of      input      from      parent      uni-    disturbing effects.                                           access     to     full     and     effectz've     Izealth
                   have     tended     to      keep      the      biomedical    versities.    This    may    not    be    ideal.     But,                                                                  servz'ces   is   not   available   to   all   our    peo-
                   researcher,       the       educator       and        the    since     our      system      has      developed      no    THE  PROBLEM  ITSELF                                          ple.    And    it    is    a    diversion    to    engage
                   practitioner     on     his     own      narrow      path    other    unifying    force,    it    is     comina     to                                                                  I     debate     on     whether      adequate      health
                   have     by     the     same      token      kept      us                                                    0              There      are      those      who      ask:       What     11  -
                   from       developing       a       mechanism        capa    be     the     fact.     Paul      Sanazaro      recently    ldroblem? What crisis?                                        services    are    a    privilege     or     a     right.
                                                                                defined     the     "broad     outlines      of      aca-                                                                  However     the     statutes     read,     the     strong
                                                                                                                                               The     problem     has      been      defined,      in        I
                   ble    for    looking    at    the     health     problem    demic,      scientific,      and      social      adapta-                                                                  T)roiDability      is      that      our       electorate
                                                                                                                                             @vhat    I    think    to    be    unfortunate     terms,
                   for   what   it   actually    is:    A    tightly,    in-    tions     in     our     medical     (centers)."      lie                                                            '     comes    closer     to     regarding     these     bless-
                   terrelated,            enormously            complicated,    cites   a    redefinition    of    goals    to    include    as   the   failure   of    the    fruits    of    biomedi     n(,s    as    a    right    than    as    a    privilege.
                                                                                                                                             cal    research    to    reach    the,    bedside.    The
                   and         overwhelming         important         unity-    broad         community          involvement          and    fact    is    that    they    are     indeed     reaching     Our     country     has     been     sold     on      the
                   We     have     not      developed      an      organiza-    restructuring      of      the      medical      schools,                                                          @e,     proposition    that    if    we    use    public    funds
                                                                                                                                             the bedside-but very spottily. If t
                   tional    pattern    that    is    strong     and     re-    administratively           and            curriculumwise.                                                                  to      enhance      the      development      of       a
                   sourceful      enough      to       foster       simulta-    His       hope       and       apparent       expectation    biomedical    researcher    has    a    fault    it    is     Climate      favorable      to       biomedical       re-
                                                                                                                                             certainly   not   that   lie   locks   up    his    find-
                   neous         and         appropriate         development    is   that   all   this   can    be    done    so    judi-    .                                                             search,     the     country's     health     will      be
                                                                                                                                             ngs   in    his    files.    On    the    contrary,    he
                   of     all      three      main      components.      And    ciously    that    none    of    the    -ood    in    the    1                                                             the   better   for    it.    This    I)rol)ositioti    is
                   now    that    the     ii-ribalance     is     aljl)arent                                        11)     I,        svs    I't]Sli(@s  into   print   iii(I   sorii(-titri(,s   onto        t,@
                                                                                -es(,tlt,  acirti'tt(,(Ilv  otityrio(l(,(                                                                                  (,,I (,ot,l,(,(,t  is   far   ts   it   qo(.S;   but   it
                   at    tll    a    cotinterreaction     has     set     in    t(,Ill will 1)(,  lost.  'I'llis  may  I)ossll)lv    1)(@    tll(, television S(.I-(.(.Il  iiiii(@li  too  l@(,a(li  v     s  not  (,oyiil)](,t(@  in  itself.   It   his   tal@(@ii
                         tends at times to                             tli(,    tli(@ (,.is(- if tli(, 1)i,o(-(@ss  is  an  oi.(l,(!I@ly     ;had                                      @LTI(I     tlil!    LIS    0111Y    part    of    the    way    toward    the
                   imbalance    and     to     set     the     stage     for    and       evolutionary       one.        There        are    practicing      physician      (@oijie      all       too     realization      of      the      public      expectation
                   remedial     action     ,vhich     may      turn      out    those,    on    the    other     hand,     %vlio     feel    (Itjl(7k]y    to    be     apprised     of     resear(@ll     and,  I  believe,  of  the  intent         of         the
                   to   be   less   than   optimal.    -Unl(@ss    an    ef-    that   the   goals    are    so    I)atei@itly    (-]ear,    fliiclirl(,s   TTIC)st   of   which   are    llkelv    to     Con ress.        Regional        Medical         Proorarm
                                                                                                                                                                                                              9
                   12







                is  a  i-nod(,.rate,   evolutionary   measure   stratum  is  the  most  abstract;  the   low-  of    modem    diagnostic    and    therapeu-   never   before    actually    pooled    their
                designed  to  take  in  the   rest   of   the   est  strata  are  those  items   which   deal  tic   methods   are   much   too    expensive   resources  to  the  extent  that   the   mag-
                                                                with   such   mundane   matters   as    corn-  to  be  installed  and   staffed   in   every   nitude    of    the    problem    unquestion-
                                                                munity   structure,   the   distribution   of  town  and  village  in   the   country.   And   ably requires, to do so now?
                TI-IE     REST      OF      TFIE      PACKAGE   health     personnel,      emergency      and  the  lack  of  access  to  such  methods   is      Very  frankly,   I   doubt   that   anyone
                                                                screening   mechanisms,   and    the    like.  one  reason   physicians   decline   to   set   can  say.  The  law  will   not   of   itself
                  To  complete  the  job   so   well   begun,   Our   research   societies   have   accepted,  up   shop   in   small   communities.   Medi-   fundamentally    change    the    goals    of
                complementary     steps     are     obviously   not  implausibly,   the   upper   strata   as  cal   school   researchers    have    devised   the  basic  researcher  and  the  service  he
                necessary  and   we   begin   to   run   into   their  proper   baillwicks   and   have,   in  most   of   these   advanced   methods    and   renders,   Items   which   are    in    them-
                conflicts  of  interest   and   philosophies.   effect,   continued   down   the   years   to  have,    therefore,    indirectly    partici-   selves  justifiable  and  necessary  to   so-
                This  stacfe,   as   I   have   already   in-
                          0                                     create     valuable     and     indispensable  pated  in   the   maldistribution   of   phy-   clety.   The   law   will    not    overnight
                timateci,    might    have    been    avoided   forums   for   their   members.   But    most  sicians.  Should   we   therefore   now   de-   transform    the    desperation    many    of
                had   @ve   developed   a   unifying    plan-   of  theiTi  have  shown  no  great   interest  stroy   these   tools   and   dismantle   the   our  physicians  feel  as  they   battle   to
                ning   mechanism   as   we    proceeded    in   in  the  lower  strata  and  have  at  times,  system  that  produced  them  so   that,   as   carry  their  service  loads;  nor  will   it
                the   development   of   a   very   necessary   in   fact,   unofficially   reacted   against  in  the  early  19th   century,   our   great   necessarily   convince   all    our    physi-
                climate   favorable    to    research.    But   proposals  to   attack   such   problems   in  medical  centers  will  have   no   more   to   cians,  or  for  that   matter   the   entire
                this  has  not  happened  and  it   is   rea-   depth.   There   has    been    an    unhappy  offer  than  one  man   carrying   the   tra-   public,  that  our  traditional   system   of
                sonable to ask why it has not.                  resistance  to  the  fact  that  the   strata  ditional   doctor's   bag   of   instruments?   health  service  needs   updating.   And   as
                  Should   the   researcher,   public   serv-   are   interdependent   and,   indeed,    con-     No  one  today   seriously   argues   that   for   the   consumer,   the   law    provides
                ant  that  he  undeniably   is,   have   done   tinuous.                                       we   should   take   such   a   course    al-   him   with   new   avenues   of    participa-
                it?   Should   the   medical   schools   have     Nor   have   the   medical   schools   been  though  one   occasionally   sees   nostalgic   t'on in  planning  but  it  will  not  neces-
                taken'  t'he  lead  in  it?   Or   should   the notably   successful,   as   a   group,    in  statements    that    have    somewhat    the   sarily   educate   him   in    distinguishing
                practicing   physician,   busy    man    that   creating  some   sort   of   planning   mech-  same    effect.    Obviously,     what     is   between    what     is     reasonable     and
                he   is,   have   brought   it   about?   The   anism   that   would   have    prepared    us  needed   is   an   effective   link   between   professionally  Justifiable,   on   the   one
                                                                                                                                                                                I
                obvious  answer  is  that  for  various   and   better  for   what   we   must   now   under-  the  patient,  wherever  he  is,  the  physi-   hand,  and  what  is   not   only   medically
                complex  reasons  no   one   of   the   three   take.    Many    of    our    schools    have  cian,  the  investigator,   and   the   medi-   indefensible   but   also   extravagant   and
                -irrn,s of oiii-  profession  hLs  been  able
                                                                inaiji-,tjrat(,(l or participated in  efforts  (,.a]  (-enter.  'riie.  R(,gloii@il  Medical   wasteful,   on   the   other.    The    back-
                to c)l)(@i-at(@ above the 1)t-lri(ill)le of in- to  sliorc  ul)   the   educational   process  Program   law   was   designed   to   develop   @,round  against  which  the   law   is   be-
                dependent coexistence.                          itself  and  to  assist  in  correcting   the  such  a  linkage   and   to   improve   those   ginning  to  operate  is  not,   in   itself,
                  The   researcher,    accustomed    as    he   maldistribution   of   physicians   by   set-  that  already  exist.   And   it   puts   the   especially   favorable.   We   are    passing
                is   to   logical    and    methodical    ap-   tin@   up   programs    designed    to    en-  primary    responsibility     on     regions.   in all aspects  of  our  national  life  from
                proaches     to     biomedical      problems,   courage    young    graduates    to    tackle  The   medical   schools   and    their    in-   a  period  of  spacious,   eager,   and   re-
                might   have   helped   by   broadening   his   eneral   practice   in    relatively    large  vestigators,   along   with   the    consumer   sourceful  projection   to   one   in   which
                definition  of  research  to   include   some   areas.  These  efforts   have   failed.   The  and  the  physician,  are  inevitabl            Our   attitudes   are   much   more   anxiety
                as  ects  of  the  distribution   of   health   schools   cannot   by   their   own   efforts  specified by law as participants.           y   ridden   and   our   outlooks    much    more
                 p                                                                                                 I
                services.   This    could    probably    have   counter   the   forces   that   are   produc-                                                  constricted  than  Nvas  the  case   a   fe@v
                best  been   undertaken   through   the   re-   ing  ma'or  shifts  not  only  of  physicians  CAN IT SUCCEED?                                 years aao.
                search   societies;   but    it    has    not   and   other   professionals   but   also   of    But  can  the   law   really   succeed   in     A   sequel,    in    Secretary    Gardner's
                @iapl)cri(@cl, The  tendency,  (in  the  con-   the   population   at   large.    Nor    have  accomplishing   such   a   goal?   Will   'it   words,  is  ".  .  .   the   bitterness   and
                trar%,,  has  been  to  establish  a  strati-   they  any  way  of   undoin,,,   the   simple  really  succeed   in   indLicin,,,   relevant   all,@er   toward   our   institutions    that
                fi(-d attitude  toward  resear(@li;  the  top   fact  that  many  of  tile   most   effective  but   disparate    elements,    which    have   wells  up  when   high   hopes   turn   sour.

                                                                                                                                                                                                          13










                               No   observer   .   .   .   has   failed   to   note      Initial    cooperative    efforts    have,    for   that   are    neither    justifiable    on    health   CONCLUSION
                               the    prevalent     cynicism     concerning     all   the    most    part    been     encouraging.     The   grounds   nor    within    the    means    of    the
                               leaders,    all    social     institutions.     That   basic   goal   so   far,   and    it    is    indeed   Nation,   rich   thou-h    we    still    are.    If      My      assignment      was      science      and
                               cvnicism    is    continually    fed     and     re-   basic,   is    to    help    the    physician    and   all   this   should   transpire,    it    will    be   service.   Altering   the    title    sliahtlv,    I
                               @e@ved   by   the   rage   of   people    who    ex-   other   health    workers    outside    our    great   clear   that   the   course   of    evolution    and   have   stressed    the    point    that    research,
                               pected    too    much    and    got    too    little   centers     provide     more     adequately      for   moderation     is     not     appropriate,      that   however    rarified,    is    service.    I     have
                                      soaring    hope     follonved     by     rude   the   needs   of   their   patients.    The    focus   stronaer     medicine     is      required.      The   plead     for     the     preservation     of      a
                               disappointment      is      a      formula       for   is   on   the   physician   and   gives   him   full   differences    between     the     three     conipo-   favorable     climate     for      research      and
                               trouble."   It   is    a    dan(,erous    time    in   voice  in,  if   not   total   control   over,   the   nents   of   our   profession   will    appear    to   have    .tried   to    indicate    that    the    de-
                               the   life   of   the    Nation,    and    one    in   plannin,   process.   It   does   not,    per    se,   the    layinan    to    be    irreconcilable     and   strtiction   of   the   present   climate   in   the
                               @vhlch   -,ve   are   all   too   likely   to   fall   tamper      Nvith     the     all-important     cli-   his   natural   tendency   will   be    to    assume   hope    of    accomplishing    the     broad     and
                               into   the   paradox   of   t)]aTliln,r   the   very   iiiate for r(,seLr-(,.Ii I)t.it it  does  strori(,Iy   that   we   cin   riitke   no    (-oritt-ll)t.it'o--   riece-,sarv   ,(-)als-in    solving    the    crisis
                                                                                                                                                                                                    if          ']I
                                                                                                                                                                                                       you   wi   --will   have   no    sucii    effect.
                               accomplishments     of     our      recent      past   indicate    the    need    for    new    types    of   othei,   than   purely   te("Illllcll,   to   ti   c
                               for    the    dilemma    we    now     face.     But   research     and     research      training.      So   solution    of    the    health     problem.     And   On    the    negative    side,    I    have     iii-
                               none   of   this   actuallv   changes   the    prob-   far,   it   is   indeed   moving   us    toward    a   we   will   be   in   no   position   to    preserve   dicated   that    researchers    and    their    or-
                                                                                                                                                                                                    ganizations have I               I
                               lem   at   hand.   It   'will    not    simply    go   more    complete,    or    balanced,     view     of   the    valuable    and    the    oood    that    has                             ven    little     evidence
                               away    because    -,ve    are     frightened     by   the health problem.                                    been  so   painfully   built   up   in   the   past;   of    understandin-    what    is    involved     in
                               national    and    international     events     that      One    can    predict,    I     believe,     that   the   way   will   then    be:    Out    with    the   the   genesis,   the   care,    and    the    mainte
                               lie   outside   the   field    of    health    alto-   firm    directions    will    emerge    from     the   old    and    in    with    the    new.     Ilut-and   nancc    of    the     research     climate.     The
                               gether.   It   is   fortunate    indeed,    in    my   planning,      that       inadequately       defined   this   is   the    key    question-who    will    ay   i-nedical    schools    have     tried     to     be
                               view,    that    the    Regional    Medical     Pro-   regions      will       restructure       themselves   what the new is to be?                                 even'thing     to     all     men,     They     have
                               gram    concept    emerged     Nvhcn     it     did.   alon-   lines   that   make    sense,    and    that      A   moment   of    truth    in    health    plan-   made    ingenious    but     ineffectual     efforts
                               It  was   basically   a   late   product   of   that   the   peripheral   physician   -,vill    begin    to   ning    is    at    hand    and    the     processes   to   build    a    world    for    the    researcher
                               period     of     eager,     resourceful     pro'ec-   get   the   help    he    needs.    The    essential   of     polarization     have     already      beaun.   and    to    discharge    an    incredible    arraN,
                               tion   but    must    now    be    implemented    in   service    the    researcher    must    render    is   The     (,onccpt     of      lZc<,Ional      Medical   of    service    and     educational     obligations
                               a   very   different   setting.   I    have    heard   in    helpina    to    design    planning    experi-   Prouram    in    this    troubled     environ     is
                                                                                                                                                                                                    as    @vell.    The    service,    research,     and
                               the   law   ref6rred   to   as   the   worst,   most   ments    and    in    evaluating     results.     If   the   concept   of   reason    and    good    sense.   educational     elements     have      not      ),et
                               ill-conceived    piece    of     health     legisla-   his   own   field   of   training    and    interest   There    is     nothinc,     else     that     hol@s   found    the     common     ground,     the     uni-
                               tion   ever   passed   by   Congress.    But,    im-   make     it     inappropriate     for     him     to   serious   I)roii-iise   of   doin,   the   'cb   et-
                                                                                                                                                                                      i             lying   instrument    they     need     in     order
                                                -h   it    undoubtedly    is,    it   render   this   service,   he    must    at    least   fectively  and  'Lid'c'otisly.  And
                               perfect thou     0                                                                                                                j   I I                  i t  is   to    Drina    the    total    health     establish-
                               is    potentially    the    most    important    and   comprehend     the      need      for      research-   heartening indeed that it seer-ns           to    be             "I
                               its    basic    concept    the     most     enlight-   er-,   who   can.   All   this   is   beginnin,   to   @vorkin,,   in   its   initial   phases    of    im-   ment   to   the    level    of    development    the
                               ened.    Politics    aside-as    much     as     one   happen. So far, so @ood.                               I)Iezyicntation@   that   as   a   result   of   the   situation now requires.
                               can   set    it    aside-the    law    does    great      But the future, dependin,                                  r   of    the    concept    disparate    ele-      If     the     Re,ional      Medical      Program
                                                                                                                           ,,   in    some   powe
                               credit   to   the   Congress   that    passed    it.   measure     on     circumstances     outside     the   merits    arc     becoiiiin,     less     disparate;   law   is    not    a    perfect    mechanism     for
                                                                                                                                                                                                                              ring    instrument,     it
                               -I'he   reason   is   simplv   that   it    provides   health   fielcl,   may   bring   a    time    Nvlien   that    effective     inquiring     and     sensible   creating that unifN'
                               a   common   xN,ork--,Iiop   in    -,@,hl(,Ii    the   the   researcher   and   soi-ne   of   our    incdi-   I)Ianiiin(,,       (,ettln,ff  t,iticl(,i-  way.  It   Is    tli(,    closest    approximation    on    the
                               components     of     our     profession      (!,,in   (-al   schools   1)(@(,otiie   so   dlsliitei,est(@d   (lo(@s not ltistll-(, tll(' ti-itiltil)ll of iiit(@l-  ciii-i-(@tit  s(,ciie.  And  @vlill(,  the,  (@ai-ly
                               no",,    with    consumer     participation,     be-   and   iticlifterent   as   to   clisen(@age    them-   ll,,,(.@nc(-  and   moderation   but   it   clo(.,,s   i@c.-sults of  it,.;  'ml)leri-)(@litation  are  not
                               ,@in   to   liar-nryier   out   the    system    our   selves.    Practitioners    may     follow     suit.   metric(,  us   to   e.\aiii'iie   the   1)i-obal.@le   alto,etlier    orclerlv    and    uniform,     tliev
                               bLzr(-@eoninz Nation needs.
                                                                                      The      consumer       may       make       demands   effects of doctrinaire extremism.                      are in stim encotira(rincr

                               14






                                               QUALITY             AND  cilities,   To   some   extent,   they   have   for    Heart    Disease,     Cancer,     and   ship    to    surrounding    suburban    and
                                          AVAILABILITY              OF  also     undertaken      cooperative      en-   Stroke.  All  of  us  here   are   generally   rural  areas  from   that   experienced   by
                                               HEALTH             CARE  deavors    in    health    manpower    devel-   familiar  with   the   legislative   history   many  of   us   in   childhood,   This   new
                                     FOR        HEART         DISEASE,  opment,  patient   care   such   as   labora-   and  intent   of   the   program   and   its   set  of  living  circumstances  is  inducing
                                          CANCER,              STROKE,  tory   services,   administrative   services,   present state.                                 many   changes,    particularly    in    the
                                               AND             RELATED  and other aspects of health care.                 The   other   extensive   endeavor    that   service  industries  such   as   transporta-
                                           DISEASES       IN       THE     To   safeguard    our    environment    in   is    concerned     with     regionalization   tion,   education-and   now    health.    We
                                                                FUTURE  the interest  of  health,  as  well  as  aes-   undertaken   recently   by    the    Federal   can  no  longer   plan   in   this   country
                                         AS        RELATED         TO-  thetic   considerations,   water    pollution   Government     in      partnership      with   solely  on  the  basis  of  the  small  com-
                                                                        and  air  pollution  control  districts   are   State  and   other   agencies   is   compre-   munity;  we  must  also  plan  for  the  big
                                                       REGIONALIZATION  ,  -
                                   OF         HEALTH          SERVICES  oeing   established   in   many   parts    of   hensive   health   planning.   The    latter   community-the region.
                                                                        the  country.  Similar  efforts   will   soon   seeks     to     organize      comprehensive     Another   force   toward   the    regional
                                                                        be   underway   with   respect    to    solid   planning   for    health    through    State   concept  is  growing  public   belief   that
                                           Lester    Breslow,     M.D.  waste,   and   possibly   noise.   The    new   governmental   action   and    the    forma-   health  care  costs  must   be   held   down
                                  Professor   of    Health    Services  environmental    control    agencies     tend   tion  of   areawide   or   regional   bodies   somehow,   perhaps   by    greater    atten-
                                                        Administration  to   lie   somewhere   between   State    and   within  and  between   States.   The   scope   tion   to   organization.   The    Congress,
                                       School   of    Public    Health  local    government,    both     functionally   embraces     both     environmental      and   reflecting  that  belief,  has  called   for
                                        University    of    California  and   geographically.   Prodding    by    the   personal health services,  as  well  as  de-   more  efficiency  in   the   health   indus-
                                                  at    Los    Angeles  Federal   Government   is   playing   a   big   velopment   of   health    facilities    and   try.  The  tremendous  costs   involved   in
                                                                        role  'in   their   evolution.   Those   con-   personnel.   It   seems   clear   that   the   applying  just  one  set  of   advances   in
                                                                        cerned  with   regional   planning   of   pa-   Congress     intends           comprehensive   medical   science,   namely   organ   trans-
                              o   those   concerned   with   the   im-  tient  care  services  and   those   in   the   health  planning  to  be  a  global  effort,   plantation,  are  causing  tol)  budget  of-
                         Tprovement   of   health   care    in    this  environmental     field     have     remained   bringing  together  what  is  done  in   the   ficials  in  Federal   and   State   Govern-
                         country,    regionalization    has    become.  almost  entirely   oblivious   of   one   an-   environmental  health  field,  in  the   Re-   ments  to  burn  the   midnight   oil.   How
                         the  ordei,  of  the  day.  The  regionaliza-  other.   This   is    unfortunate,    because   gional   Medical    Progi-airi,    and    in   fast  should  we  develop  these  new   pro-
                         tion  idea  is  growing  both   rapidly   and  both  have  the  goal   of   protecting   and   health   facility   and    manpower    plan-   cedures   and    how    can    economy    be
                         in a variety of forms.                         improving    health,    and    each     could   ning-with     an     emphasis     throughout   maintained?      Furtheniiore,      Congress
                           For     example,     recently      covering  learn   from    the    other's    experiences   on regional considerations.                    has  expressed   a   public   feeling   that
                         most  of   the   populated   areas   in   the  with   many   similar   problems   with   re-     Why   this    rather    sudden    emphasis   the  benefits   of   medical   science   are
                         United  States  is  a  network   of   several  spect   to   regionalization.   Groups   re.-   on regionalization?                            not   being   applied    uniformly    enough
                         score   regional   voluntary    health    fa-  sponsible    for    environmental    measures     Probably    it     derives     principally   to   all   segments   of   the   population.
                         (,,Ility  planning  bodies.  They   are   us-  and  those  responsible  for   patient   care   from   our   Nation's   coming   to    grips   This  latter  point  has  been  well   docu-
                         ually    based    on    metropolitan    areas  services-to       advance       healtli-Ilave   with   the   changed   character   of    our   mented  during  the  past   decade   or   so
                         and    extend    beyond     local     govern-  more   in   common    than    they    usually   life,  especially  the  trend  toward   met-   in  the  case  of  new   immunizing   agents
                         mental    Jurisdiction    over     geographic  realize.                                        ropolitanization.   Migration   from    rLl-   despite  the  fact  that  their  application
                                                                          The   Congress    has    recently    estab-   ral   areas   and   small   towns   of   the   was   organized   by   local   health    an-
                         areas    with    Populations    of    several
                         thousand  to   several   million.   Initiated  lished   two   iiia'or    programs    involv-   United  States  to  the  cities  in   recent   thorities   and    the    medical    profes-
                         largely    by    hospital    groups,    these  iiig rationalization  of  health  sei@\,ices.   (:Iccades  has  not  only  expanded   cities   sion.'  Reflection     on    the        much
                         agencies  vary   in   streii-th   and   scope    One  of  these  is  the   ob'ect   of   our   but  has  brought  acl'acerit  cities   into   slower  and  uneven  spread   of   the   cy-
                                                                                                      i                                       i
                         of  effort.  They   have   been   principally  concern    in    this     Confet-eticc-lVork-   large    metropolitan     complexes.     The   tologic  test for cancer    2 and      other
                         concerned  with  I)Iaiiiiiii-  hospital   fa-  shop,   the   Re-lorial    Medical    Pro-ram   latter  have  a  quite  different  relation-   well-known    medical    advances,     where

                                                                                                                                                                                                                 15

















                                                                                                                                                                                                                                            I           I
                        relatively     little     systematic     effort      has    throughout     Maine     and     part     of      Massa-       A    potentially    big    boost     to     regional-    represented       the       principal        nat'onivide
                        been      undertaken,      will      indicate       fur-    chusetts,      in      connection       with       Tufts    ization     of     health     services     came     with    movement        toward        re-lonalization         in
                        ther    justification    for    the     public     feel-    Medical     School     and     the      Pratt      Diag-    the    passage    of    the    Hill-Burton    Act     in    the health field.
                        ing      that      improved      organization,      per-    nostic     Hospital     in     Boston,     with     see-    1946.       Two       years       earlier,        Thomas       In      other      Countries,      some      prooress
                        haps    on    a    regional    basis,     would     lead    ondar-y       centers       at       Lewiston        and    Parran,     then     Surgeon     General     of      the    has      been       made       toward       re-lonaliza-
                        to   better   as   well   as    less    costly    health    Bangor,      Maine.-'       The       services       in-    Public      Health      Service,      had       proposed    tioii    and,    as    in     the     United     States,
                        care.                                                       eluded      complete      diagnosis       and       sur-    regionalization      of       hospitals       as       a    principally     with     respect      to      hospitals.7
                           Regionalization        also        arises        from    ger-y    in     Boston     for     patients     selected    means    of    raising    the    level    of     medical       For    example,     in     1946,     the     National
                        growing     recognition      within      the      health    by    participating    physicians    in     the     sur-    care     in     a     community.      When      Con,ress    Health     Service     in     England     created      a
                        field    that     the     present     complexity     and    rounding      areas;      consultation      in      lab-    apl)ropriat(,,c]     funds     for     assistance     in    ,vst(@iii    of    l@e,,Ional    Hospital     l')oaz@(Is
                        specialization     of     health      care      requires    oratory     diagnosis,      radiolo-      and      clec-    hospital     survey      and      construction,      re-    1-CSI)OnsilDle     for     both      hospital      coii-
                                                                                                                         @y
                        exploration       of       new        patterns        of    trocardiography;            and             postgraduate    gionalization  was          incorporated            into    struction      and      operation.      Under      tli(,
                        oilganization.                                              education     through      teaching      clinics      at    the      prouram       design.       However,       even    aLlthorltv    of     the     Ministry     of     Health.
                           Hence,      the       trend       toward       metro-    several     hospitals     and     courses     at     the    with      the      subsequent      authorization      of    the      regional      boards      cultivate       s@,s-
                        politanization,       public        concern        about    medical      center.      The       medical       school    specific       funds       through       the       Hill-    tematic       and       cooperative        relationships
                        the   cost    and    use    of    health    care,    and    thus     entered     into     direct     support      of    Burton       mechanism       for       studies       and    with      respect      to      purchasing      supplies,
                        professional       response       to       the       now    individual     practitioners,     with      the      arm    demonstrations,      little      was       done       to    re(@rtiltment     and      training      of      person-
                        highly      specialized      nature      of       health    of    iml)rovin(,,    tli(@    quality    of     medical    I)rortiot(,.      regionall@ition      until       tfi(!    n(!],     consultant      services      and      otli(@r
                        care-all    these     and     possibly     other     in-    practice.                                                   1960's. There was a 15 to 20 yeai-                          21si)('(@ts  of  iri@inagement   artiori,,   ill   tll(@
                        fluences    are    focusing     attention     on     the       Around      Rochester,      N.Y.,      with      sup-    in     national     action.     During     that     time    hospitals    in     their     areas.     The     medical
                        possible       advantages       of       regionalization    port       from       the       Commonwealth       Fund,    progress    was    being    made     only     by     oc-    schools    with    their     large     teachin-     hos-
                        in health care.                                             the      Council       of       Rochester       Regional    casional        voluntary,        privately         sup-    pitals,     however,      report      separately      to
                           A,,    with    all     such     social     phenomena,    Hospitals    w,-t-,     organized     in     19@6     to    i-)ort@ecl  (-fTort,,  @,@icii   is   In   l@o(Ji(!stf@r    tti(@   Mirilstrv   riot    tliroti(,Ii    tii(-    r(,-
                        one           and  for                                      I)r-ovl(](,:                                        rot'    :111(i                                      li;tll()Il:ll   I,ioIl:ll 1)();It,(Is.
                                                                                                                                                                                                                      f)tjf.l)oS(-',' (@f'  llosl)lt@ll  S(.I-vl(,("
                        l[Ig SI)OIII(I,          flit'                      Into    all                ol 11(@:lltll                                                   III         ;11,  - S      ' )
                        Iiist,or-y.   What   we   now   see    is    the    sud-    visor-y  service   in   (@Iiiii(@al   in(@dicinc   Vince    opposition  ,Ill  SOIII(@  (ILI-,Il't(@r's   toward         S@ve(l(@,n    has    been     divided     into     seven
                        den    flowering     of     an     idea     that     has    hospital     @Ldiiiinistration,     joint      hospit@il    Governmental        participation        in        tfi(@    eg'ons   each   consisting   of    3    or    4    coun-
                        roots in other times and places.                            services   on   a    regional    basis,    and    stand-    planning      and      organization      of       health    ties.   At   the   heart   of   each    reion    is    a
                           In    1920,    the    Dawson    Report     to     the    ards   for  hospital  operation             .5       The    (,,are.      Widespread      advance      be(ran      in
                                                                                                                                                                                                            lii.-hlv     developed      medical      center,      in
                        Ministry     of     Health     of     Great      Britain    Rochester        University         Hospital         and    the    early    I    960's     @vhen     the     Public,           I
                                                                                                                                                                                                            five    of    the    seven     re,ions     a     medical
                        projected     a     network     of      primary      and    other      large      hospitals       in       Rochester    Health      Service      gave      grants-in-aid      to      I
                                                                                                                                                                                                            scnool. A tv
                        secondary       hospitals,        affiliated        with    served as the base for this effort.                         the     locally     organized,      regional      vclun-                    pical    countv    in     the     region
                        teaching     hospitals,     as     a     pattern     for      Other        medical        schools,         Including    tary     health     facilities     plannin-      bodies.    will     have     one     general     hospital      with
                                                                                                                                                These      have      rown      in      number       from
                        achieving     effective     integration     of      hos-    those     of     the     University     of      Virginia                                                                rclatl%,elv    specialized     services     and     Lis-
                        pital      services      throughout      the       coun-    and     Tulane     University,     from     time      to    one    in    1945    to    a    handful     in     1960,    ually     some     smaller     general     and      cot-
                        try,'   Over        the     years,      this         has    time    have     sou-lit     to     establish     closer    to about  80      at    the     present     time.     As    ta-C.  hospitals.
                        served    as     a     model     for     regionalization    working       relationships       with        physicians    noted above,        these     bodies      have      pro-      l,'ollo%vin,'@    this    brief    review    of    the
                        in various countries.                                       and    hospitals    in    the    areas    around     the    vided    diverse     ranaes     of     service     -tiid    I-)a(,k,@i-otirid,   it   may   now    be    al)proI)ri-
                          Beginnino-      in       1931,       the       Bingham    medical      centers.';      This       effort       has    lia%,(@  acl-ilev(,cl   vai-vln,ff   degrees   of   (@f-    at(, to (consider a definition of reg'
                                                                                                                                                                                                                                           I                   loll-
                        Associates      Fund       inaugurated       a       re-    taken   the    fot-iyi    mainly    of    I)ost(rra(ILI-                                     @t(l,,,(,nt  of   tti(,    @iliz@itioii, aTI(I Son)(' Of III(,                  is-
                        c@ional      system       of       health       services    ate education.                                                                                                                                  it.
                                                                                                                                                Regional        Medical        I't-oc@rain,        the@@    S@IES Surrounding

                        16







                                                                    cated in  the  following  list  taken  from           praisal   of   services    rendered  sential   to   maximum   advance   in   the
                                                                    the same source as the definition:                    and costs of medical care.           current situation.
                                                                          In  essence,  a  range  of  desirable      (6)  Development of programs          of     One   major   issue   in    implementing
                                                                       goals  for  developing   regional   sys-           research specific to area        or  regionalization   thus   is:   What   shall
                                                                       tcms   of    health    services    would           regional   interests   and    prob-  be   the   scope    of    any    particular
                                                                       include:                                           lems;   opportunities   "to   learn  component?
                                                                       (1)  Continuous    opportunities     for           the  truth  about   matters   which     Shall  one  element,  for  example,   be
                                                                            postgraduate  education   for   all           otherwise  must  be   accepted   on  limited  to  the  placement  and  size   of
                                                                            levels of health personnel.                   faith,  and   to   stimulate   cor-  hospitals?  Shall  it  also  consider  spe-
                                                                       (2)  Participation   of   the   regional           rective action."                     cific facilities  such  as  for  laboratory
                                                                            organization   in   planning    and      (7)  Continuous   study    of    medical  work  and   radiation   therapy?   Further,
                                                                            expanding  of  systems  of   under-           care   given   outside   the   hos-  shall  it  include  educational,  advisory,
                                                                            graduate    education     conducive           pital   toward    improvement    of  and  consultation   service   on   clinical
                                                                            to   attracting   and   maintaining           office  and   home   services,   as  matters  to  physicians  in  the   particl-
                                                                            an   adequate   flow   of    health           well    as    recommendations    of  pating  institutions?  Shall   it   provide
                                                                            workers  from  every  health   dis-           new  forms   of   health   services  for  the  actual  transfer   of   patients,
                                                                                                                          for the region.                      when     deemed     appropriate      medic-
                                                                            cipline into service.
                                                                       (3)  Advisory  services  to  small   in-      (8)  Creation   of    a    program    of  ally,  from  one   hospital   to   another?
                                                                            stitutions  and   agencies   unable           health   education    related    to  Shall  it  endeavor  to  link  up  services
                                                                            to attract  and  support  the  full           all  aspects  of  the  regionaliza-  within a health facility  to  those  avail-
                                   DR. BRESLOW                              range   of   medical,    technical,           tion   system   for   the   general  able  outside  in  the   community?   Shall
                                                                            and   administrative   specialists.           public.                              administrative,   rather   than   clinical,
                         While  several  definitions   have   been     (4)  Development      of      systematic      (9)  Encouragement     of     participa-  services  in  health  facilities   be   the
                       set forth, it  seems  most  useful  to  use          utilization    and    sharing    of           tion  in   regional   health   pro-  focus?   Shall   effort   be   devoted   to
                       a broad definition such as:                          equipment       and       personnel           grams  of   the   physicians   with  standardization    of    procedures     and
                            Regionalization   is   the   organiza-          within   the   region   based    on           only  home  and  office   practice,  records for purposes of evaluation?
                         tion  and   coordination   of   all   the          distribution    and    availability           the   dentist,   the    pharmacist,     This brief listing  of  potential  scope
                         health  resources  and   services   with-          as   related   to    adequacy    of           and  the  nurse,  medical   records  in  hospital  regionalization  implies  two
                         in  a  defined  area,  for  the   purpose          health services, such as:                     librarian,  and  all  other   tech-  sets of questions  for  those  involved  in
                         of  maintaining  the   highest   possible          (a)   hospital beds  and  services,           nical   and   administrative   per-  Regional     Medical     Programs:      (1)
                         level of  medical  care,  and  of  adapt-          (b)   laboratory facilities,                  sonnel  throughout   the   region.'  What shall be  the  scope  of  activity  in
                         ing   a   comprehensive    health    pro-          (c)   public  health  and  visiting      With   regionalization    viewed    thus  a   particular   regional   medical    pro-
                         gram   to   the    characteristics    and                nurses.,                        broadly,  it  becomes   clear   that   both  gram?  and,  (2)  how  shall  this   relate
                         needs of the area.'                                (d)   blood bank operations,          regional  planning  of   hospital   facili-  to   regional   development   of   hospital
                       If the latter part of  this  definition  is          (e)   purchasing  of   clinic   and   ties   and   Regional   Medical    Programs  facilities  and  to  comprehensive   health
                       taken  to  include   environmental   health                hospital supplies.              for    Heart    Disease,    Cancer,     and  planning in the region?
                       services  and  health  education   of   the     (5)  Uniform    methods    of    report-   Stroke   are   important   components    of     Rather  than  struggling   over   'uris-
                       1-)tiblic (as I believe it should)  ,  then          ing  financial,  professional,  and   it. Uticierstaiidirl- this relationship  of  diction  with  others  engaged  in  region-
                       it  encompasses  all  activities   directed          all  other  service  activities  to   Re-ional     Medical      Programs      and  al  health  care  planning   and   develop-
                       toward  the  impro@@eiiieiit   of   health.          make  possible  continuous   coiii-   other  coiriponents   to   regiorialization  iiient,  those  responsible,  for  Regional
                       The  scope  is  more  sl)e(@ifically  indi-          parative   and    evaluative    ap-   of health  care  in  its  totality  is  es-  Medical  Programs  might   do   better   to

                                                                                                                                                                                                        17








                                                          important           contr             h                                                                                                     I                1                1     1             corn-
                             determine the most '                                 i-   throu@-    out    the     country.     In     defining    tions   vary    from    one-half    to    10    rii'l-    to appreciate the motivation and
                             bution    they    can    make    to    the    improve-    and     ainin(r     acceptance     of     a     proper    lion,    and    distribution    from     center     to    pctence    of    these     a,eiicies.     both     the
                             ment    of    health    care,    which     now     ap-    role,  it will    be    essential    not    only    to    periphery    mi-lit    vary    from    25    to    250    @vell-estal)llshecl and the                     ojies,
                             pears    destined    to    be    planned    on     the    specify    the    particular    scol)c    of    func@-    developments     as     well     as      consideration    their     potential     for     health     de,,-elol)-
                             basis    of     refflonalization.     That     contri-    tions   to   be    undertaken    by    the    Re(,lon-    or    more     miles"."     In     developin--     Re-    iiient,    and     their     ultimate     coinniunitn-
                             bution mav        be,   on   the    one    hand,    to    al   Medical   Proff   rams,   but   also   to    work    gional    Medical    Procyrams,    as     in     other    of     interest      @vitli      Rcional      Nledical
                             extend    the    excellence     of     the     medical    out    their    relationship    to    other     health    aspects     of     health      care      re-loiializa-    Proai@ams.       Eventually,       the        se%-cral
                             center in handling heart            disease,      can-    care  developments  which  are                   based    tion,     the     primary     focus     should      be    ina.ioz-    aencics    sponsol,iii,@-     i-e,,ion-,ii
                             cer,  and stroke,  amon,            the       re,lon's    on a regional concept.  Study               of     the    on     function;     area      considerations      are    health activities must entei@          into       con-
                             hospitals    and    physicians;    and,     on     the    historv   and   current   status    of    the    other    secondary.    NNIliat    to    do    and    the    re-    structive     relationships     A@itli     one     an-
                             other   hand,    reflect    back    to    the    medi-    developments,     as     well     as     consideration    sources   necessary    to    do    it    should    de-    other.    This    could     be     accelerated     b@@
                             cal    center    the    substantial    obstacles    to    of    the    main    strength    of    the    Regional    tcrmine the                      boundaries         of                                             tll(-    his-
                                                          ttit-oti,,iiout  a   i-c-                                                              tli(, enterprise.                                         tc),-'C..tl  role   tjicl   ctirr-(,jit   i-(!@,ioiial
                                                                                       Medical      f't-ogi-arris--iiieclic@il      (,x(,c,]-
                             gion,    such    as    isolation     of     individual    lence-will    be    helpful     in     workin-     out      Again,    it    would    seem     desirable     that    health   acti\,itics   of   the   %,ar'
                                                                                                                                                                                                                                                            IOLIS
                             physicians       and        inadequate        planning    the i-cjationship.                                        Regional       Medical        Pi-o.-ram        leaders    agencies.
                                                                                                                                                                                                            -1
                             of     facilities.     Regional      Medical      Pro-       What  to   do,   in   the   sense   of   scope   of    study  carefully  the                              as-      Coiisid(,i@   for   a   iiiorn(@nt   the    pl'(,Iit
                             (rrams    arc    clearly    intended     to     become    fLin(-tioii,   may   seem   a   sliffi(@iently   large    1)c,,ct,; of otfi(,r i-c,,'ori   lic@iltli
                                                                                                                                                                          i   al                           of the Stii, (@on Geiier-@il In            i,(@,,arcl.
                             a     two-way     street;     and     some     believe    issue     foi-     consideration     today.      13LIt    ol)ments.       Understanding        their        his-    He     must     ultimately     respond     to      the
                             that   those   in    the    medical    centers    have    perhaps    brief    attention     can     be     given    torical,       functional,       and       philosophic    sc\-eral   rcaional       health             endeavors
                             as   much   to   learn   as   those    elsewhere    in    to    two    other    issues    in     re-ionalization    bases   will    be    extremely    useful    in    ar-    which  the  Public        Healti-i     Service      is
                             the region.                                               of    health     care:     Ge@,raphy     and     spon-    riving    at     mutually     acceptable     clcfiiil-    now  spoii,;oz-in-:      Regional        -.%,I(,cllcal
                               An      approach      by      Re-ional       Medical    sorsliip.                                                 tions of roles.                                           Pt-o(,rarns,     liosl)it@il      development      and
                             Program     leaders,     based     on      such      a      The    question    of    size    and     clistribli-      For       l@e-lonal       Medical       Pro,,raii)s,    coii)l)rehcnsiv(,,    health     I)Ianninc,T.     I-le
                             concept    of    their    relationship    to     other    tioii     for      Re,lonal      Medical      Programs    initiatirig    sponsorship     has     come     large-    @volild  surel@,   be   ,rateful   for   field   solu-
                             current       re-ional        developments,        may    is,    of    course,     largely     determined     by    ly    from    the    medical    centers,    as     one    tions    to    the    problem    of     interrelation-
                             be     useful.     Certainly,      Regional      Medi-    the     availability      of      medical      centers    might     expect.      Participatin-      and      ad-    ship among these programs.
                             cal     Program     personnel      are      encounter-    for       participation.       More        (,encrally,    visory    elements    come    from     the     re(@ion      In   sui-nina@,,   the    Re    "onal    '-%Iecllcal
                             ing    in    their    realons,    States    and    the    with     i,esIDect     to     re(@loi)alization     of    generally.  In  the case of other                         p,,),,
                                                                                                                                                                                                                rain
                                                 "I                                                                                                                                                           I        for    Heart    Disc,,as(,,    (,2inc(,i-,
                             country, persons       who       call       themselves    health             "the      ftiri(laiyiental      ,c-    rent     re,lorial     @icaltli     (leveloprll(,Iits,
                                                                                                                                                          Z,                                               @ti)(I Strok-(,@    is    one    important    (-Ollll)o-
                             hospital      planners,                  comprehensive    quireincrits   @is   to   @lzc!   al)l)eat-   to   be:    such    as    hospital    I)Iarinin,,,    and    corn-    ticnt  in      the      rapid      development      of
                             health    planners,     and     the     like.     Even    (1)     Each     re@,ion     should      be      larue    I')rehenslvc      health      planning,       sponsor-    health  care   on   an   area@@,ide   oi-   rc,@oioii-
                             thou-h    initially    startled     by     the     en-    enouch     to     include     (or     warrant      the    ship     has     come     from     hospital     rotips
                                                                                                                                                                                                           al   basis   in   this   countn@.   To   fulfill   its
                             counter     and      reactin-      momentarily      on    inclusion    of)    such    an    amount    and    va-    and     State      health      authorities.      Other    particular      mission,       those       responsible
                             the   falrlv    low    blosocial    level    of    "my    rietv    of    resources    for    health     services    affencies   in   wide   -,-ariety   no@@-   are    be-    @'ill   have   to   define'   Scope    of    function,
                             jurisdiction,"       perhaps       Regional       Med-    that,   when   tliev    arc    I)i,ol)er]N,    i'nt(,-    (,Ortlirlg Involved     in     tr(,a%vl(l(@     @tii(I    (@o                             ancl       ,pc)iisoi--
                                                                                                                                I                                                                             11      i(@  ('OV
                             ical    Program    leaders     can     move     enei,-    @,ratecl,  the   re,,Ioii   will   be   s(@ll'-stiffl-    r(!.qlorial health
                                                                                                                                                                                                           slill)   all in relation   to    otti(@r    i-c,(,Ional
                             geticallv     into     the     negotiations     neces-    clent for most I)ui@I)os(,@,;; (2)               i-(,-    So('I('tl('S,          ('OLIII(-Il',,   local    and      li(@.iltli activities         ai-(,   also   ,ettiII(,
                             sarv   to    establish    an    al-)propriat(!    role    ',loll  slio(lici  be  sii)all   enoLi(,Ii   to   make    i-(-gloiial (,o\,@c-riiiiierital  I-)oclies,   iticlt,-   iiiidc,rNva%,. In  clarlf\,ln,u  these          i,cla-
                             for     their     programs     in     the     complex,    the      administrative      center       or       any    pendent      (@oriiinissions      and      CoLin("Ils.    tiotishll)s, it ma-,! be useful for              those
                             fast-paced     progress     that     is     oc(,urrinu    other    unique    feature    ac(@@sll)le    to    all    ;tj)cl otli(@t's. Ag2LIii, it   1)(@
                                                                                                                                                                         I             iTill)ol,t@tilt         tocl;in to @idol)t @i          broad        con-
                             in   health        care              rc,,ionalization     parts of  tli(@  t-e(,Iozi.  JZ(@c,'onal  I)ol)tila-      foi,    lzeglorial    Medical    Program    leaders       (-(,I)t  of  i-egionalizatl(-)n  in  lif-altii  af-
                             1 8







                             fairs,   specify   the   particular   activities   (8)   Building    America's    Health.    Report                           QUALITY              AND   many    misunderstandings     and     an     un-
                             which      Regional       Medical       Programs           of   the   President's   Commission   on                     AVAILABILITY                OF   certain    but    hopefully    great     future.
                             will    undertake,    become    sensitive     to           the  Health   Needs   of   the   Nation.                           HEALTH              CARE   The   zeal   and   enthusiasm   of    the    men
                                                                                        Vol.   2.   Superintendent   of    Docu-
                             the    other    major    agencies    and    pro-           ments,    U.S.    Government    Printing                FOR         HEART          DISEASE,   and       women        including        numerous
                             grams     involved      in      regionalization,           Office, Washington, D.C. 1952.                               CANCER,                STROKE,   medical     leaders-reflect     the     dramatic
                             and    ultimately     achieve     a     complete   (9) McNERNEY, W. J. and RIFDEL,  D.  C.:                                   AND             RELATEI)   appeal  that   it   has   for   many   individu-
                             pattern   varied   in   different    parts    of           Regionalization   and    Rural    Health                      DISEASES        IN        THE   als  of  good   will   and   high   hopes.   The
                             the     country     according     to     circum-           Care.  University   of   Michigan,   Ann                                             FUTURE   @,a-uely   defined   authority   of   the    act
                                                                                        Arbor, 1962.
                             stances,    in    which     Regional     Medical                                                                        AS         RELATED         TO-   seems    to    many    inadequate    to    bring
                             Programs     can     make     their      maximum                                                                                                         about    the    innovation     and     organiza-
                             contribution    to    the     improvement     of                                                                       DEVELOPMENT                  OF   tional changes they seek.
                             health   care   for,   the   American    people.                                                                                              PERSONAL      To   Battistella,'    the    act's    promise
                                                                                                                                                     HEALTH                 SERVICE   is to facilitate-
                                                 References                                                                                                                              ".   .   .   the   planning,    organization,
                             (I ) MERRILL, M. II.,  et      al.:   Amer.   J.                                                                    Dwight     L.     Wilbur,     M.D.      and    delivery    of     health     services
                                     Pul,)Iic  Health  48;   146   (February)                                                                         Palo     Alto,     California      within     a     fiinctionally-based      re-
                                     1958.                                                                                                                          President-Elect      gional    framework,    capable    of    cir-
                             (2)  BRESLOW,  L.  and   HocHSTIM,   J.:                                                                                                                    cumventing       State-local        political
                                     Sociocultural   Aspects   of    Cervical                                                             Anierican       Medical       Association      boundaries      and      orthodox      health
                                     Cytology  in  Alameda   County,   Calif.                                                                                                            channels.        Additional        excitement
                                     Pub.  H.   Rep.   79:   107   (February)
                                     1964.                                                                                              his        Conference-Workshop         pro-      centered    on    the    possibility    that,
                                  Interim   Report   on   the   Future   Pro-                                                      Tvides    an    excellent     opportunity     to      once      launched      and      successfully
                                     vision of  Medical  and   Allied   Serv-                                                                                                            demonstrated,     the     application      of
                                     ices.     Consultative   Council      on                                                      consider   the   potential   impact    of    the      regionalism    might    spread     to     en-
                                     Medical     and     Allied     Services,                                                      Regional      Medical      Programs      author-      coiyipass   a   number   of    other    prob-
                                     Ministry  of  Health  of   Great   Brit-                                                      ized   under   Public   Law   89-239   on    the
                                     ain.    London:     HMSO,     Parliament                                                                                                            lems  pressing  in  on  the  health   fielcl,
                                     Command     Paper     693,11920.                                                              development    of    personal    health    serv-      ancl   might    lead    eventually    to    a
                             (4) GART,AND,             An    Experiment    in                                                      ices.  It  is  especially  fitting  that   those
                                              J. E.:                                                                                                                                     complete     reorganization     of     health
                                     Medicine:  A  History   of   the   First                                                      most   active   in    conducting    this    com-      services."
                                     20  Years  of  the  Pratt   Clinic   and                                                      plex   and   potentially    highly    beneficial
                                     the   New   England   Center    Hospital                                                                                                         In    another    portion    of    his     recent
                                                                                                                                   activity   be   brought   together    at    this
                                     of    Boston.    Cambridge:    Riverside                                                                                                          aper, Battistella  has this       to say:
                                                                                                                                   time  to  review   planning   efforts   of   the   p  "                 1
                                     Press, 1960.                                                                                  last  2  years  and  consider   their   transla-       .  .  .  to  have  insisted  upon   a   more
                             (5)   RoSENFEi,i),   L.    S.    and    MAKOVER,                                                                                                            comprehensive     and     idealistic     vcr-
                                     H.   B.:    The    Rochester    Regional                                                      tion    into     operational     implementation.      Sion    would    have    been     politically
                                     Hospital   Council.    Harvard    Uriiv.                                                        In many  resl)e(@ts  this  act  is  quite  ex-
                                     Press  (Commonwealth  F ii ii d                                                               ti-aordinary.   Its    geiiesis    and    promo-      naive    arid    would     have     precluded
                                     C.irnl)ridge, 1956.                                                                                                                                 the  passa,e  of  any  legislation  at   all.
                             (6) ROFNIER, M. 1. and                                                                                tion  as  described  in   the   recent   article      To this %'@
                                                          MORRIS,  R.  C.:                                                                                                                          vav of  tliirikin,,,  a  slice  of
                                     Hospital   Regiorializatiori   in   Per-                                                      in  the   Atlantic   Monthly   are   ititt,igil-      pie is  better  than  no  pie  at  all.  Some
                                     spcc,tive.  Pub.  H.   Rep.   74   (10):                                                      ing,  to  say  the  least.  'I'he  diverse   in-      of   the   1)'II'S   Supporters    take    an
                                     916-922  (October)  1959.
                                                                                                                                   tei,pi,(,tations among \various  C)I)S(@t-v(@i-s      evoltitioiiarn,  point  of               arid
                             (7)  RoF,'IIER,  M.  I.:  Personal  (-Oiriiiiii-
                                     rii(,atiori.                                                                                  of  its  loll"-t(,I-Ill  objectives  @ll'),,Ycst      sit ....  est  that  a  (combination  of  es-











                          calating   problems   in    the    delivery                                                                                                     in  the   qualit@@   of   diagnostic   and
                          of  health  services  and   rising   expec-                                                                                                     treatment   capabilities   available    to
                          tations   for   better   and   more    eco-                                                                                                     different   patients   within   this   Na-
                          nomical   care,   will   inevitably   trig-                                                                                                     tion,  in  the  area  of  heart   disease,
                          ger   an   expansion   of   the    program.                                                                                                     cancer-,  stroke,  and  related  diseases,
                          Eventually,    they    see    the     seeds                                                                                                         (2)   That   tlaroucli   the    mecha-
                          planted    by    the     Heart     Disease,                                                                                                     nism   of   re-Iona]    cooperative    ar-
                          Cancer   and   Stroke   Act   leading    to                                                                                                     raiigenierits  of  the  people,  liastitu-
                          a   complete    reorganization    of    all                                                                                                     tions,    organizations    and    agencies
                          health   services   ,vithin    a    reional                                                                                                     iii\,olv(-d in li(@altli in  that  re(,ion
                          framework."                                                                                                                                     these  differences   can   be   lessened."
                          The   article   by   Clark'    also    pro-                                                                                                     According   to   Maver,    this    program
                       poses   a   national   blueprint   and    sug-                                                                                                  is designed  to   strengthen   existing   in-
                       gests   various   models   Nvhlch   might   be                                                                                                  stltiitions  rather  than   to   create   new
                       follo,A,ccl in estaljllsliiii(,  this  nation-                                                                                                  ones. Ile stresses the point  that  tfils  is
                       ivide    program.    Any    impartial     phy-                                                                                                  not  a  national  pro-ram  but   a   regional
                       sician   @vho   studied   the    Clark-Battis-                                                                                                  one,   and   he   underscores    that    word
                       tella   thesis,   as   presented   in    their                                                                                                  "cooperative."   He   points   out    further
                       papers,    would    reach    the    conclusion                                                                                                  that-
                       that   RMP   was   in   fact    designed    to                                                                                                            it   is   important    to    under-
                       provide   an   instrument   by    which    the                                                                                                     stand   that    the    Regional    Medical
                       organization   and    delivery    of    health                                                                                                     Proorams   are    not    simply    another
                       care  of  the   American   people   could   be                                                                                                     kind   of   mechanism   of   funding   in-
                       changed    in    a    revolutionary    manner.                                                                                                     dividual  projects.  It   does   represent
                          These  articles  are   well   written   and                                                                                                     a  new  kind   of   conceptualization   in
                       have     the     commendable      characteris-                                                                                                     the   approach   to   health   care    and
                       tics    of    unequivocation    and    candor.                                                                                                     education.  Whether  it  is   capable   of
                       Although    one    might     disagree     with                                                                                                     serving this function  onl@,  tir-ne  will
                       the    conclusions,    one    cannot    impugn                                                                                                     tell."
                       the  authors'  motivations.   The   fact   re-                                                                                                     I  applaud  this   point   of   view   and
                       mains,   however,   that   the    issues    as                                                                                                  the  emphasis  -iven  to  these  aspects   of
                       presented   by   this   school   of    thought                                         DR. WILBUR                                               the  program   bv   the   division   of   Re-
                       are   not   designed   to   stimulate   strong                                                                                                  alonal  Medical   Programs.   If   the   pro-
                       physician   support   of    these    programs.  mate   which    engenders    voluntary    co-  on local  initiative,  flexibility,  and  de-    ffram in fact is  clearlv  one  clesianed  to
                          Dr.  Marston  and   his   staff,   on   the  operative  action  to  improve   the   health  (@isionrnakin,'@;  and  the  reason  for  the    catalyze and  to  facilitate  the  dc@@elol)-
                       other   hand,   and   manv    of    vou    who  care   organizational   patterns   and    de-  pro,ram   is   the   relationship    bet@veen    ment   of   better    programs    that    now
                       are    active    in    the    proaram,    have  livery   systems   which   currently   exist.  science and service."                            exist to serve Patients  and  tl-ieir  phvsi-
                       sought   through    talks,    articles,    and  As Marston  has  so  \vell  expressed  it  in     The  tivo   key   assumptions   On   which    cians,  it  will  undoubtedly  receive   ell-
                       actions   to   promote   a   different   basic  several   addresses:   "The   focus   is   on  the   purposes   Of   Public    Law    89-239    tliuslastic  cooperation   from   the   medi-
                       concept  of  the   program,   that   is,   the  the  patient;  the  inechaniSTYI   is   coop-  rest, according to Mayer,' are:                  (@al profession  and  related  i-oLips.  @@7e
                       creation  of  a  local   and   regional   cli-  crative   arrangements;   the   emphasis   is        "(1    'I'liat  there  are  differences    krio@%, that  the  law  and  its  legislative

                       20











                                                                                                                                                                                     I                             1
                   histor@,  stress  the  %@oluntar@,   coopera-               rent   emphasis   on   the    working    to-               compel   changes,   some   of    which    may              cult   to   disagree   with   this   statement
                   ti%,c  nature  of  t@ie  pro,ram   and   that               gether of  regional  groups,  it  will  ful-               be   favorable    and    some    undesirable.              from   the   Report   on   Regional    Medical
                                                    .1
                   interference  ,@'ith  existing  patterns   is               fill   its   purpose   of   improving    the               RMP   is   in   a   strategic   position   to              Programs   to   The    President    and    The
                         'f'(@allv I)rohibit(@cl. As Dr.  M@ti-s-              quality, ;.L(:c(@s'bil@tv  and  availability               bring   about   changes    acceptable    both              Coti,ress ' of June 1967-
                   sl)(.,cl I
                   to., r, said in a recent talk--                             of li(@altli care, pfi),s,cian and institti-               to    physicians    and    their     patients                           every  persoi-i  whose   life   and
                          "'I'li(,se  i-)rograrris   face   the   cli,,tl-     tic)nal        performance,        and         consumer    that      will      improve       performance       and       well-being    may    be     in     'eopardy
                                                                                                                                                                                                                                               i
                      lenge    of    influencing    the     quality     of     satisfaction.     On     the     other     hand,     if    patient       satisfaction        without        under-       from     one     of     these     diseases     should
                      @icalth      services       without       exercising     RMP     becomes     an     instrument      for      the    mining    patterns     of     behavior     that     are       have     the     full     strength      of      modem
                      Federal     or     State      governmental      con-     establishment       of        national        standards    traditional,       and,        more        significant,
                                                                                                                                                                                  I    I                medical      science      available      to       him
                      trol    over    current    patterns    of     health     with      the      coercive      compliance       corn-    considered      by      the       medical       profes-       through     the      cooperative      efforts      of
                                                                                                                                                                                                        the      medical      and      related      resources
                      a(@tivities."                                            pellcd     by     such     standards,      it      will    sion    essential    to     the     preservation     of
                                                                                                      ldc       resistance        from    high cluality care.
                      Public    statements    of    tills    tyl)(@    are     arouse   nationw                                                                                                         of    the    region    in     which     he     lives.
                                                                                        'tris,                                               'Fll(,,   sensitivity    of    medicine    to    the       These    are    the    goals    to     Nvhlch     Re-
                   (@ri(@ouraging                    of tl  I(!                I)hysi(@i,        institutions,       and        allied
                   standing   by   those    r(@sl)onsibl(.,    for    cli-     @icaltfi      professionals.      What      can      be    possible        establishment        of        national       -ional       Medical          Programs            are
                                                                               gained      by      cooperation      and       meaning-    standards     under     RMP     for     the      treat-       dedicated."
                   recting     this     program      of      the      pro-
                   founcilv     complex      problems      and      social     ful   participation   will   surely    be    lost    if    ment     of     certain     diseases     was     demon-       This      utopian      ideal,      however,      will
                   and           coiiimunltv            interrelationships     the    use    of    coercive    power,    @vhich    for    strated    recently    when    it     appeared     that    be    realized    in     varying     degrees     depend-
                   that     confront      al,I  those  who              be     the     moment     lies     dormant      in      Public    IZMP     might     be      moving      toward      such    ing   on   the   ability    of    the    medical    pro-
                   participating.      The       innate       difficulties     Law      89-239,      becoi-nes      its       dominant    a     development.     I     have     been      assured    fession     and     the     health     care     industry
                   of     achieving     a      consensus      among      a     characteristic.                                            by    Dr.    Marston    that    no    proposals     for    to     make     available     such     services      and
                   large    number    of    disparate     local     acfen-       I    have    dwelt    on    these    basic     issues    such        national        standardization        have    facilities,    and    upon     the     patient     popu-
                   cies,   all    traditionally    striving    to    main-     at     some     length     because      one      cannot    received     any      sympathetic      hearing      and    lat'on   to    utilize    resources    as    they    be-
                   tain      their      independence      and      special     discuss    this    sub'ect    from     the     perspec-    that,   on   the   contrary,   it   is   his    feeling    come available.
                                                                                                                                                                                                        I    am    deeply    impressed    by     a     recent
                   prerogatives,      arc       well       known.              tive    of    personal    health     services     with-    that     such     proposals     run     counter      to
                                                                               out    first    considering    the     basic     issues    the    spirit    of    the    legislation    and    the    article     by     Lahav     '     on      "Methodologic
                      Rational        decisionrnaking         i)y  ind(@.-     .
                                                      ivatc  (@n ' '           I                                                                      I        I     I   I                           Problems       in       Health       Manpower        Re-
                   pendent  public  and  pr'                      t t  ('s     nvolved    in    the    dcvclol)i@iietit     of     the    in@triner   in    which    it    is    being    adinin-
                                       I                            i i ,                                                                                                                                           I
                                                                               f)rogram
                   on    a     voluntary     basis,     hoA,ever, is    an                  as a whole.  Change              is    ex-    'stered.   I     applaud     this     attitude,     and    search."      His      observations      are       espe-
                   objective    that    is    worth     pursuing.     -Un-     Pected by the vast majority of                   think-    I  urge    that   it   become    a    part    of    the    cially     gen-nane     as     you     develop     meth-
                   like     many     other     countries,     our      Na-     ing    persons-,    and     the     medical     profes-    fabric    of    your    thinking    as     you     con-    odology       for        effective        implementation
                   tion     has     reached     its     preeminence     in     s on, like others,      is    changing    its     tech-    duct these regional programs.                              of   this   law.   He    identifies    some    of    the
                   many areas of activity because               of   tll-s     niclues     and      operational      I)ro(-.(!cl@ir(,s       Another      aspect      of      the       currently    countless      variables      that      make      health
                   unique     combination      of      multiple      inde-     constantly.       Sometimes        these        changes    evolving      RMP      program      that       deserves    economic      research      so       difficult       and
                   pendent    focal     points     of     activity     co-     are     forced      by      external      environmental    commendation     is     its     scientific      spirit-    facile        conclusions        and         recommenda-
                   operating     on     a     voluntary      basis      to     factors     which     lead     to     improved     pre-    that   is,   its    willingness    to    depend    upon    tions    so    perilous.    He    notes,     for     ex-
                                                                               v(,ntion,      diagnosis,      and      therapy      of    observation       and        experimentation        be-    ample,         that         Government         sponsored
                   achi(n,c    a     commonly     desired     goal.     De
                                      identified       this       Liniclue     (liscas(!.   At   other   tliTies,    (lian,@es    are,    forc      reaching      firm      conclusions.      The    I)ro,rams     can     contribute     to      a      more
                   American      ability      to       become       as'so-     forced      which       are       unacceptable       to    danger      of       national       blueprints       or    rational      distribution      of      medical      and
                                                                                                                                          i-nodels     is     their     usual      inflexibility.    other    health    facilities     but     that     their
                   elated    %@@lt@i    others    to    plan    and    op-     physicians      and      their      patients.       The
                   crate     programs     in      the      absence      of     current        health        manpower         shortages    Your    objectives    arc    laudable,     and     they    ability    to    effect    a     comparably     rational
                   cc,@i-itral      ,o%,ernmental      direction       and     and    escalating     health     care     costs     are    require        implementation        which         per-    distribution      of      health      personnel       is
                   control.    If    l@MP    riiaintains     its     (@ur-     examples      of      external      pressures      that    i-nits   ready   change.    It    would    be    diffi-    relatively   small    because,    in    a    free    so-

                                                                                                                                                                                                                                                           21











                                     ciety,  distribution   of   professional                      placement in  an  efficient,  rationally                     Continuin,   education.   The   problems                      recent   Presidential   Commission    on
                                     manpower  is   predominantly   a   func-                      organized,   and    economically    con-                     of medical care and  contini-ting  medi-                      Health --%Ianpo@,,,er on @vhicia  I  had
                                     tion of personal decisions made  by  in-                      ducted   system   may   be   even   more                     cal education are inseparable. In  fact,                      the                 of serving. You                    re-
                                     dividual practitioners.                                       important.                                                   continuing        medical         education         offers    call    that    one    of    its    rather    contro-,,Cr-
                                         In      discussing      rural      health      centers        In    this    connection,    the    recent     (,,om-    the     greitest     potential     for     rapid     wide-    ,ial     recommendations     ,@@as     tl@i,-tt      rell-
                                     in      rural       northern       Michigan,       -,where    ments      by      I-)r.      Marston'      when       he    sl)i-(@ad    Solution    of    the    identified    pi-ob-    censtire      of      physicians       be       considered
                                     McNerney      and      Riedel      '      found       that    talked   to    a    group    in    Illinois    are    es-    leiiis   or   difficulties    in    the    eneral    at-ea    as     one     means     of     stimlilatin-,     pli@@si-
                                     their     producti%@ltv     was     lo@v     in      terms    peciallv appropriate-                                        of    patient    care.    In    the     planniri",     and    cians to continuousl@- to re%@'
                                                                                                             I                                                                                                                                                            ic@v       new
                                     of   unit    cost    and    that    they    had    cliffi-           "As    one    views     the     current     health    early      operational       IZMP       programs,       it    information,       l@'hate,,@er        technique        is
                                                                                                                 i
                                     culties    in    attractiii,,     and     iiiaint@iiiiinc,        scene,    L     seems     inevitable     that,     as    plays t iiitiot- i-ol(.@,.             AMA        is          used    to    assure     a     I)Ii@s'c',Ln's     Lil)-to-
                                     qualified       professional        and        administra-        an    increasing    proportion     of     our     na-    1)cciallv    anxious    that     this     asl)e.(@t     of    dateiiess,     the     I)ro%Fis'oii     of     continitin,
                                     tive     personnel,     Laliav     noted     that      the        tional    wealth     is     devoted     to     health    the     evolvin,,     program     1)(.,     emf)liaslzccl.    education      throti,li      tli(,      cle@-elol)ln(--nt
                                     difficulties    in    this     situation     could     not        and     as     the     expectation     for     health    Marston and Mayer,!' in                their       article    of  core  curricula           and       other        tech-
                                     be      modified       easily       under       conditions        services    continues    to    rise,    there    will    on        "The        Interdependence        of        Re-    niques,     and     the     utilization     of      corti-
                                     of         "nonsocialized         medicine"          where        be     marked     pressures     for     the      most    gloiial       Medical       Programs       and        Con-    inunications        technology        now         i-apidIN
                                     practicing       physicians       had       a        large        cfTective     allocation      of      health      rc-    tinuing Education," in(licat(,-                               becomin-      available,       must       be       pursued
                                     measure       of       independence.       The        keen        sources.     These     pressures      will      exert            "The      following      two      points      con-    Vigorously.
                                     observation         that         decisionmaking         on        influ(!nccs    in    such    critical    areas     as        cerning      the      development      of      contin-          The      RMP      program       has       stimulated
                                     a    voluntary     basis     may     tend     to     frus-        the      distribution      of      resources      be-        uing      education      activities      within      a    widely       favorable       reaction       from       the
                                     trate      the      impatient      administrator      with        tween     short     and     long     goals,      that        given         Re-ional         Medical         Program    medical     profession.     As      a      whole,      the
                                                                                                                                                                                                                                                                                  innina
                                     limited      authority      clearly       applies       to        s,        between        biomedical         research,        are    of     prime     importance.     First,     the    Iiiedical  profession  at the be@,'                 '   "I
                                     RMP.     I     urge     a     frank     discussion      of        for    example,     and     the     immediate     de-        Division      of      Re,ional      Medical       Pro-    of     the     year     1968     is     prol)abl@     more
                                     this     question     and     your      resolution      of        livcry    of    service.    Within    service     it-        grams    can    make    grants    for    two    I)iir-    deeply     involved     in     the     plannin-      proc-
                                                         I                                                                                                                                                                          to   determine    the    natu,re    of    the    Re-
                                     the     problem     in     favor      of      voluntarism,        self,   there   will    be    pressures    for    the        poses    only    (a)    to    plan    or    (1))    to    css
                                     for    the    gains    that    you    will     make     in        distribi-ition     of     effort     between      im-        establish        Rc,ional         Medical         Pro-    c,loiial    -.%Iedical    Pro@rams     than     it     has
                                     terms    of     flexibility     and     physician     sup-        I)rovements    in    cluality    on     -th(,     one        grams.     It     cannot     riiakc     grants     for    been  in  the  plannin, of any
                                     port     will     far     more     than     offset     any        hand    and    cxt(!nsion,,    of     t(-c(@ss     to        the   estal)]iS]IITI('Ilt    of    continuing    (,cl-    Oil-"  l,'ecleral  T)roaram.  %fan@,           of     our,
                                     losses you may incur.                                             licalt@i  care   on   the   c)tl)er;   tli(@   @illo-        ti(,,atiori i)ro,,rirns."                                 most  (listin,rUiSll(@(I  nl(@CI'C.@               leaders
                                        Another       important       point       made       by        cation    of    resources    for     general     pur-        Understandin,r        the        preclusion         of    are participating full           oi-  part-time         in
                                                                                                                                                                                                                              the Re-ional Prc),rams.
                                     Lahav    is    his     emphasis     on     the     coordi-        poses     as     opposed     to     targetive     ob-    support      of      re-loiial      continuin-       edii-                              z:l
                                     nation     of     scarce     resources     rather     than                                                                                      n                         "I                   Many      State      and      cotintn,       medical
                                     the   mere    creation    of    ne@v    ones.    It    may        je(,,tivcs;      exploration      of       mechanisms    cation     prograi-ns     alone,     we     hope      that          .ties     are      cooperating      aIctively        or
                                                                                                       to    alleviate    the     actite     shortage     of    special   ei-npliasis    will    be    given    to    this    'Ocl
                                     well   be,   as   we    strive    touether    to    create                                                                                                                               in    an    advisory    capacit@,     and     have     ex-
                                                                                                       all    health    talent;    and    the    need     to    aspect     of     a     re-ional     prorari-i,      since
                                     the     best     possible     health      care      system        explore     the     division      of      resl)oiisi-    to   a    sl,,,tilficant    de(rrce    the    (,ap    that    pressed        their         enthusiastic         support.
                                     for   our   nation,   that   the   (@ml)liasis    is    of        billtv    bet%@,ecii    those    health     rcsl)oii-    may    exist    between     sciences     and     se,-%.,cc    Dr.     (;Lillatt,,"'     for     example,     in      the
                                     RMP         on         cooperation,          coordination,        sibiliti(@s     carried     out      through      the    can     be     minimized      by      such      continuing    Oklahoma       State       infeclical        .,Association
                                     and     regional     plannin,,     will      turn      out        (rovei,nrnental     sector      and      the      re-    education.      Incidentally,      this      I-)i-ol)lciii    Jour?zal for @kpril 196/@ said:
                                     to    be     far     more     productive     than     pro-        sponsibilities     of     the      voluntary      in-    of   (,ontitit,iiii,,,   the   education    of    I)IINs'-           "The        Re-lonal        -.%Ied'cal         Pro-
                                     urams     dc@sineci     simply     to     increase     the        stitutions and organizations."                           cian,s     and      otliei-      health      professionals          (@raiii    has    the    potential    of     inakin@
                                     output      of      health       professionals.       Cer-        I   N@,ayit   now   to   turn   to    another    sub-    in     a     rapidly     chairman     scientific      cli-          remarkable        impingements        in         the
                                               tli(- litter  is  ii(,(,(,ssai,y@  but  tll(-]I-    i(@('t  of                          to                                                        ;It           I)%,  ti)(@          (,otitirilliti",                   of






              cians,    an    objective    to    which     we          "There  is   no   question   of   the   pro-   existing   facilities;    rural    medical    man-    conservative    also    can    feel     reasonably
              @ia-,@e   al@@!avs   been    dedicated."             fcssion's   ability   to   do   the   job.   The   power   is    under    study;    a    number    of    comfortable  in   the   context   of   this   pro-
              North    Carolina    prepared     a     special      important  step   is   to   direct   our   total   hospitals    have     opened     their     records    gram  because   it   is   not   intended   to   be
           issue    "    devoted    to     RMP     in     May      talent   and   energy   to    it.    The    'ob-   for   review   of   current   handling   of    pa-    a   rcvolutionar),    substitute    or    a    na-
                                                                                                          i
           1967.  In  an  editorial  in   that   issue,   the      @vell    done-will    reassert    and     secure   tients   with   heart   disease,    stroke,    and    tional    blueprint    for    existing    patterns
           following comment is made:                              our   leadership   in   health    affairs    and   cancer;      communications       among       hos-    of behavior.
                 "In   the   months    and    years    ahead,      assure    an    ever    improving    state    of   I)Itals   within   a   region   are   being    ap-      Rather,   it   builds   upon   the   past    and
              these    early    times    of    the    program      national health."                                  praised;     interconnecting      color      tele-    the     present,     adding     new      features,
                'II   no   doubt   be   re(,arded   as    the      In    Georgia,    Dr.    Battey,"     a     mem-   vision   among   these    hospitals    is    being    changing    old    ones,    as    local    demands
              Nvi
              critical   period,   @vhen   the    shape    of   her   of   the   steering   committee    for    the   considered,   as   well   as    the    educational    and   resources   make   possible.    Its    flex-
              things     to     come     became     apparent.   pro,ram, said:                                        television      network;      the      transporta-    ibility,     pragmatism,      and      acknowledg-
              Thus   far    the    \Icdical    Societv    has               it   is   the   intent   and    sincere   tion   of   laboratory   specimens   to    central    ment    of    regional    variations,     particu-
              pla@@cd    a    creative    role     and,   our      desire     of     the     members     of     the   areas  is  under   study;   the   use   of   heli-    larly   appeal   to   me   as    wise    emphases.
                                                                   Georgia       Regional       Medical        Pro-   col)tcrs  for   transport   of   the   sick   and,      This   program   can   make    a    real    con-
              State's    progrwn    is    out    ahead     of      gram    advisory    group    that    this    ap-   perhaps,    physicians,    is    a    possibility,    tribution    to    personal    health     services
              inanv   others   because    of    this    atti-
                                                                   proach,    during    the     planning     phase,   and    an    extensive    library    project    is    if   it   continues   to   pursue   what   appears
              tude.  'I'lic  only  scrisible  course  is   to      will   seek   out    and    find    those    in-   already     underway.     The     strong      sup-    to   be   its   main   thrust    today-to    serve
              continue    to    act     intelligently     and      tcrested    individuals     all     over     the   port   of   the   County   Medical   Society    is    as  a  catalyst  for  and  to   facilitate   those
              coilstructi@rcly."                                   State   who   will   be    anxious    to    take   implicit.   This   same   attitude    of    study,    winds   of   change    Arhich    blow    in    the
              Dr.   Frank,   jones,'2   the   president    of      part  in  what  ii:iay  Nvell  be   our   great-   inquiry,      and      active       implementation    right   direction.   If   your   zeal   and    en-
           the   Medical   Society   of    the    State    of      est   opportunity   to    achieve    the    best   exists    in    many    other    medical    groups    thusiasm    are    tempered    with     a     sym-
           North Carolina at that time, said:                      of    medical    care    for    all     patients   in the country-                                       pathetic    understanding    of     the     tradi-
              cl,   .   .   the   medical   society    repre-      utilizing   the   regional   and    the    truly      Clearly,     RMP     has      stimulated      a    tions   and    basic    motivations    of    those
                                                                                                                      healthy    atmosphere     of     voluntary     co-
              s(-,nting    the    physicians     of     North      cooperative approach."                                                                                   who   now   render    health    care,    I    pre-
              Carolina    is    involved    in    the     Re-      In    Missouri,    a    physician    who    ini-   operative     review     of     current     health    dict   that   they   @vill   cooperate   willingly
                                                                                                                                                                                                                         p
              gional     Medical     Program.     It      was   tially     had     serious     misgivings     about   i-)rograms    and    a    refreshing     @villing-    with   you,   and   that   in   this   cooperation
                                                                this    pro-ram     is     now     conducting     a   ness  to  express   self-criticism   of   a   con-    you   will   have   the   basic   ingredient   for
              involved     in     a     somewhat      similar              @D
                                                                valuable   regional    pro'ect    on    the    man-   structive  type.   In   a   sense,   the   program    success.    Basically,    we    all    have    the
              pI-<)C,rarn   before   Heart,    Stroke,    and                               i
                                                                agement       of        cardiac        emergencies.   combines    the    better    features    of    the    same    desire:    To    help     the     American
              Cancer    was    birtlied,    and    it    will   Under     his     direction,     certain      defi-   liberal      and      conservative      approaches    physician   to   provide    the    best    quality
              continue    to     be     involved,     working
                                                                clencics     have     been      identified      and   to   a   creative   society.    The    traditional    of  care  to   the   American   people,   in   the
              @vit@i   the    i-cl)r(!sentatives    of    the   many     individuals     and     facilities     are   liberal     dependence     on     the      Federal    American tradition.
              public   and   the    other    deliverers    of   cooperating      enthusiastically      to      rem-   Governi-nent   as   a   means   of   solving   all
              health   care   and    the    involved    State   c@y these deficiencies.                               problems    is    mitigated     and     redirected                     References
                                                                   I am imf)ressed also by                   I        into   a   new   type   of   program    sponsored,     (I)    BATTISTELLA,    R.    M.:    The    Course
              governmental     agencies     in     a     con-                                       an   art    cle   .
                                                                                                                                                                                     of   Regional   Health   Planning:    Re-
              tiniiing    f)i-o@,r@im     directed     toward   'In tli(,  Oiiozi(i@t,,a  (county  M(,(Il(,@il  So-   it is       by tli(!               Govei-tini(-t)t             view   and   Assessincnt    of    Receiit
              (ILialit), care at all levels."                                                N(.,.@N,   York    rc-   ]-)Lit   emphasizing   the   use   of   local   as             Federal    Legislation.    Aled.     Care
              In the sairic
                              .Tournal,    Dr.     Musser,':'   (OL]ntliig   tli(@   specific    I)ro'ccts    being   x%,(,Il  as  Federal  funds  and   dcl)e   d   iig             5: 149-161 (May-June) 1967.
           execut'v(@    director    of    the    association   (-ons'(Ierc-(l      under      their       l@a'onal   upon      local      regional       decis'onmaking     (2)   CLARX,   H.   T.,   Jr.:   The    Challenge
                                                                                                                                                                                     of    the    Regional    Medical     Pro-
           established    to    conduct     this     program,   Medical    Programs.     All     available     rec-   and    si(,nificaiit    participation    by    the                     Legislation.   1.   Med.    Educ.
                                                                                                                              0                                                      grams
           said:                                                oi-cls   are    being    analyzed    to    evaluate   private      nongovernmental      sector.      The             41: 344-361  (April)  1966.

                       @114 0                                                                                                                                                                                               23


                                                                                                                                                                  ------- - --









                                     (3)    MAYER,     W.     D.:     Regional     Medical    (10)    GULLATT,    E.    M.:    President's     Page.                               QUALITY                  AND   cellence   for   the   last   8   or   9    years.    I
                                              Programs-A         Progress          Report.               J.    of    Okla,    State    Med.    Assn.                         AVAILABILITY                    OF   do    not    @vant    to     lessen     m@@     feeling
                                              J.   of   Med.   Assn.   of   Georgia    56:               (April)  1967.                                                            HEALTH                  CARE   about      excellence       or       an-,,bodv      the
                                              143-147     (April)     1967.     (Presented    (11)   N.   Carolina   Med.   J.   Vol.    28    (May)
                                              at    the    Second    Georgia    Conference               1967.                                                        FOR            HEART             DISEASE,   impression I am not in favor of                     ex-
                                              on    Medical     Education,     Mar.     4,    (12)   JONES,   F.    W.:    The    Medical    Society                        CANCER,                     STROKE,   cellence  as fai- as  @ve can brina                 ex-
                                              1967,      Callaway      Gardens,       Pine               and    the    Regional     Medical     Pro-                               AND                  RELATED   cellence,    but    Nve    need     to     think     of
                                              Mountain, Ga.)                                             gram   in   North   Carolina.   N.    Caro-                         DISEASES         IN         TITI',   avi'labil'ty    from    the    point    of     %,I(I%@,
                                     (4)    MARSTON,    R.    (2.     and     ScirNtir),r,               lin(i   Me(l.   J.   28:   17'3-175   (May)                                          F U'I'U I-'  ,  E   that  excellence  is   fine,   but   if   it   is   not
                                              A.     M.:     Regional     Medical     Pro-               1967.
                                              grams:   A    View    from    the    Federal                                                                                  AS           RELATED            TO-   available    it    really    isn't     verv     helpful
                                                                                              (113)    MUSSER,     M.     J.:     North     Carolina
                                              Level.    (An    address    delivered     to               Regional      Medical      Program.      N.                        THE                      POPULATION   to any particular patient.
                                              the     Continuing      @Medical      Educa-               Carolina    Med.     J.     28:     176-182                                                                 And   I    thought    I    would    go    back    to
                                              tion   Section   of   the   Association   of               (May) 1967.                                                                                              an   experience    I    had    in    the    war.    Mr.
                                              American     Medical     Colleges,      Fri-
                                              day, Oct. 27, 1967.)                                   BATTEY     L.     L.:     Georgia      Regional                                                     Panel:   (Stephen)       Ackerman       told       me       this
                                                                                                         Medical     Program.     J.     of     Med.                                                                                           d
                                     (5)   Report   on   Regional    Programs    to    the               Assn.    of     Georgia     56:     141-142                    Roger      0.       Egebe@g,       M.D.   mornlna     that     I      ha    sed     this     once
                                              President    and    the    Congress.    Sub-               (April) 1967.                                                                               (Chairman)   before,   but   I   hope    it    was    a    different
                                              mitted    by     William     H.     Stewart,                                                                            Dean,      School       of       Medicine   "roup    or    smaller    group,    because    as     I
                                              M.D.,      Surgeon      General,      Public
                                              Health    Service,     U.S.     Dept.     of                                                                 U?zz'vcrsz'ty      of      Southern       California   came    cast    on    the    plane     vesterdaN7     I
                                              Health,     Education,     and      Welfare.                                                                                       Los       Aneles,       Calif.   thou-ht,   "There    is    the    basis    of    N@@@at
                                              U.S.     Government     Printing      Office                                                                                                                        I -,vant to say."
                                              (June)  1967.                                                                                                                Ray      E.      Trussell,      M.D.      I    was    at    Western     Reserve     at     the
                                     (6)     LAHAV,     E.:     Methodologic      Problems                                                                Director,      School      of      Public      Health   beginnin-    of    the    war    and    helped     form
                                              in      Health      Manpower       Research.                                                                       and          Administrative           Medicine
                                              The   New   Eng.    J.    of    Med.    277:                                                                                                                        the    fourth    general    hospital     there:     and
                                                                                                                                                                              Columbia               Universitv
                                              959-962  (November)  1967.                                                                                                                                          we      were      commissioned.       The       iinmar-
                                     (7) MeNFRNrY, W. J. and RIFDFL,  D.                                                                                                            New       York,        N.i.   ried      men      became      lieutenants,       those
                                              C.:      Regionalization      and      Rural                                                                                 Frank      P.      Lloyd,       M.D.   who      were      married       became       captains,
                                              Health    Care:     An     experiment     in
                                              three      communities.      Ann      Arbor,                                                                          Director,         Medical          Research   and   if 'vou    had    a     number     of     children
                                              Mich.:   Univ.   of    i%licliigan    Press,                                                                                      Methodist              Hospital   You   might     make     major.     Well,     I     had
                                              1962, p. 175.                                                                                                                       Indianapolis,            Ind.   four    children    so    I     became     a     major,
                                     (8)    MARSTON,     R.     Q.     University     Hour                                                                                                                        and   that   Nvas   the   way   it    was    done    in
                                              sponsored       by        Alpha        Omega                                                                                  Amos         Johnson,          M.D.   that   outfit;   possibly    for    the    same    rea-
                                              Alpha,     University      of      Illinois,                                                                                             Garland,            N.C.   son,  I   was    the    assistant    chief    of    the
                                              Oct. 4,  1967, unpublished.                                                                                                                                         medical service.
                                     (9) MARSTON, R. Q.  and  MAYER,  W.
                                              D.:    The    Interdependence     of     Re-                                                                                                                          This    @vas    a    talented    group,    as     the
                                              gional      Medical       Programs       and                                                            This       transcript       has       been       reviewed   encral     hospitals     affiliated     -,vith     uni-
                                              Continuing     Education.      J.      Afed.                                                            and       approved       by       the       participating   versities   were,    in    the    sense    that    they
                                              Fduc.      42:      119-125       (February)                                                                                                                        had    assistant    and     associate     and     other
                                              1967.    (Presented    to    the     Section                                                                                                                        professors     and     clinical      professors      in
                                              on     Continuing     Medical     F,(Iti(:a-                                                                   R.    Ecl--BF.RC.    Noxv,    we     are     talk-   the    various     specialties.     There     was     a
                                              tion   at   the    77th    Annual    Meeting
                                                                                                                                                      D     iTig     about     excellence     or      qLialit@,   talent   in    deptfi    here.
                                              of    the    Association     of     American
                                              Nfedical C(,Il(@                                                                                        and Lvailahilit@, of                                  And        We             in  Mi,ll)ot.ii-ti(,   @tiici   set
                                                                     San  Fi-;tTi(-is(!(,,                                                                                                                                     I      I
                                              Oc@t. 21, 1966.)                                                                                        1  lia\,e  I)e(@ii  I)eatliig  the  (]rLIT11S   for   ex-   Lil). Soozi I \@'as @isst,,,ii(-cl  to  tli(@  Iol)  of

                                  2.@t






                 setting    ul)    a    venereal    disease     hospital    they   should   do    the    best    they    can    with    corner."    And    a    little    further     question-    patients,    or    of    them    to    care,     becomes
                 because    that    seemed    a    little    more    im-    the     work     that     comes     to     them.     And    ing   showed    the    slab    was    to    lay    them    a   vital    part    of    any    pro,-ram    that    is
                 portant     than     a     general     hospital      at    now,     with     the     advances      in      medicine    on   while   they   are    waiting    for    the    am-    going     to     succeed      in      this      Regional
                 that   f)olnt   in    our    flistory.    But,    after    that   have   occurred    in    the    past    two    or                or    the     licai'se.     And     further    Nledical Program.
                 a   while,   I   managed    to    feel    that    there    three      cle(@ad(,s,      it      perhaps      becomes    questions     brought     Out     that     this     was       'Flie  transportation  of             care,       the
                                                                                                                                                                                                               1  @
                 @,vas  i,ornari(@(@  in  New   (;uiri(@a   or   sortie-    necessary     fc)r     some      representatives      of    tli(-    concept    tti(-y     had     of     medicine.    availability  of care, is        just    as     inil)or-
                 I)rjdv    needed    me    there    and    I     managed    those   doctors    to    go    out    and    seek    the    And   I   am    sui-c    this    applies    in    large    tant  as  the  excellence  of            care.        We
                     I
                 to    et    there.    It     was     the     experience    work for themselves or for others.                          areas    of    our    country    to    certain    parts    must think of these thin,s               as   a    coor-
                     9                                                                                                                                                                                                                 0
                 1    had    in    Ne%v     Guinea-the     fact     that       There    are    30    million    people    in     the    of our Population.                                         dinated    plan    where    we    use,    insofar     as
                 I    got    through    it-that    has     driven     me    United     States     who     hardly      know      what      Now,   to   take    Los    Angeles    as    an    ex-    Nve    can,    the    people     who     are     already
                 into   the   things   I   am   interested   in    no@v.    medical   care   is.    As    some    of    you    know,    ample    again,    I    have    long     been     asso-    working    in    the    areas,    and     bring     peo-
                   In    the    front    lines    one     could     find    -,N!(-   have   started   a   project   in   the   Watts    (,rated     with     the     Los     Angeles     County    ple    into    those    areas    @vhere    they     have
                 'L    lieutenant    who     had     recently     gradu-    area   of   Los   Angeles,   and    @v(-    are    work-                                                ,It    ilos
                    I                                                                                                                   I-losl)lt@il, which is .11, ex(-,cll(.                     not     chosen      to      work      because      there
                 ated   or.   if   one   were   visitin,,    the    Aus-    iiig   with   a   group   of    people    there    hol)-    1)ltal.    And    for    those    who    are    acutely    wasn't    much    reward    of     the     kind     they
                 trallans,   a sergeant who did           not       have    ing   that   we    can    turn    the    project    over    ill  and  for   those   less   ill   it   -ives   very,    really had to have.
                 a    medical     education     except     as     taught    to them when it gets going well.                            very    good    care.    But    it    is    about    13       So   just   to    begin,    I    Nvould    like    to
                 by    the    doctors,    but     who     was     avail-       When    we    first    got     this     group     to-    miles   from   Watts.    And    it    is    13    miles    make     'the   plea    that    availability    in    our
                 able    to    the     people     when     they     were    gether,      we      asked      them      what      they    from    many    other    areas    of    Los     Angeles    case   s  every  bit  as  '
                                                                                                                                                                                                            I               1         important          as
                 %%,ounded    or    when    they    were    first    ill    thought     they     needed     most      in      Watts-    where    people    also    get    sick     and     can-    excellence.
                 \@'ith    malaria    or    when    they    first    had    finally,   a    worri@iii    got    Lil)    and    said,    not     on     the      A,hole      afford      private       Dr.    TRUSSELL.    I    would    like    to     talk
                 the    @)eginnin,,    of    an     emotional     break.    "@@lhat  we  need  is  a  slab  on                 every    Physicians.                                                to   the   issues   of    availability    and    qualitv
                 He was available to stem things                                                                                           I   think   we   should    picture    a    N%,omai-i    and     the     opportunities     for     and      chaf-
                                                                    Just
                 as    they    started,    and     he     handled,     I                                                                                              cas     who     has     a    lenges    to     our     RMP     from     some     urban
                                                                                                                                        in  one  of  those  ar
                 would    say,    probably    80    percent    of    the                                                                child   who   is    sick.    I    have    seen    these    experiences     which     I     have      had,      from
                 cases that came to him.                                                                                                infants     and     small     children     come      in    some       New       York       State       experiences,
                    It    was    my     considered     opinion     after                                                                moribund     who     should      have      been      in    and     from     some      frustrations      I      have
                 being  tlic@i-c   for   about   a   year   that   prob-                                                                a   couple    of    days    earlier.    Even    if    a    had      beina      a       member       of       HIBAC,
                                     cl                                                                                                                                                                                         'I     that     establishes
                 ,tblv   more   ,oo   A,as    done    in    the    thea-                                                                mother   Nvith   a   family    of    two    or    three    @%,Iilcli is the counci
                 ter   and   iriore   help   was    given    the    sol-                                                                or   six   children   knows    that    one    of    her    policy   for    medicare    subject    to    the    al)-
                 dictrs   by   t@ic   d(--,ctc)rs   or   corpsmen    who                                                                (,Iiil(.Ireti   is   sick   and   that    she    should    1)i@oval     of     the     Secretary     of     Health,
                 were    available    at    the    time     help     was                                                                take   it   to   a   physician,   a   hospital   or   a    Education, and Welfare.
                 needed    than    by    those    who     might     have                                                                clinic   it    may    be    impossible    because    of       Each         Regional         Medical         Program
                 been    better     trained     in     narrower     spe-                                                                the   distance.   For   her   13   miles    is    prob-    operates    in    a     different     climate.     There
                 cialities,    but    who    were    t@vo    or    three                                                                ably   a   greater   distance    than    50    or    60    are        different        precedents,        different
                 hospitals anvav.
                                                                                                                                        miles   is   in   a   rural   area.   She    may    not    t]-iinlas    going     on,     different     understand-
                                              problem     exists      in
                    I think the      sarri(.                                                                                            even    bay(,,    the    money     for     bus     fare    in(,@s,   different   cle,@recs    of    -,@rillingiicss
                 society    at     the     present     time.     Doctors                                                                which   1.9   almost   $2    a    round    trip.    She    to   face   ul)    to    the    realities.    And    Re-
                 %%ho   fla,,-(@   been   in    practice    have    been                                                                can't     ii-npose     on     her     neighbors     be-    (,Ional     Medical     Programs     may     be      the
                 tau,ht   foi-    -,.ears,    for    encrations,    per-                                                                cause   there   aren't    that    i-fiany    cars    in    leaders.     I     have     described     RMP     legis-
                 hal).@     siric(,     Hippocrates,     that     -:h(@v                                                                the    areas    we    are    talkin,     about.     And    lation   as    the    first    legislation    in    this
                 Shouldn't @o out and look foi-                                             DR.  EGEBER(;                               the  transportation  of            care     to     such    country    that     ever     gave     the     scientific

                                                                                                                                                                                                                                                         25




                                                                                               -          . .... @, @-- --                                                    - - -@, @   I  . --      1. - -    -










                                    community    a    chance    to    get     together   minimum.    This    is    what     medicare     is    even    more    minimum     standard.     As     a    study   made   of   what   kind   of    care    I
                                    and   tell   the    public    what    it    needed   faced    with.    Congress    enjoined    us    to    national      instrument,      medicare       con-    ivas  payln,-   for   in   %@oluntan,   hospitals
                                    and how they would like to do it.                    see  to   it   that   any   hospital   which   had    tributes    nothing    to    raising     standards    in   Ne@v   York   City.   It   that   time,    I
                                                                                               'lization    committee    and    was     ac-    of  care   in   most   hospitals   of   any   size    was    author'z'n,    about    $60     or     $70
                                       Re(rional      Medical      Proo-rams       may   a uti                                                           1                                   1                     1 1
                                    be   the   leader   and   innovator,   or    IZMP,   credited    by    the    joint    Commission    on    and    importance.    'I'here    are    absolutely    million  of  care  fol-  poor   people   in   the
                                    as  is  true  in  some   urban   areas,   has   to   Accreditation     of     Hospitals     must     be    no  controls  on   the   quality   of   the   med-    voluntary     s@Istem,     in     addition     to
                                    find  a  way  to   fit   itself   into   what   is   certified  as  a  provider,  if   it   also   com-    ical  care  or   on   the   utilization   of   the    spendin-,  a  couple  of   $100   i-nillion   ill
                                    already   (,oin-   on   in   order   to    achieve   plied   with   Title   VI.   That   is   a   mini-    care    outside    of    hospitals    except    as    the municipal system.
                                    its   ooals   and   make   the   kind   of   addi-   mum standard.                                         carriers   may   draw    attention    to    excess      @Ve   found   that   85    percent    of    the
                                    ti%,e   contribution   to    which    Dr.    Bres-      There   were   a   lot   of   hospitals   which    utilization   which,   as   a   result   of    fee    care        ,@,cre    purchasln,-    from     the
                                    lo@v    addressed    himself    so    well    this   were   not   accredited.   So    we    took    the    review,   may   appear    to    them    to    have    voluntary    s%lstem    ,@!as     in     approved
                                    morninc,                                             joint       Commission       standards,        and    o(@cLirred.                                           teacliin(,  pi-o,,rarns,  and  I  ,%@otild  skis-
                                       I   think   that   i-nany    in    this    room   modified   them   and   said   if   the   liosl)i-      So    (,a(,Ii    R(,,@iont]     Medical     pro-    f)cct  that,  as  a  national  @(,ol,c,  that  is
                                    @@IoLil(I do      to think  sci-lotisl@,  a]-)otit   tils  ''let  note  @tri(I  ]'Hill  zt  utilization    ,i,aiii ofl,(.I@s -,I iii@li-vt,lotls il)str,lllll(,rlt       (100(l. f@tit 15              of     that
                                    Dr.  l@reslo@v's   iiiessa(,c   because   it   was   coirlriilttc(,  @in(I  (Compiled   with   'I'Itl('    to ftii,tli(@r stljiitilat(, an  interest  in  and    care   was   in   hospitals   that   were    il)-
                                    the   voice   of   experience.   If    you    look   VI,  they  could  be   certified.   That   is   an    furtherance    of    standards.    It    has    an    proved   for   nothing.    The@    didn't    have
                                    at  the  studies  of  duality  of  care  in   this                                                         opf)orttinity   to   draw   on    the    I)rof(,s-    interns.   'fhev   might   lia@re   had   I-   or
                                    country-and     thev     are     time      consum-                                                         sional  talent  in  the   re,-']on   (and   there.    2-vear   approvals   in   a   couple   of    spe-
                                    in-   and    cxl-)ensive-yoti    find    a    wide                                                         is  t  lot  of  talent  in  every  part  of   this    cialties.     These      hospitals           tll(--
                                    range    of    excellence    in    care.    Almost                                                         country)     and     let     that     professional    same   hospitals   that   turn   up   in    reed'
                                    invariably,     the     highest     scores     are                                                         climate    develop    which    one    finds     in    cal  audits  with   lo@@,   scores,   in   health
                                    achieved   in    the    medical    centers    with                                                         centers    of    excellence    which    we     all    department       inspections       with       low
                                    teaching     programs     and      the      lowest                                                         strive   for   and   realize   we    will    never    scores,  in   laboratory,   testings   with   low
                                    scores    in    the    small    proprietary    and                                                         have   completely.   But   let    RMP    be    the    scores.
                                    voluntary     hospitals.     I     don't     think                                                         professional   leader   to   the    extent    that     And    so,    through    the     auspices     of
                                    there  is  any  reason   to   argue   that   there                                                         is   possible.   Let    RMP    speak    out    for    the     Interdepartmental     Health      Coi-in-
                                    are   not   differences   in   quality   of   care                                                                                                               'I,    which    %vas    started    bv     Commis-
                                                                                                                                               the person who is aett'                               cl
                                    in   a   given   City   or   in   this    country.                                                                                       ing    poor     care    ioner     Leona      Baurii(TartneIr    when    she
                                                                                                                                               and   in   favor   of    that    per-son    ettinz
                                    There   are   exceptions   to   the   rules   that                                                         better,  care.  But   this   is   voluntary,   and    was   Commissioner   of   Health   in    '.\'ei&,
                                    I  have   mentioned.   I   can   think   of   sev-                                                         it does require courage.                              @'ork   City,   we   set   up   some    standards
                                    cral   excellent   small    hospitals,    and    I                                                                                                               which  wre  a-reed  to   b-,r   all   the   citN,
                                                                                                                                                 I  would  point  Out         that     we     are
                                    can   think   of   several   poor   large   hospi-                                                                                                               a(,encics-bv   the   citN,   controller    N@,lio
                                                                                                                                               now  in  a  ri-itich  lar,r(!r  ball  -aiiie  than
                                    tals.     Nevertheless,     the     Generalization                                                                                                               disbursed
                                                                  "I                                                                           we   were   at   the   turn   of   the   centur),.               th"  money..   by   the    Board    of
                                    emerges    from    the    studies    that     have                                                         There      are      many      oi-aanized       ap-    Hospitals    Nvho    established    policv    for
                                    been done in this direction.                                                                                                                                     the     Department     of     Hospitals,,     and
                                                                                                                                               proaches   to   the   deliverv   of   care,    and
                                                                                                                                                                            I                        bv      the       Inter-Departmental       Health
                                      One    thinks    about    remedies    to     un-                                                         these      offer      excellent      opportunities    I
                                    even   quality   of    care.    One    immediately                                                                                                       I       Council. And we
                                                                                                                                               foi- dealiri@,@ with the subject of qu                                       just    set    out    some
                                                                                                                                               itv.                      1  1      1
                                    supports   Dr.   Wilbur's    view    that    there                                                             There      are      administrative       deci-    simple little Guidelines.
                                    shouldn't   be    a    national    standard    be-                                                         sions   that   can   be   made   and   have   been     First,   we   announced   @lie   @N'OLlld    not
                                    cause,   as   somebodv   pointed   out,   a    na-                                                         Iiiade in certain settinas,                           pav  for   care   in   a   @'oluiita@,   hospital
                                    tional  standard  %%'OLIICI   @iak-e   to   be   a                DR. 'I'RUSSELL                             F,  or  example,  tt  one  tiriie,   I   had   a    which    was    not    accredited.

                                    26





                  Secondly,      we      prohibited       payment    tary   hospital    codes.    For    example,    the   its   money   and   its   policy   in   that    di-   by    the    Governor,     then     approval     by
                                                                                 1                                         1                    1        1
               for  care  of   children   on   pediatric   sci-v-    code    prohibits    ina'or    surgery    by    men   rection.                                              the State Commissioner of Health.
               ices    which    were     not     approved     for    who    are    not    trained    to     do     major      And finally,      in   some   parts   of    this      Whatever       Regional       Medical       Pro-
               residency training.                                   surgery.                                              country,       i@caionwide       planning       has   -rams   is   going   to   achieve   in   the    way
                  Third,   we   required   that   adults    eith-      This    code     has     now     been      upheld   gone    far    ahead    of    this    recent    RMP   of    major    program    changes    and     facil-
               er  be   cared   for   on   a   service   approved    throu    h    the    Federal     Supreme     Court,   pro,,raxn.    In     New     York     State,     we   ity   changes    in    New    York    State    will
                                                                            9                                                  11
               for  residency   training   or   be   taken   care    thereby   determining    the    right    of    gov-   have   a   System   of    seven    councils    cov-   have    to    be    done    through    this    pre-
               of by clualified specialists.                         ernment   to   protect   all   patients   in    in-   ering   the   entire   State.    There    can    be   existing     network     of     mandatory     corn-
                  We    set    up    some     other     standards    stitutions     which     have     been     licensed   no    building,    no     modification     of     a   muiiity     planning.     By      some      people,
               t  h   r   o   u   g   h   the   Interdepartmental    rather   than   'ust   patients   who   are    paid   building,   no   establishment    of    a    build-   this   has   been   viewed   as    the    end    of
               Health    Council,     using     expert     advice    for   by    public    funds.    This    code    has   ing,    without    approval    of    this     local   voluntarism,    by     others     the     beginning
               from   outside   of   ,o@,ernment,    on    %vliat    now    been    adopted    essentially    for    all   refflonal   council    Nvhlcli    is    a    localy   of a control of       excess     costs      through
               kinds     of     services     amputees     needed.    hospitals in New York State.                          elected     rroul)      broadly      representative             ing unnecessary
                                                                          1                                                                                                      prevent                          building       and
               The   city   then   offered   all   the   institu-       We   now   have   a    code    in    New    York   of    the    community,    then    the     approval   of   rational    planning    for    health    serv-
               tions  in  the   citv   an   opportunity   to   be    State   wliic@h   affects   all    hospitals    and   of    a    State    Council    which    is    again   ices.
               certified as am    Iputee    centers.    And     14   which     establishes     a      minimum      which   broadly     representative,     but      aldpointed      Dr.   LLOYD.   Health    is    a    major    re-
               out  of  the  vast   array   of   health   facill-    is   far   bevond   the   requirements    of    the                                                         source   of   a    community    and    a    nation,
               ties   in   New   York   City    qualified.    The    joint   Commission.   In   fact,   one    of    the                                                         and    it    should    spend    its    money     to
               cltv   then   adopted   a   policy    of    paying    requirements     is     that     every     hospital                                                         protect   its   health.   I    do    not    believe
               for  services  to   ariiputees   only   in   those    must    become    accredited.    I     once     re-                                                         that     spending      monev      for      research
               14 centers.                                           (juired    every    proprietary     hospital     in                                                         and       continuing       education        compro-
                  With  the  help  of  a   groLil)   of   outside    New    York    City    to    become     accredited,                                                         inises  the   delivery   of   health   care   serv-
               experts,   11    nongovernmental    @%,Itfi    the    and     33     became      accredited      compared                                                         ices.   And   the   country   need    not    delete
                                                                                                                                                                                 funds    from    research    and    from     educa-
               exception   of   one   who    happened    to    he    to 1 3 that fiad already been.
                                                                        When  it comes  to av 1
               a  cancer  expert  in   the   Cit@,   Health   De-                                      a'lability     of                                                         tion   to   finance   the   delivery   of   medical
               I)artnient,   A,c    established    some    stand-    service,   there   have    to    be    some    very                                                         care.
               ards  to  guide  the   paN@ment   for   the   care    large-scale    public     decisions     made.     I                                                            The    delivery    of    medical     care     is
               of    patients    with    cancer    and    limited    am    all    for    continuing    education.     We                                                         spotty    and    the    quality    varies    within
               J)avments    to    the    hospitals    that    met    have    one    of    the     lar,est     continuing                                                         the     country.     Regional     Medical      Pro-
               those standards.                                      education      programs      in      my      school                                                         grams   can   work   in   a   variety    of    ways
                  These      were      administrative       decl-    [Columbia]    of    any    School     of     Public                                                         in   our   communities.    One    of    the    best
               sions   which   were   made    about    the    use    Health    in    the    country,    but     training                                                         ways  that   it   can   function   is   by   devel-
               of   public   funds,   but   called   on    expert    brl.(,,Iit  practitioners  to  (@ive  better   care                                                         opin',  in   areas   that   do   not   have   corn-
               advice     outside      of      -overnment      to    to    private    patients    will    not    satisfy                                                         prehensive     health     care     planning     and
                          them.                                      the   intent   of    l@e(,I()nal    Medical    Pro-                                                         undertaking    the     development     of     corn-
                                  li;i(i  to  (.ofrl(,  to  solllf'-                    ll.)S to  1)(@  III  ilill)l-()V(I-                                                      I)i-eliciisiv(- I)t-o(,i-aiiis that will  clclivel,
               itilrif-I that 11, 1101@    Ill  this  ('011TItt'@l:  lli(,llt,  III  III(,  s(@i@vl,(.(,  Nvlil(@li  is                                                          (Itiality lic@iltli  care  to  the  I-)ol)tilation.
                               @Ol't Of 1-t@l-ILIlatOl-V                          ill  Lill),Ill  settings   Lo   people                                                         We   do   not   believe   that    there    is    an
               nisrn@s.   A   hospital   (-ode   was    developed    who   are    entitled    to    free    care.    And                                                         unusual     rising     expectation     for      un-
               Birth   the   rich)   of   an   expert   committee    Re,,-Ionai     Medical     Prorams      has      to                                                         usual   medical   care.   I   believe   that    the
               C)f @tboLlt (",O         to  @-IOVCrn  I)roprl(,.-    i-nakc   i   conscious   decision    to    allocate                    DR.LLOYD                             legitimate    expectations    of    the    citizens
                                                                                                                                                                                                                                  27





                               of     this     country      regarding      medical house    sales    technique,    and     we     sent know   how   remote    I    am    and    back    to community   does   not   need   a    physician,
                                                                                                                                                                                                 I                        c    small
                               care   have   not   been   really   fulfilled   and into    the    private    practitioner's    of-fice what     fundamental     basis      of      primary And I be.1'.eve that nian@, of th'
                               that   this    country    has    paid    for    the individuals    with    a     sjyiall,     3-rninute iriedical   care   I   go,   I   practice   in   mv communities   in   this   country    who    now
                               delivery   of   medical   care   that    has    not movie    that    showed    how    a    Pap    smear village where I was born
                                                                                                                                                                   and     I      have have   physicians   will   no    longer    have
                               been    rendered    under    the    systems    that should   be    done.    We    left    samples    of been    practicing    there    34    years.    When them   when   the   ones   -,vho   are    there
                               we now have.                                      twenty   Pap    smear    kits    and    paid    for I  went   back   to   practice   in   my   village, now   pass   on.   I   am   sure   my    commu-
                                 If    the    country    was    receiving     ade- them,   to   be    read    and    returned.    This it   had   642   people   in    it.    But    after nity   will   not   have   another   one   when
                               quate    medical    care    and    the     delivery has    increased    the    use    of    the     Pap World    War    11,    we    had    a    population I  am  gone.   And   I   don't   think   tlae@,
                               was   good    and    the    quality    was    good, smear   in    the    community    in    which    we explosion   and   we   have    got    700    people need one.
                               there    would    be    no    real    reason    for have    been    working    some    200     percent. now.                                            When    I    came    there,,    people    who
                               the     Regional     Medical      Program.      The I    believe    that    the    Regional     Medi- It   is   my   contention   that   people    Nvho lived    5    miles    from    my     community
                               mere    fact    that    we    are    here     means cal    Programs    should    be     a     mechanism live   in,   Dr.   Egeberg,    the    Watts    dis- were   over   30   minutes   away    from    mv
                               that   in   some    way    the    volunteer    sys- for     further     experimentation     in      the trict  of   Los   Angeles   oi-,   Dr.   Tr-ussell, office.    Now,    we    have    paved    road,
                               tem    has    failed    in    delivering    quality delivery    of    medical     care.     Now,     we the   Harlem   district   of    New    York,    are running   in   every   direction,   a    hospi-
                               medical care to its population.                   must   go   outside    of    the    medical    pro- perhaps    more    remote    from    the     stand- tal 17  miles  on  each  side  of  us'.  where-
                                I   believe   also   that   we   need    to    re- fession   for   help    in    the    delivery    of point     of     having     adequate      available as  we  had   a   hospital   45   miles   a@vav
                               evaluate   the   delivery    of    medical    care; medical   care.   I    do    not    believe    that health   care    for    them    than    are    most @vhen   I   started   there.   And   by   auto-
                               and   I   feel    that    the    private    practi- we   can   depend    totally    upon    the    uni- of   the   people   who   live   in   rural   corn- mobile  or   ambulance,   a   person   can   be
                               tioner  may   not   be   able   to   be   available vcrsities   oi@   the   public    health    depart- rnun't'es throughout     the             United in  c@ither-  one  of  these  hospitals   with-
                               for  all  of  the  services  that   he   has   been ments   for   the   delivery   of   care.   It   is States.   There   has   come   to    be    in    my in  15  or  20  minutes  if  thev  are   in   a
                               available    for     before     and     that     we community     involvement,     and     it      must thinkin,     another     dimension     of      what big enouah hurry.
                               should    look    much    more     into     provid- be     a      community      involvement,      that constitutes    adequate    health    care    co-,,- So  that  I  think  it  is  axioriiatic   that
                               ing  that  first  line   of   medical   care   with will     make     health     care     much     more erage.    And    that    dimension    relates    to any    community    that     cannot     support
                               other     personnel.     In     continuing     edu- available      to      the      population      and time.   And   I    firmly    believe    that    any at  least  two   physicians,   a   measure   of
                               cation,    I    believe    that    the    programs, also     have     some     control     over     the person   who    is    within    30    minutes    of -roup  practice.,  can  ]II   expect   to   re-
                               althou    h    extensive    in     the     country, quality  of  care   that   is   rendered   to   thea
                                    9                                                                                              dequate    health    care     facilities     avail- ta'n  one.  And  I   think   that   the   prob-
                               have   failed   in   -etting   into   the    physi- population.                                     able    is    adequately    covered     for     the lem  that  @ve  are  goin,,  to  have  to  face
                               cian's office.                                    I    believe     that     the     Regional     Med- matter of health care.                          in  this  countrv  and  it  is  -oing  to  have
                               We     have     been     concerned     with     one ical    Program    can    serve    this    purpose. Now,    we    realize,    those    of    us     who to  be  faced  at  a  community   level,   per-
                               small    program     and     having     physicians, If   it   serves   the   purpose   only   of   per- come      from      small      communities      and haps   ivith   some   measure    of    stimula-
                               private    practitioners,     do     Pap     smears petuating  the   type   of   care   that   we   are rural    communities,     that     every     cross- t'On     from     regional     programs     and
                               in their office.                                  now   giv'n@    it    will    be    'ust    another road     in     every     community     wants     aOther   approaches   to   the   provision    of
                               We    held    several     meetings     in     which line   of   frustrations   for   those   who    are doctor   just   like   they   want    a    preacher health care for people, is to       stimulate
                               all     practitioners     in     the      community looking    to    the     Government     for     the and     sometimes     need      an      undertaker. these small communities to         combine
                               were    invited.    And    then,     we     checked provision     of     adequate      and      quality And    in    my    village,    the    man    wanted into a lailger community,.
                               the   laboratories   to   see   if    the    number medical care.                                   to   be   convenient   so   lie   built    directly In  nianv  instances,  it   is     entlt-cln-
                               of    Pap     smears     increased;     the     Pap Dr.   01-INSON.    I    guess    I    was    chosen @icrogs   the   street   from   iii(,   But   tliit possible to'ta@-(- fotii- or  fl\@(,  siiiall(@Ii,
                               smear   statistics   did   not   show    a    large to  tilk  to  you  here   today   to   I)rin,,   to s a  little  bit  too  close,  and  that  stilliti- rural  COMT-nUllit]CS,  where   each   of   the
                               increase.                                         you    a     message     about     remote     areas latcci   me   to   iij)(@rade   my   cluality    of (,orriiiitinities  is  within  a   measure   of
                               So    we    did    a    different     thin-.     We and   the   provision    of    health    care    in care.                                         20  or  30  miles   of   another   commiinitn,.
                               took   a   pa-C   out   of    the    pharmaceutical these   areas.    And    in    order    that    you I    firmly    believe    that     evez-v     small and someavliere in the center 'denti
                               28







                                                                        And   I    don't    think    I    would    do    this    week.    The    same     thing     with     weekends.    medical     students      will      not      identify
                                                                        @i(,aill.                                                Oii(@   physician   can    cover    zLI]    of    the    Nvith it arid %vill not go into it.
                                                                           I'@kit if we        by   W()[-]<Illg   with   tile    eiiiei-g(@xici(,,s foi@ tii(, entire gi-otil)  cilir-      A   little   story    about    the    ability    of
                                                                        communities     arid     @illowing     the      cori-    iiig  oii(-,  w(@(!keiid,  and  the  otlici-  tlii@ce    the     l@egloilal     Progi@ains     to     produce:
                                                                        sumers   to   have   a   part   in   the    planning,    or   four   can   have    time    off.    And    that    We    have    seven     counties     in     southwest
                                                                        get   a   half    dozen    communities    to    agree    will   make   life   tolerable   so   that   a   per-    North     Carolina,      in      the      Appalachian
                                                                        each   to   give   up   their   little    one    com-    son   can   live   with   his   family    and    help    region,    that    are     quite     unique.     They
                                                                        munity    and     form     a     larger     community    to   bring   his   children   up   and    keep    his    are     mountainous      counties,      and      they
                                                                        in    which     the     community     can     support    family a closely knit unit.                              do     not     have     too      many      resources.
                                                                        half   a   dozen   doctors   more   or   less,    can      So   I   think   that   the    one    thing    that    They      have       110,000       people.       They
                                                                        support     an     excellent      school      system,    we     must     do-and      i-naybe      the      Re-    have     62     doctors.     They     have      eight
                                                                        can    support    excellent     religious     facili-    gional    Program    can     be     the     stimulus-    hospitals,   t@vo    of    which    are    accredited
                                                                        ties,    can    support    good    cultural    facil-    @ve   must   have    some    effort    to    consoli-    by    the     joint     Commission     on     Accred-
                                                                        ities,   then,   there   is   reason    to    believe    date      the      smaller      communities       and    itation of Hospitals.
                                                                        that     there     will     be     physicians     who    have     medical      care      available      within      This   community    got    a    little    bit    of
                                                                        will    be    @villing    to    move    into    these    the time limit of 30 minutes.                            catalystic    aid    from    the    Regional     Pro-
                                                                        areas.                                                      Now,  if  we  are   goli-ig   to   do   this,   we    (@raiii     interested     in     community     plan-
                                                                           But    we    do    have    to    have    a    com-    have    to    have    the    type    of     physician    ning.      They      organized      a       community
                                                                        munity    adequate    to     be     attractive     to    who   can   earn   a   living   in   a   small   com-    planning       corporation.        The        doctors
                                                                        physicians   if   we   are   going   to   get    phy-    munity.     And     that     physician     has     to    organized      an      Academy      of      Medicine,
                                                                        sicians   in   there.   And   one    key    to    at-    be   trained   a    little    more    broadly    than    all   62    of    them.    The    hospitals    agreed
                                                                        tracting    a     physician     and     keeping     a    the       presently       conceived       specialist.    to    have    the    joint     Coniii-iission     oii
                               DR. JOH-,SON                             physician    in    this    sort    of    a     commu-    This   physician   has   to   be   able    to    take    Accreditation     of     Hospitals      come      III
                a   location   @,,,h(,rc   two,   three,   four,   or   nity    is    having    a    situation    which    is    ctre  of  soi-iiethin,'@   like   75   or   80   per-    aiil    Survey    every    hospital    there     with
                     I)Iiysl(-Iaris (@an  lo(:at(-  @Lri(i  (10  (@x-   tolerable    to    the    physiciaii's    wife,     a    c(@nt  of  all  of  tli(,,  ills  that   beset   man-
                                                                                                                                                                                          the  idea  in  riiind   that,   after   the   sui-vcn
                                                                        little  bit  attractive   Lo   tll(@   I)Ilysi(@ian's           And if %v(@                  to  li;tv(!  this    @v@is   done,   there   would    be    @xii    effort
                   @Vell,   now,    a    coriitnuriity    that    can   @vife.  There   is   no   one   factor   i-nore   in-    physician,     the     medical      scl)ools      are    to   build   in   the    center    of    this    area
                support    four    or     five     physicians     can   volved    in     where     a     physician     lives,    going   to   have   to   face   up   to   the    fact    which,      incidentally      is      called      the
                also   afford   to   have    an    attractive    com-   particularly     as     it      involves      smaller    that    they    have    to    produce    a     family    "State    of    Franklin,"    a     facility     that
                munity     where     a     physician     and      his   communities,       than       the        satisfaction    physician    or    a    primary    physician.    Arid    wo,ild    upgrade    the     facilities     available
                family    might    want    to     move     and     to   that   his   wife   gets   from   living   in    that    no     place     else     except     the      medical    for     every     person     in     the     community
                raise    a    family.     Certainly     not     every   community.                                               schools can do this.                                     and   those    ooing    to    every    hospital    in
                crossroads    can    do    this.    I    have     re-      Now,    also,    a     group     of     physicians       And   if    they    are    going    to    do    it                   0
                uretted     many,     many     times      that      I   can    reasonably    expect    to    provide     con-    effectively,    they    must     have     an     oia-    the        community-the         X-ray         treat-
                                                                                                                                                                                          ment,      the       electrocardiographic       work,
                raised   my   children    in    the    small    corn-   tinuous     and      comprehensive      care      for    going      program      providing      this      sort    laboratory      work,       multiphasic       screen-
                rnunity   where   I   did   because    I    had    to   their    peol3le     around     the     clock     and    of    care    @vithin    the    confines    of    the    iii,.   And    they    a-reed    that    the    joint
                send    t@iem    off    to     preparatory     school   around    the    calendar,    because    one     pcr-    medical    school    and     the     hospital     as-      0                    Z,
                @@@ien   they   were   about    8    or    9    years   son   can   take   night   calls   this   week,   an-    sociated    with    the     medical     school     in    Commission      @vould      work      with       this
                old,  and  I   am   sure   I   lost   much   of   the   other   next   week,    and    i-naybc    you    only    order    that    the     medical     students     can    project    with    the    idea     in     mind     of
                contact    that     A,ould     have     been     good   have   to   take   the   night   calls    one    week    identify   with   this    system    of    the    Pro-    doing    some     innovative     work     in     this
                for   me   to    have    had    with    my    family.   out    of    every    month    or     every     fifth    vision    of    health    care.    Otherwise,     the    area    and     that     ultimately,     within     a
                                                                                                                                                                                                                                             29









                                         year   or   two,   the   situation   would   be   so    good   care.   I    have    been    sitting    on    a       Again,     with      regard      to      community       To   enlar   e   a   little    on    vour    state-
                                                                                                                                                                                                                                    9
                                                                                                                                                                                                                                               1    7
                                         improved,   as   to   the   provision    of    qual-    tissue    committee    in    a     large     hospital,   involvement,     we      are      not      economists,     ment    about     availability.     Dr.     Egeberg.,
                                         ity   care   in   this   area,   that   the    joint    and    have     noted     that     men     who     are   we     are     not     businessmen,      and      manv     one    of    our     problems     in     New     York
                                         Commission     would     agree      to      accredit    practicing      good      surgery      don't      mind   times    in    the    community,    @ve    can    find     Citv    was    too    much    availability.     NeN@-
                                         all   of   these   eight   hospitals   with    their    aetting    the    unusual     letter     that     they   these aids that we need.                                   York    City    has    traditionally     been     the
                                         central    unit-to    upgrade    them     as     one    get     from     the     tissue     committee,     for      Dr.      EGEBERC,.       Thank       you,       Dr.     portal of entn'     for    poor     people.     Right
                                         unit.                                                   whom    they    have    nothing    but    the    high-   Lloyd.    I     think     medicine     has     perhaps     no@,,,,    @ve    have    our    immigration     from
                                          I    have    been    on    the    joint     Commis-    est   respect.    It    is    men    who    are    not   suffered   from   feelino,    that    it    has    had     the     soutli     and     from     Puerto      Rico.
                                         sion   now   for   7   years,   and   I   am   work-    doing     good     work     really,     I     suppose,   to   have   a   majority   in   most    groups    that     These   people    need    free    care.    And    for
                                         ing  with   it.   And   I   think   that   that   is    who     move     to     other      hospitals      when   decide   on   medical    affairs.    If    they    had     decades    the@,    have    received    free    care.
                                         going    to    be    a     demonstration     project    the     tissue     committee     looks      critically   worked   more    often    with    less    than    half     The   problem   ,vas   that    it    @%,asn't    uni-
                                         that   all   of   the    Regional    Pro@rams    may    at their work.                                           the    votes    they    might    have    had     sonic     foririly   good,   ,inci   we   had   to
                                         Well   look   to   with   pride.   X'ncl   it    may      We   must   give   tli(@   type   of    care    that   [llot'(, ilisiglit Y-til)f)ccl into them.                  ;L massive, i(,o@(,,aiiization.
                                         cut    a    pattern    whereby    we     can     im-    a    community    @voulcl    like    to    have.    We      Di-.   'I'i-Lissell   bi-oi-iglit   out   one   way       And   I    am    sui-c    Dr.    Johnson,    -,vlio
                                         prove    the    quality    and    availability    of    have   given   the    kind    of    care    that    we   of   assuring    a    higher    level    of    medical     obviously      hasn't      been      in       Harlem,
                                         health   care   for   the   people   in   the    re-    would  like   to   give   at   times,   and   it   has   care    @vliich    I    thought     was     intriguing     will   be   greatly   relieved    to    kno@v    that
                                         mote areas of this country.                             been    not    what     has     been     wanted     in   and    almost     needs     repetition.     It     has     Columbia     Un'versitv     stafTs      the      Har-
                                         Dr.    EGEBERG.    Now,    I     am     going     to    that     community     or     needed      in      that   been     said     that     perhaps     another     way     ](,in  Tfosp'tal   lin(f(-,r,   Zi-   city   contract
                                         address    a    question    or    two    and    per-    '01,1111LIllity.       The       (Community        many  Of @ISSLII-illg L            level of                      (@Liri,critly  at   the   rate   of   $12.5   million
                                         haps    people    will     disagree     with     one    times    will    know    much     more     of     what   care    might     be     through     having     every-     a    year.    It    is    matching    interns     and
                                         another   here.    I    would    like    to    start    they    need    than    we    do.    And    we    must   body   in    practice    belon-    to    some    or-a-     filling   residency   slots.   There   '
                                                                                                                                                                                                                                                            is   a    neA,
                                         Nvith   Dr.    Lloyd    if    he    doesn't    mind.    talk     to     people     in     communities-I     am   nization     responsible     for     the      delivery     800-bed     hospital     which     .v'll be        open
                                         He      stressed      something       very       im-    talking     about     groups,      civic      leagues,   of   medical   care.   And    I    would    like    to     next year. And three        s      are       somewhat
                                         I)ortant-(,oriiriitinity       involvement        in    labor  union,.,,  tzi(i  tli(@  likely  ---who   I)ave   ;isl@  Di-.              %vii;it  lif-  tli'i)l@s   of                 lf:itl(.Ill iii;lrl  fil(@N'
                                                                                 And        I    fill  I()  t(@ll  us   ;tl)oll(   (II(,   (I(-l]V(!I.y   lll;tt.                                                        VI.;Il.s @lL@o.         illi-                   IS
                                                                                                                                                                                                                                                               I      irig
                                         @VOI)Clel- if ]IC %@'OLI]CI tal@e LL (@otil)](@    of                                                                                        think tli@it                   )111(" to I)Ll'lcl a Stit(., off-i(,(, build'
                                                                                                  I  was  in  I)r-.t(@tice                                                              liat       I)Iivs'(,'ans
                                         minutes   to   enlar,e   on   this   'ust   a   bit-                                   for      about       10   1.)ocly  %voit](I  agree  t                                iList   10   blocks   t@vav    from    the    liospi-
                                                                                                 years,  too,  so  that  I  can  tall@  as   a   I)rac-   who    are    in    association    with    one     an-     tal--,vhich is real progress.
                                         lay versus medical.                                                                                                          I          I   I       I
                                                                                                 titioncr.   A   physician's   office   is    a    very   other      contribute      to      more       thinkin,     With       respect       to       making       thin,s
                                         Dr.    LLOYD.    I    believe    that    the    lav-                                                                                                                          ']able  also,  Dr.  Egeberg,  a-a'
                                                                                                                                                                                                                     -a
                                         men can be sophisticated enough                   @o    inefficient    operation.    It    is     only     be-   and    self-criticism    and     that     they     are     ak                                                in.
                                         have    something     to     do     with     talkin@    cause    we    have    so    much     profit     built   better    doctors    by    virtue    of    belongiti@-     I   want   to   sav   voti   can   do   some   things
                                                                                                 in   that   we    can    run    the    business    the   to some kind of an association.                            %,,,hen   thev   'are    of    proven    -value    bv
                                         about   the   quality   and    the    delivery    Of                                                                                                                                   'them,    at    least    Nvhei-e     there
                                                                                                 way   we   do   it.   It   is   a   very   inefficient    In      urban      areas       and       particularly     reqlllrin-
                                         medical    care.    I     believe     that     third
                                                                                                 operation,     and     we     have     shown      that   in the    New    York    City     area,     we     have    is an institutional ri-ht to
                                         parties   who    are    paying    for    the    care                                                                                                                        I         I                          impose         a
                                                                                                 we     can     take     many     procedures,      that   tinl@iao@@,n     thousands     of     doctors      who     requirement.     It      is      generally      rcc@-
                                         can     certainly,     again,     have     something    1)hN,sicians    have    been     doing     all     the   l@iav           (Ynized       hospital        appoint_     nized that cervical c@tol
                                                                                                                                                             c no reco,                                                                             0       is    a    pre
                                         to   say   about   the   quality   of   care    they    'time    because    of    the    history    of    them   merit.    This    creates     some     vei,@@     real     %-entl,.7e   technique   N%,hicii    has a        @,c@
                                         are  paying  for   and   ho@v   the   care   is   to    doing    them,    and    get    people    who     have   I)i@oblerns   for   RMP   in   tr,.,In,-    'to    in-     Iii,h   @-ielcl   in   @@-oi-neri    betn@-cen    th'
                                         be supplied.                                            much    less    training    to    do    these     pro-   volve    these    individuals    in     (,oiitiriLi'n-     a-  @s  of  21  aii(ir).r)-in  fact,   70   [)erccrit
                                                                                                                                                                                I                       I      ,     11 (-
                                         You   are   not   afraid    at    all    of    other    ce(Iiii-cs   c%-eii    better    than    the    ])IIV-   CCILI(:atioii.   I   don't   k-iio@v   NN,Iiat   tli(,     of   all   cancer   of   the    cervix    in    Ne@@-
                                         involvement     when     you     are      delivering    siciaiis.                                                ansnver is.                                                York   State   that   is   reported   is   in    that
                                         30




   on  your   state-            age  group.  And  in   our   State   hospital   meeting   in   southern   California    where   introduce  these  people   in   their   form-   charge  as  much  in   order   to   pay   the
   ty, Dr.  Egeberg,            code,  there  is  now  a   requirement   that   this  question   of   Pap   smear   came   up   ative   years   to   an   attractive   commu-   bills  at  the  end  of  the  month.  We  are
   s  in  New   York            any   woman   who   hasn't    had    a    Pap   along  these  same  lines.  And   there   was   nity,  you  might  do   something.   But   so   going  to   have   to   make   medical   care
   ailability.   New            smear   within   the   previous   year   when   a  sharp  difference   of   opinion.   Every-   many   of   them   have   gone    out    into   more  available,  but   I   don't   want   us
   ionally been  the            she  is   admitted   to   any   hospital   in   body  over  the  age  of  60   thought   this   preceptorship     programs      and      have   to  get  way  out  in  left  field  and  make
   r  people.  Right            New  York  State   and   is   in   that   age   was  a  real  interference  with  the   prac-   seen   communities   like   the   one    that   it   available   from   those   who    cannot
   migration    from            group has to have a Pap smear.                  tice  of   medicine   and   that   a   county   I live  in  where  I  am  on  call  24  hours   supply quality care.
   Puerto      Rico.               There is also a requirement           that   society  was  trying  to  tell   people   how   a  day  7  days  a  week  around  the   clock
   cc care. And  for            anybody    who    hasn't    had    a    chest   to    practice.     Practically     everybody   around   the   calendar,   and   the   educa-
   eived free  care.            X-ray   within   the   previous   year    has   below  50  thought   it   was   a   wonderful   tional facilities, the  cultural  facilities,
   t it wasn't  uni-            to  have  a  chest  X-ray  unless  the   Com-   thing.                                          et  cetera,  are  not  up  to  par,   and   I
   had  to   undergo            missioner   of   Health   deems    it    epi-     Dr.  Johnson,   you   talked   about   get-   would   say   that   a   preceptorship   pro-
   tion.                        demiologically    unnecessary     in     that   ting    physicians    into    smaller    com-   gram,  if  it  is  a   forced   preceptorship
   Johnson,      who            hospital     to     have     this     uniform   munities.    I    am     sometimes     amazed   program,  will  start  with  a   bias   built
   n   in    Harlem,            requirement.                                    how  many  people  want  to  live  in   these   in   against   it.   A   preceptorship   pro-
   d  to  know  that               There   are    some    high-yield    chest   large   sores   that    we    are    breeding   gram  has  as   much   potential   for   harm
   staffs  the  Har-            X-ray    programs    in    Harlem,    Bedford   around   the    country,    but    apparently   as it does for good.  BiAt  if  you  can  in-
   a  city  contract            Stuyvesant,   and   the    Bellevue    areas.   they  do.  I  have  heard  that  it  is   the   troduce  folks  into   an   attractive   com-
   of $12.5  million            On  the   other   hand,   you   can   go   50   wives  who  feel  that  they   would   rather   munity   and   get   them    interested    in
   ng  interns   and            miles  out  of  New   York   City,   and   it   live  in  a  large  community.  And  I   have   fishing   and   hunting,   and   so    forth,
   There  is  a  new            isn't  worth  the  money  to  take  a   chest   often  thought  that   if   some   of   these   you   can   coerce   them   a   little   bit.
   h  will  be  open            X-ray  on  everybody.  It  is  left   up   to   people  could  he  introduced  to   a   small   Maybe   you   can   teach   the    wife    to
   s  are   somewhat            medical  judgment.  But  it   is   the   phi-   community,   maybe   that   would   be    all   shoot quail.
   n  they  were   a            losophy   in   New    York    State,    rein-   that would be required.                            I   do   believe   this,   however,   that
   he  Governor   is            forced  by  the  law,  where   a   preventive      I  was  on   a   medical   manpower   com-   this   business   of   putting    communities
   office   building            measure  has  proven   of   value   to   pri-   mittee  concerned  with   the   armed   serv-   together   cannot   be   done   by    bureau-
      the     hospi-            vate  patients  as   well   as   public   pa-   ices  not  too  long  ago  in   which   some-   crats;  it  cannot   be   done   by   medical
   ress.                        tients,  it  is  now  being  built  into  the   body    suggested    that     perhaps     the   educators;  it  cannot  be   done   by   peo-
   making     things            requirements on      hospitals   to   provide   draft's   main   drawback   was    that    it   ple  from  the  top  down;   it   cannot   be
   geberg,    again,            that    preventive    measure     for     all   didn't   involve   everybody   and    perhaps   done  by  people   who   represent   a   mass
   do  some   things            hospitals.                                      everyone  ought  to  take  a  year  of   some   pool    of    practical    ignorance,     you
   oven   value   bv               This  does  not,  of  course,  extend   to   kind  of  service.  Those  who  didn't   have   might   say,    about    how    to    provide
   t   where   there            private   practitioners   in   Dr.    Lloyd's   to  go  into  the  armed  forces   might   do   health   care   services   for   people    in
   t  to  impose   a            program.   And   his   description   of   en-   their   service   in   some   small    commu-   these communities.
   nerally    recog-            couraging   more   doctors   to    do    more   nity,   and   many   of   them   might   stav      But  we  are  going  to   have   to   make
   tolo,gy is a pre-            Pap    smears    was    a    very    exciting   there if they fell  in  love  with  the  com-   health  care  available,  and  I   do   agree
   ich  has  a  verv            discussion.                                     munity    and     their     responsibilities.   that  the  physician  is  going  to  have  to
   between       the               Dr.    EGEBERG.     Thank     you,     Dr.   Would  you  care  to  remark   on   that?   I   learn  to  use  his  time  better.   I   have
   et,  70   percent            Trussell.                                       know what you are going to say.                 four  assistants,  and  I  assure  you   that
   cervix   in   New               just  one   interruption   here.   I   re-      Dr.   JOHNSON.    I    would    be    very   my   productivity   is   much   greater   be-
   rted is  in  that            cently   attended   a   medical   association   glad  to  comment  on  that.  If  you   could   cause  of  that,  and   I   don't   have   to

                                                                                                                                                                                                                           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












                                                                                                                                                                                                                       ing  to  mass  produce  what  re-
                                                                  DIVISION        OF             I would  like  to  focus  on  some  of               stethoscope  given   to   him   by   Sir                by try'
                                                    REGIONAL             MEDICAL             our  contemporary  Issues   by   quoting                 Thomas.   Sir   Thomas   dedicated   his                quires the most sklileci  craftsmanship.
                                                                           ,PROGIZAMS        suitable  words  from  the  past.   "Our                 I)ool@ to ])Is                                   and        "'fliis point of view, I believe,  Is
                                                              REPORTS           ON-          ]Knowledge  of  the  clinical  pathology                 Einthoven.  Last  week  at  the  Univer-                contrary to  our  national  history  and
                                                                                             of        heart  has  advanced  with   such              sity  of  Cliica-o  Board  of   Trustees                commitment.  I   think   we   have   the
                                                PROGRESS       AND       ISSUES
                                                                                             rapidity    during    the    last     decade,     and    dinner      for      the      faculty,      Professor   capabilities   as   a    societv    to    make    the
                                                                                             the   subject   as   a   whole    has    become    so    Chandrasekhar,     in      speaking      of      dis-   @-erv  best   available   to   all   our   I)cople.'@
                                                                                             technical,   that   at   the    present    time    it    tiiiction   in   science,    traced    the    gencal-      Dr.    Shannon,    in     a     para-raph     that
                                                  Robert      Q.       Marston,       M.D.                                                                                                                                                         I
                                                               Associate          Director   is   difficult   or    well-nigh    impossible    for    ogy   of   Nobel    Prize    winners    in    cliein-   @ve    have    quoted    often,     stated,     4'al-
                                                                                             the   general   reader    to    keep    pace    Nvith    istry     in     an     unbroken      student-teacher   though     Nve     must     contend     with     manv
                                       National     Instz'tutes     of     Health      and
                                                                                             its    progress.    The    writings     are     seat-    relationship    back    to     1901.     I-le     em-   diverse     geographic     and     social     circum-
                                                           Director,      Division      of   tered;   they   call,    in    the    reading,    for    I)hasized     the     point      that      excellence   stances,     N'IH,     in      administering      the
                                                Re-l'onal        Medical        Pro(irarns
                                                                                             considerable          preliminary           knowlcd-C    be,,ets   (@xc(@llence.   i\,Tecliciiie   has    been   Re(@ioiial      ,%,Iedi(.al       Prorams,       will
                                                                   Karl      D.      Yordv   Of tile Subject matter discussed.                        particularly dependent on tfi(@                         strive   to   preserve    existing    (-.enters    of
                                              Deputy      Director,      Division       o@      "In   coiiteinl)latin,r   tile   Worl@   Of   tile    tor  con(:cl3t,  the  I  to  I   ratio   of   student   excellence     in     science,     education,     and
                                                Rc,lonal         Medical          Programs   past   few   years,   it    seems    to    me    that    to    teacher    or     physician     to     patient.   service   while,   at   the    same    time,    work-
                                                                                             a    sta-c    of     the     enquiry     had     been    The   i-inqllcstioned   validity    of    this    ar-   in(y   with   State   and   local   forces,    evolve
                                                                                             reached    at    which    it    was    possible    to    rangement         to     assure           excellence,   a   system   that    ,vill    make    available    to
                                          he   pro@ress   and   issues    in    the    im-   give   a   review   of   the    main    results    of    though      proven      through      the       years,   the    bulk     of     the     population     medical
                                    Tplementation        of         individual         Re-   the    numerous    researches,    and    to     place    constitutes     a     major      challeii-c      when   services   that   are   e-,celletit    in    qualit@,
                                    gional      Medical      Proorams      are      stated   before    the    student     of     general     medi-    you   and    I    address    the    complex    issues   and    adequate    in    qljantltv-at    least     in
                                    in    your    agenda.    They     are     the     same   cine    the     evidences     upon     Nvhich     the    of    the    maintenance     of     excellence     in   a   major    segment    of    the    diseases    that
                                    progress    and    issues    faced    by    the    di-   chief    conclusions    of    the     present     day    the      organization      and      delivery       of   plane us all.@'
                                    vision   vie@ved    from    a    slightly    different   rest.                                                    health services.                                           It   is   appropriate   to    consider    for    a
                                    perspective.                                                "A     number      of      I)Iicnoi-ncna,      ob-      Two   speakers   on   otiz-    I)z-o,,raiii    last   rtiotiient the Re,,-Ional         @l   cli(!al   Pro-
                                       This Nlear     your       stecrin-        committee   served     in     (@linical     and      experimental    year  spoke  pointedly  On  this                                 it)   the   context    of    hire    Federal
                                    has     focused      this      entire      Conference-   studies,   are   described   side    by    side    in    Undersecretary        Cohen        said,        "Some   role    in    the    organization    and    deli\,er@
                                                                                             this   book,   and   an   attempt    is    made    to    have   ar,ued    that    there    is    an    incoii-   of   health   services.   In   its    present    out-
                                    Workshop  around  the              question         of
                                                                                             show     the     manner     in     which     abnormal    sistenc),,     or     even     conflict,     bct@veen   lines,   that   role   is   relatively   neN@,,   ex-
                                    quality   and    availability    of    health    serv-
                                                                                             actions   of   the   heart,   as   they   occur    in    high     quality      and      -,widespread      use.   cept for the fac'l'                               and
                                                                                                                                                                                                                                     I ities pro@-rams
                                    ices.   In   our   report   to    you    this    morn-
                                                                                             patients,    may    be    identified    with    simi-    They    believe    that    excellence     is     such   some   of   the    pre%,Iotis    StiTnLilatic)n    of
                                    ina,   the    division    of    Re-lonal    ivfeclical
                                                                                             iar    disturbances    artificially    created     in                                                            I)Iaiinin,,   as   cies(@i@ibeci   N,est(,rda\   I)%-
                                                                                                                                                      a   rare   and   tender   flonvci-   that   it    can
                                    Programs      will      present       reports       on   laboratory      experiment."       This       qi-iotc                                                            Dr.   Ilreslo@v.   Experience   ,@,ith    the    ina-
                                                                                                                                                      only    I)Iooin    in    special    and     carefully
                                    selected    areas    related    to    this     general   is    from    the    preface    of     Sir     Thomas                                                            ior    new    components    of    that    role     is
                                                                                                                                                      protected     environments.      'I'licy      fill",C
                                    problem.    Dr.     Bucher     will     report     for   Lewis'  book- on       "Mechanism       of        the                                                            limited. The effects of medicare              an   cl
                                                                                                                                                       "O'ested   that   we    can    lose    e%,ei-vtllinu
                                    his   (Troup   on   progress    in    the    use    of   Heartbeat,"         published                December    suo'
                                         0                                                                                                                                                                    medicaid are       ]List       becoming        known.
                                    operations       research        techniques        and   1910.                                                                                                            --\,fost of the   Re-lonal      -.\Iedical       Pro-
                                    methodolc%,@y.     Dr.     Schmidt     @vill     docu-     I     have     chosen     Sir     Thomas      Lewis     As  I  @vas  proofreading  this   sl)ecch   I   Nvas   ,,rams  have      not     @,et     entered     opera-
                                    ment   the   increasing   activity    in    the    di-   because     Dr.     William     Bran(@fi      Porter,    Informed   that   one   of   my    great    teachers,   tioii@il  phase.  'Flic
                                                                                                                                                 I    l,ord Florcy, wlins(,- d(@v(-Iopi@i(@lit  of  1)(,ni-
                                    vision   centered    on    the    substanti-,,c    im-   jziv I)i-ofessoi- of                 @v@is  a   stti-                                                              riil-)i-eliensi@re   health   1)lanriin,,   is   at
                                                                                                                                                      (@illiii earned liiiii a  Nobel  I)rize,  diecl  Feb-   (@o                                       n
                                    provement of health services.                            dent    of    Lewis'    and     always     used     a    ruary 22, 1968. (R.Q.M.)                                a    still    earlier    stage    of     development.
                                    34





  cc  what  re-                                                                                                      An   expanded   health   services   research   environment  for  the   exercise   of   that
  f  tsmanship.                                                                                                      program   is   mostly   intent.   But    the   peculiar  propensity  and  genius   of   our
  I believe, is                                                                                                      urgency  and  public   awareness   are   in-   society  to  invent  new  institutional  and
  history   and                                                                                                      creasing,  and   one   can   describe   some   organizational    frameworks     to     meet
    have    the                                                                                                      characteristics  of  the   road   that   lie   new   challenges.   In   my   previous   re-
  to  make  the                                                                                                      ahead.                                         sponsibilities,   I   have    often    heard
  our  people."                                                                                                         The  nature  of  this  Federal  role  al-   young   physicians   and   medical    scien-
  @graph   that                                                                                                      most  certainly  is   different   from   the   tists  from  other  countries   praise   our
  stated,  "al-                                                                                                      current  Federal   role   in   the   support   unique  ability  to   bring   together   the
  with     manv
                                                                                                                     of  medical  research,  such  as  the  grant   skills  of  those  from   many   disciplines
  ial   circum-
                                                                                                                      rograms  of  the  National  Institutes   of   to  focus   on   particular   problems.   To
                                                                                                                     p
  istering  the
                                                                                                                     Health,  or  in  the  direct   delivery   of   carry  this  approach  into   the   problems
  rams,    will                                                                                                      health  services,  such  as   the   Veterans   of  health  care  will  require   not   only
  g centers  of
                                                                                                                     Administration  hospital  system.  It   will   the focusing  of  a  variety  of  individual
  cation,   and
                                                                                                                     probably  be  different  from   the   emerg-   talents,  but  also  a  wide  range  of  in-
  time,   work-
                                                                                                                     ing  Federal  role  in  support  of  medical   stitutions  and   organizations,   each   of
  rces,  evolve
                                                                                                                     education,  though   the   fuller   outlines   which  can  make  a   particular   and   es-
  available  to                                                                                                      of  that  role,  while  further  along  than   sential  contribution  to  the  solution  of
  ion   medical                                                                                                      the health services role, are still  in  the   the health care problems.
  t in  quality                                                                                                      process of being determined.                     Regional    Medical     Programs     them-
   at least  in                                                                                                         Federal  research  support   is   primar-   selves   have   challenged   our    capacity
  iseases  that                                                                                                      ily  involved  in  the   support   of   some   for  organizational  invention  with  a  va-
  nsider for  a                                                                                                      functions  within   an   institution.   Sup-   riety  of  results.   One   concrete   mani-
  edical   Pro-                                                                                                      port   for   medical    education    becomes   festation  of  a   creative   organizational
  the   Federal                                                                                                      more  concerned  with  the   viability   and   response   has   been   the   emergence   of
  nd   delivery                                                                                                      strength  of  the  total  institution.   But   new   nonprofit   corporations   to    serve
  present  out-                                                                                                      it   seems   apparent   that   the   Federal   as   the    common    arena    where    many
  ly  new,  ex-                                                                                                      role  in  the  organization   and   delivery   institutional   interests   can   meet   for
  rams      and                                                                                                      of  health  services   must   be   concerned   COTTliiion   purposes.   These   new   orga-
  mutation   of                                                                                                      not  just  with  single   institutions   but   nizations  will  be  tested  in   the   com-
  esterday  b\,                                                                                                      with    the     interrelationships     among   ing years to  see  if  they  can  truly  en-
  ith  the   ma,-                                                                                                    many      institutions,       organizations,   compass   the   many   relevant    interests
                                                                                                                     health   personnel,   and   the    consumers   within   a    new    unity    of    purpose,
  that role  is
                                                                                                                     of  health  services.  The   importance   of   relate effectively to  other  activities  in
  edicare   and
                                                                                                                     the  consumer   was   described   forcefully   the  health  field,  and  avoid   the   dan-
  ing    known.
  edical   Pro-                                                                                                      by  Dr.  Lloyd  in  his  presentation   yes-   gers  of  becoming  protective  or   static.
                                                                                                                     terday. It is  clear  that  this  role  will     In   stimulating   new   structures    and
  ered   opera-
                                                                                                                     not  be  characterized  by  the  direct  de-   relationships  in  health,   much   of   the
  rience   with
                                                                                                                     livery  of  health  services  by  the   Gov-   Federal role  will  probably  be-  indirect,
  nnin- is   at
                                                                                                                     emment   on   the    Veterans    Administra-   through   influencing   a   vast   and   dy-
  velopment.                                              DR. MARSTON                                                tion  model.  Rather,  we  see   a   fertile   namic  health   endeavor   that   is   based

                                                                                                                                                                                                              35











                                 on     local     institutions,     organizations,   of   our   resources   and   energies    in    the   and   related   diseases    to    be    available      the   quality    and    quantity    of    care
                                 and initiatives.                                    health   field.   We   must   be   as    concerned   to all."                                               and  service   available   to   the   region's
                                    A   Governmental   role    will    not    pre-   about   integrating   the    public    and    pri-      We   have    described    the    process    of      population   and   to   do   this   as    eco-
                                 dominate   at   the    actual    meeting    point   vate   segments    of    the    health    endeavor   regionalization   in    the    following    terms      nomically as possible.
                                 of    the    provider     and     consumer     of   as   with   avoiding   the   isolation   of    the   in the new Gut'delines:                                   Finally,    regionalization    also    con-
                                 health   services,   even   though    the    pro-   ivory   tower   or    the    solo    practitioner.      Re-lonalization    among    the    full    ar-      stitutes    a    mechanism     for     coordi-
                                 portion    of    financing    through     Govern-   There   will    be    a    continued    need    to   ray  of   available   health   resources   is   a      nating   its    categorical    program    with
                                 mental   channels   is   likely   to    increase.   focus   on   special   problems,   such   as   the   necessary   step   in   bringinc,    the    bene-      other   health    pro@rams    in    the    re-
                                 The   efforts   to   preserve    voluntary    ac-   critical   health   problems    in    the    urban   fits   of   scientific   advances   in   medicine      gion.   As   a    result,    their    combined
                                 tion   will   continue   to   shape   the   char-   slums,   but   that   special    attention    will   to  people  wherever   they   live   in   a   re-      effect  may  be   increased   so   that   thev
                                 acter of the Federal role.                          need    to    include    the    development     of   gion   they   themselves   have    defined.    It      contribute     to     the     creation     and
                                    While      maintaining      local      freedom   relationships      between      these      special   enables   patients   to    benefit    from    the      maintenance   of    a    svstem    of    corn-
                                 of   action,   one   aspect   of   the    Federal   efforts  and  the  rest  of   the   health   serv-   inevitable    specialization     and     division      prehensive   health    care    @vithiii    the
                                 role  is  clear:  It  must  facilitate  the   im-   ices   framework   in   order   to    avoid    re-   of    labor    which    accompany     the     ex-      entire region.
                                 plementation    of     productive     and     de-   placing old isolation with new.                      pansion     of     medical     knowledge      be-      Because    the    advance     of     knowledge
                                 sirable     change     in     areas     affecting      If   these   are   some   of    the    possible   cause  it   provides   a   system   of   workin.@   (,I-ianges   the   nature   of   medical    care,
                                 health    services.    One    of    the     major   outlines   of   the   Federal    role    in    the   relationships   among   ficiltli    f)(@rsonii(@]   i,(-gionalizitlon  call  best  I)(-   viewed   as
                                 forces for chinge is the strong                     orq@iiiization ;tri(I (](-Ilv(@t-y  of  li(",Iltll   ;III(] tll(' ill'.,'tiltltlotl.S :11)(I Or'l-@tiliZ@ttioll" ;L ('()I)tillilottS 1)10('('SS I;Itill-l- (1)@iti  ;I
                                 foi-  high  st@tri(lat@cls  of  excellence   that   services,   flow    (lo    l@(@gloti@Ll    Medical   in @vl)lcli tl)cy %voi-k. 'I'Iiis               @t  I)]Ltil   which   is   totally   developed   arid
                                 has    permeated    our    medical     activities   Programs     relate?     Di@.     Breslow     said   (@ori,ri,itmeiit   of   individual   and   insti-   then  implemented.   'J'Iils   process   of   re-
                                 and   that   has   led   to   so   much   impres-   yesterday:    "To     those     concerned     with   tutional   spirit    arid    resoi-irces    which   (xionalization   consists   of   at   least   the
                                 sive      accomplishment      throughout      the   the    improvement    of    health     care     in   must   be   worked   out   by    each    Regional   following   elements:                Involvement,
                                 history     of     American     medicine.     The   this    country,    regionalization    has     be-   Medical   Program.   It   is    facilitated    by   identification    of    needs    and    cpportli-
                                 tradition   of   excellence    and    its    con-   come   the   order   of    the    day."    Because   voluntary    agreements    to     serve,     sys-   nities,   assessment    of    resources,    defi-
                                 tinued   pursuit   will   continue   to    create   regionalization    is    essential     for     ac-   tematically,   the   needs    of    the    public   nition  of   objectives,   setting   of   priori-
                                 much   of   the   need   for   changes   in   the   complishing   the   purposes    of    this    pro-   as   regards   the   categorical   diseases    on   ties,     implementation,     and     evaluation.
                                 organization    and    delivery     of     health   gram,   we   have   chosen   in    our    revision   a   regional   rather   than   some   more   nar-   I  will  describe   and   discuss   these   seven
                                 services.   The   same   tradition   will    also   of    the    Guidelines    to     describe     the   row   basis.    Regionalization    @vithin    the   elements   in   the   process   separately    al-
                                 continue    to    create    opportunities     for   mechanism    for    achieving    the    goal    of   context     of     Regional     Medical      Pro-   though   in   practice   thev   are    int'e'rre-
                                 improved     health     care.     The     Federal                                                        grams     has     several     other     important   lated,    continuous     and     often     occui-
                                                                                     the    Regional    Medical    Programs    as     a
                                 commitment    to    the    wider     availability                                                        facets:                                             simultaneously.
                                 of   the   best   in   medical   care   and   the   process of regionalization.                               It  is    both    functional    and     geo-      First,     involvement.      The      involve-
                                 continued    support     for     the     develop-     That    goal     is     described     in     the     araphic     in     character.     Ftinctionallv   ment    and    commitment     of     individuals,
                                                                                     Surgeon     General's      Report      on      Re-                                                , 5
                                 ment    of    medical    excellence    are    two                                                          regionalization      is      the      mechanism   organizations,     and     institutions     which
                                 aspects  of   the   same   interest.   This   re-   gional    Medical    Programs    as    .    .    .     for   linking   patient   care   with    health   Nvill  eno-age  in  the   actlvltv   of   a   Re-
                                 lationship   was   a   central   theme   in   Dr.   clear   and   uneqi-iivocal.    The    focus    is
                                                                                                                                            research    and    education    Nvithin     the   ional    Medical    Program,    as    well     as
                                 Chapman's    presentation     when     he     re-   on   the   patient.   The   ob'ect   is   to   in-     entire   region   to   provide    a    mutually   those which           be   affected    bv    this
                                 ferred   to   research   in   the   service    of   fluence    the    present     arrangements     for     beneficial interaction.                           activity,    must     underlie     a     Re@ional
                                 mankind.   But   to    accomplish    this    role   health   services   in   a   manner   that    will       Regionalization     provides     a      means   Program.   By   involving   in   the   steps   of
                                 of    facilitating    productive    change,    it   permit    the    best     in     modem     medical     for     sharing     limited     health     man-   study  and  decision   all   those   in   a   re-
                                 will  be   necessary   to   capitalize   on   all   care   for   heart   disease,   cancer,    stroke,     power    and     facilities     to     maximize   gion   who   are   essential    to    implementa-

                                 36





  tity of  care            tion  and  ultimate  success,  better   solu-   problems  in   delivering   the   best   med-  process   of   setting   operational    objec-   grant   to    implement    an    operational
  the  region's            tions   may   be   found,   the   opportunity   ical  care  for  the  target  diseases  on  a  tives   to   meet   identified    needs    and   program    which    encompasses    all    or
  this as  eco-            for  wider   acceptance   of   decisions   is   regional  basis.  And  it  must   go   beyond  opportunities.    Objectives    are    interim   even  most  of   the   projects.   Implemen-
                           improved,     and      implementation      of   a  generalized   statement   to   definitions  steps   toward   the    goal    of    Regional   tation  can  occur  with  an  initial  oper-
  on also  con-            decisions   is   achieved    more    rapidly.   which   can   be   translated   into   opera-  Medical     Programs,     and      achievement   ational    program     encompassing     even
  for   coordi-            Other    attempts    to    organize    health   tional   activity.   Particular    opportuni-  of   these   objectives   should    have    an   a    small    number    of     well-designed
                           resources   on   a   regional   basis    have   ties  can  be  identified   by:   ideas   and  effect  in  the   region   felt   far   beyond   projects,  provided  they  will   move   the
  gram     with            experienced   difficulty   or    have    been   approaches   generated   within    the    re-  the   focal   points   of    the    individual   region    toward    the    attainment     of
  in  the   re-            diverted  from   their   objectives   because   gion,   extension   of   activities   already  activities.  This   ripple   effect   can   be   valid  program   objectives.   Because   re-
  r    combined            there  was  not   this   voluntary   involve-   present   within   the   region,   and    ap-  one   of   the   greatest   contributions   of   gionalization  is  a   continuous   process,
  so that  they            ment   and   commitment   by    the    neces-   proaches     and     activities     developed  Regional Medical Programs.                       a  region  is  expected   to   continue   to
  ation     and            sary  individuals,   institutions   and   or-   elsewhere    which    might    be     applied     Element   number   five   is   setting   of   submit    supplemental    and     additional
  in  of  corn-            ganizations.  The  act  is   quite   specific   within   the   region   as   part   of    the  priorities.   Because    of    limited    man-   operational   proposals    as    they    are
  within    the            to   assure   this   necessary    involvement   process of regionalization.                    power,  facilities,   financing,   and   other   developed.
  knowledge                in  Regional  Medical  Programs  -.  It   de-     The   third    element,    assessment    of  resources,   a   region   must   assign   some     After    the    implementation    of    an
  edical  care,            fines,  for   example,   the   minimum   com-   resources.   This    implies    a    continu-  order  of  priority  to  its  objectives   and   operational   program,   there    are    two
  e  viewed  as            position    of     Regional          Advisory   ously   updated   inventory    of    existing  to  the  steps  to   achieve   them.   Besides   potential  threats  to   be   avoided.   One
  her  than   a            Groups.                                         resources  .  .  .  an   inventory   of   ca-  the   limitations   on   resources,    factors   is the projects  will  lose  their  regional
  eloped    and              To    insure    a    maximum    opportunity   pabilities  in  terms  of   function,   size,  to   consider   include:   (1)   Balance   be-   identities   by    becoming    institutional
  rocess of re-            for   success,   the   composition   of   the   number,    and    quality.    Every    effort  tween   what   should   be   done   first   to   projects,  and  thereby   cancel   the   op-
  at least  the            Regional    Advisory    Group    should    go   should  be   made   to   identify   and   use  meet   the   region's   needs,   in   absolute   portunity  for   the   operational   program
  volvement,               beyond     the      minimum      requirements   existing inventories,  filling  in  the  gaps  terms,   and   what   can   be   done    using   to   have   regional   scope   and   effect.
  d    opportu-            to  be  reflective  of  the  total   spectrum   as   needed,   rather   than   setting    out  existing     resources     and     competence;   The  other  threat  is  that  projects  will
  urces,  defi-            of  health   interests   and   resources   of   on  a  long,  expensive  process  of   creat-  (2)   the   potentials   for   rapid    and/or   lose  the  relationships  one   to   another
  g of  priori-            the  entire  region.   And   it   should   be   ing   an   entirely   new   inventory.    In-  substantial   progress   toward    the    goal   which   maintain    the    interaction    of
  evaluation.              broadly   representative    of    the    geo-   formation     sources     include     compre-  of    Regional    Medical     Programs     and   patient  care,  education,   and   research.
  these   seven            graphic  areas  and   all   of   the   sOc'O-   h,nsive     health     planning     agencies,  progress     toward     regionalization     of   Preventing   these    breakdowns    requires
  parately, al-            economic  groups   which   will   be   served   hospital    and     medical     associations,  health  resources  and   services,   and   (3)   project    and    program     administration
  are  interre-            by the Regional Program.                        and   voluntary   agencies.    This    inven-  program   balance   in   terms   of    disease   of a  high  order.  It  also  requires  sus-
  ften    occur              The    second    element,    identification   tory   provides   a   basis   for    informed  categories  and  in  terms  of   emphasis   on   tained     communications,      involvement,
                                                                                                                          patient   care,   education,   and   research.   and   the   application    of    evaluation.
                           of   needs   and   opportunities.    A    Re-   judgments    and    priority    setting    on
  he   involve-            gional    Medical    Program    must    iden-                                                     The  purpose   of   the   preceding   steps     This  brings  me  to  the  final   element
                           tify the  needs  as  regards  heart  disease,   activities     posed     for      development  has  been  to   provide   a   base   and   im-   in   the   process    of    regionalization:
  individuals,             cancer,   stroke,   and   related    diseases   under   the   Regional   Program.   It    can  perative   for   action.    Thus,    implemen-   Evaluation.   Each    planning    and    op-
  tions   which                                                            also  be  used  to   identify   missing   re-                                                   erational activity  of  a  region,  as  well
                           within   the    entire    region.    Further,   sources--v   'ds   requiring   new    invest-  tatlo?i  is  the   sixth   element.   In   the
  ty of  a  Re-            these  needs  must   be   stated   in   terms               oi                                 creation  of  an  initial   operational   pro-   as    the    overall    Regional    Program,
  . as well  as                                              I             ment   and   to    develop    new    configu-
  ted  by  this            which offer opportunities        for    solu-                                                  gram,  no  region  can   attempt   to   deter-   should   receive    continuous,    quantita-
                                                                                                                                                                                                  I
  a    Regional            tion.                                           rations   of   resources   to   meet   needs.  mine   all   of   the    program    objectives   tive,  and  qualitative   evaluation   wher-
                             This   process   of    identification    of     Definition    of    objectives    is    the  possible,   desiati    appropriate    projects   ever   possible.   Evaluation   should    be
  the steps  of
  ose in a  re-            needs   and   opportunities   for    solution   fourth   element.    A    Regional    Program  to  meet  all   the   objectives,   and   then   in teri-ns  of  attainment  of  interim  ob-
                           requires  a  continuing   analysis   of   the   must  be   continuously   involved   in   the  assign    priorities    before    seeking    a   'ectives,  the   process   of   regionaliza-
  mplementa-
                                                                                                                                                                                                                     37












                              tion,  and  the   goal   of   Regional   Mecii-      Ultimately,   the   overall    success    of   cal   Programs.   lor   instance,   the    car-                             DIVISION           OF
                              cal Pro,rams.                                     any   l@egional    Medical    Prograiri    must   rriarking  of   some   of   the   l@Mi'   funds                 l@EGION,/\I,         -.\IEI)ICAI,
                                 Objective    evaluation    is    simply    a   be  J'udged  by  the   extent   to   which   it   by  the  Congress  is   viewed   by   some   as                                          PROGRAMS
                              reasonable     basis     upon     which      to   can    be    demonstrated    that    the    Re-   a  threat  to  the  concept  of  regional  ini-                          REPORTS              ON-
                              determine   whether    an    activity    should   gional   Program   has   assisted   the    pro-   tiative     and     regional     determination.                     A   NE@@'            EMPHASIS
                              be   continued   or   altered,    and,    ulti-   viden  of   health   services   in   developing   We   believe,   however,   that    this    will
                              ma:tely,   whether   it   achieved   its   pur-   a   system    which    makes    available    to   not  occur.  We  must  try   to   continue   to
                              poses.   Also,   the    evaluation    of    one   everyone  in   the   region   the   best   care   estimate    honestly    the    potential     of           Alexander     M.     Schmidt,      M.D.
                              activity   may   suggest    modifications    of   for  heart   disease,   cancer,   stroke,   and   RMP.     One     organization      was      de-      Chief,     Continuing     Education      and
                              another   activity   which    would    increase   related diseases.                                 scribed   sardonically   by    the    Economist                            Training        Branch
                              its effectiveness.                                   In  giving   you   some   of   the   content   as    a    "permanent    institution    devoted                       Division    of     Regional
                                 Any   attempt    at    evaluation    implies   of  the  revised  Guidelines,  I   would   like   to  proving  there  is  not  enough   food   in                          Medical         Proarams
                              doing whatever      is  feasible   within   the   to  reassert,  as  was  done  in   the   report   the   world."    Results,    not    assertions,
                              state of the art     and    appropriate     for   of  the   Surgeon   General   to   the   Presi-   will be needed.                                            Richard     F.    Manegold,     \,I.D.
                              the    activity    being    evaluated.    Thus,   dent  and   the   Congress   that   the   basic      And   yet   the   consciousness    of    the         Associate    Director     for     Program
                              evaluation    can    range    in     complexity   concepts    of     the     Regional     Medical   problems  of  our  society  is  not  due   pri-              DeL,elopnie?it     and      Research
                              from     simply     counting     numbers     of   Prograi-ns   reitiain   unchanged.   As    @,ou   marily   to   our   increased   s(-tisitivities                       Division   of   Rc.(,,ional
                              people  at  a   meeting   to   the   most   in-   review   the    revised    Guidelines,    which   but  more  to  the  streii,,,tli(@iieci   power                          M(,(Iz'c(zl Pro,,(,rai7i.@
                              volved     determination     of      behavioral   I  liol)c  to  have  available   for   you   in   of  the  people  in  clerfiariding  that  then'
                              changes in patient management.                    draft  form  on  Friday,  you  will  find   in-   needs   be   met.   The    question    remains,
                                As  a   first   step,   however,   evaluation   creased clarity, not surprises.                   however,   whether   the   inertia    of    the        r.    Mane@old    and     I     appreciate
                              entails   a   realistic   attempt   to   design     I   believe   that   it   is   important   to   system  in   a   large   and   complex   nation   Dthe     invitation     extended     to      us
                              activities  so  that,  as   they   are   imple-   point  out  that  this  program  is  still   in   can be overcome.                                  bv    vour    prooram    committee    to    re-
                                                                                                                                                                                                           ificant    recent    de-
                              mented    and    finally    concluded,     some   its  infancy.  It  has  not   yet   been   sup-     The   ener   ies   and    high    hopes    of   port  on some sign
                                                                                                                                                9
                              data  will  result   which   will   be   useful   ported  by  a  critical  mass  of   money,   it   those    now    working    in    the    regions   velopments       in       Reional       Medical
                              in   deter-mining   the   degree   of   success   still awaits extension of  its  initial  legis-   must    overcome    the    problems    of    an   Pro,rams.     These      developments      have
                              attained by the activity.                         lation,   and   it    still    must    document   ingrained    system.    Through    no    choice   two    things    in    common:    Thev    on'g-
                                                                                                                                  of    any    individuals,    the    time    for   inated  in   regions,   but   have   stimulated
                                By  this  rather   detailed   definition   of   more   firmly   its   value.    However,    all
                                                                                the  pressures   leading   to   its   existence   change   is   now.   The   forces   of   evolu-   chan,e  1-iere   at   the   division   of   Re-
                              regionalization,    we    arrive     at     the
                              criterion  for  'udging  the   success   of   a   have  intensified  in  the   past   two.year'S,   tion   should   prevail    and    the    system   -ional     Medical     Proo-rams.     Secondlv,
                              region    in    implementing    the     process   and   new   conditions   such   as   the    im-   should   move   to   respond   to    the    de-   thev  reflect  the  current   status   of   the
                              of   regionalization.    Success    is    meas-   plementation     of     medicare,     medicaid,   mands of the Nation's needs.                      proo-rams.     These     developments      rep-
                              ured  by  the  degree  to  which  it   can   be   and   a   greater   concern   for    increasing                                                     resent   a   new   emphasis   on   the    rele-
                              demonstrated    that    the    Regional    Pro-   costs   have   become   realities.   We    also                                                     vance  to  patient  care  of  both   the   pro-
                              gram   has   implemented    the    seven    es-   have   gained    some    meaningful    exl)erl-                                                     uraiiis   and   the   division.   During    the
                              sential    elements     of     regionalization:   ence-exemplified    best    by    this    meet-                                                     next    few    minutes,    I    @vould     like
                              Involvement,     identificaion     of     needs   ing itself.                                                                                         to    characterize    further     this     nenv
                              and   opportunities,    assessment    of    re-     As  the   programs   evolve,   now   and   at                                                     emphasis.
                              sources,   definition   of   objectives,   set-   times    unexpected       problems         will                                                       To    @ain    pmpectivc,    I    would    re-
                              ting   of   priorities,   implementation,   and   emerge,   and   some   of   them   will    test                                                     Tiiind  you  of   the   first   Nationil   Con-
                              finally, evaluation.                              sorely  the   stability   of   Regional   Mcdl-                                                     ference    on     Regional     Medical     Pro-

                              38







                                                                                                                                                            of numbers . .  .  .  If  additional  per-
  ISION    OF          grams,  held  here  one  year  ago.  Those   nent to  a  particular  project,  to  long
  MEDICAL              of  you  who   attended,   or   who   have   range program goals.                                                                    sonnel  are  employed   in   the   present
  OGRAMS               seen  the  recently  distributed  Proceed-     As   regions   matured,   the   division                                              manner  and  within   the   present   pat-
  TS      ON-          ings  of  that   meeting,   may   remember   perceived  this  important  shift  of  em-                                              tems and  'systems'  of  care,  they  vAll
  MPHASIS              its  dual  purpose:  To  encourage   ideas   phasis.  Last  fall,  the  division  reor-                                              not  avert  or  even   perhaps   alleviate
                       from  a  representative   group   of   in-   ganized  so  as  to  respond   better   to                                              the crisis. Unless  we  improve  the  sys-
                       dividuals that could  be  used  in  prepa-   evolving  regional  needs.  The  plan  for                                              tem  throu  h   which   health   care   is
  idt,   M.D.                                                                                                                                                           9
  in                   ration  of  the  report  of  the   Surgeon   this  reorganization  has  been  given  to                                              provided,  care  will  continue   to   be-
  cation  and          General  to   the   President   and   Con-   you  in   the   News,   Information,   and                                              come  less   satisfactory,   even   though
  ing  Branch          gress,  and  to  provide  an   interchange   Data release  of  January  1  1,  included                                              there  are  massive  increases   in   cost
  f  Regional          of  information   on   planning   and   on   in  your  Conference  book.  One  of   the                                              and numbers of health personnel."
  I  Programs          the  goals  of  the  program.  The   first   major results of  the  division  reorgani-                                                The  report  then  goes   on   to   make
  gold,  M.D.          meeting   did   much    to    characterize   zation  was  the  appointment  of  an  As-                                              a  number  of  recommendations   in   sev-
  r   Program          the  program  in  its  early   stages   of   sociate  Director   for   Program   Devel-                                              eral  areas.  But  you  may   have   noted
  d  Research          development.   The   meeting   was   dedi-   opment   and   Research,    Dr.    Richard                                              in  the  report   that   while   pages   1
                       cated  principally  to  the  problems   of   F.  Manegold.   This   new   activity   of                                              through 31 speaJ-. to the  specific  prob-
  f  Regional
  1  Programs          definition and  elaboration  of  the  con-   the  division  represents  the  main   re-                                              lem   of   health   manpower,   pages   32
                       cepts   of    cooperative    arrangements,   sponse  to  the  stimulus  from  the   re-                                              through  77,  or  more   than   half   the
                       local initiative, and evaluation.            gions.   The   activities   of   the   new                                              report,  are  concerned   with   improving
                         The  meeting  now   underway   is   sig-   branches  of  the  division  will  be  di-                                              the health care system.
  appreciate           nificantly different. It is  obvious  that   rected   toward   major   problems    per-                                                In  point  of  fact,  whether  one  con-
  ded  to  us          major  program   goals   have,   for   the   ccived  by  the   regions.   These   prob-                                              siders  the  manpower  shortage,  or   the
  ttee to re-          most  part,  been  defined  and  accepted.   lems  will  grow  out  of  the  acceptance                                              increasing demands  for  service,  or  the
  recent  de-          Based  on  these  goals,  program  activi-   by regions of the patient  as  the  proper              DR. SCHMIDT                     rising  costs  of  medical  care,  or  the
  l   Medical
  ents   have          ties have begun.  Indicative  of  this  is   focus  of  its  program.  Because  of  op- ing   Education    and    Training,    For   lack  of  health   care   in   our   urban
  They  orig-          the  relatively   rapid   development   of   erational  activities  there  has  been  a What?"-demonstrates      the       accept-   ghetto  areas,  or   even   the   problems
                       operational    programs.    Six     months   renewed-or   in   some   cases   a    new- ance  of  the  challenge   to   make   Re-   surrounding      continuing      education
  stimulated           ago,  four   regions   were   operational;   emphasis  on  the  relevance  of   program gional  Medical   Programs   relevant   to   and   training   of    health    manpower,
  on  of  Re-          before  the  next  6  months   are   over,   and  projects  to  the  system  of  health major health care issues of today.           one is  forced  to  consider  the  present
  Secondly,                                                         care.
  tus of  the          we    expect    between    24    and    36                                                 These issues  are  readily  identified.   health  care  system,  and  how  it   must
                       regions  to  have  submitted   their   re-     Titles   from   the   printed    program There are  now  at  least  six  groups  of   change.  Predictions  are  that  by   1975
   nts   rep-                                                       of this meeting illustrate  this  emphasis distinguished individuals  in  the  health   many   new   patterns   will   have   been
  the   rele-          quests   for   operational   funds.    The   on  the  patient   and   the   System   Of fields,  in  government,  in  professional   established    which    will     determine
  th the pro-          obvious  implication   is   the   regional   health care. I need  only  to  select  two organizations, or  in  foundations  Iseek-   many aspects of our  work  in  the  health
  uring   the          planning   is   fairly   well    advanced.   examples   from   papers    being    given ing  a  rational  approach  to   what   is   field.  The  relevance  of  this  to   the
  ould   like          I lowever'  we   have    been    intrigued   later today. One title is  "Clinical  Data viewed as a health  care  crisis.  One  of   Regional     Medical     Programs      was
  this    new          by  the  impact   of   regional   planning   Collection  with  a   Purpose."   Another: these,  the   President's   National   Ad-   stated by Dr.  Ward  Darley:  "It  is  the
                       which  the  first   operational   pro'ects   "Nursing   in   the    Regional    Medical visory   Comm'ss'   n   on   Health   Man-   response to  the  heart  disease,  cancer,
                                                           i                                                                  1 10
  would   re-          have   had.   Regions   have    discovered   Programs:  Alliance  for   Better   Care." power,  reported  recently  "There  is   a   and  stroke  legislation  more  than   any
  onal   Con-          the benefits of shifting  their  attention   Even the title  of  the  discussion  group crisis in American health care  .  .  .  .   other one thing  that  is  presently  pro-
  dical  Pro-          from  the  immediate   objectives   perti-   on     continuing      education-"Continu- The crisis, however,  is  not  simply  one   viding    the    common    ground     upon

                             29@14 0-68                                                                                                                                                             39










                                   which  the  interests  are  gathering   that             continuing   education   and   training   of            education   was    specifically    mentioned            one is  to  make  assessment  of  needs  for
                                   are  necessary  to  plans  that  will   meet             health     manpower     forces      Regional            in our enablin- legislat'o
                                                                                                                                                                                    1  n  as  a  means      educational   prorams,    this    assessment
                                   not  only  the   growing,   but   also   the             Medical   Programs   to    consider    other            of  improving  the  health  i-nanl)o@ver  of            must be  based  on  the  sN,stem  of  health
                                   changing   demands    of    our    society."             major  issues.   One   region   has   within            the     Nation.     Continuing     education            care, the role of  the  Ilarriei-,  and  his
                                   This  responsiveness  to  major  issues   is             it  an  expensive  and  excellent   facility            has  been  accepted  as  a  reasonable   and            needs.  Inescapably,   ",hat   a   physician
                                   newly   being   emphasized    by    Regional             for  the  production  of  audio-visual   ma-            desirable   process   by   most    evervone-            or  a  nurse  or   a   technician   actuallv
                                   Medical Programs.                                        terials,  such  as  color   motion   picture            but  the  question  asked  bv  Dr.   6corffc            does  is  what  mi-ist  deteri-nine  cduca'-
                                      Acceptance  of   the   challenges   posed             films  and  television  tapes.  Because   of            Miller in his article in a          recent   issue      tional  needs.  A  paper  to  be   presented
                                   by the  health  care  crisis  is  well  dem-             the  need  for  such   materials   by   that            of  the  journal   of   Medical   Education,            later  todav  accepts  this   premise,   and
                                   onstrated  by  the  activities  of  regions.             reff ion, the production  facility  and  the            and  to  be  asked   by   our   panel   this            i@eports on a  studNr  of  physician  office
                                   One  region,  faced   with   the   not   un-             re-ion  are  worklnl-   cooperatively.   But            afternoon - "Continulnl-                     Educa-     practice.  I  ,vould   like   to   emphasize
                                   common   situation   of   a   large   number             attention   has   shifted   from   the   me-            tion,  For  What?"  is  a   very   important            by  repetition  a   most   important   point
                                   of  hospitals  wanting  to  establish  core-             chanics   of   the   production   and   dis-            one.  The  answer,  at  least  for  Re-ional            made   by   Dr.   Dwight   Wilbur    Yester-
                                   nary  care   units,   was   initially   con-             tribution  of  teaching  aids  to  the  need            Medical   Programs,   -,vould   appear    to            dav.   The   problems   of   medical    care
                                   cerned  with   the   mechanics   of   build-             for  the   determination   of   the   proper            have  been  given  by   these   words   from            an@   medical   education   are    insepara-
                                   ing  and   equipping   such   units.   Their             content  and  use  of  such   materials   in            the  report  of  the  Surgeon   General   to            ble, and  medical  cciti(-ation  offers  the
                                   attention  shifted,  however,  to   a   con-             teaching   programs,   'I'lic   re-Ion   and            the llrcsicleiat. "'I'lic ultliyiate  objec-            (,i-catest potential  for  rapid  and  wide-
                                   sideration   of   how   the   region   might             the   producer   have   'ointly   begun   to            tive  of  Regional   Medical   Programs   is            spread  solution  of   identified   problems
                                   give  the  best  diagnosis   and   treatment             study  these  problems   in   the   specific            clear  and   unequivocal.   The   focus   is            or deficiencies  in  this  general  area  of
                                   to  all   patients   with   myocardial   in-             terms  of  educational   needs.   In   addi-            on  the  patient.  The  object  is  to   in-            health  care.  In  medical  education,   at-
                                   farction.  What  started  as   an   emphasis             tion,    they    have    reco-nized    their            f]Lience     the     present     arrangement      for   tention    must    be     focused     directly     on
                                   on   hardware   in    hospitals    developed             unique   ability   to   conduct    such    a            health  services  in  a  manner  that   will            the    questions:    "Will    this    effort
                                   the   potential   of   bringing   the    best    tal-    study,    which    promises    benefits    to     all   permit     the     best     in     modern     medical   chan,c      behavior?"      and,      "Will      this
                                   ent   in   a   region   together   to   consider    a    regions.                                                care   for    heart    disease,    cancer,    stroke,   chanue   in   behavior   result,    in    fact,    in
                                   number     of     critical     problems,      includ-       On   the   other   side   of   the   country,    a   and   related   diseases   to   be    available    to   the     patient      receivlnl-      the      maximum
                                   ing    the     need     for     trained     manpower,    region     unable     to     produce     its      own   all."                                                   benefit      of      modern      knowledge?"      The
                                   tli(- need fOl- Sf)('Cl@LIIZ('(l T-(",oiti@(7(,s  in     ;tii(lio-visti@il Cards has                to   (I(,-      M@iiiy                   flo%%r                                           not orliN@ fi-ol@i till,  tie%%r
                                   @l ('Oiiltiititill@, hospital, :113(i III(,  II(.I.(l                         ils  II(.(.(I  I,()I.
                                   to doclilll(..Ilt for.  cv:llti@Ltioll  I)tll'l)os(.s                   ',Ill(l  only  then   to   S(.(.Ill.(!   ill ol.(](,I. to          tll(.Ili illol.(@ (@los(.Iv   @.@Ls(., ])[It @is \%,(.II      tli(@
                                   what     emerges     from     a     possible     dra-    them    from     a     neighboring     region.     In   to  tli(,,  ol)'(,cAives  of  I\'cglotial  M(,(Ilc@it   (-)f       svstcnis of health care.
                                   matic   change    in    the    care    of    patients    these      ways,      interregional       cooperative   Programs.    For     example,     @t     contiliuin,,       I   have   said   that    these    emphases    of
                                   within a region.                                         arrangements     are     being     structured      in   education   task   force   of   one   r@,   on    has   the    regions    have    stimulated    the     divi-
                                       Another    region,    finding     itself     with    order      to      solve      elaborate      hardware   stated       that        -enerally,        continuing   sion   to    respond,    and    I    mentioned    the
                                   a    number    of     small     hospitals     already    problems.   The    point    to    be    made,    how-   medical    education    is    to    be     considered   establishment   of   a   ne@v   office    for    pro-
                                   having        established        coronary        care    ever,   is    the    switch    from    primarily    a   as   part,   and   only   part,    of    the    inte-   gram         development         and         research
                                   units,   has   turned   to    the    difficult    but    hardware    problem    to    the     larger     issue   grated    activity    of    that    program.     See-   within   the    division.    As    vou    mav    have
                                   necessary    task    of    studying    the     eftec-    of   the   proper    use    of    educational    aids   ondly,    the    obje(@tivcs    of     the     educa-   noticed    in    the     information     vou     have
                                   tiveness   of   these   small    units,    and    the    within a program.                                       tional    programs     would     relate     direction   received,       the        already        established
                                   cost/benefit   realities    of    such    units    in       I   -,vould   like   to   turn    now    to    the   to   the   objectives   of   the    region    as    a   branch     of      Continuing      Education      and
                                   small hospitals.                                         central     issue     of     continuing     education   whole,    and    Nvould     be     based     directly   'I'raining   @vill   be   closely   allied    -,@rith
                                       Even       the        problems        surrounding    and       training        programs.        Continuing   in   the    health    care    process.    Thus,    if   a     Regional      Health      Services      branch.







             This  alliance  will  allow  the  desired  separate   educational   function    from                         DIVISION         OF  the  staff  of  DRMP,  they  be,,an   wor
             interaction between the branches.          service.                                               REGIONAL               MEDICAL  on a number of  topics.  In  August,  two
               The    Continuing     Education     and     The    Regional    Health     Services                                    PROGRAMS  individuals  with  experience  as   medi-
             Training    branch    will    add    some  branch   will  be  prepared  to  conduct,                      REPORTS            ON-  cal administrators  joined  the  Division
             needed units to those  already  existing.  encourage,  and   support   research   on         OPERATIONS                 RESEARCH  for  a  6-month  period  on  leave   from
             We  have  had  an  Allied   Health   Pro-  needs,  criteria,  and  methods  for  new         AND        SYSTEMS         ANALYSIS  their respective institutions  (Dr.  Jack
             fessions section for some time,  as  well  and  improved  capabilities  for   deliv-                                              Hall'.  Director  of  Medical   Education
             as  an  Education  Evaluation   and   Re-  ery of  health  services  on  a  regional                                              of  the   Methodist   Hospital   Graduate
             search  section  headed  by   Dr.   Frank  basis.  There  will  necessarily  be   an                   Robert    Bucher,    M.D.  Medical  Center  in   Indianapolis,   and
             Husted.  The  latter  section   is   pre-  important  relationship  with   the   de-              Dean,    Temple     University  Dr.  Robert  Bucher,  Dean  of  the  Tem-
             pared  to  consult  with  regions   about  veloping National Center for       Health                School   of   Medicine   and  ple  University  School   of   Medicine).
             the difficult  task  of  program  evalua-  Services Research.  There  will  also  be               Consultant  to  Division   of     The similarity of interests  of  these
             tion. We  are  now  establishing  an  in-  developed relationships with      private            Re,lonal    Medical     Programs  people  soon  made  it  obvious  that  we
             structional media unit, and     a    cur-  institutions, medical school      depart-       Herbert  P.  Galliher,  r.,  Ph.   D.  would  function  best  in  some  type  of
             riculum design unit, among        others.  merits   of   community   medicine,   and                               i  .           team fashion, and the feeling  is  shared
             A  reference  unit  will  be  set  up  to  professional associations.                  Professor  of   Industrial   Eizgzneerzng  by all that a great deal of progress  has
                                                                                                             University   of   Michigan   and
             assist in the collection  of  information    The  branch  will  obviously   have   a              Consultant  to   Division   of  been  made  because  of   our   "coopera-
             specifically  relating   to   educational  review  and  evaluation  functio                                                       tive arran-ement."  It  is  my  privilege
                                                                                               n,            Regional    Medical     Programs              0
             and  health   service   programs.   These  which will lead naturally to  a  role  of                                              today to give this  presentation  on  be-
             units  are  intended  to  serve,  on  re-  consultation   and   service    to    the                    Jack   H.   Hall,   M.D.  half of the group by  (1)  using  an  ex-
             cluest, regional as  well  as  divisional  regions.                                         Director   of   Medical    Education  ample  for  illustrative  purposes,   (2)
             needs, and will  work  closely  with  the    The  challenges   faced   by   Regional                     Methodist      Hospital  summarizing  briefly  some  of  our   ac-
                                                                                                              Indianapolis,    Indiana    and  tivities, and  (3)  making  a  few  major
             as   yet   embryonic   Health    Services  Medical   Programs   are   now    readily
             branch.                                    apparent and, while  great  in  size  and              Consultant  to   Division   of  recommendations.
                                                        scope,  are  matched  by  the   potential            Re-ional    Medical     Programs    There have been, to date,  few  if  any
               The    Regional     Health     Services     -                                                   t,                              demonstrations of the  successful  utili-
                     I                                  for solution  offered  by  the  programs.
             branch  is  now  being   developed.   The  The  fragmented  medical  services,   the                    Maurice   E.    .0doroff  zation of operations  research  in  rela-
             need  for  this  branch  was  anticipated  rising costs of care, the shortages,  the                              Asszstant   to  tion to the health  care  system.  Never-
             in the earliest days of   the    ivision.  impersonalized   and   disjointed    sys-              Director   for   Health   Data  theless, a number  of  attempts  are  un-
             However,  because  of     the    pressing  tem,  and   the   educational   imperfec-                              Division    Of  derway     to model portions  of  the  sys-
                                                                                                             Regional    Medical     Pro@rams  tem,   and   these    appear    promising
             need to support early     planning    ef-  tions are the fabric of our  health  care
             forts, and tfi(., relatively lilgh(@r prioi-- crisis.     new  e@ripliasis  be'                                                   enough     to 'ustify our  conviction  that
                                 I                                                            ing                                                          i
             tv  ass'                                   placed  on  these  major  issues  by  Re-                                              an effort   to  develop  health   related
             1      1,gned    to    the    educational
                                                                                                      n  March  1967,  the  Division  of  Re-  operations  research  should  be   under-
             programs,  creation  of    the     Health  gional   Medical   Programs   is    being       gional   Medical   Programs   entered  taken. As we do so, we  must  be  i-nind-
             Services   branch   was   delayed.    The  reflected  by  the  developing  resources  into a contract Nv'th  the  University  of  ful of the lessons  learned  from  devel-
             new  emphasis  upon   the   patient   and  and energies of the programs.                                 1
                                                                                                   Michigan   College   of   Engincennu    to  opments  in  other  areas.  Probably  the
             the  system  of  health  care   obligates                                             obtain the consultative services of    Dr.  most  notable  contributions   of   oper-
             a new priority. Further, it  is  now  ap-                                             Herbert  Galliher   and   his   operations  ations research have been in  the  fields
             parent   that   medicine,   a    holistic                                             research   group.   Toaether   with    Mr.  of  industry,  transportation,  and   de-
                                                                                                                         n
             system,   can   no   longer    reasonably                                             Maurice   Odoroff,   biostatistician    on  fense.  In  each  instance,  it  took   a

                                                                                                                                                                                      41











                    decade  of  intense  work  before  a  rea-   and   connected   with   Regional   Medi-   the  operations  researcher   produces   a     The upper  line  on  the  slide  repre-
                    sonably   complete   definition   of   the   cal   Programs   should   recognize   the   feeling of  frustration.  I  am  going  to   sents  the  health  care  demand  of  the
                    system  was   accomplished.   The   health   opportunity  and   responsibility   which   take  a  risk  at  this  time  and  assume   population  in  the  re-ion  over  a  pe-
                    care   system   has   complexities   which   we  bear  in  this  development.   Opera-   that  many  of  this  audience  have   had   riod of  time.  The  increase  in  demand
                    exceed  any   of   these   and,   although   tions  research  can  function  only   as   little more  experience  with  or  insight   in each of  the  succeeding  years  is  a
                    some   of   the   specific   methodologies   there  is   an   operational   laboratory   into operations  research  and  the  proc-   function of  anticipated  growth  of  the
                    already   developed   may   be    utilized   within  which  studies  can   be   under-   ess  of  modeling  than  1  have  had.  If   population. The  solid  line  below  this
                    with   minor   modification,   we   should   taken.  As  the  reoions  develop   their   this is true, it is foolish to try to  ex-   represents  the  amount  of  care   capa-
                    not expect  the  health  system  to  yield   cooperative  endeavors,  they   will   be   plain,  utilizing  vocabulary  with  which   bility which  would  be  present  in  the
                    to definition in a  matter  of  months  or   constructing  the  organizational   forms   we are  familiar.  Rather,  I  thought  it   region during the next  10  years  if  no
                    even a year or  two.  This  leads  one  to   which  have  previously   been   unavail-   might  be  helpful   to   review   briefly   new  capability  was  produced.  In  this
                    reason that  initial  attempts  should  be   able. In the past, an institution  repre-   one    specific     mathematical     model   hypothetical  situation,  in   order   to
                    focused   on   specific   problems   which   sented one of the  few  health  organiza-   which  we   have   been   developing,   in   build a model,  we  have  expressed  each
                    can  be  clearly  defined,  and   a   more   tional entities which existed,  but  they   order  to  illustrate   the   process   by   of these  quantities  in  terms  of  time
                    global   approach   should   be   reserved   rarely  related  themselves  to  a  popu-   example.                                     per year, and the  symbols  define  these
                    for  a  time  when  more  of  the   pieces   lation, and  tended  to  deal  only  with     The   operations    research    approach   terms.  For  example,   N(t)   represents
                    of  the   puzzle   have   been   described   isolated episodes of illness. A  Regional   to  an  operational  experiment   may   be   the  amount  of  capability  existing  in
                    and codified.                                Medical  Program,  on  the  other   hand,   thought of as consisting  of  six  defini-   time period t.
                       Those  of  us  who  are  interested  in   has the  opportunity  to  concern  itself   tive  steps:  (1)  Formulating  the  prcb-     This  line  would  diminish  by  virtue
                                                                 with the  totality  of  the  spectrum  of   lem;  (2)  constructing   a   mathematical   of annual attrition if  no  persons  were
                                                                 specific  disease  processes  and   their   model  to  represent  the   system   under   added  to  the  system.   Assuming   that
                                                                 management.  Thus,  the   country   could   study;  (3)  deriving  a   solution   from   the training of  people  will  be  accom-
                                                                 logically  look  to  this   program   and   the  model;  (4)  testing   and   refining   plished within the region,  the  heaviest
                                                                 each  of  us  involved  to  lead  in  the   the  model  and   the   solution   derived   line  represents  the   situation   which
                                                                 development    of     more     systematic   from it; (5)  establishing  controls  over   could occur if  some  of  the  capability
                                                                 methods  of  relating  our  resources  to   the solution;  and  (6)  putting  the  so-   (X   amount)   were   to   be    directed
                                                                 the benefit of all our people.              ILItion  to  work.  Performance  is   then   toward  teaching.   Assuming   a   2-year
                                                                   In   examining   my   own   experiences   compared   with   expectations   and,   if   training course, at the end  of  2  years
                                                                 during  the  past  6  months,  I  realize   necessary, the process is  recycled.  This   there  would   be   manpower   capability
                                                                 how difficult it is for  a  physician  to   particular  example  represents   an   ap-   added  to  the  realon   as   represented
                                                                 gain  an  understanding  of   just   what   proach   to    the    manpower    develop-   by the  dotted  line,  and  if  the  same
                                                                 the  discipline  of  operations  research   ment  problem  within  a   closed   system   amount   of   teaching   were   continued
                                                                 represents.  General   contact   with   a   such as a region. It  is  not  being  pre-   in  each   year,   the   total   manpower
                                                                 systems  approach  as  applied  to  plan-   sented  as  a  finished  product  nor  for   capability per year  would  rise  as  de-
                                                                 ning efforts may lead  one  to  the  con-   the purpose  of  conununicating  its  con-   picted  by  the   continuation   of   the
                                                                 viction  that  there  is  a   methodology   tent. Rather, it is presented  as  an  il-   dotted line. It now  becomes  clear  that
                                                                 available  which  can  help  to   clarify   lustration of the  first  three  steps  in   one of the  objectives  of  any  strategy
                                                                 complicated  processes.  However,  as   a   the  operations  research   process.   The   should  be  toward  the   diminution   of
                                                                 specific  approach  is  made,   unfamili-   first stage is  that  of  formulating  the   the -ap  between  demand  a@-id  existing
                                                                 arity  with  the   mathematical   symbols   problem, and slide 1 illustrates  this  in   capability over a period  of  time,  this
                                 DR.BUCHER                       and  formulae  which  are  the  tools  of   graphic terms.                               gap  being   designated   as   A(t).   In

                    42









                                                                         SLIDE I





                                                                                     n  -7








                                                                                           ('73)












             x













                1967         68           69           70            71           72           73           74          75


                                                                                                                                                   43











                            order  to  examine  this   more   closely,                                                                       SLIDE 2
                            let us  look  at  two  of  the  blocks  in                                                                                                               + 4)
                            somewhat   greater   detail.   The    next                                                                                                        N
                            slide (slide 2) illustrates the  situation
                            as it exists  in  the  hypothetical  model
                            at this time. The total  area  is  defined                                                                                               AL
                            as N(t)  and  is  expressed  in  this  in-                                      t
                            stance  as  minutes  per  year.  The  area                                  N                                                                       q   X
                            labeled  X(t)   represents   the   portion
                            of  the  capability  which  is  given   to
                            teaching during  year  (t)  and  the  area  TEACHING                         x  t                                  z
                            designated  p(t)  represents   that   por-
                            tion being devoted  to  care  during  that
                            year. For  example,  if  this  block  rep-
                            resented  physicians,   the   N(t)   would
                            be  the  total  number   of   minutes   of
                            physician time  tvailable  for  the  year,
                            @in(i X(t) @votil(i 1)(,, the total iiiitnl)ct-
                            of minutes of plivslclaii  time  expended
                            in teaching.
                              The  block  to  the  right   represents
                            the situation 4  years  hence.  There  is
                            anew value for  N  (t)  since  additional
                            capability has  been  produced.  This  is
                            desi nated as q  -  X  which  means  that
                                9
                            the number  would   be   equal   to   the                                      t
                            amount   of   personnel    produced    by          CAR E                    p
                            each unit  of  teaching  time  multiplied
                            by  the  amount  of  teaching  time   ac-
                            tually expended  (X).  Q  is  essentially
                            a student-faculty ratio figure. The  dif-
                            ference  designated   by   Z   represents
                            the attrition  which  is  anticipated  by
                            loss of  people  due  to  death,  retire-
                            ment,  or  other   types   of   departure
                            from  the  system.  This  can  either  be
                            expressed in numbers  or  as  a  percent-
                            age of  the  total  number.  No  teaching
                            time is indicated in  this  second  block
                            since this  must  be  decided  and  corn-                   1967                                                                      1 971

                            44








                                                                           SLIDE  3                                                                      needs  which  can  be  fulfilled  only  by
                                                                                                                                                         a physician, type 2,  those  that  can  be
                                 NEED   ni(')                                                                                                            fulfilled by a registered nurse, etc.  The
                                                                                                                                                         capability   existing    (designated    N)
                                                                                                                                                         can  also  be  divided  in  terms  of  the
                                                                n,                                                                                       types of  skills  which  exist.  The  next
                                                                                                                                                         side (4) is  a  matrix  which  illustrates
                                                                                                                                                         the  interlocking  activities.  A   person
                       - - - - - - - - -  -  -  -  -  -  -  -                                                                                            having capability of type  I  can  do  all
                       - - - - - - - - -  -  -  -  -  -  -  -                                                                                            of the tasks required for  all  four  care
                       - - - - - - - - -  -  -  -  -  -  -  -      t                                                                                     types.  A  person  of  capability  type  2
                                        2 - - - -  -  -  -  -   n2                                                                                       can accomplish care types  2,  3,  and  4.
                       - - - - - - - - -  -  -  -  -  -  -  -
                       - - - - - - - - -  -  -  -  -  -  -  -
                       - - - - - - - - - - - -  -  -  -  -  -                                                                                            In  the  hypothetical  region  posed,   we
                       - - - - - - - - -  -  -  -  -  -  -  -
                       - --- - - - - - -  -  -  -  -  -  -  -                                                                                            also stated that  a  person  of  capabilty
                                                                                                                                                         type 1  teaches  students  of  type  1  or
                                                                                                                                                         2, and  so  on.  In  addition,  there  are
                                                                                                                                                         varying course lengths  for  each  of  the
                                                                                                                                                         student types. T e mat ema
                                        3
                                                                3                                        CAPABILITY  Ni                                  bols must  reflect  these  varying  types,
                                                                                                                                                         and   the   numerous   possible   combina-
                                                                                                                                                         tions  and  permutations  of  efforts  ex-
                                                                                                                                           N             pended  by  the  various  capabilities  in
                                                                                                                                                         providing  types  of  care  and  types  of
                                                                                                                                                         teaching are obvious.
                                                                                                   - - - - - - - - - -  -  -  -  -  -  -                   One  other  assumption  made   in   this
                                                                                                   - - - -- - - - - - - -  -  -  -  -  -
                                                                                                   - - - - - - - -  --  -  -  -  -  -  -
                                                                                                   - - - - - - -    2                      N             process is that it is linear in ran-es  of
                                                                                                   - - - - - - - - - -  -  -  -  -  -  -     2           normal operation. It is  likely  that  ab-
                                                                                                   ----------------
                                                                                                   - - - - - - - -  -  -  -  -  -  -  --
                                                                                                   - - - - - - - - - -  -  -  -  -  -  -                 solute linearity does not  exist  in  bio-
                                                                                                                                                                                      wever,    for
                                                                n4                                                                                       logic or social systems. Ho
                                                                                                                       -@4+-+              N             computational  purposes   it   is   appro-
                                                                                                                        Ill  11   1.         3           priate  to  assume  linearity  under  con-
                                                                                                                                                         trolled conditions as  is  illustrated  in
                                                                                                                                                         the  next  slide  (5).  As  time  expended
                                                                                                                                           N             in teaching is  plotted  against  the  ca-
                                                                                                                                             4           pability   produced   by   that   teaching
                                                                                                                                                         effort, it is quite possible that  a  non-
                                                                                                                                                         linear relationship exists. At  the  lower
                   puted  on  the  basis  of  needed  produc-   construction  of  a   preliminary   mathe-  situation somewhat more realisticall         point of  the  curve,  it  is  conceivable
                                                                                                                                                    Y.
                                                                                                                                                         that minor'           ts  in   expenditure
                   tion of persons for future years.            matical  model.  However,  the  real  life  It can be seen that the need (desig                      incremen
                      In  simple  terms,  we  have  now  for-   situation is  not  quite  so  simple.  The  nated n) is divided into several types.      of time  in  teaching  would  have  little
                   mulated  the   problem   and   begun   the   next  slide  (3)   perhaps   depicts   the  For example, type I might be those           effect on  the  production  of  capability
                                                                                                                                                                                                , i


                                                                                                                                                                                                 45











                                                                                                             SLIDE 4                                                                             it  could  be  approached  best   in   terms
                                                                                                                                                                                                 of  a  multitime  period   linear   program.
                                                                        CARE TYPE                                           TEACHING  OF  STUDENT TYPE                                              We  can   anticipate   in   the   medical
                                                                                                                                                                                                 system   that   some   models    may    defy
                                                       1                2                3                4                                  2                3                4                 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.
                                     U-i
                                                                                                                                                                                                    One   other   thing   which    must    be
                                                                                                                                                                                                 done  is  to  constz--,iin  the  computation
                                                                                                                                                                                                 so  that  it  will  not  produce  Linacccpt-
                                                                                                                                                                                                 able   solutions.   '['we   constraints   in
                                                                                                                                                                                                 this  problem   are   illustrated   on   the
                                     co                                                                                                                                                          next   slide   (7).   The   quick   solution
                                     -<   3                                                                                                                                                      @vould  be  to   turn   everyone's   efforts
                                     CL
                                     <                                                                                                                                                           toward   teaching   and    therefore    pro-
                                                                                                                                                                                                 duce   the    needed    manpower    rapidly.
                                                                                                                                                                                                 However,   this   would   be    unacceptable
                                                                                                                                                                                                 since  the  level  of  care  rendered  would
                                          4                                                                                                                                                      be  intolerable   at   the   current   time.
                                                                                                                                                                                                 Thus, the first  constraint  states  that  a
                                                                                                                                                                                                 tot
                                                                                                                                                                                                    al of all  of  the  types  of  capability
                                                                                                                                                                                                 rendering  care  in  a  given  time   period
                                                                                                                                                                                                 must be  (treater  than  or  equal  to  some
                                                                                                                                                                                                 minimum   level    of    care    which    is
                                  and that at  the  upper  end  of  the  curve         but  a  few  examples  can  be   shown   and         production  of  j-type  persons  by   i-type
                                  there   might   be   a   saturation   effect         explained.  The  next   slide   (6)   illus-         teachers   during   time   period   t    and         stated.
                                  wherein    large    additional    increments         trates  the   general   statement   of   the         mintis the loss  of  j-type  personnel  dur-            Another   constraint    is    that    the
                                  in   teaching   time   might   produce    no         amount  of  capability   which   exists   at         ing  the   preceding   time   period.   Each         -,iiiioiint of capability  devoted  to  care
                                  significant increase                                            time.  The   equation   reads   as        activity  can  be  represented  in  iiiathe-         and  to  teaching  must   not   be   -reater
                                                           in    manpower    pro-      a given                                                                                  I
                                  duction.   However,   the   part   of    the         follows:   Ni  (t)  (the  amount  of   j-type        matical   symbols    and    each    positive         than  the  total   amount   of   capability,
                                  curve  with  which  we  are   usually   con-         capability  at  time  period  t)  is   equal         statei-nent  of  fact   becomes   a   mathe-         existin, NN,ltliin the s-,7steii-i itself at  an@-
                                  cerned  is  probably  close  enough  to  the         to   the   amount   of   -type    capability         matical formula.                                     one time.
                                  straight  line  to   allow   the   relationshil.)    @vliicli existed at  the  previous  tiiii(,,  I)e-      Ul)  to  this  time   the   ol)(-ratioris   re-      While    construction    of    -i     n-iatlic-
                                                                                                                      ii of  the  L'i-iie   searcher  did   not   know   @vliat   sl)e(-'f-i(@   iiiitic@il model is %vitli'l
                                  to be expressed as a linear one.                     riod plus the ,iuriiiiiatio                 I                                                     I                           I        I I tll(- SI)II(@l-(@ of
                                     No attempt will be made to              illtis-   expen(led    in     teachin,@     the     j-tyl),@   itiethoclologies   Vince   t(@ctiriiclitcs   could   competence  of  tl@ic  or)cr,@Ltioiis
                                  trate all of the mathematical              state-    student by  the I     -                              be  utilized.  As   tli(,   situation   was   d's-                it is
                                                                                                               type   teacher    tilli(@s                              I     I            I                   1 1 ilili)Ot@t@ilit  to  reco(,tiiz(,
                                  ments    which     describe     this     problem,    the   factor    relating    tcachina    time    to   played it was possible to        identify     that   that  lie  cannot  do   this   alone,   but   must

                                  46







                                                           SLIDE 5                                            I)Iified  hypothetical   situation   utilized   another  time.   Hopefully,   it   may   have
                                                                                                              to  develop  the  model.   Real   situations,   helped  to  give  some   insight   to   those
                                                                                                              when   placed   into    the    model    form,   of    you    unfamiliar    with    operations
                                                                                                              will often  result  in  an  increase  in  the   i-(.,scai-cli on  the  way  in  -,Vliicll  it
                                                                                                              liuiribcr   of   variables    and    computa-   ftiii(7tioiis.
                                                                                                              tional time  will  rise  in  relationship  to      It  is  essential   that   there   be   an
                                                                                                              this  increase.  While  this   may   prohibit   atmosphere   of    partnership    and    par-
                                                                                                              manual   solution,   coi-nptiter    solutions   ticipation   between   the   operations   re-
                      0                                                                                       ii-iay nevertheless be  feasible  at  a  cost   searcher   and   a    teammate    ivho    can
                      0
                                                                                                              that  is  reasonable  in  rel-,ition  to  the   identify  a  problem,   state   the   problem
                  X   >-                                                                                      planning priority.                              clearly   and   precisely   in   English   or
                                                                                                                 Credit   for   the   mathematical    meth-   graphic  illustration  and  assist  in  find-
                                                                                                              odology  for  this  problem  is,due  to   Mr.   ing  the  most  suitable   units   of   meas-
                                                                                                              Leonard   Krystynak,    a    graduate    stu-   urement.    The     operations     researcher
                                                                                                              dent   working   with   Dr.   Galliher.    He   can   then   formulate    the    mathematical
                                                                                                              has  derived  the  initial  solution  and  is   statements   which    summarize,    in    un-
                                                                                                              currently    subjecting    the    model    to   ambiguous    specification,     the     exact
                                                                                                              further   testing.   We   are   now   prepar-   facts  and   principles   of   the   problem.
                                                                                                              in@ real-life data  for  insertion  into  the   From  here,  he  can  identify  the  specific
                                                                                                              model.  However,  it  is  not   our   purpose   type  of  mathematical   process-es   to   be
                                                                                                              to  exaxnine   this   specific   model,   and   utilized   in   identifying    the    optimal
                                           TIME EXPENDED IN TEACHING
                                                               x                                              further   discussion   on   it   will   await   strategy.

                                                                                                                                                       SLIDE  6
                 have    the    partnership    of    someone   strategy    by    selectively      searching
                 familiar  with  the  system  and  one   who   among the totality  of  all  feasible  corn-
                 can  assist  in  obtaining  the  most   ap-   binations   and    permutations    of    al-                                                57 qii Xii(t) - zi(t-l
                 propriate    methods    of     measurement.   locating  time  expenditure  for   each   of
                 As  was  stated,  this  particular  problem   the  capability  types  in  each  time   pc-
                 has  been  cl(-fined  as  a  multitime  pe-   r'od  to  each  type  of  care  and  to  the
                 iod    linear    program.    Without    en-   teaching  of  each  specific  type  of  stu-                OTAL AMOUNT OF CAPABILITY EX]'
                 dea@7ot-in,  to  explain  A,Iiat  a  linear   dent  in  each  time  period.  This  partic-
                 pro-,ram is, I %@,oi-ild only state that it   ular  model  with  the   hypothetical   four          THE AMOUNT OF CAPABILITY WHICH EXISTED AT PREVI  US TIME
                 is one  @vhic@i  has  been  used  for  many   types of  care  and  personnel  results  III
                 purposes,     and     computer     programs   a  linc!ai-   program   problem   consisting          THE AMOUNT OF CAPABILITY PRODUCED BY A UNIT OF TEACHING
                 exist  to  enable  tl)e  solving  of  those   of I 10 formulas and 200 variables.
                 @@-hich  are  complicated   and   extensive     Once  the  data  has  been  iiiserted,   a          THE AMOUNT OF TEACHING TIME EXPENDED
                 (e.g.,  In  the  autoi-nobile  industry   a   man   using   a   calculator   could   solve
                 linear pro@,-rain  on  the  assembly  ol-)-   the  1)roblei-n  in   several   weeks.   The          THE ATTRITION WHICH OCCURRED DURING THE PREVIOUS TIME
     c           cration is  rkin  each  night).  In  brief,   (-()ml)utcr, ho@vev(@r, can solve it in sev-
     ;t          the metlicidolo@,   picks    the    optimal   eral minutes. Of course, this is a s'                                                                           1 A(')
                                                                                                        im-                    OBJECTIVE---MINIMIZE
                                 @y

                                                                                                                                                                                                         47











                                                                     SLIDE    7                                                    a mathematical model has  been  de-                   4. Reoional economic problems  in
                                                                                                                                   veloped and is being  validated.  A                 industry related to location of plants,
                                                                                                                                   stochastic model is being attempted                 warehouses, and sales re(rions have
                                                                                                                                                                                                                       n
                                                                CONSTRAINTS                                                        with the ob'ect've of d(-termiti'n                  been ass'stecl by anotlici- set of i-nathc-
                                                                                                                                                                              lioi%,
                                                                                                                                   many coronary care units should  be                 iriatical  processes  ,N@tilcli  give   promise
                                          Pi           mi (t)                                                                      provided   in   each   locality.   If   success-    in   approaches    to    regional    economics'
                                   @TOTAL  OF CAPA                                                                                 ful,  the  model  may   be   useful   for   each    in   health   care.   The   group    has    ex-
                                                                                                                                   region.                                             amined    this     and     some     preliminary
                                      MI NIMUM- LEVEL                                                                                 2.     The     methods     of     approaching    work has been done.
                                                                                                                                   production   scheduling    problems    in    in-      5.   The   study    of    patient    traj'ec-
                                                                                                                                   dustry  may  be  applicable   to   a   host   of    tories   has   also   been   instituted.    The
                                                                                                                                   medical    problems.    The    example     cited    methodologies   in   this   problem   are   re-
                              2          pij  ( t )  +  xxii(t) <- Ni(t)                                                           today   is   one   of    these.    Another    on    lated   to   those   which   have   been    de-
                                                                                                                                   which   work   is   progressing   is   that   of    veloped     and     used      in      marketing
                                                                                                                                   coronary     care     capability     programing,    research and consumer behavior.
                                      AMOUNT  OF CAPABILITY DEVOTED  TO CARE                                                       This    represents    a    miiltitime     period      It   is   our   conviction   that   we    arc
                                                                                                                                   capability      programing      of      coronary    'ust   entering   upon   the    threshold    of
                                      AMOUNT  OF CAPABILITY DEVOTED  TO TEACHING                                                   care    modalities    and     of     manl)ow(.,r    a  new  scientific  devcl<)pmci-it   in   nied-
                                      TOTAL AMOUNT  OF CAPABILITY  EXISTING                                                        provision.   The   objective   would    be    to    ical   care.   Hopefully,   -,ve   may    leave
                                                                                                                                   determine    as    accurately    as     possible    two   major   points   with   you    at    this
                                                                                                                                   how    the    division    and    the     regions    time.
                                 The   last   slide   (8)   illustrates   the    a   number   of   problems   to    which    the   should   allocate   their   funds   and    other      First,    health     operational     research
                              process  and,  in   addition,   indicates   the    group  has   directed   its   attc@titiori.   A   r(.,sotirc(,s  in  the  establishment  of  coro-    will be  successful  oniv  a,,  there  is  full
                              magnitude  of  input  ii(,(!cl(,c]  at   ca(@li    ina'or portion of  out-  activity  has  1)(-eii   nary  care  units  and   rTianl)o@vcr-.   'I'lic    teajri%vork   between   the   Operations    re-
                              stage  by  operations  res(.,ar(,Iicrs  and  bv    cxpeiacied   in   reviewing    the    acc,,,om-   time   clynaml(.s   in   this    problem    ti-c    searcher    and    medical     people.     Full
                              medical   people   familiar   with   the   svs-    plishments   of   OR-SA    in    other    areas   comparable   to   those   shown   in   the   ex-    time   commitment   of    significant    i-ned-
                              tem    and    capable    of    making     value    and   assessing   possibilities   of   relating   aiiaple.                                            ical manpower is essential.
                              judgments.  One   can   see   that   the   bulk    these      accomplishments      to       health      3.   A   rheumatic   heart    disease    con-      Second,     Regional     '-%Iedical      Pro-
                              of  the  effort  in  all   but   two   of   the    problems.   A   few   specific   examples   are   trol   model,   which    includes    a    multi-    -rams    represents    an    operational    ex-
                              staaes   must   be   contributed   by   medical    cited:                                                                                                I
                                                                                                                                   stage   model   of   the   disease   and    con-    pertinent.   Operations   research    is    the
                              people.   The   actual   solution   is   purely       1.   Within   industry   and    the    mili-   tains  both   cl)idemiolo-ic   and   I)t-of(.-s-    science     of     operational     experimenta-
                              mathematical    and    the    model     testin-    tary    services,    OR-SA    has     developed
                              phase   is    often    heavily    mathematical.    theories   and   methodologies    related    to   sional training components         , is  I)eiiia    tion.  Thus,  those  of   us   here   assembled
                                 The     particular     methodology      used    the   prediction   of   demands    for    prod-   develol3ed.   This       utilizes      decision-    have  one  of  the   best   opportunities   for
                              in   the    example    given    (linear    pro-    ucts   and   services.   One   example   of   a   theoretic    niethodolo(ries    -,vlilch    have    a    leadership     contribution     in     the
                              o,ramina)   is   only   one   of   many   which    health  problem   to   which   these   may   be   been   developed   foi-   process   and   qlial-    development    of    its     application     to
                              are  available,  and  this  is   but   one   of    applied  is  that   of   coronary   care,   and   ity   control,   and   military    surveillance.    health.





                              48














                                                    SLIDE 8


  @S

                               FORMULATE PROBLEM    CONSTRUCT MODEL       DERIVE           SOLUTION
  y                             -------              ------------
                                                     - - - - - - - - - - - --
                                --------------       ------------
                                ------------         ------------
                                - - - - - - - - - - - --- - - - - - - - - - - - -
                                ------------
                                - - - - - - - - - - - -  -- M D
                                                     -------------
                                       D-            - - - - - - - - - -  -  -
                                -------------        ------------
                                - - - - - - - -  -  -  -  -- - - -- - - - - - - - -- OR
                                -----------
                                              -----------
                                ------------              OR
                                      0 R
  )f














                                - - - - - - - -        - - - - - -          - - - - - - - -  -  -

                                -- - - - - - - - - -  -  --- - - - - - - - - - -  -
                                - - - - - - - - - - - -- - - - - - -        - - -MD - - -  -  -
                                -- - - - - - - - - -  -  --- - - - - - -  - - - - - - - - -  -  -  -
                                - - - - - - - - - -  -  --                - - - - - - - - - - - -  -
                                - - - - - - - -  -  -  -  -@--7-=M D

                                                     -------------
                                     FA b
                                      - - - - - -    - - - - - - - - - - - - -
                                                     - - - - - - - - - -  -  -10
                                                                               OR
                                                            D



                                APPLY SOLUTION      ESTABLISH CONTROLS      TEST MODEL








                                                                                                     49


















      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.



















                                                                                      51











                                         A       NATIONAL        VIEW   division of  labor  as  we  all  move  to-   of three or four major  types.  The  first   sic'an  time  by  tak'n,  over  tasks   in
                                 OF         DEVELOPMENTS          IN-   gether  to   meet   the   Nation's   needs   concerns training of  individuals  in  the   intensive  care  units,  hyperbaric  cham-
                                             HEART            DISEASE   for better health care.                      techniques  of  cardiovascular   research,   bers,  emergency   rooms.,   hemodialysis,
                                                                          Our   mutual   involvement    in    this   diagnosis, and  care.  Our  trainina  pro-   and other  functions.  The  Institute  has
                                                                        common   endeavor   obviously   is   Corn-   grams  have  several   ainis   of   impor-   looked  upon  such  an   effort   as   re-
                                  Donald   S.    Fredrickson,    M.D.   ple-@ and our roles  are  not  so  clearly   tance to  regional  activities.  Currently   search, for all discoveries of '
                                                                                                                                            1 11                                            1         impor-
                             Director,   National   Heart   Institute   divided,  for  discovery  and  application   we have as  fello,,vs  or  trainees  I)rl-   tance are not molecular in         nature.
                                                                                                                                                                                     1    1
                                  National   Institutes   of   Health   are  not  casilv  separated.   Society-not   marily learning how to     do    research,   The  broader  application  of   successful
                                                                        unreasonably-supports  all  of   our   ac-   nearly 1,800 individuals.   Since its  in-   portions   of   such   prototype   exper,-
                                                                        tivities  because  it  expects   something   ception,  more  than  I  1,000  scientists   ments  is  not  within  the  resources  of
                                                                        better for  itself.  It  gains  when  dis-   have  been  trained  under  the   training   the Institute  and  is  distant  from  the
                              ome  time  ago  I   would   have   con-                                                                         ips      program.   center of its mission. It is mu
                           S   sidered   this    morning's    program   covery is applied.  In  this  sense,  dis-   grants  and  fellowsh'                                                       ch  closer
                           best  defined  as  an  "interfaith   meet-   cover-y  may  only  become  real  when  it   Some  of  these  men   are   now   leading   to Regional Medical Programs.
                                                                        becomes    practical    and    safe    and   and  participating  in  aspects  of   l@e-
                           ing."   My   judgment    and    pronuncia-                                                          I     1    1                         A  second  program  of  direct   impoi--
                                                                        clearly  beneficial,  and  when   it   be-   gional   Medical   Programs,   and    more   tance   to   Re-ional   Medical   Programs
                           tion   have   improved   alike.   I    now
                                                                                   'lable to those  who  need  it.   will follow.                                 is  the  development   of   cardiovascular
                           know that  this  is  better  described  as   comes rival                                   1
                           an  "interface  meeting."   Defining   the     Thus,  the  Heart  Institute   has   its     Of more    direct relevance is  a  rela-   research  and  training   centers.   These
                           surfaces  at   which   the   programs   of   stake in delivery of  such  gains  it  may   tively  new  program  of  clinical  train-   are units Ienvisoned  in  the   President's
                                                                        achieve   through   research.   And    RMP   ing -rants. Begun in  1966,  35  of  these   Commission   for   Heart,   Cancer,    and
                           the categorical  institutes  and  the  Re-
                                                                        has  its  stake  in  applying  the  mecha-   grants  are  currently   being   supported   Stroke  and  for  which   plannin@   funds
                           gional    Medical     Program     mutually   nisms of  discovery.  For  how  shall  you   by  the  Institute.  The  ob'ective   here   were first awarded '
                           interact  is  a  difficult  exercise,  but                                                                            i                                     in fiscal year  t966.
                           essential to perform.                        know, 'save  by  applying  the   best   of   is  to  train  physicians  who  understand     With  respect  to   the   Cardiovascular
                                                                        experimental   methods,   how   to   solve   enough  of  research  to  make  it  easier   Reseach   and   Training   Centers    pro-
                                                                                                   I
                             In  organizational     language      the   the problems  of  application,  to  deter-   for  them  to   apply   new   developments   oram,  I  should  begin  by  stating  that
                           mission  of  the  National  Heart   Insti-   min                         valuate    the   and to teach  them  to  others.  They  are
                                                                            c the needs, and to e                                                                 no centers  are  presently  in  existence.
                           tute is  to  develop  new  knowledge  that   worth   of    interventions?    And    how   an  essential   "hybrid"   ingredient   Of   At least one  is  ready  for  fundin-  and
                           will lead  to  both  a  reduction  in  the   shall  new  techniques   be   taught   and   the plans to ii[)gracle the  I)rict'ce  of
                                                                                                                                                                  IO arc now  in  the  plannina  stage,  but
                           rate  at  which  healthy  individuals  de-   disseminated   most   widely   except   by   cardiovascular  medicine.   'I'licy   will   the  first  specific  operational   grants
                           velop    cardiovascular    diseases    and   those   who   have    acquaintance    with   not all  remain  in  1-iniversltv  centers   under  the  center  concept  are  expected
                           improved   care   of   those   who    have   the method of their discovery.               and  most  are  not  expected  to   pursue   in  1969.  Thereafter,   -iven   available
                           such diseases.                                 We   have   common    purposes,    then,   research as a major means of the'
                                                                                                                                                              ir
                                                                                                                                                                  funds to support  the  operation  of  such
                             The   major    mission    of    Regional   and  must  be  prepared   to   blend   and   livelihood.  Their  contributions   should
                                                                                                                                                                  centers,  the  NHI  timetable  calls   for
                           Medical  Programs   would   seem   to   be   cxhange  our   eflorts,   expertise,   and   have a major  impact  on  the  success  of
                                                                                                                                                                  two  to  become  operational  in  1969;  a
                           to promote   the   application   of   that   resources  at  many  points  of   contact.   Regional Medical Pr@,-rams.
                                                                                                                                                                  total of five  in  1970;  seven  in  1971:
                                                                                                                                                          nter-
                           knowledge and to  see  that  its  benefits     As  we  see  the  programs  in  the  rc-     'I'he Heart Institute    is also i
                           are available  to  the  greatest   number.                                                                                  training   10 in 1972; and t2 in 1973.
                                                                        gions unfold,  there  are  several  inter-   ested in some aspects of the                    I
                             This  separation  of  the  concepts   of   faces   between   these    programs    and   of  special  paramedical  skills.  On   an     What -,vill these centers     be?     We
                           discovery  and   delivery   seems   splen-   those of  the  Heart  Institute  that  are   experimental  basis,  we  have  been  sup-   hope  they  will   represent   true   car-
                           didly convenient.  It  is  also  not  very   particularly identifiable  at  this  point   porting,  for  example,  the   Duke   Uni-   diovascular  "centers   of   excell   nce"
                                                                                                                                                                                                     c
                           helpful Ln(I cotil(i be              wrong   in tilli(@.                                  @,(@rsit.y (,fl'or-ti to tf'.'Iirl I)IIysi(@l;ttl                    tll(- Pt-(,-,](If,llt,s
                           if interpreted as 21 I)L'I-f(@(@tly  WOI'l@@Ll)]('            litstittit(, @l(@t'tv'[tl(!S ;LI,(, ;Ls.@lst;tiits. 'I'll(!S(,. iii(liv,(Itl;llss:tv(@ I)IIY-

                           52






                                                                      While  the  center  will  be   conducting        pect them to be  foci  of  activities  rele-       vascular    rather    than    cerebral    in
                                                                   a broad range  of  studies,  it  will  also         vant to Regional Medical Programs.                 origin.
                                                                   be  involved  in  research  directly  rele-           We   expect   to   increase   the   number
                                                                                                                                                                             A  third  kind  of  program  of  interest
                                                                   vant to  the  solution  of  clinical  prob-         of  planning  -rants  to  20  or  30.   This       to   our   discussion   this   morning    is
                                                                   lems   posed    by    the    cardiovascular         will  provide  a   competitive   basis   for       coordinated  research.   Much   of   it   is
                                                                   diseases.                                           selecting the 10 to  12  that  will  qualify       funded   by   contracts   and    aimed    at
                                                                      Thus  it  will  provide,   or   else   be        eventiaally  for   full   operational   sup-       solving   specific   problems   of   general
                                                                   closely  allied  with,  personnel  and  fa-         port.  The  criteria  of   excellence   that       interest  and  judged   to   be   especially
                                                                   ciliti(@s essential to the conduct  of  ad-         we  have  set  for  these  centers  are  ad-       important.   Generally   these   deal   with
                                                                   vanc(-@d   diagnostic    and    therapeutic         inittcdly   hi,-h.   Given   the   continued       accelerating     developmental      research
                                                                   procedures,   'I'lic   operational    grant         availability  Of  funds  for  this  program,       or  testing  out  on  a  large   scale   the
                                                                   will provide funds  for  the  care  of  re-         we   expect   that    enough    institutions       efficacy    of    possible    interventions.
                                                                   search  patients  both  on   an   inpatient         will  -radually  develop  the   capabilities       Both   are   the    inevitable    byproducts
                                                                   and  outpatient  basis.  The  center   will         needed   to   qualify   for   an   equitable       of  more  basic  research.   All   tend   to
                                                                   be  a  clinical  rcsource.for  referral  of         geographical  distribution  of  centers   to       be     expensive,      complicated,           and
                                                                   patients   requiring    highly    sophisti-         be achieved.                                       highly   demanding,   both   of    Institute
                                                                   catcd  diagnostic   or   therapeutic   pro-            Meanwhile,   there   are   many    units,       and   community    resources.    They    are
                                                                   cedures  not  generally  available  in  the         smaller   than   the   centers    envisioned       also   essential    for    advancement    of
                                                                   average  community  hospital   or   clinic.         above,   which   are   now   being    funded       means    for     managing     cardiovascular
                                                                      The  center  will  provide   a   training        as  program  projects.   They,   too,   pro-       disease.
                          DR. FREDRICKSON                          resource  for  equipping   scientists   and         vide   a   combined   attack   on    cardio-          The first  of  these  is  our  Artificial
                                                                   physicians with tli(-,  sl@ills  and  tech-         vascular   diseases   by   multidisciplinary       Heai-t-Myocardial          Itifarction     pro-
                  As  we  are  now   planning   for   them,        niques    of    modern    biomedical    re-         support.  The  Institute   was   a   pioneer       gram.    This    program    is     combining
                each  center  will  be  an   organizational        search.  Throu-h  its   clinical   training         in   creating   such   programs   and    be-       bioenginecring    and     biomedical     ap-
                                                                              s, it should be a  focus  for  cf-       lieves  they  have  significantly   enriched       preaches   to   the   problem    of    heart
                unit,   existing   within   the   framework        program
                of a i.iiilversity or similar  institution,        f(,@ctive  dissemination   of   the   fruiti   of   the  clinical  capabilities   in   major   lios-   disease  in  general   and   the   actite   heart
                                                                            arch   to   the    region    which    it   1)'t@ils,  both   Lin'@,ers'ty   and   tinaffil-   attack in particular.
                for   the   purpose   of   attacking   a   broad   its  r@,@e                     I        I       1    1                   1    1                                  1
                range     of    cardiovascular           disease   serves.   The   activities    of    the    center   lated.  Again,  the   basis   for   fundin-   is      The    bioengineering    attack    on     this
                                                                                                                                                                  0
                problems.                                          will   be   national   or   even    international   primarily     research     productivity.     The   enormous     health     problem     is      being
                  ideally,,  the   center   would    be    orga-   in  scope  but  it  @vill  exert  its   strongest   cluality   of   the   diagnosis    and    treat-   carried   out    by    the    Artificial    Heart
                II;                                          (Ii-               on      cardiovascular      research   i-netit  in   these   institiations,   ho@vcvcr,   branch.    It    is    presently    concentrating
                 lz(,c]         a sit    I
                                    I gl(, outstanding
                rectoi-.   It   would   be   staffed   with    a   2,,id  clinical  care   in   the   region   where   has   invariably   gone   up   hand   in    hand   on   the   development    and    refinement    of
                corps  of   scientists   and   clinicians   rep-   it is located.                                      with research.                                     devices    to    provide    pumping    assistance
                resenting   not   only   the   clinical   disci-      It  is  axiomatic   that   a   good   clinical      I  expect  that   Dr.   Masland   will   deal   to  damaged   or   failing   hearts.   There   is
                plines,  but  also   the   physical,   engineer-   research    program    in    a    hospital    has   with    activities    relative     to     stroke   reason   to   believe   that    temporary    car-
                ing, and social sciences.                          a   way   of   improving   the    medical    care   centers,   for   his   Institute   has   a   far   diac,    assistance    can    salvage    patients
                                                                                                                iits   lar    -  share  than  otirs  in  such  a   pro-                          -ary  loss  of  sufficient
                                                         so,(,
                          I                       - for        il              by tfi(,, regular warcl I)at'(,                                                                    of  a  teriil)oi
                   l'i-(-)vis'on  will  I-)(-  ir)a(l(,
                           to work  in  stifllcj(!iitly  (@lo,;c   in tli@it lio.,il)ltal. In  -the  case  of  tli(@            We         pleased  to  I)(,-  able  to   (,,ji,(I'ac I)tiiiil)iii,@  reserve.  We  i-ice(I
                proximity    to    encourage    free    exchange   center,  we  hope   that   it   will   serve   as   participate   in    j.oint   council    activities better    devices    and    more    investigation
                of    information,    ideas,    and    construe-   a   standard   of   excellence   for    hospitals   concerning  this                         ffering   to  prove   their   capabilities   as   well   as
                                                                                                                                              pro-ram,  o
                                                                                                                                                   n
                tive criticism.                                    in  its  sphere  of  influence.   We   also   ex-   such    program    help    as    is    primarily   their    limitations.    Within    the    present

                                                                                                                                                                                                                         53











                                     constraints,   we   are   also    supporting    re-    to     determine     what     drugs     or     other   the    problem     of     sudden     death,     that   susceptibility      to      atherosclerosis      and
                                     search   aimed    at    solving    certain    vital    measures    miaht    be     used     to     minimize   lar-C    segment    of    infarctions    or    other   coronary    heart    disease.    It    thus    seems
                                     problems     of     materials,      pumps,      en-    heart-muscle       damage       resulting       from   coronary    deaths    which     do     not     reach   reasonable     to     suppose     that      elevated
                                     ergy,     and      controls      necessary      for    the attack.                                            the hospital.                                          blood   lipids   also    advei@l@,    afTect    sur-
                                     development     of      a      permanently      im-       They   will    seek    to    understand    better      'I'he      Myocardial      Infarctioii       pro-   %,lv-al    among    patients    who    have     sus-
                                     plantable   device   to    replace    the    heart.    the     development     of     arrhvthmias,     car-   grain   will   seek   to    coordinate    the    ac-   tained     heart     attacks      bv      increasing
                                     It     is     presumed-and     I     think     cor-    diogenic    shock,     and     other     potentially   cumulation      of      knowledge      Of      man),   their    susceptibility    to    recurrent     heart
                                     rectly-that    such    a     device     will     be    lethal    complications    of    the    acute    at-   aspects  of   its   specific   concerns.   Its   co-   attacks     and     related     complications     of
                                     feasible.   It   will   only   be   desirable    if    tack     and     means     for     more     rational   operating    research    units    need    not     be   preexisting coronary heart disease.
                                     it    permits    complete     rehabilitation     of    management.                                            restricted   to   10   or   12   large   operations.       We   hope   to   establish    that    long-tenri
                                     a     productive     individual.     We     proceed       They    will     evaluate,     more     precisely   Ways     are     being     considered     now     of   reduction    of    blood    lipid    levels     will
                                     on   this    premise.    In    this    regard    it    and     thoroughly     than      has      previously   how   the   facilities   of   the   Regional    Pro-   confer     some     protection     against     these
                                     should   be    noted    that    heart    transplan-    been     possible,     both     accepted     methods   gram   might   be   utilized    and    joined    iii   complications     and     thus     improve     lon--
                                     tation   and    artificial    devices    are    not    of    treatment    and    promising    new     ones,   this effort.                                           temi survival amoncy these patients.
                                     mutually      exclusive.      Indeed,      develop-    including        assisted-circulation        techni-      Of    direct    importance     to     the     Re-       We   hope   that   one   or    more    of    the
                                     ment   of    both    possibilities-as    a    total    ques and devices.                                      gional     Programs     is     an     example     of   lipid-lowering    drugs    being     tested     will
                                     problem       of       "cardiac        replacement"       The    units    themselves    will    be     well   coordinated   res(-@ti,cli   to    try    out    the   reduce   the   5-year   mortality   rate    by    25
                                              to                                                            ;Ill(l                         ;Irl(l  (.ffl(.;I(.y  of  ;I,               I()  I)II'Vi'lit              of, error,(,.
                                        Of more                ])Cl,tlllerlce to Ite-                  I.01.                                                        iiif;ti-(@tioii. 'I'lils  is  tli(,       'I'lie drugs 1)('illg C%',Lltt@tLcc[      Coll-
                                     gional    Medical    Proc,rams    is    the     co-    and   patientcare.   An   aim    is    to    attract   Coronary       Drug       pi-oject-a       secondary   'ugated     equine     estrogens,      d-tllyroxine,
                                     ordinated     program      to      improve      all    to    this    neglected    problem     those     who   prevention trail.                                      nicotinic     acid,     and     chlofibrate.     All
                                     phases    of    medical    management    of     the    have   felt   infarction   to   be   too    hopeless      Mortality    from     first     heart     attacks   are   known   to    reduce    blood    lipids    and
                                     acute   heart   attack.   This   is   the   primary    or    complex    for    application     of     their   is    about    30    percent;    but    with    each   to  be   free   of   serious   toxicity,   and   all
                                     goal     of     the      Myocardial      Infarction    special skills.                                        recurrent     heart     attack     the     patient's   are     currently       available       to      tile
                                     branch     of     the     Artificial     Heart-Myo-       The      MIRU's      will       be       training   chances    of     survival     decrease     sharply.   practicing physician.
                                     cardial Infarction program.                            grounds     for     medical     and      paramedical   Most   heart    attack    deaths    are    due    to       The     study      involves      55      clinics
                                        Presently   it   is   supporting   the    estab-    people    needed    to    extend     acute     coro-   recurrent    attacks;    and,    with    each    re-   throughout       the       continental        United
                                     lishment       of       Myocardial       Infarction    nary   care   to   as   much    of    our    popula-   currence,    the    likelihood    increases     that   States,      Hawaii,      and      Puerto      Rico.
                                     Research    Units,    or    MIRU'S,     at     five    tion    as    possible.    The    ultimate    effec-   death   will   be   sudden   or   else   occur    so   Eventually,   it   will   involve   a    total    of
                                     university       medical       centers.       Even-    tiveness     of     the     MIRU     program      is   swiftly      that       hospitalization       proves   8,500    patients,    more     than     1,200     of
                                     tually, 10 to 12 will be established.                  dependent     upon     the      development      and   impossible.                                            which   are    already    enrolled.    The    clini-
                                        Each   of   these   units    will    be    espe-    clisset-niiiation    of    new    knonviedge     and      The    oal     of     the     Coi-oniry     DRLI@   cal   phase   will   be   coi-npleted    in    1974.
                                                                                                                                                              9
                                     cially   equipped   and    staffed    to    conduct    techniques    that    can    be    applied     when-   project  is  to  see   if   lipid-lowerin(l,   drugs   Aiiion-    the    clinics     particll)atin-     are
                                     intensive   research    on    acute    heart    at-    ever    and    wherever    heart    attack     cases   can     improve        long-term            survival   some     involved      in      Re@ional      Medical
                                     tacks     and     their     complications     while    start.                                                 amony    heart    attack     patients     by     re-   Prourams.   Here    is    an    example    of    how
                                     providing    unexcelled     medical     care     to       The       Myocardial       Infarction        pro-   clueing     the     incidence      of      recurrent   Realonal     Pro,rams     with     its     coordina-
                                     heart attack patients.                                 aram     will     do     more      than      develop   heart    attacks     and     other     complications   tion,     access     to     large     number      of
                                        These    units    will    attempt    to    learn    MIRU'S.    It    will     actively     support     a   of    preexisting    coronary     heart     disease.                 and     special      expertise      in
                                                                                                                                                                                                          patients
                                     as   much   as    possible    about    the    pres-    program    to    develop    animal     models     of      Elevated      blood      lipids,       especially   patient      management      may      find       op-
                                     ently    unpredictable    clinical    course     of    infarction,     study     contracts     to     close   blood     cholesterol,     have      been      found   portunity       for       important        research.
                                     acute   heart   attacks.    They    will    attempt    gaps    in     knowledge,     and     to     examine   consistently     associated      with      increased   Field     trials     arc      indispensable      for

                                     54






                            determinin-      applicability      of       research    these    products    be    met    without     serious    components      of       blood       that       occur                     A           NATIONAL            VIEW
          and
                            findin(,s.    'I'lirougli    R.MP     the     "field"    strains on existing blood resources.                     through     outdating      in      storage.      This          OF               DEVELOPMENTS               IN-
          seems
          vatcd             is    now    better    organized    and    can     be      'I'hc     clinical     demand     for      specific    includes    the    study    of     chemical     addi-                                                   CANCER
          t sur-            more helpful than ever before.                           blood    components    such     as     red     cells,    tives  as   well   as   the   storage   of   cellular
                               There    are    other    NHI     field     trials,    platelets,    or    specific    protein     fractions    components      at      very       low       tempera-
          sus-              such   as   effect   of   relief   of    extracranial    has     increased     rapidly      during      recent    tures.       Present       freezing       techniques,             Kenneth       M.       Endicott,       NI.D.
          !asing            occlusions    on    incidence    of    strokes,    of    years.    It    will    probably     increase     far    which      are       expensive       and       rather    Directoi-,      National       Cancer       Institute
          heart             the   value   of   renovascular    repair    or    of    more   rapidly    in    the    near    future,    for    cumbersome,     need      to      be      streamlined            National      Institutes      of       Health
          ns of
                            treating     1)@lelonephritis,      or      hyperten-    the    use    of    whole    blood     where     some    and,      where      possible,      automated      if
          3e.
                            sion,    of    gamma     IobuJins     in     prevent-    sl)c(@ific   blood   component    is    called    for    their   full   potential   is   to   be    exploited.
          -term                                                                                                                                   I                     I
          will              inly   hepatitis   after    open    heart    surgery,    is     being     increasingly     considered      un-    The     National     Cancer     Institute,      like-    -Decent        and         important         develop-
                            to    name    a    few.    A-ain,    some    partici-    desirable    and    wasteful.     The     list     of    wise,    has    a    considerable     program     re-    -L@   ments   in   the    field    of    cancer    at
          these
                            p,tnts      in RMP      units       are       already    such     components      is      increasing,      and    lated     to     blood      products,      particular    the    moment    are    not    in    its    treatment
          long-             involved.                                                includes   frozen   cells,   as    well    as    pro-    platelets     and     other     formed      elements.    and    diagnosis,    but    its    prevention.    The
          nts.                 Finally,    there   is   one    more    new    co-    teins    latelets, and leukocytes.                           It    is    planned     that     the     National    pace    of    discovery    in    the     relationship
          f the                                                                           I p
          I will            ordinated      program      that      deals      with      The   use   of    the    specific    blood    corn-    Blood      Resources      program      will      also    of   viruses   in   the    production    of    cancer
          Dy 25             p 'roblems     of    great    national    and     re-    I)onent    to    correct    a    specific     deficit    study    the    feasibility    of    better     corn-    is    indeed    rapid.    I     personally     regard
                            gional     concern,     the      availability      of    yields    superior     clinical     results     while    puter-based       inventory        systems        for    it   as   certain   that   viruses   play   an    im-
          con-              blood and blood fractions.                               diminishing     the     risk      of      transfusion    blood     and     blood     products     than     are    portant    role     in     causation     of     human
                               This     is     the     National     Blood     Re-    reactions.   At   the    same    time,    it    makes    now    available     on     a     regional     basis.    cancer    and    I    entertain     some     optimism
          xine,             source     program,     now     in     its     second    it   possible   for   a   single   unit   of    blood        These,     then,     are     some     of      the    that   we    may,    indeed,    discover    an    ap-
          . All             year     of     operation.     Althoii,,Ii      head-                                                                                                              lood    I)roach   in   that    direction    in    the    pro-
                                           ,tt Nill, this                            to S(!I,V(, ill(- ll(.(,(Is of iii@iiiy                  1)i-(@(,nt @oils of the Nit'oiial B                         it'oii  of   this   disease.   'I'li's   has   il-
                                                                                                    ill(.              ilo@lis   of'   the                                                             V(ll  I            l    I
                                                                                                                                                                                                       ready  been  @iccoiiil)llsliecl   -,vitli   re,,ai-(l
                                                                                     N;itloti;tl l')Ioo(I                               Is        o;tl, of (-,otii,s(-, is to iiisiti,(.,. tliit all                                                 n
                                         of Institt.it(,,s @Aricl (livisioi)s  of                                                                                                                      to   certain    cancer    ill    experimental    ani-
                            NIH,     other      l,ederal      a(,encies,      and    to   il]SLII-C   an   adequate   supply   of    blood    @icle(ILi@itc     supply     of     whole      blood,
          inics                                        .    . 'D                     fractions    to     meet     clinical     and     re-    plasma,    or    specific    blood    fractions    is    mals   and   I   do   not   think    man    is    all
          fired             jion-Fccl(-ral      organizations       such       as    search     needs.     With      contract      support    always     available     whenever      and      wher-    that   different.   That    is    the    only    hope
                            the     American     Red     Cross     and     Amerl-                                                                                                                              at    the    moment    for    any     general
          @i(@o,                                                                     from      this      program,       the       American    ever it is needed.                                         see
          a] of             (-all Asso(-]@Ltioll of I'@100(i 1))@itik,;.             National   l@ed   Cross   ii   @vc)rkiiig   oil    an        T-low   some   or   all   of    these    programs    solution of the I)robleirl.
                            participants    share    a    coi@rimon     interest:                                                                 'II    specifically    interlock     with     re-       No\v    we    are    certainly    not     lackitig
          0 of              All    are    concerned    in    some    way    @vith    ritegratcd      blood      fractionation       system    \v  '1onal    activities    is    to    be    resolved.  causes   for   cancer.    There    are    at    least
          ,Ilni-            the      acquisition,      processing,       stora-e,    for      the      large-scale      production      of    gi                                                                                        hemicals        that
          974.                                                                       specific  blood components.                              Your   presence   will    be    of    the    greatest    a thousand different c
                            distribution,   usaffe,    or    study    of    blood
                                                  I'D                                                                                         importance    in    i-nakin(y    our     own     pro-    can    produce    the     disease     in     animals'
          are               and     blood      products.                                When  perfected,  such              a     systei-n                                                                               now    how     many     of     them
          lical                The    major    goal    of    the    program    is    could    be    installed    in    large,    strategi-    grams      more      meaningful.      We're      glad    We do not k
          how               to    improve    all     phases     of     technology    cally    located    blood    banks     around     the    you're   here.   We   will    do    our    best    to    have     something     to     do      with      human
                                                                                                                                              %vork   ivith   ),on   and   for   you    in    everv    cancer.     Several     fori-ns     of      radiation
          lina-             related   to    the    handling    of    blood    and    country    to    serve     regional     needs     for                                                             produce       cancer.       Various        hereditary
          of                blood      products.      Oniv      through      more    blood and plasma fractions.                              way we can.                                              factors   seem    to    operate    from    time    to
          in
                            efficient    production,    stora(,e,    and     dis-       Other    major    concerns     of     the     pro-                                                             time;    endocrine    imbalance    and,    in     the
          op-
          @rch.             tribution      of      blood products      can      a    gram    are    research    on    ways    to    reduce                                                             light    of    some    recent    studies,    probably
          for               steadily        accelerating        demand        for    the   losses   of   whole    blood    and    cellular                                                             arrangements      of      the      immune       mech-
                                    292-414 0-68-5                                                                                                                                                                                                        55




                                     m




                                     anisms have something to  do  with  it.                         and its preparation for  loans  to  phy-                         of the medical  schools  have  qualified                         able  to  make   available   sometlllncr
                                     There are  so  many  causes  of  cancer                         sicians and hospitals around the  colin-                         and are being funded  Linder  this  pro-                         much    better     than     N!oLi     have     no@@,     fol,
                                     that     to     eliminate     them     all     would      be    trv.    '17tiat    program    is    still    in     existence    (,i'aiii.   I   iiil"-Iit   iii(ll(-atc   that   oLir    i(]-    Iii,,Ii %,olt@i(,(@  tlici@al)\..  Oi@(-,  of  tli(@  ,i-cztt
                                     a    superhuman     task.     But     the     virus     al)-    but    as    @'OLI    call    well     @tl)l)reciate,     the    visol's                         halt    (-V(@1-y    (.fl,ol-t    sliol'tl,,es,    we    believe,    so     fai-     as     the
                                     proach, I think, offers                      liol)e.            (]eV(-Ioj)lll('Ilts  III  ill('  field   of   l@@icli@-I(Ioti    Slioill(i  1)('              to              this      ti(@@v    1)1-01)(,I-                         of
                                       Now,  that is  not  to say tl)at                              siti(-e  I!)'i7  liziv(-@   soiiic%vli@it   cliiiiiiii,,Iic(l    I)i@o,,i-aill,   III   YOLII'   tCI'IIIS,                        tl(@Ilts   is   (Concerned,   is   the    sl)(.)i-ta,,c    of
                                     are    not     advances     in     the     diagnosis     and    the     importance      of      ra(IlLim      use.      'I'hc    noiiiinational       or       interfaith,"       so        we    radiation      therapists.      At      the      risk      of
                                     treatment      of      cancer.      There      is      slow,    second    was    a    -rant    to    Di-.    E.    0.    Law-            cnco@tra,,ccl       the        medical        schools    I)cln,,r   shot   down    by    sor-n@,    of    niN@    col-
                                     steady       proaress       in       sur-ical        mana-e-    rencc     in     California      for      cxaminlnl-      the    to      lll%'OIVC      11ILiltiple      departments       and    lca"LleS    ill    the     audience     who     are     acii-
                                     ment      and       impro%@ei-nents       in       radiation    potential      of      the      cyclotron       for       the    establish    t     1)z-o-i@aiii     ,vliicli     does     not    cral    radiologists,     I     would     like     to     rc-
                                     therapy.     Of     particular     interest      to      me,    treatment of human cancer.                                       become     a     captive     of     a     single      depart-    port   that     we     have      been      adn@isecl      and
                                     because      of      my      background,      has       been       The      institute      was      very      small       and    merit.                                                           @ve     a(rree     that     the     trainino-      aeneralIN7
                                     progress     in     chemical     treatment      of      can-    consisted       larcely        of        an        intramural       In    the     late     1940's,     radiation     was     a    -iven     in     therapeutic      radiolo,@,      in      the
                                     cer   so    it    is    now    possible    to    say    that    basic        research        proram        until         1946    field    of     intense     interest,     and     the     ra-    Course of         preparation           for           general
                                     some     forms     of     human     cancet-      can      be    %vli(-n    tlic@    present     i-)Ii(,iioii)crlal     growth    (]lo](),,.ists   Nv(,I-(.'    very    tilti(.Il    interested    I',I(Ilolog@F     Is     quite     lrll(le(filate.      About
                                     cLii-ccl    with    drugs.    That     is     an     iml)or-    of    Nltl    1)(,(,ati.     Shortly     after     that     a    in    ]indicate.     I'm     litl)l)y     to     say     that    6  ,ears a,,o      we       launched       a       I)ro-raiii
                                     tant       development,        even        tliouh        the    number      of      new      pro,,rams      were       estab-    they    still    are.    One     of     the     nc@v     pro-    to     inil)ro%-e     and     increase      the      trainin,
                                     field    of    application    at    the     present     time    lishcd      by      the      National      Cancer      Insti-    grams    at    that    time,    Nvlilch    has     a     real    of       therapeutic       radiologists.        It        was
                                     is     quite     limited.     Chemotherapy,      in      the    ttitc     which     were     aimed     at     the     problem    relevance      here,      was       the       clevcloj)i)icnt    stai-tlln(,  to  cl's(-n-,@er   tl)at   'II   1   960   there
                                     better     centers,     has      come      to      represent    of    the    provision     of     services.     The     first    and    installation     of     a     series     of     incga-    @,,,ei-e     some      15      therapeutic      racliolo,ists
                                     an       important       therapeutic       device        for    of      these      pi-o-i'ams      was       a       teaching    volta,Te      instruments      for       exploration       of    in     training     in     the     United     States,      of
                                     palliating         advanced         and         disseminated    grant      to      medical      schools      and       dental    their         therapeutic         possibilities.         From
                                                                                                                                                                                                                                       @@,hicli     eilit     @vei-c      forel,,,zi      nationals.
                                     cancer.    Its    skillful    use    can     keel)     many,    schools       for       improving       the       unclergrad-    this      has      come      the      present      Generation    After 6             of intensive effort in               this
                                     many         people          reasonably          comfortable    uate      education      in      the      diagnosis       and    of       linear       accelerators       and        betatrons    field,  the  ntii-nber  of  Ai@iierican                   na-
                                     and       productively       engaged       until        vir-    treatment        of        cancer.        That        pro,ram    and     the     like.     This     program      has      'ust    tiolials in ti-ainin, has (@ ne from                   se-,--
                                                                                                                                                                                                                           i                                              @o
                                     tuallv the end of their disease.                                was      discontinued      about      2       years       ago    been brOU-Ilt Out and dusted off                     and         en  to  70.  There is quite a little                      em-
                                      We      have       lon@       been       concerned       at    and     replaced     with     a      nenv      one      which    lvcn    a    new    start    @vitlilii    the    past    year    phasis given to radiation bioloc,                         and
                                                                                                                                                                                                                                                                                      ny
                                     the     Cancer     Institute      with      the      problem    has    a    much    broader    tar-et.    It    is     called    or     two.     The     radiologists     aclvlsln(,r      Lis    radiation      research      in      the      course       of
                                     of    the     provision     of     services.     The     Na-    the       Cancer        Clinical        Training        Grant    believe     that     the      present      -eneration      of    ti-aiiiin-.     About     15     oi-     16     are     bein-
                                     tional     Cancer     Institute,      which      is      the    pro,ram      and      is       aimed       at       improving    hire      ener-v      sources      is      outmoded      ancl    trained      each      ,@ear.      Thev       are       bein-
                                     oldest      institute,      was      char@d      by      the    the       educational        environment        in        the    that    it    is    possible    to     ci@eate     a     neav    snapped    Lip     in     the     medical     centers     and
                                     Congress,    with    the     total     job     of     bring-    medical         schools         and         university-teach-    generation      of       radiation       sources,       pai@-    schools      and      we       could       place       i-nanv
                                     ing      the      disease      under      control.       The    in-      hospitals      to      enhance      the      edlica-    ticlilarly     lincai-     a(@celei-ator's     and      clec-    more     than     we     leave.     We      are      continu-
                                     Cancer     Institute,     created     in      1937,      had    tional    c.-<I)cricnce     of     everyone     @@,lio     is    ti-oii I)etiii sources                will      be       much    in,,,    to     expand     the     triiiiinl-     base     as
                                     ai-ithorization      from      the       be,,lnnin-       to                  c(Iti(,ation  Vince  ti-@iiiiiiio'  '                        't(@cl   to    iii(icl(,i-ii    cl@tv    treatment.    more     persons     (-oriil)letc      tli(,      tt@aiiiin,,
                                                                                                                                                        I       in    more stil
                                     ciiga,c in the provision of services                      as    that   institution.    'I'lic    ti-ainin,,    1)1-0(rl,@1111    We              (](,Velol)lli(@lit                   till-       @iticl     iTiove     to     an     institution     N%'Iiet-c
                                     @vell as in research and education.                       It    no     Ion--er     aimed     just     at     the      medical    clerwan,.    I    hope    Nvitliln    a    matter    of     a    thev   can   set   Lil)    a    ne\@-    focus.    I    would
                                     is     interesting     to     look     back     and      see    student      but      at      the       house       officers,    few    itlontlis     to     let     contracts     for     the    think    it    mav    be    from    5    to     10     @-ears
                                     what     has     been     done     about      this.      Two    nurses,          paramedical          personnel,          and    fabrication     of     the      first      new      machines,    before     there     will     be     enou-h      to      ade-
                                     of    the    first     thin@s     done     included     pro-    post(,radiiite       students       such       as       prac-             Nvill     (ro     on      trial      in      perhaps
                                                                        I                                I                                                                                                                             (Itiatcl@ man      the medical schools                   that
                                     curement    of    a    large     supply     of     raditin@i    ti(@in,,     I)h@lsicians.      Al)l)i-oxifiiitcly      fialf    three    ot-    folit-    I)I@i(,cs    so    we    may     be    will be in existence at tli@it time.
                                     56







                                                                                                                           Id   of   cancer    is    somewhat   Kettering Institutes d i s t r i b u  t  e  d
                                                                                                                  The fie                                                       1
                                                                                                                unique  in  tern-is  of  its  research  base.   around   in   the   50    regional    medical
                                                                                                                Along  about   the   same   time   that   the   programs   with   which    you    are    con-
                                                                                                                Coii(,i-ess   was   establishing   the    Na-   cci-nccl. This  is  not  to  say  that  there
                                                                                                                tioll@ll         Institute, sevei-@Ll (',Olll-  is 110 cztiicci-  potential.  I  -,@,otildn't
                                                                                                                iiaunitics or  States  did  the  same  thing.   ,vant  to  suggest  this  but  we  have  very
                                                                                                                The   State   of   New   York-    established   few   complete   centers.   This   has   been
                                                                                                                the   Roswell   Park   Memorial   Center   at   a  matter  of  great  concern  to   the   Na-
                                                                                                                Buffalo.   The   State   of   Texas    estab-   tional   Cancer   Institute   for   a    long
                                                                                                                lished  one  in  Houston,  the  M.   D.   An-   while  and,   since   1960,   we   have   had
                                                                                                                derson   Hospital.    Private    philanthropy   funds  provided  by  the   Con,ress   to   do
                                                                                                                established   the   Sloan-Kettering    Insti-   something about this.
                                                                                                                tlite  in  New   York   City   which   became     These  are   cancer   center   funds;   Dr.
                                                                                                                associated    with     Memorial     Hospital.   Fredrickson      mentioned      the      same
                                                                                                                Through  Dr.  Farber's  effort,   the   Chil-   thing  in  the  heart   field.   We   had   a
                                                                                                                dren's     Cancer     Research     Foundation   running  start  on   him   because   we   al-
                                                                                                                was  established   in   Boston.   There   was   ready   had   some   complete   centers   and
                                                                                                                another   one   in   Philadelphia,   one   in   some  bits   and   pieces   that   might   be
                                                                                                                Detroit,  and   these   have   come   to   be   put   together   around   the   country.   So
                                                                                                                the   backbone   of   cancer   research   and   we  have  tried  to  build  upon   -,vhatever
                                                                                                                advanced   cancer   clinical   training    in   nuclei  we  could   find.   And   I   rru'ght
                                                                                                                the  United  States.  If  they  have  a  uni-   mention  some   of   the   things   that   we
                                                                                                                versity  affiliation,  most  have  a   rather   encountered.   In   one   institution,   per-
                                                                                                                tenuous  one,   and   many   of   them   have   haps,    the    department     of     surgery
                                                                                                                none  at  all.  These  are  the  cancer  cen-   would  be  sufficiently  interested  in   the
                                                                                                                ters   in   the   United    States-some    of   cancer field to be ,N,illin-- to set aside  a
                                                                                                                them  are  large  and  very   expensive   or-   substantial  number  of  research   beds   to
                                                                                                                ganizations.   I   think   the   budget   for   create  a  cancer  clinical   research   cen-
                                                                                                                the     Memorial     Sloan-Kettering      may   ter   which   then   mi-ht   tale   on   some
                                                                                                                be on  the  order  of  $25  million  a  year,   "iiiterdenomiiiational"      flavor       and
                                                                                                                including   the   hospital.   Such    centers   serve  as  a  focus  for  other  departments.
                                                                                                                as   Memorial   Sloan-Kettering,   1\1.    D.   In   other   medical   schools,   it    would
                                                                                                                Anderson,    Roswell    Park,    have    what   turn   out   to   be   the   department    of
                                                                                                                I  regard  to  be  an   adequate   cl'   ical   radiology. In  a  few,  very  few  I  niig  t
                                                                                                                base   to   serve   geographic   regions   in   acid,  the   department   of   medicine   was
                                                                                                                terms  of  training,  consultation,  and   of   interested,  and  we  bcan  with   a   clini-
                                                                                                                accepting   referred    patients    afflicted   cal  center  that  was   oriented   primarily
                                                                                                                with almost any form of cancer.                 for  chemotherapy.  It  is   most   unusual.,
                                                                                                                   It is  quite  obvious  that  in  the  near   in  fact,  I  am  sure  I  wouldn't  use  all
                                                                                                                future  we  are  not   going   to   have   50   of  the  fin@ers  on   one   hand   to   list
                                                                                                                M.   D.   Anderson   hospitals   or    Sloan-   medical  schools  that  had  a   stron,   in-
                                                    DR. ENDICOTT
                                                                                                                                                                                                           57






                                                                                                  large,   is    likely    to    see    enough    patients     broad    spectrum    of    different     kiii(-Is     of    sary  for   sc\-et-al   ;tdja(,(,iit   i-c-,'
                                      terest    in    the    three     ma'or     areas.     We                                                                                                                                                                         ions     io
                                      I)e-ari     making     these     ,rants     in     1960.    of    the    ri,,ht    ,7aricty    in    a    reasonable     cancer.    We    tried     orgarilzitiff     this     on    coordinate and (-oi)solidate their
                                      I think    there    are    perhaps    20     by     now,    time    to    carry    out    a    therapeutic    trial.     a    re@iorial    basis,    eastern,    middle     wcst-    forts.
                                      most    of    them    limited     pretty     much     to    So   it   became   necessary    to    set    up    sonic     er,ri,   far   Nvest.   It   didn't   work   very   well      NV(@ i-iiade a little try about a
                                                                                                  kind    of    cooperative    network    ii-i     \vla'ch     arid     we     finally     collapsed     the      thin,    ago   \Keith   a   sl)c("-,il   problem   I   iiii'llit
                                      one field.                                                                                                    1                                                                                             I
                                         At   the    time,    or    shortly    I)efoi@e    the    a     number     of     institutions     could      work     about   2   to   3   years   ago   aiici   put   it   on    mention    in    the     field     of     CI)oi-iocarc'
                                      legislation      was      passed      which      created    on     a     common      protocol      to      coml:)are     a    national    basis    operated    by    the     Uni-    oiiia   in   Nvoiii(,,ii.   It   is   now   I)ossll)](,
                                      this   I)i,o,,i,aiii,   ,ve   were   (,i@,cn   an   al)-    this     therapy     with     that      therapy.      We     -,-crsitv    of     Wisconsin     at     the     present    treat   this   disease   \@itli   cli'tias,   to   sa\,
                                      propriation  of  funds             for          planning    Nvere       particular]),       interested       because     time,.                                                      the titer[is,  Ltiid  foi-  tli(,  \\-oiiicti  to  lia%
                                      grarits    by    the    (otigress    and    have    made    we     had     a     large      drLI,      developi-nent       We    have     reaclieci     the     stage     Nvlicre    SUC(@CSSfLil    I)i,e-iian(@l(,s     afterwards.     'I
                                      a    number    of     such     gi-aiats,     some     of    program       arid       this       meant        nothing     we   do   not   believe    that    the    present    Or-    (IC) SO  I-CCILII1,cs  lattice,  (@xtciisl\.c  I-,Il)ol
                                      whicl-i     looked      to      ariibitiotis      cancer    unless     the     dru,s     were     given     clinical     -anizational        framework        for         tlicra-    atoi-N7    facilities    arid     treatment     ftclil-
                                      pro(,rarris.    One,    in    a    lar,e     metrol)oll-    trial.    So     be,iniiiii,,,     about     1956,     a     pctitic    trials    is    adequate    to    meet    our    ties  iiici  sl)c(-Iallv  ti,i@iii(,d
                                                                                                                              iN,-c      groups       were     needs   for   the   testing    of    new    dru,s    and    arid  lal)
                                      taii    area    in    the    west,     envisions     the    series   of  cooperat                                                               I                                              oi@atot-@-   people.   The,    iii(,lcleii((,
                                      construction    of    a     700-bed     cancer     tios-    established      which      have      involved      hos-     Nvc   are   ,oiii-   to   set   tip   a   much   smaller    is   low   in   the   United    States.    'I'lle    ca
                                      pital     in     connection     with      a      general    I)ltals      and      primarily      medical      school     organization        for        that,        concentrated    arc   tiilcl(@r 1,000, so it                   proposed
                                      hospital      which      would      provide       sei-v-    faculty     members     all     over     the      United     Nvithiri    just    a     few     institutions.     How-    some,   of   the   leaders   in   this    field    that
                                      ices,    serve    as    a    research    and    reaching    States.    They    be-an     in     the     field     of     ever,      the      usefulness      of       cooperative    @i   regional   @il)l-)i,oacli   be   made   to   tlii,
                                      centers,    and    as    a     geographical     referral    chemotherapy.      They       were       later       ex-     network    still    remains;    in    fact     it     is    I)iol)leiii  I)\,  setting  air)   perhaps   a   little
                                      center.     The      entire      administrative      and    tended      to      examination      arid       combina-     about    the    only    way    to    test    out     new    dozen    (-etiteis    scattered     at     sti'ate,,"],
                                      staff  sLil-)I)ot-t   for   this   is   being   included    tioii    therapies,     sur,,(,ry     arid     clieiiio-     therapeutic      ideas       in       a       reasonable    c(,iit(@rs    throughout    tli(@    country    wtici@@
                                                                                                                                                                                                                                                               be  I  Ot,   0111%
                                      in    the    planning.    I    don't    know    if    it    therapy,     radiation      aiicl      surgery,      and     time.   Of   course,   we    are    not    go    n    to    tli(,, disease ('(-)Lll(l 110\\             I
                                      will   ever   come   into   being,    but    at    least    different      modalities      of      radiation      so     abandon    this    program    -    we,     are     olti,    dia(,iioseci  but   @ilso   ti-(,atcd.   'I'llese   ol,
                                                                                                  that     at     the     present     time     al-)I)roxi-     to keep it go'
                                      soriicoiie is taking a swiii(, at it.                                                                                                     ing.                                         OLISIV \NOIII(L f)(' ('Tl(',Ig(@Cl in  r(,scai,cli
                                         Our        involvement         in         therapeutic    iiiately    one-sixtli    of    Out,    entire    budget       However, I  think  that we have                      a    We                       I)i-.   -NI@ti'stoii    aboard
                                      trials     has     been     extensive,     arid      has    is   invested   in    therapeutic    trials    of    one     common     task     liei@e     to     see     wlietlici-    this   problem   @iiid   it   (I(,\   (,loped    tliltt
                                      stretched    over    many    years.    I     am     sure    sort     or     another.     In     sonic     instances,     much    of    this    (could     be     better     orga-    x@  @is  (,rNr             to ti-N@ to (-Io  tl)is  I)\
                                      there     isn't     an      institution      represented    these    have    been     organized     On     a     re-     iiizecl  and   I)ctt(,t-   a(,coiiil)lislic(l   Nvithiii    tli(,  @IP 1)(,(,@iuse                      in R@\1  1)
                                                                                                  -lional basis.  This  tisii                                  tli(,,    frame@vork    of     the     RMP.     'I'her(,    has  to  1)(,,   'ii'ti-it(@cl   I
                                      here     that     has      not      participated      in                                      ally          happened                                                                                                  ocall@     iji(I
                                      these   trials   at   one   time    or    another,    or    with     tli(,,      more      common      types      of     are  ol)%,Io@islv  some  of   the   ie,(,Iotis   tli   t    filleted I)N, t,ll(, lo(. II     (,()Illlllltt(,c     Valid
                                      in   one    way    or    another'.    As    you    know,    ttimors     where     you     could     find      enough     ha\-eii't      a      lar,,c      enough      population    (,oiiie   to                     That   N@-otilci   1),
                                      caricei@   is    the    second    leading    cause    of    patients    in    a    rc(,ioii.    More     ordinarily,     base  to  i   iak(,,   this   feasible.   If   you   arc    I)I'Cttv          to                        tliouolil
                                      death,     but     that      doesn't      mean      very    they   have   been    ot-,,aiilzed    on    the    basis     ,olti,,  to   sttidv   a   disease   @vli'cli   has   an    it   Ic    at   that   state.   N\'(,    sought    @iii
                                                                                                                                                                                                        I                        @'Ist
                                      iriuch   because   it    is    really    a    collection    of    specialties.     'I'he     pediatricians     seat-     incidence     of     perhaps     10,000     cases     in                  to             this I)I'ol)lclll  until
                                      of   relLiti%7cly    rare    diseases.    I    don't        tt,i,ecl   around   in   the   (lill(li-eli@s    liospi-     tli(,,  United  States   in   a   @,(,ai-, then     tli(,   tli(,  RMP  ciii  slitk(,  (lo\@ii  @i,  little   !)]I,
                                      know    how    many     types     there     are,     you    tals     I)arid     to-etticr     to      study      the     intermountain  plateau   out                 in     iiiv    but  I  think  it   is   a   (,ookl   exiiill)l(,   (@l
                                      can't   get   the   1)atliolo,,lsts    to    a-ree    on    therapy    of     actite     leukemia     or     rhabdo-     home     country     just     will     not    g(,ti(@rate   N@liat  might  1)(,  done  ilitelll(,,(,IltlN-   1,
                                      that,    but    there    are    probably    well    over    iii@Tosar-coiiia or what have You.                           (@iioti,,Ii  cases  to  do  iii(j(@li  %vitti.  If  this               @t    collection     of
                                      100.    This     presents     very     serious     prob-        We    made    on(,,     effort     in     stiid@'in-     were   to   be   undertaken   in   soiric,   of   tli(-,                 tliit,  ai-(@  extr(,itlclNl   (liffic@iii
                                      leitis    in    therapeutic    trials     because     no    (Inigs   in   Nvliat   is   called   Phase   2   studies     iiioi-(,  sl)ai'S(Ilv  s(@ttlecl  s(@ctioils  of   tti(@    'Lli(i               to   tr(@.it.
                                      slil,,,Ic      institution,      no      matter      how    where    you    try    a    new    drug    a-ainst     a     cotiliti@y,   it   @votild   1)rol)ablv    be    iieces-                      @@@oti](I like to  @l(lill,lt  trial!

                                      58









                                                                                                                                                                                                 rela-
                  are kibitzing.       should  1)(,  able                  A        NATIONAL        VIEW      Drs.     Fredrickson     and     Endicott   as yet extremely inadequate in
                                                                                                                                                                            I
              to do a lot  i-norc  about  cancer  and  so         OF          DEVELOPMENTS          IN--   have  very   al)ly   presented   their   In-   tion to the size of the problem.       Esti-
              are engaging in  a  Itixur@,  of  kibitzin@                                                  stitutes'  programs  in  heart  disease  and   niates place stroke mortality at       200,-
                                                       .1'                                        STROKE
              And  we  have  several  studies  in   prog-                                                  cancer as they relate, or              ulti-   000  deaths  a  @rear.,  and  morbidity   at
              ress that may turn  out  to  be  useful  to                                                  niately relate, to your  worl,  in  the  re-   2  million.  Costs  exceed  $1  billion  per
              vou. One is  the  c%,aluation  of  the  re-             Richard    L.    Masland,     M.D.   -lions. I  would  like  to  review  for  you   yeai-  in  medical  and  nursing  care   and
              quirem(@nts  in  the  field  of   radiation         Director,   National   Institute    of   the  form  and   some   of   the   substance   loss of earnings.
              therapy  foi-  an  adequate  therapy   cen-   Neurological   Diseases   and   Blz'izdne,@s   of  the  program   of   the   National   In-
              ter  in  terms  of  equipment,   personnel,           National   Institutes   of    Health   stitute  of   Ncurolocrical   Diseases   and   JOINT COUNCIL
                                                                                                                                n                         SUBCOMMITTEE
              the population  base  that  it  can   sene,,                                                 Blindness in stroke.
                 bable   case   load    per    population                                                     Our  efTort  and,  in  fact,  the   whole      Our program in       stroke   began    to
              pro
              base. Tfic groul)  ,vhich  is  working  oti                                                  national effort  in  the  stroke  field  are   take shape about 7       years   a-0    with
                                                            T   am   sure   the   excitement   we   have
              this, created by  one  of  the  study  sec-   JL felt  here  in  Bethesda  at  seeing  Re-
              tions, is a grotil)  of  academic  radiolo-   g'onal  Mcclic@al  Pi-ograi-ns   come   into
              ,ists. They are going  to  try  to  develop   bcin(,  has  not  been  as  great  as  yours
              some outline  for  the  ideal  center.  One   in  the  regions,  because  you   can   look
              can learn a  lot  about  this  from  Europe   forward to the  thi-ill  of  being  in  (II-
                                 t(
                                   ) li@tv(@ R@l(litIffIll(,- I-(Ic@t contact With tll(@ 1)(-ol)l(', You
              iii;@t ;1,11(1     (11(!Y (lo @LlilioSL ;Lll                              \%'(@ (I()
                                                                                                 g(@   L
              ra(li@Ltioii tli(@i-al)y. 'I'li(-y @ti-(! @IISO ('(!- 11101't@   1001@ at  tll('  national
              %@eloping  what    they    call     halfway   picture, and  I  can  assure  you  that  to-
              houses. These, I    think,   are   a   more   day   there   is   considerable   excitement
              realistic plan of what      could  do   to-   in that.
              dav %@@itli then manpower  @v(@  have  ;met            whole   concept    of    blanketing
                   the resources                            the   country    with    regionally    based
                I am happy to report to           that  I
                                                            programs    for    improving    distribution
              think  we  have  more  resources  that,,N,e   of  medical  services   and   speeding   the
              need  in  one  area.  I   think   we   have   application  of   research   and   technical
              more   cobalt   machines   than   we   need   advai-ices   was   so   revolutionary   that
              and  one  solid   contribution   would   be   many  of  us   expected   great   opposition
              a  cobalt  collection   pro(,ram   to   get   and  difficulty.  'I'lic  opposition  turned
              some of them back. 'rliank you.               out  to  be   ncgligil-)Ic   compared   with
                                                            tll(,                -iiicl @ilthougli  cii-
                                                            cleavers  of  this  kind  arc  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                                         L
                                                            practical  realization   of   one   of   our
                                                            highest goals.                                                                      DR. MASLAND

                                                                                                                                                                                                    59









                             fon-nation  of  a   joint   Council   Sub-          (2)  the  si-ipport  of  broader,   coordi-          ably,  depend'n-  on  the   problems   they           than 3         old., reports are  be-'nnin,-
                                                                                                                                                       1 1                                                                         01
                             committee    on    Cerebrovascular    Dis-          nated  attacks  on   oroups   of   problems          are  attacking.  Several  are  devoted  ex-           to flow frot-n them in  considerable  x-ol-
                                                                                                         0
                             ease  consisting  of   National   Advisory          by perhaps as  many  as  15  to  20  physi-          elusively to sin(yle  approaches,  such  as           time, and @ve have            hi,h  hopes   for
                             Council  members  from   the   Heart   and          c'ans and scientists,  plus  various  kinds          epiclem'ologv
                                                                                                                                                         ot- the study  of  aphasia;        this part of our pro-i-am.
                             Nei-iroloffy   Institutes,   and    other    con-   of   technicians    and    other-    sLil)portin(,   others ai-(@.               with   several    i-e-       More    recently,    on     recoriiincnclatioii
                             SLI]t,ints expert  in  Specific  liters.  'I'lils   staff.                                               latc(l                  sti(@lt -Ls tll(@             of tll(@ @joint  C@Otil)Cil  Stil-)(@olillilittcc,
                             (Il'OLIJ-) is the chief "Ilicilli@', force of tll(',   @V(, nonv li@iv(@  16 of              ct@iit(,I,s                 of,               blood   flo',@',               ofl'(@l-(,Cl ,I-@ilits fol. 'I,    type
                             pro,ram,   and   has   been   in    larae    part   @vorkin(,-    exclusively    in     cci-cbrovascu-   cel-cl,)ral cellitlai- itietal)ollsiii, @inct  ef-    of  facilitv  Nvh'cli  we  will   be   calliii--,-
                             responsible    for    its    coordination     and   lar   disease,   and   two    more    have    been   forts  to  affect  these  factors  with   cIrLi,s,    the   outpatient   clinical    researcl-i    ceii-
                             development.    Advice    to     the     Councils   approved   by   our   council    but    not    yet   inhaled   gasses,    and    other    means.    Al-    ter.    These    units    should     substantially
                             and    Institutes,    sponsorship    of     meet-   funded.     The     centers     vary     consider-   thou-11   most   of   these   centers   are   less    expand  our opportunities           in      epidl-
                             ings,   conduct   of   surveys,   provision    of                                                                        FIGURE I
                             the   "push"   to   -et   new    teaching    pro-
                             (yra.ms  started   are   a   fc@v   examples   of
                             b                                                                            STROKE RESEARCH                      CENTERS SUPPORTED  BY  NINDB                                    1968
                             the   @voi@k-   of   this    subcommittee.    The
                             whole   pro-ram   is    tinder    its    constant
                             revienv,   and   much   of   the    pro-ram    is
                             a   direct   result   of   the   group's   recom-
                             mendations.

                             CENTER GRANT PROGRAM
                                                                                                                                                                         MINNEAF                                                        BOSTON
                                                                                                                                                                        ROCHES
                               By   about   1960,   it    had    become    ap-
                             parent   that   many   of   the   broader   ques-                                                                                                                                                      YORK
                             tions   in   medical   research    would    prob-
                                                                                                                                                                                                                                        ELPHIA
                             ably   never   yield   to   the   piecemeal   ap-
                                                                                       BERKELEY                                                                                                                                     E
                             proach     of     simply      supporting      the
                                                                                               I\1           !I            I                   .                                           0  BLOOMINGTO
                             proposals     of      individual      scientists,                                                                 KANSAS CITY
                                                                                   7                                                                                         @ST.       Louis
                             project   by   project,   as   they   came    in,
                             no   matter    how    worthwhile    they    were,                                                                                                                                   0 DURHAM
                             individually.    We    therefore    began    sup-                                                                                                                            WINSTON -SALEIM
                                                                                                                                           I                                    "14pMEMPHISZ"
                                                                                                                                                                                 L
                             plementing     our     project     grants      by
                             awardina     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   addinff   a   little   to   the   growth
                                                                                                                                                                                                                      MIAMI
                             of  biology,   or   refining   in   some   degree
                             our  knowledge   of   life   and   disease,   and

                             60






                                                                 FIGURE 2                                                                  Personnel  at   a   central   registry   at
                                                                                                                                          the  University   of   Iowa   have   analyzed
                                 CEREBROVASCULAR  RESEARCH  PROJECT  GRANTS                                                               the   accumulated   data   on   over    6,000
                                                             NINDB - 1968                                                                 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-
                                                             MINNEAPOLIS                                                      BOSTON      bility  of  various  age  groups,  sex   dis-
                                                                      I        ,,      MILWAUKEE                                          tribution,    most    common     sites     of
                                                            ROCHESTER
                                                                                                                              YORK        aneurysms,   sites   related   to   age   and
                                                                                                 CLEVELAND
                                                                     IOWA CITYO')             --7.   0 @,              PHILADELPHIA       sex,  percentages   of   patients   who   had
                                                                                        CHICAGO                        I                  warning  signs,  the  relation  of   environ-
                                                                                                         ik            LTIMORE
                                    0                                             NDIANAP               11                                mental  events   to   hemorrhage,   and   the
                                                                                        OLITSO                ORGANT    WN  ,
                                                                                                                                          value    of    angiography    in    detecting
                                  SALT   LAKE    CITY                                       0 BLOOMINGTON
                                                                                                                                          multiple     aneurysms.     Also     produced
                                                            KANSAS CITY I    ST    Louis,
                                                                                                                ID DURHAM                 were  new  analyses  of  the   mortality   of
                                                -------                                 WINSTON-SALE
                                                                                        f
                                                                                      1-@           I"                                    nonslirgically  treated  cases,   the   risks
                   LOS  ANGELES                         I                                                                                 of  death  and  of  rebleeding   at   various
                                             0                                                                                            time   intervals   after   hemorrhage,    the
                                           ALBUQUERQUE
                                                                                            I                   CHARLESTON                statistically  critical  size  of  aneurysms,
                                                                                            KS                                            and  the  influence  of   age,   sex,   aneu-
                                                                                                                                          rysiai  site,  and  general  patient   condi-
                                                                                                                                          tion  on  survival.  Among  the   stud@s
                                                                HOUSTON                                                                   liigliliglits was the  statistical  verifica-
                                                                                            ANS                                           tion of  intracranial  aneurysm  as  the
                      Number of Grants                                                                              MIAMI                 most  common   cause   of   subarachnoid
                                                                                                                                          hemorrhage-51   percent.    Next    most
                                                                                                                                          common  is   hypertensive   arterioscle-
                                                                                                                                          rotic  cerebrovascular  disease-t5  per-
          ml()Iogy  and  other  areas  where  ambu-  studies in such fields as  neurophys'ol-    t'st'cal studies, because of the large   cent. Other findings Nvere    that   the
                                                                                        1        1 1
          latory patients can  be  helped  and  can  ocy and  biochemistry  to  clinical  in-                 a that can  be  collected   peak  frequency   for   hemorrhage   due
                                                                                                 amount of dat
                                                                                                                                          t  aneurysm I'    ,i th the 50 to 54
          make a contribution to  research  at  the   estimations of drug effectiveness,  the    and  analyzed  throu-h  the   combined   0             les  1                 age
                                                                                                                    0
          same time.                                 improvement   of   diagnostic    devices    efforts of a number  of  institutions.   'rotip  and  that  hemorrhage  from  an-
                                                     and                         devc1olDmcnt    The Institute has  been  supportin-  a   etii-vsm is more common in  Nvomen  b-,r
            Pro'ect  grants.-In  addition  to   the        t(@(,hn'qLlcs,  and                                                               I
                                                                 1                                              udy   of    Intracranal   a ratio of  3  to  2,  thouo-  men  pre-
          broadly targeted ,vork  of  the  centers,  of  ever  more     ingenious    surgical    Cooperative   St                  ni                              nh
          about  50  research  projects  are  bein,  approaches.                                 Aneurysms   and   Acute   Subarachnoid   dominate  below  age   40.   The   studv
          conducted   with    Institute    support.    CooperatiL,c   students.   -   Another    Ilemoi@rhacre  amon,  24   university-   also revealed that headache and  dizzil-
          These  cover  I)ra(,.ticallv  the  entire  ldromising  approach  to   the   problem    based centers here  and  abroad  since   ncss  occur  before  hemorrhage  in   at
          spectrum     f rom   basic     laboratory  of stroke is  through  cooperative  sta-    1958.                                    least 90 percent of the cases.
                                                                                                                                                                                61













                                                                                                            FIGURE 3                                                                                              serves  as  another   illustration   of   what
                                                             COOPERATIVE  STUDY  OF  INTRACRANIAL  ANEURYSMS                                                                                                      can  be  done  cooperatively.   As   the   Re-
                                                                                                                                                                                                                  ,Ylonal    Medical    Prorams    develop,    I
                                                                               AND                   SUBARACHNOID                   HEMORRHAGE
                                                                                                                                                                                                                  am  sure  they  will   provide   many   excel-
                                                                                                       NINDB              1968                                                                                    lent   new   opportunities   for    collection
                                                                                                                                                                                                                  and analysis of data.

                                                                                                                                                                                                                  TRAINING
                                                                                                                                                                                                                    One   of   the   principal    reasons    for
                                                                                              ------                                                                                                              the   modesty   of   our   past   efforts   in
                                                                                                                                                                                                          TON     stroke  research   has   been   the   shortage
                                                                                                                                                      ut                                                          of   people   trained   in    the    necessary
                                                                                                                                                                                                        K
                                                                                                                                                       GAI                                                        professional   specialties   and    scientific
                                                                                                                 10WA CITY                                                                                        disciplines.  Since   its   establishment   in
                                                                                                                                                                                         ILADELPHIA               1952,    the    Institute    has     allocated
                                                                                                                                                                                                                  about   25   percent   of   its   budget    to
                                     SAN FRANCISCO!                                               I                                                   BILOOMINGTO                                                                              t'lach'ii- aiici  re-
                                                                                                                                                                                                                  training support foi                 I
                                                                                                                      ST. LOUIS                           0 LOUIS\)                                               seirch-al)l)roximately            9,000    I)COPI(-
                                                                                                                                                                                                                  have    received    trainin-    during    this
                                                                                                                                                                            QDURHAM
                                                                                                                                                                                                                  period-but   it   has   only    been    within
                                                                                                                                                                                     L
                                                                                                                                                                -WlNSTON-SA EM
                                                                                                                                                                                                                  the  past   several   vears   that   we   have
                                                                                                                                                                                                                  been   able   to   begi'n   training   prorams
                                                                                                                                                                             USTA                                 specifically  in   stroke.   Now,   hoivcvei-,
                                                                                                                                                                                                                  we   are   inal-ing   considerable   pro,re-,s
                                                                                                                                                                                                                  in  this   area   with   seven   cerebrovascu-
                                                                                                         STO                                                                                                      Jar   training    programs    at    Minnesota,
                                                                                                                                                                                                                  Wayne     State,     the     University     of
                                                                                                                                                                                                                  Tennessee,    the    Medical    College     of
                                                                                                                                                                                                                  Virginia,     Bowman      Gray,      Massachu-
                                                                                                                                                                                                                  .sett-,   General   Hospital,   and   at   the
                                                                                                                                                                                                                  Mayo Clinic.
                                  With  the   discovery   and   use   of   ef-            crative  study  at   eight   institutions   of              sion. The purpose of this study                               These   are   in   a   sense    supplemented
                                                                                                                                                                                                      is  to      bv   o\-ei-   130   trainin,   pro,i-ams   ill
                               fective     antihypertensive     drugs      has            hypertensive   patients   showing   signs   of              improve the  critei-ia  for  sclect',,,g  l,a-                                            c
                                                                                                                                                                                                                                       -ositi-- i-,,, and all  the
                                                                                                                                                                                   -ter-y   su@,-erN,,   anct     ietirology, neut            "I
                               come  a  decrease  in  the   number   of   peo-            cerebrovasculai@   disease,   in   order    to              ticnts for carotid ai                                       otlict-   iie@ii-olo(@ical     disciplines        ill-
                               plc   dying   of   strokes.   But    no    one    knows    learn    the    answers    to    these    iiici    other    to (,nal)l(, siit-(,(@otis  to  predict  it)  %Vlii  II
                               tile   (I(@,gi-ce   of   protection    tIles(,    drug"                   ;11)otlt  ililv,  liiII)ol,t:ltlt            t,Yi)(-S of (-;Is(@s tll(-@@ (-:ill
                               afford,     which      aiitillyl)crtczisi@,e      drugs    tionslill).                                                 @%,Itlt tlic@                'I'@v(!iity-s(,vt,ii   in-     \I(),it  ol  ()(II,  naturally,
                               have   the    greatest    effect    on    stroke,    or       Some    of    you    are    also    familiar     with    vestl,-ative    teams     are     i)o@v     contrib,,t-     in   fact   cliscll)lltie-oi-icnted,    so    it    is
                                                                                                                                                                                                                  impossible   to   state   ver\,    exactIN,    @@7liat
                               whether    the    effect     could     be     enhanced.    the      National      Heart      Institutc's      joint    ing    to    the    study.    Much    valuable     data
                                  The    Institute    is    supporting     a     coop-    study     of      extracranial      arterial      occlu-    has    come    from    this    I)ro'ect,     and     it     portion relates to stroke.

                               62





                                                                            FIGURE 4                                                                      mittee   composed   of   three    neurolo-
                                                                                                                                                          gists,    one     ophthalmologist,     and
                                         COOPERATIVE STUDY OF CEREBROVASCULAR DISEASE                                                                     several  nurses   has   been   established
                                                                  AND  HYPERTENSION                                                                       in  the  Division  of  Nursing  to  review
                                                                                                                                                          applications,  and  we  are  doing  every-
                                                                         N I N DB    196 8                                                                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,
                                                                                                            ANN ARBOR            4WPHILADELPHIA                         scientific      conferences,
                                                                                                                                                          we  sponsor
                                                                                                                                                          both on  specific  aspects  of  the  prob-
                                                                                                                                                          lem,  such  as  aphasia  and   rehabilita-
                                                                                                                                       MOND               tion, as well as  larger  meetings  cover-
                                                                                                      S' ir                          -SALEM               ing the whole  field.  One  of  these  was
                                                      -----------                                                                                         the sixth in a  series  of  biennial  con-
                                                                                                                                                          ferences  at  Princeton,  N.J.,  which   I
                                                                                                   L ------     ATL
                                                                                                                                                          attended  last  week.  This  was  a   tre-
                                                                                                                      #AUGUSTA                            mendously    exciting     meeting,     at-
                                                                                                                                                          tended by virtually  all  of  the  leading
                                                                                                  \0 JACKSON                                              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
                        Of particular interest  to  you  people   ships active  at  the  moment,  and  hope   will   give   nurses   holding   the    bacca is  organizing  a  workshop  for   us   on
                                                                                                                    I                                     -behavioral  changes   related   to   cere-
                      may  be  another  new  type  of   support   to  expand  the   program   substantially   laureate  degree  2  years   of   specialized brovascular  disease.  Also,  the   second
                                                                                                              training   toward   a   master's.    Stipends
                      we have begun  to  offer  which  we  call   in the next several years.                                                              annual   meeting   of   the   chiefs   and
                      the  cerebrovascular  clinical   trainee-     A  new  program  for  clinical   train-   for  the  trainees  will  be  funded  by  the
                      ship. These  are  for  practicing  physi-   ing  of  cerebrovascular   nurse-special-   Public   Health   Service's    Division    of senior  staff  members  of  our   ccrebro-
                      cians  seeking  a  few  weeks   or   more   ists  is  also  underway.  This   program   Nursing,   while   salaries   for   the   key vascular clinical  research  centers  will
                      of intensive study of the  latest  devel-   will  give  nurses  who  have  the   R.N.   faculty    personnel    will    be    derived be  held   next   month   in   California.
                      opments   in   diagnosis   and   therapy.   degree 6  to  12  months  of  specialized   from     NINDB's     cerebrovascular     cen- This meeting  will  be  specifically  con-
                      We  have  a  number  of  these   trainee-   "bedside"  training  in  the  field,  and   ter  grants,  or  other  sources.   A   corn- cerned  with   an   in-depth   review   of
                                                                                                                                                                                                   63











                                                                                                FIGURE 5                                                                                               Disease, reviewing the entire field and
                                                                                                                                                                                                       telling us where we  stand  in  preven-
                                                        JOINT STUDY OF EXTRACRANIAL ARTERIAL OCCLUSION                                                         1968                                    tion, therapy,, and rehabilitation. Our
                                                                                                                                                                                                       last edition, published  in  1965,  was
                                                                                                                                                                                                       well received, and is still  available.
                                                                                                                                                                           R BE@JT  BP  'SIAM          The revision will  probably  require  2
                                                                                                                                                                           ARD                         to 3 years to  produc@  but  it  should
                                                                                                                                                                             GENERAL
                                                                                                                                                                                                       be  a   valuable   reference   document
                                                                                                                                              HESTEF
                                                                                                                                                                                                       when completed.
                                                                                                                    DETROIT                                          llON FFIORE                          These  arc  the  principal   elements
                                                                                                                                                                           TC
                                                                                                                                                                        IR L@OGICAL-                   of ()Ill. 1)1.0"1"1141 ill sti-ol@c.. I NVOLII(L lil<("
                                     U CAL, S F                                                       CLEVELAND METROPOLI                N                           INSTItUFf
                                     PRESBYTERIAN                    --------                           GENERAL HOSP                                    p    N       NYU MED CENTER                    at this point to mention  the  five  or
                                       MED.CENTER                                                                                                                                                      six major areas in which our scientists
                                     VA   H      -S F.
                                           .QSP.                                                                                                                                                       are workin,, and  then  move  on  to  a
                                                                                                          LOUISVILLE U@
                                                                                                                                                                                                       very brief summarv of the field's  most
                                                                                                                                                                                                       urgent needs.
                                           UCLA                                                                                                   DUKE
                                           SOUTHERN                                                             ORIAL@
                                                                                               BAPTIST ME     M
                                                                                                HOSP., MEMPHIS
                                                                                                                                                                                                       RESEARCH AREAS
                                                                                                                                                                                                          Epidemiology.    -    Epidemiological
                                                                                         TEXAS UNIV                          ICAL      COL
                                                                                                                                 ALABAM@                                                               studies   of   stroke   are    of    Litmost    impor-
                                                                                                                                                                                                       tance,     because     detailed      knowledge      of
                                                                                                  BAYL                                                                                                 the    distribution    of    the    disease,    corre-
                                                                                                                               LANE                                                                    lated     ,vith     oenetic     and      environmental
                                                                                                                                                                                                                      ZD
                                                                                                                                                                                                       factors,     diet,     and      other      influences,
                                                                                                                                                                                                       could    provide    important     clues     to     its
                                                                                                                                                           GINSTITUTO        DE        NEUROLOGIA      causes and results.
                                                                                                                                                              MONTEVIDEO, URUGUAY                         A      considerable      body      of      evidence
                                                                                                                                                           0 Di TELLA INST CTR,
                                                                                                                                                               NEURO. INVEST.                          has      accumulated      pointing      to      varia-
                                                                                                                                                              BUENOS       AIRES,       ARGENTINA      tions   in   deaths   from   stroke    in    different
                                                                                                                                                                                                       countries;      variations       aiaion-       popula-
                                                                                                                                                                                                       tion      roups      %within      some      countries:
                          hypertension    as    related    to    stroke,     and    service,    headed    by    Dr.     Robert     Sickert    1961. The bibliography, issued c                                 9
                                                                                                                                                                                                very
                                                                                                                                                                                                       variations   from   one    titil(@    to    anotlici-:
                          will  include  s@'                          neurorad'-    it   -@Nla@,o,   has   been   very   well    re(@cived    3    months,    consists    of    a    selection    of
                                                   ions  on                  1                                                                                       1                                      1
                          olo,    of    stroke,     cerebral     iiietabolisiyi,    bv  I)Iiysi(@ians  and                           @iiid    sti@oke  tnci                I'st'ii,,s  front   tli(-   ail([    even     -seasonal     variation,;.     EI)i-
                              ,@y                                                                                                                                     I    1  1  ,                     (I(!,)ilolo(,.Ists @il,@,t,(,e tli@it @oiiie of  ill(,
                          therapy,     and     microcirctilation     of      the    iiia@,    ultimately    be    expanded    into     all    Natioii@il              of N4ecll(,liie's
                          brain.                                                    abstract    journal    wli(@n    the     volume     of    iWedicus,     and     provides     a     continual(,,,   \,,ii,iaLions    tt-c    doubtless     ac(,otiiital)lc
                                                                                                                                                                                                                   -cnce    I
                             Another      important      aid       to       com-    stroke     literature(!      becomes      sufficiently    reference to virtually all I seai-(@li            in     to   .clifTci         ri    methods    of    classifi-
                          munication      sponsored      bv      the      Insti-    heavy.                                                    the field.                                               (-ation and standards of
                          tute   is    a    service    providing    a    monthly                                                                                                                cc     tli(,v  also  a,,ree  that   some   of   the   @,an'a-
                                                                                                  otll(,t- I)tll)ll(@atiotis are  of  iii-       'I'lC   Joliit    Goiiii(@il    SLil)(,oiiirnitt
                                                                                                           I)Lll)]iSll('(1 L                  is also                plans   foi@   i,   isioll   of   tioll ill the rates is             iricl tli(,N,
                          package   of    reprints    of    stroke    it-tlclc,,                                                                                 I                   (@v
                          appearing     in      medical      'ournals.      This    -%,as(@ulai-   ]@II)Ilogral)liy   regularly    siiic(@    @t Survey    l@I)oi-t    oil     Cei,ebi@ov@iscLil@ll-   inside  this  the   object   of   ilitel@s(,   studio.

                          64







                            III,I (I (IIIIo I I to ;(@v(. I-. II pro J'(@(@t@ 1,1,; It  It','                                                           FIGURE 6
                         ,III (I two (@(: II L(@ I s (I(!\() t I -(It() t
                         iniology   of    stroke,    the    Iiistit@itc    is                                        STROKE AND RELATED                                 TRAINING PROGRAMS
                         fund'n(,   bv    contract    with    joliris    Hop-                                                         SUPPORTED BY  NINDB-1968
                         k,ins    a    national    epidemiological     study.
                         Data    is    being    gathered     and     analyzed
                         for    comparisons    of    customs    and     prac-
                         ticcs  in   (-crtification   of   deaths,   and   is
                         I)elnl-    correlated    with    hospital    records                                                                      ------
                         and     @vith     physicians      and      household
                         intmiews.    For    the    first     time,     accu-
                                                                                                                                                                                     0
                         rate    information    will     become     ava     I
                         able    about    the    incidence     and     mortal                                                                                                    ol
                         ity   of   stroke   and   the   vallditv   of    re-                                                   --------
                                                                                                                                                                                                   0
                         ported    differences     in     different     parts
                         of the country.                                                                                                                                     IE)                   0

                         BLOOD BRAIN BARRIER
                                                                                                                              ----------
                           "lithin 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-
                         curs   after   brain    in'ury,    can    lead    to
                                                   i
                         serious         complications.          Considerable             C) =Number of  Programs
                         research    effort    is    being    invested     in
                         studies    of    this    mechanism,     with     the
                         aim    of    finding    rr)cans    of     minimizing   iiiakiii(r   it    possible    to    obtain    precise   bosis    within    the    narrowed     blood     ves-     individual      tlarou(,h       modern       methods
                                                                                         "  I         I                I                                I                                                                0
                         brain (destruction following str(-)@@        c    or   illf,)t-jij@ttion  il)otit  tli(@   (,<)n(litiorl   of   S(-.1.  @c,vcril  of out-                are    coti-     of                   Investigations     on      nou-
                                                                                ti)(@            ol- tll(@          @II)CI the,  ([is-                  ()II  blood   flow   stit(li(@s,   and     i-olo,,ic@@il    control    mechanisms    are    de-
                         1',f,001-)  FI,O@@" S'I'UI)IES                         Li-il)titloii of  blood  flow  tlit-oti,,Ii  tlieii-i.   on  tlic,,                         f  tc(,Iiiiiclties     ,-(,,Iol)in,,-  -reatcr   kno@vlecl("e   of   normal
                                                                                                                                                                          o
                                                                                'I'lle  (levelol)iilc@iit  of  sliiiplcr,   less   ex-   and il]StrLI111CIltS for tIlClIl.                         processes,   as   N@,cll   as    means    -,vhereb@7
                          The occurrence of strol-c              is   a   dy-   pensive      procedures      can      greatly      in-                                                             deranued    channels    of    input     and     out-
                                               '111-icrc  are        constant   crease    the    usefulness    of    these     i-neas-                                                             put     may     be      supplemented      or      bv
                         namic  process.                                                                                                 APHASIA
                                                                                                                                            Mti(@li   can    be    done    to    remedy    the     passed.    Intensive    study    of    normal    and
                                     in  tli(,,   flow   of   blood   through   tires    foi-    early     rcco,,nit'on     of     the
                         tfi(@  13i-aiii,  New   i@ictliocls   using   radio-   stt-ol@e-pi-oi)c    individual,    and    the     pos-   disability    of     the     paralyzed,     apliasic,     clei@anged    hi--hcr    nervous    activities    is
                                                                                                                                                                                                                   0
                         f-)paquc   dyes   or   radioactive    tracers    are   sll)lc     prevention     of     vascular      tlirom-   or      otticrnvisc      neurologically      crippled     pro%,Iclin,     means     for     remediation     of

                                                                                                                                                                                                                                                     65









                       aphasia     and     other     disorders      of      the        stroke-prone      are      those       with       hyper-        especially       concerned        ,vith        applica-           Nvitli   the   best   chance   for   a   contiiiuin,,
                       intellect.                                                      tension,     with     diabetes,     or     with     very        tiori     of     currently      available      methods,           useful    or    at    least     rneanin-ful     life.
                                                                                       high-blood        cholesterol        levels.        Pro-        could    do    much    to     reduce     death     arid           N,Vlicre   and   by   @@,hotii   are    tliev    best
                       TREATMENT EVALUATIONT                                           cyrams     for     the     early     recognition     and        disability.                                                       cared     for?
                           Evaluation     of     methods      of      treatment        treatment    Of    Such    persons     is     thus     a          I,.  Yitr,,Ic(il                                   LI.S('-      @,V(@            noted    t    serious    li(@k     of
                       is    another    ma'or    area    of    research     ef-        part      of      a      total      stroke      pro-ram.        fulncss   of   sLit-,Ical   intervention    in    clis-           documents     olitlin'liio-      -iiidelines      and
                       fort.     In     addition     to     the     cooperative        Equally      important      are       measures       for        eases    of    the     cxtracranial     arteries     as           concepts      for      commtinit@--based       stroke
                       studies     which     I     mentioned     earlier,     a        the       early       recognition       and       prompt        well    as    in    the    management     of     intra-           control    I)ro,,rai-ns    that    would     titilize
                       number     of     our     research      centers      are        treatment      of      patients      shonving      minor        cranial    aneurysms    is     still     hihly     con-           total       community       resources.        Reports
                       heavily   involved   in   this,   as   well    as    in-        neurolo,,Ical     s),inptoms,      such      as      the        trovcrsial.    When    oui-     statistical     stticl-           by   expert    committees    have    been    pti    -
                       dividual investigators.                                         transient ischmic attack.                                       ics    in    these    areas    arc    concluded,     we           lisliecl   by   the   IVot-Ici   Health    Oi-,Ialli-
                           Development        of        improved        methods           2.      Early       accurate       dianosis       of         will    know    mLicl-i     more.     I     am     con-           z-,itioti   foi-   heart   disease    and    cancer-.
                       of    diagnosis    is     also     of     utmost     im-        stroke.-Ccrcbrovascular           disease            may        vinccd    that    there    will    be    a    continued           but  notlilri@,  is  a-,ra'lal)lc  in  the   sti-ok(,
                                                                                                                                                                                                                                      , 1          1        1
                         ortance.       Angio-raphy,        isotope        scan-       present    itself    in    a    variety     of     forms        i-ol(.,  for  surgery       in     some     forms     of          area.     The     joint     Council      Subcoiiimit-
                       p                        0
                       ning,           then-no@raphy,            rheoencephalo-        raning     from     the      most      minoi@      clis-        stroke until lai-,e         scale     prevention      is          tec  has   foniied   a   task   force   to   develol)
                       graphy,            echoencephalouraph@7,             and        ttirbance      of      sensation,      movement       or        achieved.                                                         and    otitlliie    a    community    control    pro-
                       the     EEG      are      among      the      diagnostic        consciousness     to     Sudden      collapse,      arid           5.  Rcstoration          of         fii7ictioiz.-Tlie          -rtin  foi-  stroke,  arid   I   kno@@-   that   this
                       tf-,cliniques       undergoing       (@onstant       im-        I)rofotinci (-omi. The clifT(@t-(@titl,,tl                                      nit@ttt-(@  of               i-esicitiils,        o(it@iiii(! %%,III be of great                to   tli(,
                       pi@o,,,ciiient and refinement.                                  tiosis  is  often  (-Ilffl(.tilt   arid   iii@ty   i,(@-        @iii(I tli(@ii- (I(-@vasL@Ltilig               oil   ('III-       I" (@glorl-,tt M C(I recall
                                                                                       quire        sophisticated        diagnostic         equip-     I)IoyalDility    arc     ina'or     elements     in     the       otlici@    public    and    ao,,,ei-niiiental     aacti-
                       NEEDS  IN THE  REGIONS                                          ment.     Each     reuion      Must      assure      itself     problem.      The      distribution      of       rchab'li-       c'cs when it becomes available.
                                                                                                              n                                                                                             1            1            1
                           Now     to     summarize     a      few      of      the    of     the      existence      of      Such      diagnostic     tating     services,     their     relatioii     to     the       All    of    these    needs    are    I)rcssin,,    arid
                       field's     most     ur-ent      needs:      In      consid-    competence,     and     of     the      orientation      of     -cncral      hospital,       the       nursiti.-       home       it   is   hard   to   assi,,n   priorities   to    them.
                       ci-in,,     the     types      of      strole      pro(,rams    us(, I)i,actic!ln,, I)Iivsiciiri                        the     and  the  (Community                                              Iltit  I  iiil,,,Iit  s@iv  ]'it  conclusion  that   the
                       ,,which     i-nav     evolve     within     the     virlotis    need  foi,   @itici   the   a,,,ailal)llitv   of   sit(-.II     otli(@l,        important         fol.     ('ollltllltllltv       "I,c@it(,St  free(]  of  III  is  i-eco@,t)ILIOII   that
                       refflons,    I    think     we     should     start     with    special services.
                                                                                                                                                                                                                                 can  be       done     for      stroke      I)a-
                       a    revienv    of    the     total     needs     of     the       3.                  E7tier,@,e?icytrcatt@zcnt.-I-'hel)a-        6.  Lo7i,@l-til,ri@i  car@@.-                    patient       ti(@rits much  iiioi-(,.  than        -,%-c   arc    do-
                       stroke     problem.      For      a      total      pro@ram,    ticnt      @vitli      sudden      cerebral      lif,ilior-     @%,'tli  stroke                  (I'sil)'I'                       irig   iio@v.   @'Ve   can                          some
                                                                         n                                                                               I                     I          I     I ity
                       any    societv    itiust    be     prepared     to     col)e    i-lia(,(@ rcl)res(,,iitsaill(,cli(@al                           S(,tlts   ;t   iiil,ol-   social   ,Ill(l   (@(.ollollll,(,
                                                                                                                                                                         I                                               sti-ok(@s,     (-@iii          I)ctt(,i-
                       in soine,,vLN, Battle the follo@vill,@                                                                                                                                                                                     I  I               I  ,
                                                                             needs:    Not all cases of (@cr(@I)t-;Ll                                                Oti(--slxtll to                            of
                                                                                                                                                                                                                         .111(l              to itiol,(t             @ti)(I %%'(-
                           1.     Strok6      Prev(,ntion.--In      its      Lilti-    are   fat@il.   Nursing   care    foi-    tli(,    (@oirii-     tli(@                'I,  out,  St@it(,
                                                                                                                                                                                                                         (,.III    (lo    more    to    I-("-,tort@     function.
                       niate,     the     prevention      of      stroke      prob-    tose   patient    requires    sl)c(@ial    sl@ills.    Lit-     (,Iilatric,  liosl-)ltals   arc,,   I)atl(.,Ilts   disabled
                       ably      depends      upon      the      prevention      of    tle     consideration     has      yet      been      given                                                                       N@lari@,     thousands     of     stroke      @@ictiriis
                                                                                                                                                       by  cerebrc)vasctilai,  disease           .  Yet       this
                       arteriosclerosis.      Lacking      this,      we      still    to   the   lo,,Istics    of    handling    these    cliffl-                                                                       @@,lio     could     be     helped     lie     helpless,
                                                                               I                                                                       represents    but    a    small    ft'actioii    of     the
                       have      the      ability      to       reco,nize       the    cult    cases.    In    re,ard    to    treati-ficiit    of     total                   '"le     need      more      infor-       sloll'IN'  cletei-loratiri,,  to%N,arcl   states   of
                       stroh-c-prone       individual       and       to       pro-    the    actite    phases    of     stroke,     here     also     niation      i-e,,ai,clin,,       the       characteristics       or-anic dementia.
                       @,ide     for      such      an      individual      certain    there     is     much     to     indicate     that      the     of    this     clis@tl)lccl     population     arid     the       'Fiiis    is    now    @@,ltliin    our    power,    and
                       p     rophvlactic     measures.     In      eneral,      the    existence       of       programs       and       personnel     resources       available       to       provide       them       Ikno@v       we      meet the challen,e.



                       66








                       PANEL DISCUSSIONS ON.                  HEART DISEASE
                                                              Panel: Jesse Ed@vards, M.D.
                                                                   Samuel M. Fox 111, 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-       The   pro@ress   I   see    for    the    future    of    the    patient,     mental     rehabilitation     Nve   think    we    @vill    learn    much,    but
                                                  HEART                 DISEASE   has    three    P's:    One,    perfection;     two,    of   the   patient,   evaluation   of    his    ca-     even   with   the   lack   of    what    ,@@e    do
                                                                                  productivity;      and      three,       prevention.    pacity    for    Nvork,    orientation    of    in-     desire   in   the   wav   of    justification    on
                                                                                                                                                                                                                        I
                                                                         Panel:   By     perfection     we      i-ncan      refinement    dlistry  as  to  the   usefulness   of   the   pre-     the   statistical   case    for    the    coi@onar@
                                                                                                                                           1                      1                                                             vcnr fenv  @N7110
                               Jesse       Edwards,       M.D.        (Cha'=an)   and    greater    availability    of    the     many    v'otisly  ill,   eclitcat'no-   the   families   as     care efforts, there are
                                              ident,       American       Heart   techniques    now    present    to     treat     the    to    the    dietarv    and    emotional     recep-     feel    what    we    are    doing    across    the
                                           Pres
                                                                    Association   afflicted   and   the    (lc\,clol)mcnt    of    new    tion   of   the    patient    upon    his    return     Nation in     this    effort    does    not    have
                                        Charles     T.     Miller      Hospital   techniques    where     applicable.     By     pi-o-    home.                                                   real virtue.
                                                        St.     Paul,     Minn.   ducti@,ity   we    refer    to    the    accomplish-       In   the   past   2    days    we    have    had       There     are     manv     opportunities      for
                                                                                  ment,   either   in   the    home    or    on    the    demonstrated          ii-iany         sophisticated     fascinating  ,%,orl,   that   still   remain   arid
                                        Samuel     M.     Fox     III,     M.D.   job,   of   the   person   who   has   heart    dis-    techniques   for   the   physical   care   of   the     most   of   them    appear    to    lend    thei-n-
                                    Chief,      Heart      Disease      Control                                                               1                           1
                                                                        Program   ease.    Bv    prevention     we     mean     accom-    patient.      These       techniques       absorl:)     selves   very    well    to    the    R-%IP    type
                                                                                  plishing    the    -reatest    of     all     accom-    physicians'   time    and    energy.    @Ve    must     effort.
                                                  National      Center      for
                                                                                  plisliments,   that   of   kccl)in-    the    divine    seek    A,ays    of    developing    nonl)liysician       This  is  a   slide   @@,lilch   I   am   sor-i-@
                                                                                                                                                                                                  I      I                                          11
                                           Chronic       Disease        Contro@   @ift  of   the   normal   heart   u"'naltei-ccl   bv    personnel    capable     of     cloin,@     certain     s  a  little complicated,  but we
                             Bureau     of     Disease      Prevention      and
                                              Environmental             Control   'disease.                                               tasks    now    traditionally    done    by     the     trv to  look  at  it  in  cas@,  stages.  It  i-na@
                                               Public      Health       Service       The   three    P's    have    been    translated    physician.                                              ililistrate   some   of    the    new    approaches
                                                                                  into   old   terms;    namcly,    treatment,    i,c-       A   reservoir   of    resources    of    various     that   perhaps   will   expand   our   I)i,(,sc@tit
                                               @%@illiam      Likoff,      M.D.   li@i]Dllitation,   and                         Iltit    Timid (livet-se tyl)(!s is -tvLllal)lc to  Lis          -oii(@(,.I)t of coronary ('ai-(,.
                                  Prcside?it,     Amc?"can      Collc,c      of   while   the   terms   are   old,   we   must    al)-    from    such     units     as     the     Nttiolial
                                                        I             I                                                                                        I                                    'Flic   boxes   on   the.,;    slide    represent
                                                                     Cardiology   ply   new   iii)agiti@itivc   icl(@as   to    iiial@    Heart   Institute,    the    llczti-t    I)isc"ls(l     @L set of li\ll-)otlictical units in a sN,st(.,iii
                                    Hahnemann          Medical          College   full   use   of   the   tools   with    @vhlch    we    Control     program,     and      the      American     of    oronary    care.,    a    system    in    the
                                                      Philadelphia,         Pa.   now @vork.                                              College of Cardiology.                                  sense    of    the    practioncer    rather    more
                                           Theodore        Cooper,         M.D.       In    a    nai-ro@v    sense    treatment    may       To     consider     development     of      many     than svstcm analysis.
                                                                                  be  considered   in   the   i-caln-i   of   ptittin,    of   the   necessary   and   new   services,    the       III  the  centci-   of   the   boxes   ]@cre   is
                                                    Associate          Director
                                                                                  out  brush  fires,   that   of   taking   (:are   of    voluntary     health     agency,     the      Heart     one    labeled    "Stin7cillaiice    foi@     DN-s-
                                           National      Heart       17zstitutc
                                                                                  illness    Nvhen    and    where     it     happens.    Association,     has     the     know-lio@v     and     i-hvthmia."   This   and    the    box    it@ii-ne-
                                     National     Institutes     of      Health
                                                                                  If   treatment   of   an    acute    illness    con-    the   will   to   assist   RMP   in    establishing     diately    belo@v     it,     "Intensive     Care,"
                                              Campbell       Moses,        M.D.   sists   simply   of    shepherding    the    patient    a blueprint for the future.                             such  as  ,@,e  can  pr ovide     for      circulatorI-v
                                                      Medical          Director   through    his    immediate     physical     I)rol)-       Dr.   Fox.   In   thinking   of   new    clevel-     failtirc-and       that       perhaps        pool@l
                                      American        Heart         Association   lem,   the   cruelest   thina   we   can    do    to    ol)mcllts   in   heart   disease,   the    interest     named    but    expressively     coii%@eyed     con
                                                       New      York,      N.Y.   a   patient   is   to   discharge   him   from   the    in   coronary   care    units    is    a    perfect     cept    of    the     carclio-@enic     shock-these
                                                                                  hospital,   for   the   disease   treated   in   the    example    of     the     synthesis     of     nenv     represent   the    majoi@    loci    of    coronarv
                                                                                  hospital     has     many     broad      rai-nifica-    knowledge    into     a     practical     operation     care efforts at the present time.
                                  R.      EDWARDS.      As      a      Regional   tions outside of the hospital.                          I)acka(re   @@,itli   @%,idesj)i-cacl   usefulness.       'I'o  the   right   here   is   a   unit.   "Con-
                            D-@%lcclical      Pro,,raiii      1),-Liacl      on       NVitlilti    our    capabilities;,    discharges    Unfortunately, @%,(, (lo not              @ill th(,     t,l 1) Lled                  iiici   Cii-e,"    the
                            heart   disease   in   January   1968,    we    are   of tll(@,             fi@oill tll(- I)o,@l)lt@ll III-                                   of  tll(-  ('o',,t-     first        of
                            in    an    exciting    atmosphere.    The     past   volves    opening    broad    avenues     of     ac-    benefit   i-atios    that    support    (@oronal,Nl     there  is  a  significant   mortality,   still   to
                            has  given  us   many   gifts   and   we   are   to   tivity,  activity   that   pertains   to   the   pa-    operations.                                             be    conquered.    Those    cases    who     stir-
                            participate   in   shaping    these    for    prog-   tient's    illness.    These    include,     ai-nong       Dr.   Jack   Hall   has   a    most    interest-     vi-,-c   tlirou,,I-i   the    stin7eillance    area
                            ress in the future.                                   many      others,      physical       rehabilitation    in,   design   in   the    @vind    from    ,vhicli     pass on to     the    proi-essi@-c    care    unit.

                            68





                       ,@bo%,e     and     further      alonu      is"Edtica-            No%v,    what    can     we     do     to     persutdc         low     otitpedience,     namely,     a      means      of         without    laorns    and    such     to     the     core-
                   tion     and     Rehabilitation,"     about      %,,,Iiich        those    iicc(-Iln@,-    the    protection    of    core-          (,cttin,       sprung       from       such        circum-         iiar@@    care    unit    at    the    main     hospital.
                   tli(@re    is    much    enthuslasi-n    but    1IISLIffl-        narv     care     services     to      make      carrier,          stances    back    into     active     life     if     the            I his    is    beautifully     done     in     Belfast.
                   clent     e%,al@tated      cxl)crien(.@c      at      this                     decisions'      A       coronary       reccp-         probabilities        seem        r@oiiably         accept-         Can   %vc    do    this    in    the    United    States'
                   time.                                                             tion    area    mi@,ht    be    of    assistance.    This          @tl)le    that    the    episode    %vlilch     sLi-,estcd         I    think    there    is    no    question    we    can.
                       The      Heart      Disease       Control       I)t-o-        is     a     concept     about     %which      iiotliin,,          the     need     for     admission     is     not      any         We   must    build    sonic    type    of    front    end
                   gram    is    very    interested    in    lookin,,,     at        i-callv    has    been    done    of    which    I     am          loii,,ct,    acutely     lycriptic.     Latei,     discus-         on    the    coronary    care    system     and     after
                   physical    rehabilitation    as     %v(@ll     as     cf-        a\vai-c.                                                           sloii    might    liell)    define     the     ol)portuni-         we     have     done     so,     -et     more     prudent
                   forts     through     an     increase     in      habitual            The    terms     coronary     care     acriun-i     or         tics     and     problems     of     this     area      in         decisions    earlier    in    the    course    of     the
                   physical    a(,ti,,,itv    to    prevent    heart    clis-        coronary     ti-ia-c     unit     @vci,c      considered,          soi-nc@vliat more detail.                                          coronary experience.
                   ease in tlc prii-nar-\, sense.                                    but    OLItSid(-'    of    the     health     professions             In   September   of   last    ),eai-    I    had    the            The       Heart       Disease       Control       pro-
                       To tll(, f@ii- rl,.,Iit is                           T)ro-    these terms                   not   1)(,    well    Lincl(-,r-     I)t-lvil(,,,e   of   i-icllnl-    out    with    the    mobile     ,rain      looks      forward      to      continuin-       to
                                               \Vlli(li                     will     ',to()(],                    I                                                                                                                                                          R(,,,@iotiil
                                                                         (I,.;II     audit                   itil@!,Ill I)I@ ;, lilt](, lil()I(l        I                                                                                                   oil  this  ;111(1
                                            1)1'()Llgllt    OIIL     I)V     1)1.      1 (7 (@ I S(..
                              -,is  was                                                                                                                 Noi,tlt                                      1);tiitl              ll()I)(' (li@it       %\'ill I)('         to   11(@ll)   kt(--
                   Fredrickson yesterday.                                                NV]iat       is       suggested?       Pcrfial)s       the     will      be      bcforc,tlic       cai'diolo(@-       meeting     line     sonic     of      these      cii-cuia-istances.
                                                                                                                                                                                                  ,@y
                             opportunity     is     to     look      at      what    receptive      ciavironi-nent       easy       to       enter,     in    San     Francisco     and     I     think     he     has        Dr.      LixOFF.      There      resides       in       the
                   rril(,,Iit   be    called    the    front    end    of    this    havin(,       a       low       impedieiicc        appearance,     done    a    o-reat    deal    to    lead    the    Nvay    in     broad       field       of       cardiovascular        disease
                           -I,    that    into    which    Nvc     would     like    if      we      can      paraphrase       our       electrical
                   s@7sten                                                                                                                              sliowin',    what    can    be     done     in     the     way     ample reason                 the         Regional         Med-
                   to    @ttti-@t(@t    1)(@ol)lc    rnor(@    promptly.     ,Nil    (@ii,,iricci-'n(,                      no       itcli-n'ssioii     of iiiobile services.                                              ical    Pro-i-ains,    structured     as     it     is     b\,
                   toffcthei,      too      many      (@ot,onary      v'ct'i-i-is              full                       I)t-'or   to   all   III-        A    physician     tii(I     it     ntit'se     --o     out           @tffoi@cis    a     i-eiiiai-lable     ol)l)oi-ttiiiltN,
                                                                      I   1                                         1  -,     I                                                                                                      -o%-e
                   C, IC   before   they    even    @o    into    tli(,    liosl)l-  %@estill@ition  of  @'                                                                                                                to ilill)l        health      care.      The       iiitensitn,
                                                                                                               i,,ns,     s@@illl)toins,     l@il)-     from      the      coronary       care       unit       @vhcrc
                   tal,    not    to     speak     of     a     coronary     care    oratory     data     and     things     of     this      sort,     they      are      otlicnvisc      employed      to       meet     of the     diseases     of     the     heart     and     blood
                   area.                                                             and      above      all,      staffed       by       competent     the     ambillance     at      the      pick-ui-)      1)oint.     vessels             ox@er@vheli-ns              comprehension.
                       It   is   estimated,    on    the    basis    of    @vliat    I)crsot-iiiel     but     possibly     in     Icssci,     num-     They    cltiickly     @,-o     to     the     sce'ne'     with     Indeed,     III     this      western      culture,      these
                   we     must     admit     are     not     too     aclecluat(-,    I)crs     than     Occur     in     the     coronary      care     claxon       hoi-ii        blo@vin--        except        when     afflictions   are    almost    a    %@'ay    of    life.
                   statistics,      that       over       200,000       indi@rid-    unit     as     @ve     lio@v     have     it      constituted     they       approach       the       iii-imediate        locale        The        economic        loss        from        abbrevi-
                   i,ials   die    (-)utsicle    of    hospitals    with    acute    because     the     probabilities     of      acute      clcc-     at    which    time     they     make     a     very     quiet     ated      and      attenuated      work       rivals       ex-
                   coronary      events      as       compared       to       es-    trical        catastrophe        I)rCSLimal3ly         @voulcl     and     thereby     not      too      alariiiin,,      ciit@,.     I)eliditures        for      prolonged                 ari-ned
                   sentiall@,       the       same       n@iniber        dyiii,,,    be     i-liuch     less.     Those     would     be     I)Limp        Most    of     the     devices     of     the     coronar),     conflict.       Prevention       is       tragically       en-
                   within     the     hospital.     This     is      a      corn-    failure     and     such     things     that     would     (,o     care     unit     are     taken     out     of     the     van     snai-led     in      concept.      Hardly      a      fragment
                   menta@,        on        our        inadequate         system,    on    in    an    intensive     care     area     as     pres-     into    the    hoii-ic    or     site     in     which     the     of     clear     fact      supports      a      myriad      of
                   if you will.                                                      entl),     constituted.     Lo@v      cost      \vould      be     suspect       coronary       case        is        found-cloc-     fashionable          beliefs          regularly          ur-ed
                       -N,fost    of    those    who    die     o@itsldc     uia-    a      licc@cssary       part,       acccptaidle,       there-     toi,,     iitirse,     iiioiiitorin,     devices,     ii-icdl-                                                            Z)
                                                                                                                                                                                          b                                upon      the      public,      and       any       standardi-
                   der     these     circtii-nstances     die      acLitcl@,.        forc,    to    tlili-d-I)arty    insurance    as    is     be-     catioti,         iiicludiiic,         intravenous          and
                                                                                                                                                                                                                           zation     is     late     and     often      uncertain.
                   'I'li(-y    arc    not    those    @@,itli    Ion,,-standin,lr    comlll,,,     iiicrc,,isin,@-1),     a     part     of     our     cl(@Fibi-illator.      'Flicy      stabilize      the      pa-
                                                                                                                                                                                                                              Treatment       is        as        dependent        i-ipon
                   svrrlplolrls  exec            in  the                  elderly    medical     scene     as      to      the      person      and     t'eiit         p)i@siologically,         reassure          the
                                            Pt                                                                                                           I                                                                 ,ature's       generosity       as       upon       scientific
                   @viio,  .as     a     matter      of      philosophy,      are    the family.                                                        patient      and       family,       and       then       from                 The       small'capsule        of        effective
                   permitted to pass on in the                                 of        The  lab        backiip       for       enzymes        and     the       usually       highly        anxious        circuiii-     (,eniLis.
                   their  fariilly,  with                     I     think      we    such should          be      available;       and       indeed     stances       accompanying        a        heart        attack     measures     often     may      lead      to      as      much
                   must  have  some  sympathy.                                       @ve    need    @vliat    @vc    might    classify     as     a     the),      quietly      move       the       patient       off     disability    as    it    was     designed     to     correct.
                                                                                                                                                                                                                                                                                       69






                     In   this    and    environment,    each   edge,  education,  and   application   defy
                   fresh  effort  in  treatment,  even  though  clear separation.
                   only  a  hopeful  inquiry,  is  understand-     Where  the  cardiac  resides   in   your
                   ably    overdramatized    as    a    break-  region,  how  great  his  number  is,   and
                   through.                                     what his fate is  over  the  years  may  be
                     For  the  stricken,   accommodation   to   a  prosaic  inquiry  compared   to   molec-
                   useful  life  is   totally   undisciplined.  ular  biology,  the  cardial   sick   cell,
                   Guidelines,   obscure   enough   in   their  or  any  other  unit  in  the   body;   but
                   own  right,   are   misunderstood,   misap-  this   simple   discovery    assumes    new
                   plied,   or   newly   structured   out   of  dinity if it  has  a  frontal  impact  upon
                   prejudice.                                   education  and   upon   application.   Sim-
                     Stung   by    peculiar    public    laws   ple  correlated  goals  then  are  rcasonl-
                   which  hold  employees   forever   res[)on-  I-)le and these are  the  attainable  ones.
                   sil3le for the consequences of  inaturin(l@     Thirdly,   judicious    assumption    of
                   heart disease, industry  is  a  traditional  regional  needs  by  respons@iblc  men   of
                   foe of rehabilitation.                       action  is  an  essential  requirement  for
                     Finally,  the  public   is   more   than   a  proper  takeoff  even  though  this   is
                   vaguely  conscious  of  these   facts   be-  perhaps  contrary  to  the  spirit  if  not
                   cause we have trained  it  to  be  able  to  the letter of the law.
                   criticize   and   in    its    acknowledged     How  far  off  from  actuality  is   the
                   restiveness  it  wants  more  of  what   is  presumption,  for   example,   that   acute
                   available,  and  more  to   be   available.  coronary    care    is    delayed,     that
                     Embodied  in   this   total   issue   are  ausculation is a limping  art,  that  clin-
                   challenges   to   advance   knowled-e,   to  ical   physiological    correlations    are
                   improve  education,  and  to  perfect   ap-  poorly   understood,   that   new   instru-
                   plication.   The   magnitude    of    Nvhat  mentation  is  unavailable  or   its   role
                   must    be     accomplished     immediately  not fully comprehended.
                   has  great  confusion  and,  just  as   ad-     It  may  be  folly  to   expect   action
                   mittedly, inertia.                           from   the   periphery   when   the   needs
                     How   can   the   wheel   be    loosened?  themselves    truly     remain     unrecog-
                   The  first  plea  is  for  simplication  of
                                                    . .      I  nized.   There   are   two   more    simple
                   objective,  for  a  clear  recognition   or
                   the  boundaries  that  must  be   set   for  determinants  of  sincere  and   definitive
                   your effort. At  least  at  the  outset  we  action. The first  is  the  forthright  en-
                   are  laboring  under   a   practical   law.  listment   of   regional   talent   through
                   Goals  should  be   interpreted   in   that  whatever   unit    or    organization    or
                   spirit,  whether  the  intent  is  to   ad-  affiliate  this  cadre  can  be  recruited;
                   vance  knowled(,e  or   improve   the   ap-  and finally, operations throu-h
                                                                                                         ex
                   placation  of  what   is   already   known.  perimental    modules    probably    repre-
                     Objectives,  secondly,  cannot   be   en-  sent the  most  effective  method  of  get-
                   gaged  as  separate   enterprises.   Knowl-  ting the show on the road.

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               Dr.  COOPER.  As  outlined  by  Dr.          Ing some critical gaps in our  infor-           contractual research in  such  areas           term  goals  of  the  American  Heart
             Fredrickson  yesterday,  we  in   the          mation.  These  findings  could  then           as pharmacological interventions  on           Association.
             J-I(,art Institute feel  t@at  %N,c  have  a   mature  into  means   of   practical   treat-   arrhythmia,      furthering       understand-      The   public   and   professional    edu-
             very practical interface  @vitli  t@ic  Ike-   irienl for this devastating disease.            ng  of  the  patholog                              ion programs o
                                                                                                            1                       ,   y   of   coronary  cat'                   f   the   Heart    As-
             gic)nal   Medical   Procrrams.    We    view      What  was  agreed  upon   at   that   time   disease  in  man,  etc.  We  have  to   reach  sociation   have    now    with    the    RMP
             our  job   as   providing   you   with   new   was  a  program   of   contractual   research   the  point  where   we   have   based   about  program    a    chance    to    expand    and
             practical  means  of  treatment   for   cor-   in   myocardial   infarction.   The   initial   50  percent  of  our  effort   in   a   major  develop  and   to   succeed,   and   we   are
             onary  heart  disease,  a   disease   @vhich   core  of  this  pro-ram   was   designed   as   clinical  investigational   effort   and   50  very pleased that this is the case.
             has not  yet  seen  a  material  benefit  in   a  series  of  research  units  which   would   percent   of   our   program   in    specific      Let  me  point  out  to   you   some   of
             terms  of   reduction   of   morbidity   and   be  located  in  medical   centers   through-   laboratory  research  projects   related   to  the  areas  where   the   various   volunteer
             mortalit@,.                                    out  the  country.  It  Nvas  originally  en-   the    management    and     diagnosis     of  agencies  can   be   useful   to   RMP.   For
               Abou@  2  years  ago  the   Heart   Insti-   visioned   there   should    be    12    such   coronary artery disease.                       example,   in   the   area   of    personnel,
             tute  had   a   very   small   but   elegant   major   research   units.   These   are   re-     Complementing this,       we    have    our  whether  -,ve  are  talking   about   vollin-
             groul)   of   consultants   surveying   many   search  unit.-,,  I  would  emphasize,   that   Artificial   Heart    program.    You    will  teer   personnel   or   professional   staff.
             of the medical  centers  in  order  to  find   are  concerned  with  the   clinical   inves-   recall,  on  Dr.  Fox's   diagram,   one   of  Many   of   the    full-time    RMP    people
             out  what  the  clinicians   need   in   new   tigation  of   the   patient   with   myocar-   the   practical    means    of    therapeutic  have  come  from   the   professional   staff
             findings  for  the  treatment  of   coronary   dial  infarction.   All   ancillary   labora-   support   for    the    complication    known  of the Heart Association.
             artery  disease;  the   thing   they   found   tory  work  is  directed  toward  this   end.   as   cardiogenic    shock    is    mechanical      'I'his is entirely  appropriate.  At  the
             out  was  most  needed  was   interest   and      In  the  past   year   five   such   ma'or   circulatory   assistance.    We    are    now  volunteer    level,    RMP    programs    are
             research  activity  in  this  disease.   Ap-   units  %vere  implemented  at   a   cost   of   spending   $8.6   million   in    contractual  providing  support  in   dollars   for   some
             parently   coronary   artery   disease   had   roughly  $5.1   million.   In   December   of   research  designed   to   improve   the   ma-  of  the  activities  of  people   -who   were
             become   somewhat   less    glamorous    for   1967   Nvc   received   an   additional   set   chines  that  are  now   available   and   to  volunteers   with    the    Heart    Associa-
             the investigators.                             of  bids  for   the   enlargement   of   this   develop   new   types   of   mechanical   as-  tion. The  same,  I  am  sure,  is  true  for
               Following  upon  this  report,   the   In-   network.   We   anticipate   that   in    the   sistance   to   the   circulation.    Perhaps  the  Cancer  Society.  One   comes   to   Dr.
             stitute  in  the  context  of  its   already   coming  year  we  should  be  able   to   add   in some  years  to  come  we  shall  be  able  Gordon   Barro@v   who,   of   course,    was
             established   Artificial    Heart    program   an additional  three  oi-  four  such  units.   to  produce  a  total  replacement  for   the  very   active   as   a   volunteer   in   the
             initiated  a   "targeted"   Myocardial   In-   Hopefully   next   year,   if   our    budget   heart, a mechanical prosthesis.                Heart    Association    for    many     years
             farction  program.   This   program   is   a   permits,   we   will   reach   the   critical     Dr.   MosEs.   Within   the    Heart    As-  and  now   is   director   of   the   Georgia
             supplement   to   the   millions   of   dol-   mass of these 12 units.                         sociation  we   have   tried   to   encourage  program.
             lars  being  spent  already  by  Heart   In-      Around  this  core  then  we   shall   at-   our  various  affiliates  and   chapters   to      One  of  the  other   areas   where   the
             stitute  grantees  in  areas   of   research   tempt  to  stimulate  further   interest   in   offer   their   assistance   to   RMP    pro-  volunteer   health   agencies   can   be   of
             Nvhich,  under  the   grant   mechanism   of   various   segments   of   the   country    by   grams   around   the   country.    In    some  use  in   the   RMP   programs   around   the
             laissez-faire   research,   bear   on    the   having  sort  of   mini-units   which   would   places   this   has    worked    out    quite  country  is  in  the   development   of   ef-
             treatment   and   diagnosis   of    coronary   be  located   in   existing   coronary   care   effectively;  in  others,   it   hasn't.   In  fective     educational     materials.     We
             artery disease.                                units.   These   smaller   units   could   be   some,    the    Heart    Associations    have  have    requests,    for    example,     from
               It  was  felt,  however,  that  the   more   the  testing  ground  for   the   application   been  really  quite  unaware   of   the   ob-  RMP    programs    to    develop     5-minutc
             organized    and    focused    program    on   of   the   new   findings   found   in    the   jectives    of    the    RMP    proram.    We  radio   spots   to   be   used   in   various
             the  problem  of  coronarv  artery   disease   centers   of   major   investigational    ef-   are  making   strenuous   efforts   to   cor-  places  around   the   country,   and   hope-
             @vould  be  a   great   stimulant   to   re-   fort.                                           rect   this   because   the    RMP    prouram  fully  other   associations   such   as   the
             search  efforts  in  the   area.   Increased      Finally,   another   segment    of    this   offers  an  opportunity   to   provide   real  Cancer   Society   programs   can   be    im-
             activity  would  be  helpful  in   identify-   program  will  direct  itself   to   specific   muscle  to   achieve   many   of   the   long  plemented,    can    help    RMP     programs
                   292-414 0-68-6                                                                                                                                                                     71









                     in  many,  many   ways   in   the   public            are   really   working   for   one   common           many  people  are  specifically  saved   by           side of the  led-er.  Now,  since  most  of
                     education field.                                      goal  and  that  is  improved  health  care           the resuscitative  potential  of  the  cor-           the   electrical   disturbances   do   give
                        This  interface   has   been   used   by           for the people of the United States.                  onary care unit,  and  the  otli(@t-,  does           Nvai-iiin(, and there are sonic  (@liang(@s
                     almost every speaker  in  the  last  2  or               Voicr.. I wonder  if  Di@.  Fox  @VOLI]D           the  very  presence  of  a  coronary   care           in  the  monitoring  that   indicate   that
                     3 days, but certainly  the  interface  be-            @,-i%!c us ]us              (,stiiiiat(, Of tile      unit with the training iiict  attitudes  of           this catastrophe is 'nim'iieiit,  it's  now
                     tween  the  public  and   the   RMP   that            effectiveness, and  in  any  way  he  wants           personnel that  -o  with  it  have  an  in-           possible  to  prevent  many  of  these  and
                     can  be  bridaed  by  a  volunteer  health            to define  this,  of  coronary  care  units           dii@ect influence on top  of  the  specific           therefore  we  no@v  say  if  vou  have   a
                      ao,ency  is   a   very   realistic   one.   After    in the present state of the art.                      bci)efits   to   the    patient    who    required    resuscitation   event   in   a    coronarv    care
                     all, the volunteer  health  agencies  have               Dr.  Fox.   Unfortunately,   %ve   don't           actual resuscitation?                                 unit   it's   probably   a   small   black   mark,
                     been    for    many     years,     long     before    have   the   statistics   we   all   would   like.      Dr.  LIKOFF.   I   think   that   there   is   a    in    the    record    because    perhaps    tliev
                     RMP,     interested     in      improving      the    For   a   while   before   the   aggressive    ap-    arowin,,,   belief   that,   in   the   area    of    iTilssed the wtrnin- sians.
                     level    of    patient    care-particularly     in    1)roacli   to   13revctit   catastrophic    events    electrical   (catastrophe,    the    acute    cor-      So it's Very difficult to answer  YoLil'
                     cancer and heart disease.                             came   in,   we   could   say   that    so    many    onary   care   unit   has   been   successful   in    question    accurately,    but    certainly    the
                        I   would   like   to   conclude   @vith    one    patients    had    conditions    considered     to    amelioratiti-   the    i-nortality    and    met--    gro@vin(,  exl3cricnc,  with  it,  if   -%vc   can
                     reference    to    Dr.    Fox's    diagram.    You    be   lethal   were   it   not   for   the   inter-    bidity   statistics   and   that   in   the   area    get   some   kind   of   data    analvsis,    will
                     recall   that   in   his   diagram   he   had   on    vention   of   a   trained    team    and    tech-    of  power  failure   there   has   been   no   in-    be  able  to   lead   us   to   some   intelligent
                     one  end  of  the   scale   the   need   for   im-    niques     with     the     monitorin-     system.    fluence    whatever     upon     the     mortality    'udgments   as   to   lioN%,   these   should   be
                     proved    ways    to    provide    better    input    At  that  time  it  would   look   as   if   there    rate.                                                 implemented    and    'ust    how     manv     -we
                                                                                                                                                                                                               I
                     into    the     coronary     care     formula-tlie    were essentially six to eight              persons      'riiere  is  also  tile  very   distinct   itil-    ii(@e(I to iii(-ct     I)ol)ttl@itioii n(@(!cls.
                     coronary     reception     area      that      lie    per    hundred    coronary     admissions     that    I)rcssion  that   the   presence   of   an   acute      VoicE.   I   think   that   Di-.   N4oses'   re-
                     talked    about-and    at    the     other     end    were   in    the    category    where    effective    coronary   care   unit   in   any   one   institu-    marks    should    be     immediately,,     quali-
                     of  the   scale   he   had   the   importance   of    coronary     care     efforts     were      savina    tion   upgrades   interest,   care,    and    per-    fied  about   the   black   mark   bit   bv   sav-
                     education    and    preventive     programs     to    them.                                                 haps  the  ability  to   treat   as   opposed   to    in,  that  it's  no   black   mark   at   all   if
                     achieve    a    more    complete    control     of       Now,   the    long-term    meaning    of    the    those   institutions   that   do   not   have   an    the    patient    also    has    power    failure.
                     the    coronary     disease     problem.     Well,    discharge    of    a    patient    having     suf-    acute   coronary    care    unit.    However,    I    Resuscitative    efforts    on    power    failure
                     it  is  at   these   two   ends   of   the   scale    fered    myocardial    infarction     and     hav-    remind you  that  this  -,vllole  I)rol)lcli-i  is    still   Occur   frequently    and    are    unprc-
                     where    the    Heart    Association    can     be    in.,    been    resuscitated     oi-     otherwise    air)  for  cxairiiiiation.   There   are   sliffi-    veritable.
                     most   useful   in    providin,    insight,    and    preserved    has    not    yet    been    defined;    clent   recliners   on   both   sides    of    the       It   would    appear    to    me    that    the
                     in    providing    people    who    are     accus-    in   the   sociological   sense   this   is   most    fence    to    warrant,    for    example,    that    triare   area    can    never    really    justifv
                     tomed    to    working    in    the     prevention    important.   But   I    think    there    is    an    this   topic   matter   was    included    as    a    itself    because    presumably    the     settin@
                     and public education spheres.                         encouraging    early     trend     to     indicate    controversy   in   cardiology   at   the    forth-    would  be  in  a   hospital   @vith   a   coronary
                        I  urge   you   as   professionals   with   the    these   individuals   do   not   become    5    or    coming   scientific   sessions   of   the   Amci--    care     unit;     trained     personnel     would
                     Regional     Medical     Programs     to      ttke    6    month    average    survivals    and     then    ican Colle,,c of Cardiology.                          monitor   this   from   tl-ic   unit   or    main-
                     advantage    of    the    experience,    of    the    (lie Lftcr-  an   intensive   attei-npt   at   rc-       Dr.   Mosi.-s,   Another   answer,   to    this    t@iiii it from the unit. It (-otilcl  I)(-  %,very
                     background     and     dedication      of      the    habilitation   and   do   not   essentially    be-    question  is  that  -with  the   InLi-oc]Li(@tiori    itiu(@li    more    c.,,I)cclitioLislv    resolved
                     workers     in      the      voluntary      health    come   of   critical   importance   as   a    part    of     continued     surveillance     we      have    merely    by     clianin-     admission     polic@
                     agencies.                                             of   their    community    or    their    families    really   had   a   clian,e   in   our   interpret-    to   the   unit,   by   havincy    patients    ad-
                        I  think  if  you  will   talk   together,   if    in   the   socioeconomic    sense.    There    are    ing   of   the   results   from    the    coronary    i-nitted   directlv   without   delav    to    the
                     you   work   together,   you   will   find    that    no data that go much beyond this.                     care  units.  Initially,  if   a   patient   stif-    unit  I-)rovidinff   thcrc'k@,cre   a   few   more
                                                                                                                                                                                                        .1
                     both   tli(@,   voluntary    health    it@,encl(@s       1)1', l@"I)'vVAI@1).S. f Stll)I)OS(@ this (Itit,s-         .1 ilia,ol,                   @iti(I %v;ts    1)(@(is         a,,,alltl)l(- in tli(-  unit  foi-
                                                             'D                                                                                 i
                     and     the     Regional     Medical      Programs    tion   has   two   aspects   to   it.   One,   how    resuscitated,  this  was   put   on   the   credit    this purpose.

                     72







                        It's   almost   implicit   if   it's    to    work ciated,       or        unrcco(rnized        symptoms research.     Some     months     ago     in      the able    a    resuscitative    measure    and     this
                      it    has     to     have     patients     admittin,, until    more     major     catastrophes     in     aclinical    literature     there     appeared     the is    a    major    magnitude    problem.    I    em-
                      themselves    to    the    unit    without     physi- fair number of cases.                     results    of     the     Baltimore     study,     in phasize    again,    this    involves    about     an
                      (-ian     recommendation      either      to      the Dr.     EDWARDS.     I      wonder      if      we which     Lilienfeld     and      his      colleagues equal    number    of    people    to    those    who
                      triacre   area   or   to   the   unit,    and    this could    'ust    have     another     comment.     It said    that,,In    the    retrospective    analysis, die in the hospital.
                      could    pose    a    regular    mare's    nest    of is,   of   course,   a   problem   to   plan   resus- they    were    able    to    document    that     an VoicF,.   I    wanted    to    thank    you    for
                      problems.                                      citativc     measures     or     preventive     meas- overwhelming     number      of      the      persons saying   the    "divine    gift    of    the    human
                        Dr.   EDWAI@DS.   I-)r,    Fox,    %votilcl    you tir(,s  in  the  p(@rsozi  who  is   about   to   die who    had    died    suddenly     sought     iaicdi- heart." So oft  le     think
                                                                                                                                                                                      en many peop
                            to              ()II  this   (111(@stioll' Sil(l(l(-,IIIY. flow (@;iii W(-,  this    in-  (-at   advice   foi-   (@oti(litions   i-elate(I   to God    is    dead    and     they     say     nothing
                      1 think W(' SliOL11CI (]('f'      I      bit              illlcl (to 1)(@oj)l(! i-(,@illy (lie that              cl's(@;ts(-.  It may          @II)OL]t   %viiat   the   D'v'zie   Physician    does
                      what   we    are    talking    aliout.    Dr.    l,ox Suddenly    from     actitc     coronary     disease, been   up    to    90    percent.    We    need    to in     cooperation     with     other     physicians.
                      has      already      indicated      that       among and   do   some    of    them    not    have    symp- have   this    type    of    retrospective    iiifor- I   just   wanted   to    thank    you    for    that
                      fatalities     in     coronary     disease      about toms     which     even     the     physician     and mation     to     develop     and     design     pro- remark made in public.
                      half    occur    outside    the     hospital.     The even        the        electrocardiogram         have spcctive studies.                     Then   I   wanted   to   ask    Dr.    Moses    if
                      individual,       sometimes        without        any failed    to    relatc    to     i-najor     coronary We    would    like    to    help    the    people fie   would   think   a   routine   test   with   the
                                illness,   that   witnesses   no    pain disease?                                     I                                           0
                      previous                                                                                        n    the     hospitals     and     the     practicing electrocardiogram     done     on      every      pa-
                      at least, suddenly     dies.      Some      people Dr.   Lil@   0   I@'F.   The    potentiality    of physician    identify     these     patients,     and tient    would    help     for     better     patient
                      do have   a   preamble    to    death    and    in sudden      death      from      coronary      artery in   some   way    monitor    them,    so    as    to care.
                      this   preamble   stage    is    -where    so    much disease    is    recognized    by    all    of    us. prevent    this     so-called     "sudden     death." Dr.    LIKOFF.     A     routine     electrocardi-
                      can be accomplished.                           Secondly,    preamble     to     death,     if     it I   think   it   is   becoming    more    and    more ogram   is   almost   worthless    as    a    screen-
                        Dr.   Fox.   I   think   what   we    are    faced does   exist,   generally   exists   in   the    form apparent   that   sudden    death    in    a    corn- ing     instrument     for     the     presence     o
                                                                                                                                                 I
                      %vitfi r(.(Illir(@s  S()rti(t  tyl)(@  (-)f  ol)(@ra- Of   'Irregulars    ot-    il-)(,i-rint    electrical pletcly   well   individual   is   real]),   not    acoronary    atherosclerosis.     Oil     the     cor-
                                                                                                            it  is    very (Common (@titity. I think tli(@i-e is     relative  Studies  that  have   been   done
                                          hot)(- I       IL          @l(@tivity Of tll(@ 11(@Ll't.   I                                                                    I
                      that   this   concept   of   the    reception  ui)likely  that  sudden   death   occurs   as    an  area  where   the   public   education     on   illeasurin(v   anatomic   changes   in
                      area is only  something  to  shoot  at.  I     a   result   of    independent    so-called      programs   of   the   Heart    Association     the  arteries,  it  has   been   repeatedly
                      think we can do better.                        power failure, that this is       a    rather    and   the   Regional   Medical    Programs     demonstrated   that   the    electrocardio-
                        The  problem  that  some   of   us   see     gradual   event   that   is    in    effect      Could offer a great deal.                      gram   remains   normal   in    the    face
                      is that  people  are  reluctant  to  enter     predictable.                                       Dr.  MOSES.  But   they   have   to   be     of    other     considerable     anatomical
                      themselves  in  anything  that   has   the        VOICE.  One  of  the  things  that   you      backstopped  with  the  professional   ed-     change.
                      formality of  the  present  coronary  care     brought  tip  seems  to  me  to  be   some-      ucation   program   and   the    physician        Dr.  COOPER.  I  would   like   to   take
                      circumstance;  and  if   we   can   reduce     thing  we  haven't   thought   about   much      has  to  have  something   reasonable   to     a little issue  with  Dr.  Likoff  on  that
                      what  we  as  physicians  don't   consider     here  at  all  and  that  is  the  epidemi-      do in these  people  that  are  identified     response.   We   recently   have   reviewed
                      to  be   much   of   an   impedience   but     ology  of  this  problem.  In  what  group,      as increased risks and we  are  not  quite     some   of   the   routine    electrocardio-
                      which  apparently  is  an  impedience   in     in   what   population   do   we   look   for    so  comfortable  about  that,   aside   from   -rams    from    the    Framingham     study.
                      the  mind  of  the  public,  if  we  can  re-  these  premonitory  signs,   and   can   -,ve    the   very   general   things    controlling   The  study  is  still  really  in   progress.
                      duce  the  steps  that  they  had   to   take  define   the   IDol)ulation   in   whom   the    the  risk  factors:  Higli-blood   pressure,   In   identifying   those   that   had   "sud-
                      prior  to  makin,   prudcnt   decisions   and  incidence   of   myocardial   infarction   or    sliock, and hypercholesterol.                  den   death",   the   retrospective    analy-
                      draw  them  in   earlier   in   the   symptom  other cardio accidents is highest?                 Dr.   EDWARDS.   Unless    we    can    do   sis     showed     electrocardiograms     re-
                      course, @v(-, lia%T  a  (@hance  of  doing        Dr. Cooi,j,-Iiz. Tli(.,  cl)iclcmiolo,ical    something  foi-  tliei-n,  we  mi,ht   scare   vealed  that  over  5,0   percent   of   them
                                   if tli(,r(! 'IS @Lfl @LIIIOII]IL Of                of                  itit(,r(@st tli(@iii to death. We would liav(,  to  plan   had  so-calleci  benign  arrliytlii-nias;   I
                      time   from    early,    usually    unapl)rc-  from    the    pragmatic    standpoint    for    soii-icthiia,,, in the Nvay of making avail-   don't  say  tl-iat  this  necessarily  demon-

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                            strates    cause    and    effect,    but    I    do   when    to    send    the     unit     out.     When   coupling,    heart    block,    and    the     like,   cli'ne     readin,.     The      machine      system
                            think   there   is   some    merit    to    pursuing   the   phone   rinus,   do   they   all   then    go?   has   been    lost    in    the    ambulance;    but   maintained     b@,     paramedical     and     enoi-
                            such   an   analysis    in    detail    with    mod-      Dr.  Fox.  I   don't   believe   I   can   really   he   doesn't   feel   this   type    of    excellent   iiecring     personnel      seei-ns      competitive
                            ern     computer      technology.      The      rou-   represent     Dr.     Frank     Pantridge's     phi-   record   will   be   maintained    at    the    100-   N@ritli  @vhat  is  likely  to  be  i-nost   availa-
                            tine     electrocardiogram     is      a      method   losophy    from    the    very    brief    time    I   percent level.                                         I)le.
                            for     obtaining     some     further      informa-   spent   here.   It's   like   a   2-week   tour   of      They     have     shortened     the     admission       The  abilitv  to   put   in   a   mobile   front
                            tion on this difficult problem.                        Vietnam.   I   had   I   day's    tour    of    Bel-   time   no%v   to   less   than    half    an    hour   end  to  this   unit   thou,h   is   still   a   bit
                               Dr.   MosEs.   I   think    what    Dr.    Likoff   fast's   unit,   but   I    had    the    impression   from   the   time   of   first   call   except   for   of    a    problem.    III    other    words,    one
                            meant    was    that    any     given     individual   that   the   physicians   of   Belfast    and    the   the   time   in   which    they    stabilize,    and   has     the     electrocrapliic              machine
                            cannot    be    labeled     falsely     or     accu-   area    around    were     the     prime     calling   become     acquainted     with,     the      patient   PlLlg(,CCI    into    the    data    phone    @vhich
                            rately from that data alone.                           source   for   this    unit,    that    there    was   on   the    scene.    This    stands    considerably   must   be   able   to   oo   throuah   clean   tele-
                               Dr.    LIKOFF.    That    is    very     correct.   nothing verging on self-admission.                     better   than   the    6-hour    delay    that    is   phone   lines,   which    don't    alivavs    exist,
                               VOICE.   I    would    like    to    say,    with      On   the   other    hand,    the    police    am-   reported     from     Edinbur(rli,     ,vhich     as   and   as   the   result   of   priority   selection.
                            this   incidence    of    the    hioher    use    of   bulances     and     nonmedical      calls      were   far  as  I  knonv   is   a   shorter   period   than   on    the    computer    and    back.    This    in-
                            hospital   beds,   that   it    would    be    ,von-   r(@c(@lvccl all([ i-(-sl)onclecl to. The  nL-          iny rel)ot-t(@(I  a,@, all  tv(@rage,                  tel'ft(-in"   has   not   been   resolved   anci   I
                            cl(-t-fiti if @v(,, (-oiil(l @isstir(-. ;t 1)@ltl(!Ilt tioti@ti              of tli(- Noi,tli l,'Ikit-o-                            III III(. tfilit(.(l             (Iiiiii@ %VI! ;ill        ;I                   front
                            lie (Gould go Into tile llosl)it@ll @is                                 kt-(-I)  @t  s@@st(-iii  in  (@()iitiol  V()I(:I.@. ()III, ()I  tll(7            III  illi@  III(-
                            icily   as   possible   @%,Itli   the   first   real   that iiil,,,Iit flot  1)(@  g(.Il(@t-@tlly  realized                  ol'  tll(@  gy-@issi'oots  is   til(@            ]II Missouri.
                            knowledge    of    a    coronary.    That    is    a   elsewhere.                                             i-(,@acly, qui(@l, iritel,])I-etitiol) of  electi-o-       We   liol)c   that   ii-i   tile    system    of
                            major   problem   in   our   area:   just   to    be      I   hope   I   make   myself    clear    in    my   cardiograms    by    a    practitioner    in     the   coronary   care   that    is    being    tried    in
                            assured   that   the   patient    could    be    ad-   ignorance   of   exactly    @vliat    this    means,   Field,   parti(@tilarly   those   in    more    i-e-   some   places    in    the    country    that    ra-
                            mitted   to   the    hospital    and    let    alone   but   I   think   one   of   the   very    important   motc   areas.   I   wonder    if    Dr.    Fox    or   diotelemetry    Nvill    be    evaluated    in     a
                            to   this   coronary   care   unit   to    be    ob-   operations    problems    to    desire    is     who   the    others    would    condiment     oil     this   (@ost-benefit    sense.    The    state    of    the
                            served and diagnosed.                                  calls    the    unit,    under     @vhat     circum-   current    evaluation    of    EKG    for    traiis-   art   in   science   permits   this   to   be    un-
                               Dr.   EDWARDS.   I    think    we    are    talk-   stances   and   under   what    level    of    rela-   mission   by    telephone    and    lie-,%,    close   clertaken,   but   at   sizable   cost   and    with
                            ing   about   an    area    of    patient    service   tive   priority   is   the   unit   sent   out   and   are   we   to    more    @viclesl)reacl    al)plica-   some    problems    with    the    Federal     Corn-
                            that    really    has    not     been     considered   Nvith       what       manning        circumstances,   bility     and     availability     of     computer-   MLliiications       Commission.       Some        of
                            in     developing     hospital     services     with   particularly   in   large    cities    where    mul-   ized    interpretations.    HoNv    good    is     a   these   have   to   be    worked    out    as    op-
                            proper       identification       through       mass   tiple calls might be concurrent.                       computer no@v on arrhythmias?                          ei-ational   problei-ns,   but   they    all    lend
                            studies   of   the   need,   and   first   of   all,      Dr.   EDWARDS.   Dr.    Fox,    do    you    have      Dr.    Fox.    Heart    disease    has     abnor-   themselves to reasonable solution.
                            the    magnitude    and    the     potential     for   any   idea   of    what    the    distribution    is   malitv.    Di-.    Caesar    Caceres    has     been       Dr.   EDWARDS.   NVe   have    in    the    room
                            doing     something     about     it.     Therefore,   of   live   patients    to    dead    patients    by   @vorking   on   it   for   some    7    years    now   Dr.   Georoe   NVakerlin    who    is    the    past
                            it   may   very   well   be   that    our    pattern   the time the service gets there?                       in   getting   this   effort    started.    As    an   i-nedical     director     of      the      American
                            of      hospital      construction      and      bed      Dr.    Fox.     No.     Dr.     Pemberton     who   example,     one     Regional      Medical      Pro-   Heart    Association     and     now     is     Mis-
                            availability    will    ultimately     change     to   is   the   epidemiologist   in    the    area    has   gram,   Missouri,   is   in    larcc    part    dup-   SOLIri     Relonal     Medical      Program      Di-
                                                                                                           0                                                                ZD
                            overcome    this     problem     and     that     is   some    statistics    and    I    am    afraid     I   Treating    a    system    @vhich    will    provide   rector.   Dr.   @Vakerlin,    @VoLild    you    care
                            what we are here for.                                  can't    aive    them    offhand.     The     number   a   means   on   the   data    phone,    to    corn-   to respond?
                                                                                          Z)
                               VOICE.   I   would   like   to   ask   Dr.    Fox   of   those   found   dead   is   I   think    rather   PLIter    on    ma-netic    tape,    and    teletype       Dr.   '"'AKY'-,RLIN.   I   N@-oLild    make    a
                                                                                                                                                           0
                            in    view    of     his     recommendation     that   minor  ancl,   in   a   recent   letter   from   Dr.   feedback      of      clectrocarclioranis.       The   comment      about      various      thins      that
                            a   mobile   unit   would    be    of    value    to   Pantridge,    so    far    nobody,    even     those   basis    of    the    Caceres     development     is   lia@7c     been     discussed.     For      example,
                            supply,   how    in    Ireland    do    they    know   with          complicated          electromechanical   to   have   the   ability   to   -ct   a   ood   ma-   with    reference    to    coronary    care    units

                            74




                     and  whether   they   really   save   lives   or gram   as   Director   for    Operations    of gional    Medical    Programs    and     siphon whom  w  can  do  little.  But  the  you  g
                                                                                                                    n    way     in     some     instances patient  who  is  a  relatively  good  risk
                     not,   we   have   a   specific    example    in the    program.    So    another     important                                            c                             n
                                                                                                            on physicia s a
                     the   Missouri   region    of    an    intensive source   for   RMP   personnel    in    additi from     practice      into      administrative and  the  one,  when  he  does  have   com-
                     cardiovascular    care    unit     which     was to   voluntary   health   agencies   is    the jobs.                            plications, who is likely to  have  one  of
                     manned    under    RMP    auspices    back    in U.S.   Public   Health   Service.   For    ex- The     matter     becomes     even      more an  electrical  nature  and  have  a  g   d
                                                                                                                                                                                              00
                     April.  According  to   the   figures   of   the ample,    Dr.    Earl    Simmons    who    was complex   as    we    add    the    need    for chance of resuscitation, that is the   one
                     people   who   are    responsible    for    that with   the   Heart   Disease   Control    pro- administrative   people,   and    the    volun- that he hesitates to put in. We     are
                     unit,    particularly    the    director,    Dr. gram  is  also  a  member  of  the  staff,  an tary   health   agencies   represent   a   very making    some    headway    in    pleading
                     Glenn    0.    Turner,    in    the    past    8associate   director   for   stroke   of   the natural  resource   or   reservoir   for   this with the  doctors  to  put  those  patients
                     months  or  so  23  lives   have   been   saved, Missouri     Regional     Medical     program. type   of   person.    I    think    we    have into the  coronary  care  units.  But  that
                     men    who    otherwise    would    have    died I  must  say  I  was  a  little  surprised  to reached   the    stage    where    among    the has been our biggest problem.
                     if  they  had   come   into   that   same   hos- hear   Dr.   Moses   recommend    the    Heart other   things   that   we   have    to    con- VOICE.   Dr.   Fox,   could   you    elab-
                     pital   during   the   period   prior   to   the Association   as   a   source   of   personnel sider  is  the   universities'   providing   an orate on  the  present  state  of  the  art
                     setting  up  of  the   present   form   of   the in  view  of  the  fact  it  has   lost   some educational      program      which       would in   programing   the   computer   to   in-
                     intensive     cardiovascular     care      unit. four or  five  of  its  key  people.  We  must train  people  for   the   jobs   that   health terpret arrhythmia?
                     This  is  only  one  unit,  but  I  think  there keep  a  strong   Heart   Association   alscl, agencies   and    RMP    require,    just    as Dr. Fox.  This  is  not  as  far  advanced
                     is  no  question  about  the  fact   that   bet- but I think  all  is  fair  in  love  and  war the   universities   now   train    individuals as is  the  interpretation  of  the  stand-
                     ter   care,   closer   attention   to   patients and  it  is  up  to  the  individual   himself to  be   hospital   administrators.   I   think ard   12-scale   electrocardiogram.   There
                     is bound to save some lives.                to decide where he wants to go.            we   have   reached   the    point    in    our are  programs  going  on  in  this   at   a
                       While it's very desirable   to          have Dr.    MOSES.    What    you    are     really medical     development,     health      devel- number    of    places:    Dr.     Caceres'
                     statistics,   I   think   that   we    shouldn't after  is  the   control   of   cardiovascular opment   in   this    country,    where    uni- group,   Warner   in   Salt   Lake    City.
                     wait  on  any   large   statistical   gathering. disease. The label or the hat'         whether versities   should   take   on   the   job   of There are  quite  a  few  groups  in  Cali-
                     RMP    should    proceed    as    rapidly     as you  are  doing  it  for  free  or   pay,   is educating    people    who    will    be    in- fornia  and   elsewhere.   None   of   them
                     possible  to  assist  in  the  setting   up   of really   not   the   most   important   thing. volved   in   the    areas    that    we    are is as  definitive  as  a  good  arrhythmia-
                     intensive    cardiovascular     units     and/or Dr.   EDWARDS.    As    president    of    the discussing.                      interested     electrocardiographer      at
                     coronary   care    units    in    representative American    Heart    Association,     I     am Dr.    WEINBERG.    I    may    have     misun- this   time.   However,   they   will    do
                     hospitals,     particularly     smaller     com- unconcerned   about   the    fact    we    are derstood  earlier,  but  I  thought   I   heard things  which  we  at  this   time   cannot
                     munity   hospitals   within    their    regions. having   a   certain   amount    of    traffic Dr.   Fox,   in   speaking   of    input    im- economically   afford   in    tying    good
                     With   reference   to   the   use    of    corn- from   the   Heart   Association    to    RMP. pedience   in   the   coronary   care    units, arrhythmia   talent   to   the   monitoring
                     puterized    electrocardiography,    this     is At  the  same   time   we   are   happy   that mention  there   was   a   certain   resistance of  patients.  They  can  present  displays
                     underway   as   Dr.    Fox    indicated    in we  have  people  that  are  attractive   to on  the  part  of  patients  into  entering of the time rate  of  occurrence  and  of
                     Missouri  and  we  are  about   to   set   up other organizations.                     those  units.  We   haven't   found   that. premature     ventricular     complexions
                     six  ten-ninals  in  various  parts  of   the But  seriously,  this   whole   subject   of The patients  like  the  units.  They  like whether  they  are  essentially  of   the
                     State.  Hopefully  there  will  be  a   total personnel  is  important   as   it   relates the feeling of security  in  there  and  if same   form,   presumably   unifocal   in
                     of  20   within   approximately   the   first to our areas  of  interest  in  this  panel. anything,   we   sometimes   have   trouble origin or multifocal,  on  the  basis  of
                     year,  and  one  thing   that   I   am   sure There  is  no  question   about   the   fact in  getting  them  out.  They  don't   like the  variance  in  forms.  This  type  of
                     will hasten  this  along  will  be  the  fact that   the   more   sophisticated    methods to leave  to  go  to  some   other   part   of display will give us the ability  to  de-
                     that  Dr.  Arthur  E.  Rickli,  who  is   Dr. of    diagnosis     and     treatment     of the  hospital.  Our  problem  in  the   in- velop criteria on  which  rules,  if  you
                     Fox,s  predecessor  as  chief  of   the   Heart patients  require   more   physician   time. put is  more  with  the  practicing  physi- will,  for  nurses  and  others  may   be
                     Control   Disease   program,    has    joined We  have  fewer  doctors  to  do   the   job cian. He is likely  to  put  in  his  high- built. As such,  I  think  that  hand  in
                     the   Missouri    Regional    Medical    Pro- as  we   program   things   like   the   Re- risk  patient  with  power   failure,   for hand  with  the  development  of  a   ca-
                                                                                                                                                                                             75









                            pability     to     "hack     the      dysrhythmia   of   normal   height   range   between    5    feet      VOICE.   I   am   aware   that   we    have    a   think   I   am    not    qualified    to    ansnver
                            electrocardiogram,"      to      use       'argon,   and   7   feet   7   inches   or   something.    We   vo-ue   for   this.   I   think   the   vo-ue    is   that.  Dr.  Likoff   may   well   like   to   corn-
                            will   be   an   ability   to    know    precisely   have  very  slack   criteria   and   the   use   of   fairly    well     documented     and     certainly   merit or Dr. Fox.
                            what   is   its    understanding    for    manage-   something     of     this     sort      immediately   it   is   accepted   by   a   large    number    of       Dr.   LIKOFF.   This    is    the    type    of
                            ment.                                                makes    much    more     sensitive     our     ap-   cardiologists.    The    problem    is    how    to   area,    the    inquiry    into    this    problem,
                               VOICE.   Dr.    Fox    spoke    abou,t    using   preciation of change.                                 prevent   or   how   to    make    our    spectator   the     advancement     of     knowledge,      with
                            an   identification   card    for    those    peo-      Dr.     EDWARDS.     Dr.      Likoff,      would   sport-conscious    public     more     aware     of   which    I    think,    the    Regional     Medical
                            ple    at    high    risk    for    electrocardio-   you   care   to   comment   on   this   point    of   the   fact   that    perhaps    they    would    do   Proc@ram   must   en-a,e   itself    if    it    is
                            graphic   or    cardio    accidents.    Here    is   the base line electrocardiogram?                      themselves    more    (rood     if     they     in-   to   be    an    effective    type    of    pro-ram
                            such   a   card.    I    am    not    member    of      Dr.   Lil-,OFF.   I   am   not    really    cer-   cILilc,cd in it a bit themselves.                     throughout    this     Country,     because     the
                            that    population,    That    is    my     normal   tain   where   this   discussion    has    drifted,      Dr.     EDWARDS.     Are     you      sl)eakin(r   aiis@ver    retarding    exercise    both     dia,-
                            electrocardiogram.                                   nor   to    what    purpose.    Is    it    implied   against     Sunday      professional      football?   nostically    and    therapeutically     is     un-
                               Dr.    EDWARDS.    Do    you     think     this   that  it  is   difficult   for   a   patient   with   I   think   it   really   is   amazing   the   num-   known.
                            electrocardiogram is really normal?                  overt   symptoms   to   be    idrni,ttcd    to    a        of   people   who   sit   theriisclvcs    down       'I'l i e, t-c arc    a-aiti    many    concepts    in
                               VOICE.   I    see    no    reason    @vhy    it   hospital  or  is  it  iiiiplit@l  there   is   some   on     a     Sunday     afternoon      watclilii,,,   this  i-e,rai-d  and  1)t-c(@iotis  little   truth.
                            couldn't   be    applied    by    'the    Regional   difficulty   in   the    emergency    station    or   @vlieri   they   could   be   cloin,   sonictliiii,   As  fai-  as  exercise  foi-  diagnosis  is   coli-
                            Medical     Pro(,rams      to      persons      in   first    care    of    this    patient     becoming   possibly to bcttei, their health.                     ccriied,  it  is  stated   by   the   most   astute
                                                                                                                                          Voicr,. We   have   been                                                               1          ilig
                            whom   appear   four   or   five   or    six    of   confused @is to what is wrong?                                                                   talkin,,   aiiion,, us that the I)Ii@,sic an tak'
                            the   cardinal   indices   of   hi(rh   liability.      Actually,   this   is   the    crux    or    the   @tl)out   the   rletection   of    coronary    dis-   @t  (-,tt-cfLil   history   and   pcrfoi-i-ning   a
                                                             n
                               Dr.    LIKOFF.    Do    you    provide    these   nexus   of   the    whole    problem.    If    this   case.   I    asl@d    the    question    for    the   ('@ir(@ful   examination   can   dia,-,Iiose    the
                            to all of your patients?                             in truth     is   ,,o   in   your   region,    then   panel to discuss the role Of CXCI-(@l'@,e,            otiset  of   coronary   artery   disease   in   all
                               VOICE. We provide          it   at   the   time   clearly    some    identification    of    a    pa-   of a practical sort that might liell-).               13Lit   about   20   percent    of    the    candi-
                            of     annual     periodic     examination.     My   ticiit    who    miaht     get     into     trouble      Dr.     EDWARDS.      Dr.      Moses,      would   dates   or   potential    inquiries    that    come
                            name   is   Webb   and   I   am   a   colonel   in   would    be    worthwhile,    but    then     would   you   care   to   say   something    about    exer-   to  his  office.   Secondly,   if   exercise   were
                            the U.S. Air Force.                                  statistical    analysis,     itself     worthwhile,   cise   as   a   practical   matter   in    coronary   performed    as    a    method    of     clarifying
                               Dr.    EDWARDS.    Your    point    is     that   be      necessary      proportionately      because   disease?                                              the    20    percent    that    he    cannot    put
                            people   should   carry   their   last    clectro-   there   arc   a   number    of    people    without      Dr.    MOSES.    I    can't    speak    to    it   his  fin-er   on,   20   percent   of   that   base
                            cardioaram     around      with      them      and   anv    warning    sians    whatever     who     act   authoritatively   from   the    point    of    view   fl('Lire-20     percent     of     20      percent-
                            use   that   as   a   baseline   in   the    event   into    deep    trouble     almost     immediately.   of   diagnosis,   but   I    think    Dr.    Likoff   -,volild   be   salvaed    by    the    more    so-
                            of a question of change.                             I  can't   really   see   this   is   a   pertinent   or  Dr.  Fox  i-nl,,ht.  I  can  say   that   there   phisticated     exercise     tolerance     studies.
                               VOICE. This is quite        possible.   It   is   point   unless    one    can    establisl-i    that   is   now    ample    data    that    the    regular       Now,    this    is    an    overview.     There
                            not  expensive.   It's   quite   easv   to   carry   this   sort   of    thin    @oes    on    routinely   exerciser,   the   person   Who    as    part    of   are    proponents    and    there    are    anta-o-
                                                                I                                      9 n                                                                                                                                 n
                            out.   If   this   were   embossed   on   an   ad-   throu,liou@     the     country.      I      rather   his  daily  lial)it   either   at   @vork   or   at   nists  to  this  view,   but   I   think   it's   a
                            dressograph    card    which    had    the    per-   doubt it.                                             play    en(,a(,cs    in    s',,n'ficant    physical   reasonably   fair   one.   Ili   all    likelihood,
                            son's   essential    data    embossed    on    the      Voicr.    Perhaps    the    time    has     come   exercise,   this   person   is   less    Vulnerable   from    the    clia,,,nostic    standpoint,     ex-
                            other  side,  it  would  really   facilitate   his   for   the   panel   to   bc-in   to   discuss   the   to    the    catastrophic    heart    attack.    He   ei,cise   cannot   do   much   for   N-ou    unless
                            admission to the hospital.                           detection     and     treatment     of     coronary   probably   is   not   any   less   vulnerable    to   @@oit    are    interested     in     phvsiolo-ical
                               Dr.    Fox.    I    think    one     commentary   heart disease via exercise.                           heart   attack   but   is   less   vulnerable    to   parameters   and   detail   of   -,%rliat   careful
                            is  this:   Dr.   Robert   Grant   used   to   say      Dr. Lil,:OFI--. Do You          ask    such    a   a catisti-ol)h(-. I think  tli(,  First  I)ai@t  of   bedside t(.@cliniqtics are apt to do.
                            our    criteria    for    the    clectrocarclio,,-   question  I)ecaits(@  you  (!revision  st.i(@ll   I   LI)(! Illtll'S (ILI('.StiOll 11@t(i to (10 %Vltl)         Ili  t(!r-iiis  of            tll(@l-c is  [)C-
                            raphy   is   comparable   to   saying   all    men   project?                                              exercise   and   the   clia,,-iiosiiig,    and    I   (Y'riii'n-  to   be   an   accumulation   of   fact

                            76






                      to  indicate  that  the  I)ct-foriiiaii(@c  of   @t   iii@itt(-i- of f@Lct, there liav(@  1)(@eri  soiii(!   time You introduce a                      of     ex-   you   run   lower   than   100    infarctions    as
                      cardiac      patient      exercised through        a  excellent      papers       published       Nvlilcli   ei-cise   in   an    individual    who    has    had   dial-nosed    On    exit,    either     dead     or
                      leisurely   routine   is    ,reatly       improved.   l@-OLIld  indicate   that   the   role   of   aiiti-   a  i-nyocardial   infai-ction   this   has   to   be   alive.
                      Ho%@,cvez-,   the    likelihood    is    apparently   coa,'Lltants   really   reflects   the   fact    Nvc   done    under    fairly    carefully    and    fire-       If  you   then   spread   this   patient   pop-
                      that   lie   dies   on   the   same   clcsl,,,iiated  have no@v  irioclifiecl  the  (@ai-c  of  the  coi--   s(-,ribcd    circumstances.    It@s    not     Some-   Lilation   over   the   number   of    beds    that
                      date, otil@, lie dies In             (:oii(litiol).   oiiai,y  patient   to   ititi-o(Iii(@c   the   exer-   thing    you     can     do     haphazardly,     and   can    be    maintained    effectively    in    the
                         Dr. EDWARI).S. Dr.  Fox,        would        you   (:isc  ('01111)OIICllt.)  so  in  effect  Nve   have   You   (,cannot   say   that   everyone   is    going   cost-benefit    sense    by    the    two     coni-
                      care to comment on exercise?                          introduced    another     variable     in     evalu-   to  be  treated  the   same;   so   I   think   this   petent     people     that      are      considered
                         Dr.   Fox.   Only,    I    don't    thinl-    we   at'n-      for       exai-nple,       anticoaulation   area    deserves    a    great    deal    of    con-   necessary for resuscitative c           rts,    you
                      1-ia%!c  the   data   today   to   indicate   when,   I)rocedLii@cs.  Dr.  Fox's  ,rOLII),  I  aiTi   cer-   sicleration,   particularly   in   view    of    the   will   come    up    with    a    very    disadvan-
                      but   I    certainly    a-ree    when    he    dies   tainly   sure,   is   very   much   interested    in   rather   significant    switch    in    Our    phil-   tageous         personnel-to-patient         ratio;
                      he   will   have   died   having   led    a    more   this;   and   if   the   Ilcart   Association   also   osophy  of   the   care   of   the   patient   Nvith   and,   therefore,    in    these    smaller    hos-
                      active  and  we  liol)e   iiior(,   i-(,@Nrai-diiig   is  iiitei,cstccl,  Nve   perhaps   ought   to   de-   myocardial iilfal-ctioil.                              I)Itals  it  seems  important   to   try   to   put
                      life.                                                 velol)     some      good      guidelines      which       1)1,. EDWARDS.  I  Nvill  ab-rce  we               together    a    combined    unit    either    with
                         VOICE.  I   think   this   is   very   pertinent   would     be     based     on      sound      exper-   haven't    even    be-uii     to     scratch     the   intensive  care   of   other   sorts,   the   post-
                      beca@isc   I   think   the   thing   that   bothers   imental   data   such   as   is    available    with   surface.   I   think   we    should    have    ques-   sur@ical    recovery    room,    back    of     the
                      most   practicing    physicians    is    the    re-   the     help     of     physicians     in     making   tions      from       someone       who       hasn't   emergency     room,     in     %vhich      patients
                      focus    and    reemphasis     on     the     post-   sounder    decisions    in    this     matter.     I   spoken.                                                in   the   area   of   trauma    and    such    are
                      coronary     inana,,Cinent     of     their     pa-   think    there    are    possibly     some     Ic,al       VOICE.   The   question   is   to    Di-.    Fox   cared   for   by   the    same    personnel,    but
                      tl(,@nt.  In   other   \@,orcts,   pati(@iits   are   compliance       (,.ascs       regarding       these   arid    perhaps    the    other     iricmbers     as   where   there   is   a   reasonable    de-ree    of
                      told   about   the   value    of    exercise    and   matters   about   Which   the   doctor    is    also   well.   Can   you   try   to    briefly    summarize   isolation,     particularly     acoustical     iso-
                      so   are   doctors   but   this   has   not    ade-   concerned.                                             Nvhat    we     know     about     the     economics   lation   of   the   coronary    patient    so    he
                      citiately been clarified     so   I   think   there      Dr.     EDWARDS.     I     think     you      arc   arid   effectiveness   of    coronary    units    in   isn It   kept   anxious   as   a   result   of   the
                      does   remain   a   ,rcat   deal   of    confusion.   qualified     to     ans@@'ei-     this     question   relation    to    the    population    served    for   bustle    and    bustle    attending    the    care
                         Now,    there    are    soiric    fairly    good   %%,Inch   I   ,,,,ould   like   to   put   to   You.   the     50-bed     hospital,     200-bcd     liospi-   of other sorts.
                      studies    that    have    been     clone.     Many   NVIiat   is   your   attitude   about   a   fori-nal   tal,so forth.                                              Much    must    be    done.    Tire    Congress
                      are   now   in   I)io(rress    trying    to    more   Nvoi-k   evaluation   of    the    patient    @@,lio       Dr.     EDWARDS.     Do      you      understand   rcco-nized      this      and      gave      moneys
                                  delineate     how     i-nLI(@h      excr- lizLs   recovered   arid   is   (@otisici(@rin,,    i,e- the question?                                        @@,iiich    are    in    the    RNIP    bud-et     this
                                                                                                                                       I-)I-. Fox. I  believe  I  do,   ])tit   I   \visli
                                                                            tilt-fill)(" to Nvol-l@?                                                                                      ycat,    specifically    to    explore    small    hos-
                      tati%,(!  phase  of'  post                                          I tliliil@ this li@ts       oil(,   ol   you hadn't @isk(,,(l it                it I'CN'('LAIS  I)Ital   and    otliel-    facility    coronary    care
                      farction     and     I     think     the     Re(,Ional tii(@  key  interesting   foci   of   tii(-   I   Icai-t my  ignoi-aiice;   I   ai-ii   soi,ry   to   say   there efTorts,    for    which    a    brochure    of     ex-
                      Medical      Pro-ram      should      involve      it- Association.       We       have       helped       With arc   no   data   that   really   tell   us   the    an- planatory    text    has    been    issued    by    the
                      s(,@lf   in   these   studies   arid   do   a   better ffo%,erninctital    a,,encies     to     sponsor     and s@,ver    to    your    question.    Part     of     the RMP office.
                      I.ob     of     both     professional     and     public Support    work    evaluation     tests.     We     feel question   I   think-   is:   Is    it    N%,orthNvlillc VOICE.     I     saw     something      in      the
                      education at this point.                              It's   a   Iii,,-Iily   important   thin,,,    to    de- to  set  fill   a   i-init   which   is   dedicated   to Springfield,     Mo.,      coronary      care      unit
                               IILL\'(@ to                 fo,-      Italy            We \would like the                           the i-clativel                       f   (@oi-oiiar),           iinl-)rcsscd    me    very    iTitich.    They
                                                                                                                               I                   Y lltll(llle, care o
                      years    ,@-c    ha%-c    preached    the    I)hiloso- physician    to     know     the     availability     of patients    in    smaller    hospitals?     And     this have         developed         something          Which
                      ph@,   of    intensive    bed    rest    and    treat- these   units   so   that   he   could   hell)    SLII)- is   an   area    of    great    interest    that    has nierits   consideration;    that    is,    the    reha-
                                                                                                                                       t    yet    been    fully    explored,    but     it bilitation     of     the     postinfarction     situa-
                      ment     of     coronary     patients     with     kid I)ort his patients.                                   no
                      gloves,   so   now   we    are    in    fact    chan,-   Of     course,      exercise      evaluation      is @vould    appear    when    you    get     below     the tion.   After   the  patient        as       cone
                      In,,  and   i-evci-slii,,,   this   position.   As   apart   of   this   program.    I    think    that    any average   acute   hospital   size   of   I    00    beds tlii-ou,li    the    I.C.C.U.,    he     conics     out

                                                                                                                                                                                                                                            77








                           and  then  he  progresses  into  a  reha-              coronary patients in the population,                            PANEL         DISCUSSION         ON-                 Dr.  BRENNAN.  I  have  been  asked  to
                           bilitative phase and  there  is  the  op-              extensive efforts in development of                                                                               talk about  the  Reo-ional  Medical  Pro-
                                                                                                                                                                                       CANCER                               n
                           portunity  where   you   can   begin   to              appropriate rehabilitation must be                                                                                c,ram  in  Michigan  and  the  needs   of
                           induce  the  philosophy  of  exercise  to              undertaken.                                                                                                       this program in cancer in  the  light  of
                           the patient  or  begin  to  talk  to  the                                                                                                                    Panel:      the  studies  that  Nve  have  been   in-
                           patient about  restructuring  his  living                                                                           Sidney   Farber,    M.D.    (Chain-nan)              volved in for the past several  moi-iths.
                           in  re@ard  to  diet  and  other   things                                                                          President-Elcct,   Ati2crican    Cancer               Now,  in  the  State  of  Nlichi-an,   we
                           which  are  going  to  greatly  influence                                                                          Society  a7id  Director   of   Research               have divided the State  into  three  sub-
                           his way of life in the future.                                                                                              Childrcn's    Cancer     Research            regions.  The  total  population  of  the
                              I  think  we  probably  ought  to  pay                                                                                                               Foundation       State  is  around  8  million  and  there
                           serious attention to this  thing  because                                                                                                       Boston,     Mass.        are 4 million in  the  metropolitan  area
                           I think it  does  offer  a  good  way  to                                                                                    Michael   J.    Brennan,    M.D.            which  is  composed  of  four   counties-
                           restructure the life  of  a  postcoronary                                                                             SCI'(77Ztific a?id  Medical  Director              Wayne,        I\/facoml),    Oakland,    and
                           patient.                                                                                                                                                                 Monroe.  The  great  problem   with   the
                              Dr.  EDWARDS.  We  realize  in   clos-                                                                                Michigan    Ca7icer     Foundation              disease is  it  is  concentrated  in  the
                           ing we haven't really  gotten  very  far.                                                                                                      Detroit,     Mich.        metropolitan  areas  because   thev   are
                           We  have  estimated   that   20   million                                                                                          Juan   del   Re,ato,   M.D.           where the population is.
                           Americans  right  now  have  heart   dis-                                                                         Director,   Penrose   Cancer    Hospital                  When  we  started  off,  we   had   the
                           ease  and  a  year  from  now  a  million                                                                                        Colorado   Sprin,@s,   Colo.            idea  that  our  biggest  difficultv  was
                           of  them  will   have   died.   We   have                                                                                 Kenneth   NT.    Endicott,    M.D.             Nvitli the delivery of care to what  are.
                           major areas of challen(,,e.  Our  biggest                                                                                                                                called the disad%rarita,,ed urban  1)ol)-
                                                        0                                                                                   Di?-cctor,  Natlo?ial  Cancer   Institute
                           challenge  is  in  the  area  of  athero-                                                                                                                                ulations.  We  have  6,000  deaths   from
                           sclerosis  and  coronary  heart  disease.                                                                                 National  Institutes   of   Health             cancer a year  in  the  metropolitan  re-
                           One  very  important   point   that   has                                                                                          Guy   F.   Robbins,    M.D.           gion. This is  about  one  out  of  everv
                           not  been  discussed  very  much  in  the                                                                                             Director   of   Planitina          50 people that die  in  this  country  of
                           past which is bound to  be  i  stil)i(-ct                                                                               Aft,t?iot-l(il Ilo.vl)ztr7l for Cancer           tll(, disease.
                           for. tll(. flittil@(.     @111(i                  is                                                                                                                                        it  tli;tt
                           the patient ,vlio tlltlll@s 11(@ Is  ',V(-Il  @111(i                                                                                        N@,7(,  )'orl, , N,          ()I- (,Ily@ I)OI)tll;Ltioll is  II)  I  1;11'1'ili,@toti's
                           nii-ht   be    dead    within    the    next    half
                              0                                                                                                                                                                     I)ovcrtv     classification      and      clisadvati-
                           hour      from      coronary      disease.       The
                                                                                                                                                                                                    ta(recl   in   one   way   or   another,   and   that
                           acute    death    occurring     in     perhaps     a
                           quarter  of   a   million   people   a   year   out-                                                                   R.   FARBER.    It    has    been    a    year    the-    stage     at     which     people     present
                                                                                                                                            Dsince     the     last     meeting      of      the    themselves    for    the    treatment     of     can-
                           side    of    the    hospital     emphasizes     how                                                             Regional    Medical     Pro(,raiiis.     A     -reat
                                                                                                                                                                                                    ccr  in   this   group   is   much   more   far   ad-
                           important    a    practical    problem    this    is                                                             deal    of    experience    has    been    atlict-ed
                           to   determine    the    identification    of    the                                                                                                                     %,anced  than   it   is   in   tl-ie   people   going
                                                                                                                                            by   many   groups   tlit-oti,,Iiotit   the   cotin-
                           individual   and   to    provide    facilities    to                                                                                                                     to    private    physicians,    then    one     would
                           prevent the catastrophe.                                                                                         try, and it  s(,(,@iii(,(l  to  the  division  tliit    think that t             lai-g      vin(@  in   lives
                                                                                                                                            tti(- tltii(@ %@,a,., i-ii)(, to (lis(-tis,,@ soiii(- of                              c sa      , I
                                                                                                                                                                                                                                                 I   rais
                              We    have    had    just     a     few     words                                                             the  cILi(@stiotis  of  caii(:(!t-  more  sl)c(@ifl-    (,OLllcl I)t! a(,coiiil)llsliccl i)@! sliiil)]N
                           about       rehabilitation       and       recognize                                                                                                               el    in,,  the  level   of   care   available   to   these
                                                                                                                                            cally. I am (,-olii,l@ to ask Dr. Miclia
                           that    if    our    economy    is     to     remain                                                             J. Brennan,      Professor    of     Medicine     at    people   to   that   available   to    the    portion
                           stable   @vith    this    tremendous    weight    of                                                             Wayne State University, to be,in.                       of   the   population   @vlilch   can    afford    to

                           78






        go  to  private  physicians           and      be    first time in the report  of  the  Presi-            patient visiting service  with  a  capac-               All  of  these  things  flow  out  of  a
        treated in private hospitals.                        clent's  Commission  on  Heart   Disease,            ity of 1,500 patients per week.                       sociolo,  cal  change  which   has   hap-
                                                                                                                                                                               oi
           However, if one corrects            for    the    Cancer,  and  Stroke.   While   a   great               Now,  of  course,  these   people   are            1)ened in  our  society.  The  lare  fam-
        fact that a great number of  these                   deal was called foi- in the way of cclu-             I)clii,,. cat@cd  foi,  in  one  way  or  an-         lly strii(,,turc  has  disappeared.  We  are
        categorically indigent people         are   I)eo-    (ational  facilities,  research   facilities,        other   at   the    present    time,    often         dcalliil- with the  unit  family  structure.
        1)lc over 65, li 'ng oii social  s(@(@Lirity         specialized  hospital  facilities,   training        shairiefully  and  often  times   far   below         In  people  past  65,   this   unit   family
        and   retirement   income,   then   it   de-         of   chcmotherapists   and   so   on,   there        the  level  at  which  we  should   be   able         structure  often  consists   of   two   per-
        %@elops  that   our   optimism   about   the         didn't  seem  to  be  any  general   realiza-        to  help  them.  But,  in  terms   of   inte-         sons,  both  of  whom  are  afflicted   with
        effect  of  .vidcspread  programs   of   de-         tion  that  until  we  arrive  at  the   time        grated   facilities   for   the    management         one  or  another  form  of  chronic  illness
        tection  among  the   poor   will   be   too         where   we   have   a    significant    major        of  disseminated   cancer,   we   only   have         or   disability.   To   talk   about    bas-
        sanguine                                             technological     improvement     in      our        at   most   in   the   Detroit   metropolitan         ing  cancer   care   on   home   care   pro-
           -i%fy   calculations   would    indicate,         ability   to   handle    this    disease-par-        area  200  bcds  that   would   qualify   for         grams  tinder  these  circumstances  is   to
        and  I  @,von't  go  into  them  in   detail         ticularly  in  that  portion  of  the   popu-        such  a   designation   in   terms   of   the         talk  about  having   to   provide   nursing
        here,  that  we  NvoLild  be  able  to  save         lation  over   65   in   which   50   percent        kind  of   men   who   are   in   charge   of         service  and   practical   nursing   service
                                                                                                                                I                     I                 in homes all over the  i
        somewhere   around   450   more   lives    a                                                              them  and  in  terms  of  the  kind  of   fa-                                      c tv
                                                             of   the   disease   is    concentrated-until                                                                                                ,   in   homes
        ),car if we  a@,e  to  this  indigent  popu-                                                              cilities  and  skills  available   to   those         which   are   small,   Nvhich   don't   have
                                                             that  time  comes,  we  have   to   face   up
        lation the  same  attention  that  @ve  give                                                  I           men   and   Nvithin   those    institutions    for    resources  to help with          the    care    of
        to  the  paying  population,  in  the  large         to  it   that   around   60   percent   oi   pec,-   the   management   of   this    kind    of    dis-    these seriously ill people.      We    have     to
        hospitals    where    we     have     the     best   ple    who    have    this     diagnosis     made-   ease.                                                 realize   that    we    must    find    ways    to
        medical   talent    and    facilities    available   this  includes   all   cases,   skin   and   else-      It   seems   to   me,   therefore,   that   the    make  up   for   all   of   those   things   which
        to us,                                               @vhere-are going to die of cancer.                   most    greatly     needed     development     for    the   extended    family    structure    did    in
           Nc)@%,,  NvYiy  don't  @vc  pick  up  t  mit(-h      Studies    on    our    service    at     Henry   the     Regional     Medical      Programs      in    the   past   for   the   elderly   and   for   the
        lat-,,Ci- iiiai@,'ri of  (@oi-iti-ol  if  we  man-   l,orci Hospital, %vlilcli is a  lat-,,(@  can(@ci-   tli(@   context   of   Our   CXiStill"   Situation    sick-all   those   kinds   of    support,    loans
        age    (freatly    to    improve    the    medical   chemotherapeutic      and       medical       man-   (not   the   situation   we   hope   for   5    or    and    physical    assistance,     nursing     as-
        surveillance     over    some@vhere     in     the   agement    service,    showed    that    in    the   10   years   from   now,    but    our    existing    sistance,      transportation,      help      with
        order of 30      percent    of    our     I)opula-   last  year  of  life,   the   mcdian   length   of   situation)    is    the    development    of    an    shopping, all of these things.
        tion?   The   reason   is   that   the   distribu-   time   required   in   hospital   for   the   full   extended-care   type    of    facility    suitable      In   the   cancer    patient    and    in    the
                                                                                                                  for    the    management    of    patients     un-    stroke   paticnt-and   these    t    o    diseases
        tion  of  cases,  according   to   disease   site,   palliation   utilization   of    the    radiologi-                                                                                           w
        is  so  far  different   in   the   private   hos-   cal,     neurosurgical,      surgical,      chemo-   der      chemotherapy,      under       radiother-    are   very   much   alike   in   what   they   im-
        pital   group   than   it   is   in   the   County   therapeutic,      and      medical       maneuvers   apy,     under     medical     management      for    I)ose    in     these     regards-these     diffi-
        hospita  -I    (,roup,    The    county    hospital  which    to    our     best     judgment     Nvere   disseminated      cancer.      These      institu-    culties   are   severe,   protracted,   and    be-
        group   is   at   a    disadvantage    in    terms                                                                    d  not  be   as   expensive   nor   as    ),end   the   reach    of    any    unit    family
                                                             needed   for   the   help   of   these    patients   ,tions nce
        of  the  fact   that   they   are   older   people   was 45 days in the last year of life.                @eavily    staffed    as     -the     conventional    structure    to    deal     with.     We     must,
                                             I y  fro                                                             lios                                       ite  to    therefore,  develop  in             I
        and  more  of  their  iiiortal't                in      Multiply    that     times     6,000     people        pital. They ought to be satell                                                stitut'onal       or-
        cancer   is   with   kinds   of   neol)lasia   for   dying   of    the    disease,    and    you    can   the    general    hospital    and     ought     to    ganizations     which     respond     to     needs
        which         do  not  at   the   present   tiriie                                                        have   a   ready   flow   back   and   forth    of    -,vhich   we   cannot   think    of    as    being
                                                                      idea   of   how   many    hospital    bed   patients   accordin-   to    need.    Unless    we    primarily   or   solelv   medical,    but    which
        possess   any   effective   system   of    therapy   get an I                                                                                                                         I
        and control.                                         days   you   require.   It   turns    out    that,   create  thei-n,   we   may   find   ourselves   in    arc medicosocial.
           This  disappointing  fact  of   tli(.@   in@it-   for   the   in@iiiagemenL   of   the   late    pa-   a   situation   where   we   don't    have    room       I-)r.   FARIII--,R.   The    second    speaker,
        ter  brou  iit  home,   after   I   had   realized   tictit,  @vc   need   somewhere   in   the   order   in   the   general   hospitals   for   the    care    Dr.   Juan   del   Re-ato,    is    director    of
                   9
        it, sorriethin,,,           I   noted   for    the   of   1,000   hospital    beds    and    an    out-   of acLite illness.                                    the   Penrose    Cancer    Hospital    in    Colo-
                                                                                                                                                                                                                        79









                       rado  Sprins.  He   is   a   member   of   the                                                                                                       'I'liere should  be  also,  of  course,  in
                       National     Advisory      Cancer      Council                                                                                                    sucl-i   a    center    cancer    chemotherapy
                       and  is  known  to  all  of  you,   not   only                                                                                                    and   other   ancillary   services   such   as
                       for  his   preeminence   in   the   field   of                                                                                                    rehabilitation,   follo@vup   facilities,   et
                       radiotherapy,   but   also   for   his   broad                                                                                                    cetera.  T-Jnless  these   circumstances   are
                       philosophy   of   patient   care,   diagnosis,                                                                                                    fulfilled,  it  is  not  likely  that  anybody
                       and research in the field of cancer.                                                                                                              in  an  isolated  place   is   going   to   do
                          Dr.   DFL   REGATO.   As   you   know,    I                                                                                                    adequate   radiotherapy   Just   simply    be-
                       am    a    therapeutic    radiologist,     al-                                                                                                    cause  he  has   the   equipment.   And   even
                       though  my  interest  in   cancer   is   wide.                                                                                                    if  he  were  skilled,   he   needs   all   of
                       For  the   purposes   of   this   session,   I                                                                                                    these   other   conditions   to   have    been
                       should   concentrate   on    the    particular                                                                                                    fulfilled  in  order  that  he  can  do   ade-
                       aspects  that  are   involved   in   the   re-                                                                                                    quate radiotherapy.
                       sponse   to   the   needs   that   you   might                                                                                                       But  to  give   you   an   idea,   assuming
                       find  in  the  field  and  the  actual  possi-                                                                                                    that   we   are   already   in   a    position
                       bihties   of   solution.    Radiotherapy    is                                                                                                    where    .we   have   decided    @vlacre    the
                                                                                                                                                                         center  is  Corn(,  to  be,  there   arc   two
                       only   second   in   importance   to   surgery
                       in the treatment of cancer.                                                                                                                       approaches   for   you   in   the    field-the
                          We  feel  that  it  is   not   enou@h,   of                                                                                                    one is  to  reinforce  the  centers  that  are
                       course, in order to create       the    possi-                                                                                                    already  there.  And   the   second   one   is
                       bilities of fruitful curative        treatment                                                                                                    (@i-eatin(y  new  centers.  Well,  the   first
                       as   well   as   palliative   treatment   with                                                                                                    one is, of  course,  easier.  It  may  not  be
                       radiotherapy,    to    just    acquire     the                                                                                                    geographically   satisfactory,   but   it   is
                       equipment.    As    we     have     repeatedly                                                                                                    much easier.
                       said  the  skill  has  to   be   there   first                                                                                                       Now,  we  figure  that   a   major   center
                       before   the   equipment   comes,   and    the                                                                                                    will need at least one radlothcrapeut'
                                                                                                                                                                                                                     lc

                                                                                                                                                                                                                     er
                       equipment  is   only   a   very   small   part                                                                                                    Llll t for every 300 new patients p
                       of the whole business.                                                                                                                            ycai-,  one  hi-h-volta(,e  or  cobalt   unit,
                          To  be-in  with,  in  oLir   own   concept,                                                                                                    and one or two  othei,  i-adiotheral)etitl(.1,
                       one   cannot    do    adequate    radiotherapy                                                                                                    units  such  as  roent-cn  therapy  of   coii-
                       in  any  place  unless  there   is   a   corn-                                                                                                    ventional    volta-e.    And    then,    there
                       prehensive   care    of    cancer    available                                                                                                    should  be   also   availability   of   radium
                       in  that  particular   place.   That   implies                                                                                                    and    superficial     radiotherapy     equip-
                       competent   diagnostic    facilities,    corn-                                                                                                    ment.   This   is   a   minimum   for   everN7
                       petent   cancer   surgery   in   the   various                                                                                                    300  new  patients  at   the   major   center.
                       specialties,     competent      tumor      pa-                                                                                                       This   equipment   will    require    addi-
                       tholo-             l                     isrc-
                             ,,y, which is an itcm often d'                                                                                                              none]   stipl)ortin-   facilities   such   i.-
                       garded.   We   do   not   treat   the   patho-                                                                                                    transverse      ton-io,,raphy,,      di-essiii-
                       logic  report;   we   treat   the   patholooic                                                                                                    rooms,    follon%,up    examination     rooms,
                       entity.   And   a   pathologic    report    is                                                                                                    treatment     plannin,      simulators      in
                                                                                                                                                                                                 'D
                       sometimes  at   variance   with   the   truth.                                                                                                    order  to   diminisli   the   time   that   is

                       80







                              riiisused   in   trying    to    study    the    patients    what     we     need     is     people     Nvlio     know    have    lived     just     long     enough     to     know    breast     amon.-     the      women      and      cancer
                              within    the    room    @@,hei-e    the    main     unit    how    to    handle     them.     The     cobalt     will    that   it   is   a    tragedy    to    put    a    tremen-    of     the     prostate     and     of     the      colon
                              is.                                                          not   do   the   job.   It   is   the   skill   and   the    dous    effort    in     the     early     dianos's     of    among men.
                                 'I-here   is,    of    course,    need    for    minor    facilities,     the     ancillary     facilities     that    patients     only     to     see      them      mistreated       In    our    hospital,     in     one     ),ear     in
                              .surgical   suites   and   all   of    this    kind    of    ,o     N%Tltli     the     department      of      radio-    or     nc,lectcd     afterwards.     If     we      under-    ,vhlch    we    made    a     record     of     it,     a
                              thing    that    ,o(@s    alon,,    @,,,Itfi    such    a    therapy,     that     are     needed.     And      these,    take    any    such     tliln(,@     as     a     regional    whole    third    of    the    patients    %vith     can-
                                                                                                                                                                                                     n   i
                              center.       Machine       shops       arc       usually    of course, arc not easily acquired.                          smears    project    for    the     dlaz-)     os's     of    cer    of    the     breast     who     were     operated
                              necessary,     accessory      to      departments      of       There    is    a    total    of    300     well-quali-    cancer   of    the    cervix    before    it    has    be-    in    our     hospital     were     women     who     had
                              radiotherapy,       because       of       all        the    fied      and      specifically      trained       radio-    come     an     infiltrating     cancer,      the      im-    cancer    of    the    breast     discovered     by     a
                              minor    different    things    that    have    to     be    therapists         in         the         country-exactly    portant    thing    is    that    the    patients     that    resident     in     training     -,vhen     the     women
                              built      to      treat       patients       adequately.    299--for     the     entire     country.     A      great    are    found    to    have     carcinoma     in     siti-i    were     not     aware     that     they     had     any-
                              And,  of   coLiz-s(,,   I   @%,o@ildn't   pass   by   the    deal    of    the    radiotherapy    will    li@ive    to    receive     adequate     treatment     or     the      pa-    thin,-    the    matter    with     them.     That     is
                                                                     I'll :III)' sli(.Il   (.olltilill(@ to 1)(@          I,()I.  soill(@  time   by    tl(,Ilts tli@it :11,(@ l'otill(I  ii)  til@it  I)i-o(-.css             it  is  fi-iiltftil,  of  (@otirse,   to   clis-
                                                                                                                                                                                                                                            Ill(l  to  tl'(",IL  it@  l@tit  it
                              ol'  sl)(-(@lti  t(@( liiioI()L,,I.SLS,                      ()I   (I(>Ill""   I)OLI)                            @Lil(i   ('@Ll'(@1110111as                                   treat-    \\'OLIICI  be.  too  brief  to  clis(@o\,ci,  a  iiliiii-
                              i,iurses,   et    (@etcra,    without    @@'IIICII    one    radiotherapy    slii(,@c     \vc     do     not     have,    iiient.                                                       her   of   early   cancers    of    the    breasts    and
                              cannot     think      about      having      an      ade-    nor   can   expect   to   have,   in   the    near    fu-        It  is  not  because  it   is   early   that   it   is    have      someone      do      a      simple      mastec-
                              quate center for radiotherapy.                               turc     a     Sufficient      amount      of      radio-    easier   to   treat   it.    In    fact,    it    requires    tomy    on    them.    This    is     the     time     to
                                 Now,    it    is    olivious    that     there     arc    therapists.    We    need    easily    eight    to     10    a    -reater     skill     sometimes     to     do     the    do     really     adequate     surgery,     and      this
                              certain    in(II(@@itioris    of     r@tcl'lotli(,i-al)\,    ti@iies  as   many   as   Nv(@   have   at   the   pi-es-    'ob    even    though    the     patient     is     early.    is    the    thin-    that    I    think     is     worth
                              that             1)4,  t@il@(@ri       ol'    %@,itliotit    (,tit          And tli(,                 of    men     in           same   tliiii@,-   applies   to   sLi(-Ii    things    ciiil)liasizill(Il'.
                              all of that, but tli(! point that %%,(!             ai,c@    the training of                                 radiology    as   ('aii(@ei-   of   tile   breast.    Nvllctllcr    the       Dr.     FARBER.     The     third      speaker      is
                              tlilii]@in,,- about is a c@eritei, that is            rc-    is  ratlici-   reduced.   It   is   of   the   order   of    clia,,nosis   is    done    in    every    doctor's    of-    responsible    for    the    lar(rest    pro(Tram     III
                              sponsible     for..     respondent     to,     all     of    50    to    60    in    the    entire    Nation.     That    fice,   as   it   should   be,   or    whether    it    is    the       world       today-the       National       Can-
                              the  needs  with  which  we  might                     be    yields,    at    most,     some     20     new     radio-    done    in    special    cancer    centers    like     our    cer Institute.
                              presented,    all    of    the     possibilities,     not    therapists    per    year.    This    is     really     a    own,    a    great    number     of     earl),     cancers       Dr.     ENDICOTT.     I      thought      today      I
                              a    selected    "roul).    The     selectivity     might    very     small     amount     of      new      radlother-    of    the    breast    can    be    found,    and     they    might    talk     a     little     bit     about     some
                              come     at     the     secondary      centers      level    apists    for    such    a     large     country     with    can    be    found     by     young     physicians     who    of    the    problems     of     operating     a     can-
                              where    the    people    in     charge     might     de-    such great needs.                                            are     specially     trained     to     palpate     thor-    cer    center    because-     we     have     sort     of
                              cide    to    take    up    onlv     certain     problems       This  presents,         I        am        certain-and    oughly     the     breasts     of     all     women     in    a   cancer   center.   Perhaps    it    is    a    little
                              that   can    be    managed    at    this    level    and    I   am   not   trying   to    make    it    worse,    but    followup examinations.                                        on     the     long-haired      side      because      it
                              then    transfei-    the    others    to    the     major    rather     ii-iake      it      evident-a      very'scri-        We     have     a     large     clinical      followup    is      primarily      research       oriented,       but
                              counters.   That   is   a   cluestioii    of    lo-istics    otis   problem   to   envisaffe.    It    isn't    easily    examination      of      thousands       of       patients    it    comprises    many    of     the     features     of
                              in    @@,@ilch    I    cannot    nor    am    I    coiii-    solved, but it is Ol-)V,IOLIS that tile  SO-                 that     were      treated      for      minor      things    so-called      excellence       which       I       think
                              petent to -0.                                                ]Lltlon    of    the    problem     is     not     neces-    like    basal    cell    carcinomas     of     the     tip    medical        schools        and        university-based
                                 My     emphasis     has     to     be     upon     the    sai7llv   to   buy   the    equipment    or    to    will    of    the     nose     whom     we     have     follcnvecl    cancer    centers    would    want.    It     is     part
                              fact     that     @%,hene%Ti,      )rou      (!ontemplatc    this    no    Ion-er    a    problem.     It     is     a    now   for   periods   of   15    to    20    years.    All    of    a    more    general     facility     in     @vhich
                              radiotherapy.     as      Dr.      Endicott      alread),    problem     and     will     continue     to     be     a    patients      are      properly       examii-ied       an-    many   diseases   are   studied.    So    it    is    not
                              indicated    @-cstci-day    in    his    brilliant    ad-    problem.                                                     nually    @viien    they    come    for     their     fol-    really      a       cancer       hospital,       although
                              clr(,Ss,      I)F-ol)@II)IY                           too       No\@,,   from    otii,    point    of    view,    out-    lo\v(ii) c\aininatioii                this    yields     a    N%rc    have    separate    %vards.    Most    of     the
                              many Cobalt units ill  Lll(@  (@OLilitiy  -1                 side   of   tll(.-   field   of   i-acliotlici@al3y,   we    considerable    iiutiibei-    of    cancers    of     tile    specialities    that     ml,,,-lit     be     conceri-icd

                                                                                                                                                                                                                                                                             81












             with   the   treatment   and   diagnosis    of and  only  a  portion   of   these   are   re- the    Memorial     Hospital     for     Cancer down  there,   this   woman   said,   "And   a
             cancer   are   represented   and    most    of search beds.                                 and  Allied  Diseases   in   New   York   City. little child shall lead them."
             them   have   separate    wards    of    their   The beds   are   expensive.   They    are    Di-.   ROBBINS.   I    have    found    that  But,  you  knonv,  you  do  have   to   take
             own.   It   is   concerned   primarily    with much   too   expensive   for   patients    who working   in   the    vineyards    which    are some  sort  of   an   approach   to   all   of
             treatment   and   research   on   therapy   of are   ambulatory.    And    we    have    Iona being   irrigated   and   nurtured    by    the these   things   and   look   for   techniques
             advanced  disease,  but   it   also   includes since     developed     arrangements      with Regional    Medical    Pro,ram    is     really and   for   ,vays   of   communicatina    that
             substantial  leavening  of  studies   of   the local   motels   for    patients    who    are one  of   the   most   stimulating   activities will   present   your   objective.   And    as
             abnormal     physiology     and     biochemis- taken  care   of   in   the   outpatient   fa- that  I  have  been  involved   in.   I   found you   know,   with   many   of   Blllv    Sun-
             try   of    the    disease    and    something cility  and  live  in  motels.  This  is   es- carly-I  am  trying  to   speak   as   a   sur- clay's  converts,  they   stopped   near   the
             which   I   regard    as    very    important- pecially  helpful  in   dealing   with   chil- geon-tliat   one   of   the   greatest   thin@s local  bar  to   celebrate   their   salvation
             we  insist  on  the  right   of   our   physi- dren,   especially   children   Nvith    acute that  one  had  to   do   was   to   take   the oil the @vay home and that was it.
             cians   to   admit   patients    with    other leukemia.   We    have    beds    enough    to Billy   Grtham   approach,   not   the    Billy But  I  think  that   from   what   I   have
             diseases  and  to   carry   out   studies   in bi-lri,-  them  in  when   they   really   re- Sunday approach.                            seen,  the  team  tliit  his  been  (I(@v(-.1-
             otli(@r- areas.                                                       ))Lit fOl' til(@ IIIOS(, Nf y       w;ls;t M(@tlio(I ],,,L minister, ()I)('([   IS t;ll@ltll-l ill(' frilly ( ;T'@Lli@1111
               No@v, I think this is  soiiictliiii,,  very ])art, they @Ll-C C@ll-CCI fOl' ill the  Out- down  in  southern  Iticilaii@i.  We   used               And this is  @t  tou(,Ii  thing
             important  in   keepin(r   first-rate   men   patient facility.                             to  have   these   men   and   women   come   foi,  surcons  to  do  because,  you  know,
             working   in   the   management   of    ad-      To  do   this   adequately,   obviously,   in to save souls. This  basically  was  the   we are  pretty  egotistical,  and  most  of
             vanced   cancer.   They   have   to    have   rccluires  more  than  the  ordinary   out-   utilization  of   a   tccliiilqli(-   which   us, I think, really shy a little  clear  of
             Some  Outlet  some   I)sycliolo-ical   out-   patient  facilities.  One  has  to  analyze   WOLTICI -et SotilS Out of the. l@@,ll)tiSL and caii(@r-  because  somehow  or   anotli(@i,
             let,  especially   the   younger@ones,   or   the kind of' Itlilng that is  going  to  be   Christian   Church   into   the   Methodist   it  is  woven  into  our  philosophy   that
             they simpl@,  can't  take  it.  They  can't   done in this facility and prepare  for  it.   Church.  And  I   remember   as   a   small   you do soiilctliln,," like  a  hernia,  and
             face  those  patients,   especially   chi]-      No@v,  I  am  convinced  that  many   of   boy one  of  these  characters  cominla  to   it gets all  done,  and  that's  fine.  But
             dren, day in, day  out,  unless  they  have   the  medical  schools,   medical   centers,   town and  taking  me  out  to  et  a  soda.   if  you  take  care  of  a  cancer  patient
             some variety in the diet.                     that are  aoing  to  be  involved  in  this   Right  a@vay,  I  was  suspicious  because,   and  there  is  a  recurrence   and   there
               Our   group    requires    ,%,hat    many   program  over  a  period   of   years   can   havin(r dealt  with  a  lot  of  ministers,   are   all   these   famllv   problems   and
             would  consider  to   be   excessive   sup-   attract  and  keep  the  kind  of  men  you   they  usually   didn't   give   very   much   everythiii," else, you sort of look  at  it
                                                                                                                                                   I   as a defeat of your    own.  To  trN,   and
             port in  terms  of  laboratory  facilities.   are  going  to  need  to  do   the   educa-   away. So I said to Mrs. Barr-first,
             Part of  these  laboratory  facilities  are   tional  job,  the  consultation  job,   the   drank   the   soda-"Why    did    you    do   develop   amon(r   sLir--cons   and   those
             directly  related  to  what  they  are  do-   central referral job, if you  will  provide                                                 workin(T   with   surgeons   an   intradis-
                                                                                                         this?"
             ing in  patients,  but  even  more  is  re-   research  beds,  some   laboratories,   and                                                 ciplinary   approach   to   look   at   the
             quired  to  do  the  research  they   @vant   a   good   ambulatory   care    arrangement     She  said,  "Guy,  I  am  here  to   help               a -,vhole, a  person,  this  is
                                                                                                         your   father.   Now,   sometimes   durin(r   patient as
             to do which is  not  directly  patient  re-   of some sort.                                                                        .  0   toLi h.
                                                                                                         my first  evening,  things  don't  go  just      9
             lated. And  I  am  sure  that  it  is  nec-      Mike  Brennan  has  talked   about   one                                                   But  there  are  more   and   more   peo-
             essary to provide this  if  you  are  goin-                                                 right,  and  I  want  you  to  get  one  of     e that are  doin,  this.  And  certainly,
                                                           possibility.  I  have  mentioned  the   use                                        . .      I)l
                                                                                                         your  friends,  and  when  I   am   givin(y
                                                                                                                                                   'D
             to  get  first-rate  men  and   keep   them   of motels.  Perhaps  we   might   @et   Dr.                                                 it falls  within  the  philosophy   of   the
             on the job.                                                                     n           my plea, if things don't --o right, I  will   way of life that I  think  can  be  clearly
                                                           Farber to mention how he            handles
               We  have  250   beds.   Of   those,   150   this   same   problem,   especially    with   give  you  a  sign,   and   you   come   on   defined as Americanism.
             are in the  clinical  center  in  Bethesda,   children.                                     down the aisle."                                I  have  been  vcrv  fortunate  to  ha%,c
             and  they  are  all   research   beds.   We      Dr.  FARBER.  The  final  formal   prcs-     And I  will  nevei,  for,@ot  to  my  dY-   been  involved  wit@   the   Cancer   Corn-
             have  another  100  beds  in   the   Public   entation  will  be   given   by   Dr.   Guy   in,- day as  I  pulled  this  other  little   mission of  the  Colle-C  of  Surgeons  for
             Health  Service  Hospital   in   Baltimore,   Robbins,  the  Director  of   Planning   at   ragamuffin out into  the  aisle  and  Nvent   a  number  of  yeai@s,  and  ivith   Murray

             82







                                                                                                                                                             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
                                                                                                                                                                   ery  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 @s.
                                                                                                                                                                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
                     Copeland   and   Lee   Clark    and    many     Many  of  you  may  or  may   not   know   6  years  ago.  We  found  out  a  lot   of  stopped.
                     of the other  people  I  see  here  in  the  about    our    regionalization    program.   things   that   you   are    finding-things     All of us  in  this  room  believe  that
                     room  I  am  part  of  a   team   that   is  We   had   a   tumor   registry    program.   that we thought were all right.              you  should  do   everything   to   get   a
                     working   with   the    regional    medical  It  has  been  going  for  a   long   time.     Well,  instead   of   shaking   a   nasty  person   back   into   the    socioeconomic
                     group. And  I  can  tell  you  we  are  100  And   under   John   Klein,   Lee    Clark,   finger and saying,  "It  is  no  good;  get  swing of  things,  but  what  are  you  do-
                     percent  behind   the   program,   and   we  and    Murray    Copeland,    we    decided   rid of it," we got together to  try  to  do  ing  about   it?   There   are   ways.   We
                     are  not  too  far   behind,   either.   We  to do an audit on  this  just  to  see  how   something about  it.  The  first  thing  we  used  to  say,  "Well,  the  laws  are   no
                     are right in there with it.                  good  it  was.  This  started  about  5  or   did  was  to  broaden  our   cancer   corn-  good;  we  can't  help  a  cancer   patient

                                                                                                                                                                                                      83











                           until  five  years."  There  are  ways  to              I don't  think  near  enough  of  us  are-             grams, I think,  to  which  you  might  be              sho%v  them.  He-  has  told   the   whole
                           take care of that.                                      and that is finding the time  to  help  in             alludino-.  One  is  the  tumor   registry              stoi@l, and I think it is up to  you  fel-
                              I  wish  you  could  see  the  way  New              the  lay  education  program.  There   are             protram  which  has  been  goin,  on   for              IoNvs  to  do  a  self-analysis  and  find
                           jersey's  DVA  works   with   the   State,               arts  of  this  country  now  where   pa-             30 years.  We  believe  that  if  you  are              what is wron,.  Is  it  vour  followup  or
                                                                                   p                                                                                                                                n
                           the  Federal  people,  and  with  the  pa-              tients come  in,  and  they  are  too  far             going  to  evaluate  how  a   patient   is              is  it  that  a  lot  of   vou   are   doing   slil)-
                           tients in the hospitals.  They  are  doing              advanced  even  to  consider  as  possibly             doing  or  has  done  or  how  you  as   a              sliod  operations  a@d   modified   simple
                           a    great    job.    New     York     is     coming    being   a   cure.   There   are   parts   of    this   physician     are     working,      there      should   inastectomies?"
                           along,   too.   This   takes   a   lot   of    Billy    country    where    everybody    has    a     radio,   be some records kept.                                      I   didn't   know   if    I    were    goin-    to
                           Graham         approach,         though.         You    70    percent    of    them    have     televisions,      Now,    just    to    take    the    names     and     et   out   of   the   room   or   not,   but   t@vo
                           can't do this overnight.                                but   in   the    local    newspapers    there    is   numbers    and    ace    and    site    and     stage   or   three    people    came    up    to    me    and
                              One   of   the   most   interesting    and    en-    nothing   on    health.    And    on    the    tele-   and   so   on,   that's    great.    But    if    you   said,    "This    is    what    we    have     needed
                           lightenino,    meetings    I    ever     went     to    vision    and     in     the     radio     programs,   just   put   that   in   a   repository   and   never   for   a   lon-    time."    And    then    I    found
                           was   one   that   Dr.   Smith    down    in    Jer-    there   is   nothing   on   health.   I   think   we   utilize   it,   it   doesn't    make    any    sense.   there    had    been    two    or    three     people
                           sey    fielded.    They    had    500     practicing    need   some    comic    books    and    things    of   And      we      have      found      administrations   Nvlio  had   been   tryin(Y   to   do   this.   TheN7
                           physicians   in   the    middle    of    the    week    this   type.    Because    if    people    can    be   don't    like    to    spend    money    on     some-   had    put    this     particular     hospital     on
                           listening     to     the      problems      involved    sold,  if   you   can   sell   a   population   cig-   thing that their staff doesn't use.                     notice  that  if   thev   didn't   -et   a   clinical
                           with   getting   the   aid   that    is    available    arettes,   why   can't   you   sell   health    pre-      One    of     our     main     efforts     throu-h   pro,,ram    alonx    with    their    tumor     rear-
                           at    the    community    level,    and    it    was    vention aaainst these diseases?                        the     regionalization     program     has      been   istry,   we   weren't   -oin,u    to    okay    their
                           great.   And   there   are   going   to   be    more      We   have   worked   hard,   and    a    lot    of   to   try   to   get    these    records    used    in   tumor    i-c-'str@,.    We    feel    keepinu    rec-
                           of those meetings.                                      money   has   been    spent.    But    there    cer-   teaching    exercises    and     in     self-evallia-   oi-ds   and   not   usinff   them   is   not    ao0d.
                              They   Nvere   a   little   surprised,    as    a    tainly     must     be     something     more     we   tion.   I   was   asked   to   go   to   a    500-bed      The   second    part    is    the    study    that
                           matter   of   fact,   how   good   a   turnout    it    can   do.   And   I   have   found   that   if   you   hospital    in     Westchester     and     give     a   we    have    been    designated     to     do     on
                           was.  But   they   had   spent   a   lot   of   time    put   a   surgeon   on   his   guard   to   try   to   talk   on   breast   cancer.    And    I    said    I   lookina   into   a    number    of    hospital    ac-
                           disseminating      information      about      this,    get  him   motivated,   if   you   get   this   fel-   would    love    doing    it,    but    I    wouldn't   tivities  to   see   if   we   can   -et   ideas   as
                           utilizing    the     many,     many     forms     of    low  goin,,  lie  is  almost   as   big   a   terror   go   unless   they   had    one    of    their    men   to  how   they   are   clolnl-   tlilno,-s   in   the
                           communication.     These     are     the      things    in  this  sort  of   thing   as   he   is   in   the   give   their   experience   in   Nvhat    has    been   inana,ement     of     cancer     patients.      @'Ve
                           that   we   have   got   to   do.   We   have    got    opcratin(r room.                                       done   and   then   I   would   be   glad   to   dis-   will   have   a   larffe    bulk    of    information
                           to   get   the   people    that    may    even    be      Dr.     ANDREWS.      Neil      Andrews,      Ohio   cuss things.                                            that can be passed on.
                           considered   by    some    as    just    too    busy    State   University.   When    I    was    in    Tuc-      Well,    one    of    their    men    went    into      That    is     the     Warren     Cole     Commit-
                           making   a   living,   but   if   vou   give    them    son   at   the    AMA    meeting,    I    had    the   the   tumor   re,isti-y,   and    he    found,    al-   tee   that   is   doin,    this    work    in    con-
                           just   the   slightest   notion   that   you   Nvant    opportunity   to   talk   to    Clif    Mount    and   thou-h    they    had     had     several     hundred   'unction    with    all    the    specialists,    in-
                           their  ideas   and   you   Nvant   them   to   hell)    Bradiaan   about   a    program    that    is    be-   breast     cancers,     primary      cases,      out-   cluclin,y   those   in   the    Acadamv    of    Gen-
                           get   this   thing   on   the   road,   it    works.    ing     done-and     I     think     you     alluded   patients    that    tlicv    had    operated,    they   cral    Practice.    In    no     N%@av     are
                           And,  of  course,  this  is   the   heart   of   the    to   this   just   a   moment   ago,   by   a   num-   didn't  have   a   siti,le   one   that   had   lived   cliai-,,ed to set    ul)    staTidarlis.     We    are
                           whole      Re      ional      Medical       Program.    her     of     organizations,     including      the   5   years.   And   this   man   ave   the    5-@,cai-   finclin, out a      lot   of    thiti,s    that    are
                                        9                                                                                                                               9
                           And   it   is   a   sermon   th,@it    ev@oric    is    Colle-C     of      Surgeons,      the      American   survivals   at   the    national    level    k,,,Itli   most   iiitci,estin(,,-.   In   one   hospital,   xvc,
                           preachin,-    that    is    %vorkin-     in     this    Cancci,     Society,     Colle,@c     of     Cli(@st               tioc](@s tticl positive iioci(@s.           former   tli(@y   liax-(-   @%,oiicfei-ftil   lioz-1-
                                                                                   SLII"ICOIIS   @iiid   otlicrs-iii   (-cancer   i-eg-      @VI]CII I ',I)Ol@(@ f         tll(' tISLI@ll Cl('I'- Y.Ofit@ll (@otililltlil]Clt]OIIS,  but  the  so(-I@il
                              There   is   another   tl)ing   I   think    that    istries   if   I   i-enici-nber   correctly.   Could   iiiition   of   a   sl)e(,Iallst.   Then   I    said,            %%,oi-kei-  had  ncvei-  met   tlic,.   mail
                           is   awfully    important    foi,    stir-cons    to    You  ,ive  us  a  1)1-0(rl-CSS  I,(.,])Ol,t  oil  that?          11-(. illy slicl(,S;  f  @ilit  not  (,Oill(, \N@ll() %vts ill              tll(.           I)]-o-
                                                                                                         'I'lict,c   are    two    pro-   to    use    them.    I    iiii    not    going    to          foi- that hospital.  And  the  social
                           do,   and   some   of   us   are   doing   it,   but      Dr.   ROBBINS.

                           84






               service   worker   had   16    mastcr's    degree   that   the   Surgeon   General    shall    estab-   College    of     Radiology,     the     American    lines. TiicN, arc  iio@A,,  testing  them  as  to
               social    service    workers    Nvorking     with   lish  and  maintain  a  list  or  lists  of  mcd-   College    of    Pathologists,    and     others.    their   feasibility   in   actual    visits    to
               her.  This  particular  chief   of   the   social   ical   facilities   in   the   country    staffed     'And   we   have    negotiated    a    contract    various   types   of   hospitals    around    the
                   'c(@ de                            I      1                1                  1                     with   tli(-   American    Collc,e    of    Stir-    country.   And   if   this   works    well    and
                           -I)Lii-tin(,nt had  1)(@eii  in  this   and                 to  1)i-ov'cl(,.  the  latest
               hospital siiict, 1952.                              advances   in   the   diagnosis   @iii(i   treat-   geolis  to  coiisi(Ic',-  this  field,  to  coil-    productively   in   the    field    of    cancer,
                  We   also   found    that,    although    they   iiicnt  of   heart   disease,   caii(.-ci-,   and   si(ler N@,liat SIIOLIICI really ]-)c present  ill    we   propose    to    undertake    similar    ac-
               didn't   1-ia@,e   a    rehabilitation    program   stroke,  and  to   serve   as   training   situa-   a  medical  facility  which  is  ,@oizig  to   do    tivities  in   the   field   of   heart   disease
               and   that   the    social    service    Nvorkers   tions in these diseases.                            the  kind  of  job  Nve   would   all   like   to    and stroke.
               didn't    actually    know     anything     about      It   further    says    that    the    Surgeon   see   in   the   diagnosis   and   treatment   of       Dr.    COLLINS:    Collins     from     North-
               what   they   A,ere    doing,    the    orthopods   General,   in   carrying   out   this   activity,   cancer.                                              western  Ohio.   I   happen   to   be   a   path-
                                                       i                                                                  When  these  criteria,   as   we   arc   call-    olo-ist in a conim        '          I
               were doing a fantastically good 'ob.                shall   from   time   to   time   turn   to   ap-                                                                               unity    hospital     pro-
                  Those    on    medicine    and    those     in   propriate     national      professional      or-   ing   them,   oi-   guidelines   are    available    viding   service   in   pathology   to    several
               the  nurslii,,,  area  and  those  in   the   so-   ganizations in the country.                         in  the  field  of  cancer,   wl-licli   we   ex-    small     community     hosl)ltals-let's      say
                                                                      The   division,   in    trying    to    deter-
               cial   service   department   said,   "gee,    we                                                       pcct   A,Ill   happen    sometime    next    sum-    from   50   beds   up.   I    have    been    im-
               had    better    Nvork    to,ether;    we    look   mine   how   to   respond   to   this   part   of   mer,   we   propose   to   make    them    avall-    pressed   with   the    fact    that    in    the
               sort   of   silly."   All   horizontal   communi-   the  legislation,  decided   that   as   an   in-   able  to   hospitals   all   over   the   country    smaller      community      hospitals,       cer-
               cations,     no     vertical      communications.   itial  step,   it   would   be   appropriate   to   for   their    own    internal    guidance    and    tainly  in   my   area,   there   has   been   no
                  Now,   coming   up   -,vith   data   of   this   consult   with    the    national    professional   to     program     coordinators     and      mem-    long-term     follo%vup     of     cancer     pa-
               type   is   not   going   to   change   the   way   organizations   of   the    country.    We    arc   bers   of   their   staffs   in   the    Regional    tients.   Perhaps   in    a    sur-eon's    owi-i
               medicine  is  practiced,   but   I   think   that   thoroughly    appreciative    of    the     great   Medical Programs.                                    personal    experience,    he    has     followed
               it  will   make   people   utilize   @vhat   they   sensitivity    of    the    medical    profession      Through    the    availability    of     these    them,   but   to   my   knowledge,   there    has
               have.   We   have   found    that    there    are   toward     federally      imposed      standards,   guidelines,  we   hope   it   Nvill   be   easier    been    no    collective    experience.     These
               some   hospitals   who    do    not    have    an   and   we    do    not    propose    to    develop   to  identify   the   gal)s   in   the   diagnosis    cases    may    move    from     community     to
               X-ray    therapy     department.     But     they   federally     imposed      standards      through   and   treatment   of   cancer,   in   the   capa-    community.
               have   a    regional    arrangement    so    that   this activity.                                      bility  of   a   region   to   carry   out   good       With   this   background    in    my,    let's
               their    patients    are    getting     excellent      Knowing     that     the     American     Col-   cancer    diagnosis    and    treatment.     This    say,    puzzlement    about    how    to     work
               care.   And   certainly,    we    wouldn't    say   lege   of    Surgeons    had    already    estab-   Nvill  be  a   guideline,   both   to   hospitals    out    a    proper    followup    situation,    I
               this was bad.                                       lished    the    Cancer     Commission,     which   in   their    development    as    better    111-    \wonder   if   a   regionwide    tumor    re(,is-
                  Dr.  FAR13F-,R.  At   this   time,   I   would   included     in     its     membership     rcprc-   stitutions  for  the  future  and  a   guide   to    try   isn't    the    answer.    Most    hospital
               like  to  call   on   Dr.   Margaret   Sloan   to    ,ntatives   of   all   the   professional    Or-   Regional    Medical    Prograii-is    in     try-    tumor   registries   I   have    been    familiar
               say   sorriethin,,   more   about    the    Amer-   a;,nizations     in     the     country      most   ing   to   develop    regionally    the    calda-
                                                                                                                                                                               th   have   been   as    Dr.    Robbins    has
                                                             hip
               ican College of Sur,,eons' relations                                                   cynosis    and   bility  they   Nvill   need   to   perform   ade-
                                       0             -             closely involved in the dia,                                                                             already      cited-dead.       The       material
               with   the   division   of    Regional    Medical   treatment   of   cancer,   we   turned   to   the   quately in this area.                                goesinto   .a  file   and   nobody   ever   looks
               Programs.                                           American     Collec     of      Sur,cons      and      I believe that we        have    been     very
                                                                                        n                                                                                   at it.
                  Dr.   SLOAN.   I   would    like    to    com-   asked   their   help   in    this    undertaking.   fortunate    in     persuading     Dr.     Warren       And   I    am    very    much    disillusioned
               ment  a  little   bit   on   what   Dr.   Robbins   The       Cancer       Commission        includes   Cole,  who  is  known   to   all   of   you   and
               has   'ust   said   and   to   set   in    proper                                                                                                               tli  the  hospital   tumor   beds.   I   -,vas
                     i                                             representatives    of    the    American     Col-   has  the  respect  of  all  of  you,   to   chair    wl
               perspective    this     activity     which     is   le,e   of    Surgeons,    the    American    Med-   the   comi-nittce,   representing    all    these    very      much      impressed      with       Dr.
               now     known     as     the     Warren      Cole   ical    Association,        the          American   professional    or,,aiiizatiois,     which     is    Smart's   presentation   on   the    Salt    Lake
               Committee.                                          Academy   of   General    Practice,    all    the   struggling    with     this     problem.     Thcv    City,  and  I  think  it   might   be   the   an-
                  Section   907   of   our   legislation    says   surgical      specialties,      the      American   have   developed   a   list   of   such    -uide-    swer. I don't know.
                                                                                                                                                                                                                           85









                        Dr.    ROBBINS.    You    are    a    -reat      her of variables,  lots  of  different  kinds     for a  checkup?  We  feel  that  it  is  ini-    (@'ii'a.  I  can't  help  but  coml)are,   as
                       straiahtman  for  Dr.  Smart,   and   I   am      of cancer,  all  different  types  of  exist-     I-)ortant  that  you  do  so.  And   if   you    I  listen  here,  the  heart  i)ro(,i-am  and
                       another  of  his  strai-htmen  and   so   is      ence  as  far  as  survival   is   concerned,     are  unhappy  @vitli  him,  let's  find   an-    tli(,  cancer  I)i-o,@ram.  They   run   into
                       Andy  Mayer  of   the   Colleo-e   of   Sur-      and yet,  the  secretary  is  not  a  statis-     other one."                                      difficulty  in  that  in   the   heart   pro-
                       creons  and  so  is  Murray   Copeland.   We      tician,  she  is   not   a   physician,   and        And  I  am  aii\lous  to  see  the  Ameri-    grain, there    is a carcliolo(,Ist  %Vlio  is
                       think  this  man  has  come  closer   to   a      even the  physician  is  not  a  statistician     can  Collee   of   Sur,cons   in   particular    the captain  of  the  team:  in  t  e  cancer
                                                                         and  is  unable  to   deal   with   the   tre
                       workable   sort   of   a   re,ional    tumor                                                   -    try  not  only  to  establish  these  cancci-    i)ro,,Tam,  there  isn't  anv  cal)ta  n   of
                       registry   than   anyone   else   that    we      mendous number of facets.                         rcaistries,  but  in  sonic  way  to  see  if    the  team.  Manv   specialists   are   inter-
                       know.  And   this   is   primarily   because       How   can   the   American    College    of      we   can't   develol)    a    mechanism    by    ested in cancer.
                       of one thin,:  He  is  doin,-  quality  con-      Surgeons    or    the    Recional     Medical     which  we  can  give   them   an   individual       When  it   comes   to   -Cttiria   adequate
                       trols and really  A,orking  with  the  local      Program   or   any   other    program    sim-     hospital automated followup.                     examination   for   cancer   of   the   lar@e
                       hospital and it,-,  staff  and  givina  them      plify    this    tremendous     number     of        I  think  for  about  $50  a  ycai-   that    1)0%%rel, I think  one  of  the  troubles  is
                       prestige  and  also  givin,  them  a   prod-      facets?   I   think   a   meaningful    corn-     most    community     hospital     registries    that  the  iiiternist,   the   surgeon,   the
                       Lict  that  they  can  use  and  understand.      putcr  pro(,ram  can   actually   service   a                                                  I   I)roctolo-ist, the  I)atholo-ist,  the  (,en-
                                                                                                                           could  ,et  a  report   of   the.   SLIT-viva
                       Mr.    Chairman,     maybe     Dr.     Smart      ,reat  number  of   hospitals   as   individ-     curves On all their patients, listiii-l-s  of    et'al  practitioner,.  are  interested,   but
                       might want to comment.                            ual   hospitals   and   yet   correlate   the     all their patients, and a  listen',  to  each    "Obodv  has  the   %%-Iiole   interest.   The
                        Dr. SMART: I believe         that   one   of     statistics  that   come   from   the   health     inclividi-ial  physician  of   the   patients    public health person is interested.
                       the   most   important   things   that    we      departments.   It   can   account   for   all     that  he  has   been   following   for   that       I\la\-be this is  a  shot  from  the  blue,
                       can  do  in   improving   the   quality   of      the    deaths    and    immediately    update     year. I  think  it  could  be  done  cheaply.    but -we have  specialties  that  deal  witl-i
                                               0
                       cancer  care  at  the  present  time  is  to      all   the   registries   simultaneously.   It     I  think  it  could  be  clone   effectively.    a  verv  narrow  part   of   medicine.   Per-
                       follow  the  lead  of  the   American   Can-      can  pick   up   the   patient   that   moves     And   I   think   that   these   tumor   rea-    hal)s  plastic  surcrerv   is   one   example.
                                                     ican     College    from  one  hospital  to   another   or   from     istries  which  they  have  been  ptisliliio'    There  is  no   specialty   board   for   on-
                       cer Society and the Amer'
                       of Surgeons in trying to       make      these    one  doctor  to  another.   It   can   simul-     could  actually  be  made  to   be   a   very    colog@7  or  tumors,  for   cancer.   Perhaps
                       hospital tumor registries     really   effec-     tancously,   then,   update   the    registry     effective  tool  in  education  and  in   re-    there  should  be  such  as   we   have   for
                                                                                                                                                                        Si  carcliolon,.
                       tive.                                             which  will  send   out   automated   letters     search,  as  well  as   in   saving   patient
                         A   tremendous   amount   of    work    has     to  doctors  to  remind  them,   at   6-month     lives through folloN@,up.                           I -,vonder what the panel
                       gone  into  the  gathering  of  this   data.      intervals,.  of  -  certain  patients.   And,        Dr.  ANDRI,-,-VVS.  Dr.   Farber,   if   I    think of that. I kno%@, it is  sort  of  per-
                       And  if  we   can   induce   physicians   to      not only that,  I  believe  that  it  is  im-     may j'tist comment to        my      colleague   haps a ne%v idea.
                       followup their  patients  regularly  .  .  .      portant  also  to  be  able  to   have   some     from   Lima,   the   department   of   health       D I-.   BRI-,NNAN:   The   American    So-
                       By   "regularly,"    I    mean    every    6      kind  of  action  arm   so   that,   if   the     of   Ohio   State   did   until    about    3    ciet\    for    Clinical     Oncoloav     was
                                                                                                             lan,    we                                                     formed ap          I
                       months,  preferably.  I  think  it   depends      patient is lost to that physic'                   years   ago   maintain   a   central   cancer                  prox  matel\  3  or   4   veai-s
                       a  little  bit  upon  the  type  of   malig-      have   some   ethical   way   of    approach-     registry. Unfortunately, th'                 -   a-0.  One  of   the   problems   -which   im-
                                                                                                                                                            is   was   un
                       nancy  they  have,.  but  they  need  to  be      ing that patient.                                 available  as  rc,,ards   follo,,%@up   mate-    raiediately  came  up  following  tl-ie   or-
       r               followed.
                                                                           And  in  our      particular    area,     we    rials. So it was   disbanded,   and   we    at   -anization   of    that    societN,    -,Vllose
                         No@v  I  think  a   tumor   reffistry   must    have  tried  to   devclol)   an   action   arm    Ohio   State   now   are   attcml)tln(,@    to   membership   consisted    lai-,elv    of    men
                       have   a   mechanism   for    relicving    the    tlll-OLI,,h   the   public   health    depart-    put  to(,@cthcr  an   automated   I)i-o(@raiii   N%,Iio  had  been  active   in   clinical   re-
                       tremendous     amount      of      secretarial    nierit @%,Iiei-e we c@in ittilize tli(@ public    sti(li  as  Dr.  Smart  has  stated  so   that   s(@ar(-Ii @is opposed I)urel@7 to the ('are  of
                       -,vork.   The   problem   at    the    present    health  nurs@  actually  to  visit  the   I)a-    we can  i-nake  this  available  tliroti(,-Ii-   ('aii(-er   patients.   was   an   impetus   on
                       time   in   the   community    hospital    tu-    tient,,vith the  permission  of  the  I)Iiysi-    out out, I-(.",ioti -,I-,  we  have  developed   tti(,  1)2irt  of  the  i-oi,il)  toward  tti(@
                       mor   registry   is   this:    A    tremendous    cian  and   say,   "How   is   it   that   You    it.                                              formation  of   a   subspecialty,   board   ]II
                       number   of    patients,    tremendous    num-    haven't I,)(@cn  golii(l,  to  your  physician       1)1-.  WII,IIAIZ.  N\Iilf)ai-,  West   V'r-   ori(-olo(,@

                       86






                  Well,  I   have   found   myself   opposed  medical   needs.   Actually,    there    are     I would  like  to  point  out  to  all  of  ultimate  salvage   rate,   in   cancer   by
                to  this  idea.   As   a   hematologist,   I  only   personal   needs-nceds    of    indi-   you the  fact  that  there  is  a  different  using   optimally   the   available   detec-
                never  found  it   necessary.   The   Amerl-  vidual persons who  are  part  of  a  social   approach    which    we     undertook     20  tion  facilities,  not  by   450,   but   by
                can    Society    for    Hematology     suc-  matrix  the  entire   integrity   of   which   years   ago,   and   that   now   is   being  closer  to  1,000  a  year  in  the  Detroit
                ceeded  in  doing   all   that   we   wanted  is  disrupted  when   the   personal   needs   adopted  in   certain   other   areas   than  metropolitan  area.  My  point   Nvas   that
                it  to  do  for  us  or  we  wanted  to   do  of   individual   members   are   not   met.   ours.  It  is  the  small  cancer   hospital  if we  brought  up  the  level  of  accessi-
                for   hematologists   without   going    the     In chronic illness, it  is  very  obvious   in  association   with   a   large   general  bility of  care  and  the  quality  of  care
                route of the subspecialty board.              and  clear   that   we   have   to   respond   hospital,  the  cancer  hospital   utilizing  for  the  indigent  to  that   which   holds
                  However,    this    does    not    detract  in  an   altogether   different   way   than   all  of  the  advantages  of   the   special  presently  for  the   nonindio-ent   popula-
                from  the  fact  that  there   must   be   a  we  have  before.  We  have   to   go   out-   institution   and   nevertheless   utilizing  tion  in  America  today,  we   would   save
                captain  of  the  team  in  every   institu-  side  the  ranks  of  medicine  as  such  to   the  talents   and   facilities   that   are  only 450.
                tion.  He  should  be,  I  suppose,  in   an  do  this.  These  are  not  simply   medical   already there.                                  Now,  I  don't  believe  that   the   pri-
                old   Latin   way    of    expressing    it,  problems;  they  are  also   problems   that     This  is  worthy   of   consideration   in  vate  profession  is   utilizing   detection
                Primus  inter   pares,   the   chairman   or  require  the  skills  of   socioloists   and   practically   any   city   in   the   United  iiietliodolo,"  in  an  optimal   way.   And
                head  of  a  group  of  equals,   who   con-  social  workers,  the   whole   rai-i-c   of   States  of  any  size  because  you  already  I a,,,-rce with you,  we  need  to  look  to
                sultatively   deal   with   the   management  helping   professions.    And    we    @nced   have  talents  there  tl-iat  can  be   used  detection  and  find  intelligent  xvays  of
                problem  of  the   patient.   As   we   know  captains  for  these  teams,  but  I   don't   and  do  not  need  to   be   displaced   in  doing this.
                from   all   human   affairs,   there   must  think  that  we   can   identify   them   in   order  to  start  a  unit  of   cancer   ap-     We   have   experience   with   a    can-
                exist a last  place  of  responsibility  and  terms  of  their  medical  specialities.  We   proach  that  will  involve   all   of   the  cer  detection  clinic  which  is  20  years
                decision.   Now,   who   that   man   should  can't  identify  them  in  terms  of   where   skills  that  are  necessary  in   pathology  old    and    which    examines     approxi-
                be will  depend  upon  the  staff  of  tli(@  tli(@y       from  ]'II  training.  We   can   as  well  as  in   radiotherapy,   clielilo-  iiiately 8,000 I:oat'ciits a yeir.  And  %vc
                                                                                                                                                                              I
                institution 'Itself. III some cases, lt,%vill only  identify  them  in  terms   of   where   therapy, et cctcra.                           kiio", -,,cry  well  %%Iliat  the  yield  of
                be  a   surgeon   who   has   a   long   and  they  stand  in  coml)ctericc,  in  interest     Dr. DAVIES:  Dr.  I)avi(!s,  N4cllll)llls.  these  eliminations   can   be.   But   out-
                wide-based   interest   in    cancer    man-  and  in  concern  at  a   particular   time.   I  would  like  to  address  this   question  has to think  in  -terms  of  priorities,  I
                agement. In  others,  it  will  be  a  radi-     Dr.  DEL  RFGATO.   I   would   like   to   to  Dr.  Brennan.  In   making   an   appeal  believe,   too.   And    the    overwhelming
                ologist.  We  have  the   Penrose   Hospital  introduce  a  consideration   in   which   I   for   an   extended   care   facility,   you  and  crushing  problem  that  is  in   front
                captain  sitting  right  next  to  us  here.  think all of  you  will  have  an  interest.   pointed  out  that  there  are  sonic  6,000  of us  today  is  that,  because  we  insist
                In other places, it will  be  an  internist.  It is a fact  that  you  would  have  easily   deaths  from  cancer  in  Detroit   a   year  semantically  in   separating   out   social
                  Our  problem  is  that  we   don't   real-  confirmed   that   this   country   has    a   and that  only  450  lives  could  be  saved  and  medical  needs   and   writing   insur-
                ize   the   degree   to    which    American  lesser   number    of    cancer    hospitals   if  you  went  the  route  of  early  detec-  ance  pro-rams   for   one   and   not   for
                medical   institutions,   the   whole    ap-  today  than  it  had  30  years   ago.   And   tion  and  increased  facilities  for  early  the  other,  we  are  ending   up   with   a
                paratus,  has  been   around   the   problem  the  reason  is  that  the  concept   of   a   diagnosis.                                    wastage  of  hospital  facilities,   a   de-
                of  acute  illness.  And  vet,  we  now  are                                                                                                                                   n    and
                                        I                     cancer  hospital   in   this   country   has     Doing  a  little  arithmetic,  since   you  moralization of the professio
                tying  in  stroke  and  cancer  (I   exclude  been  a  total,  full-time  staff  type   of   said  that  the   deaths   come   to   about  the   discouragement    and    despair    of
                heart  from  this  problem)  to  deal   with  approach  to  the   treatment   of   cancer,   one out of  50  deaths  in  the  country,  I  many    patients    and    their    families
                                                                                                                                     1                                                   1
                chronic   illness   in   this   acute   care  with    which    the    American     medical   get  a  figure  'of   some   7,000   people,  simply   because   -,ve   can't   make   the
                   in                                                                                                                     I                           1
                fra   ework.   And   the   whole   apparatus  profession  as  aA,hole  doesn't  go   along   lives, that could be  saved  in  the  colin-  sociorned'cal   product    we    need    for
                ha.,;  to  be   changed   to   fit   chronic  very well. So  this  has  been  limited  for   try, which  I  think  is  a  fairly  sizable  chronically  'II  people   in   acute   care
                illness.                                      tli(- itiost part to the treatment  of  iii-   iiiiiiib(-j-.                                 Institutions.
                   We  have  hurt   ourselves   @vitti   the  digents   or   to    outstanding    research     Dr.  BRI-"NNAN.   I   believe   that   you     Let  us  try  to  understand,   for   ex-
                idea  that  there  are  social   needs   and  institutions.                                  could  increase  the   salvage   rate,   the  ample,  why  a  doctor  keeps  his   patient
                       292-414 0-68-7                                                                                                                                                                87










                        in  the  hospital   when   he   isn't   actively   this  is  impossible;  you   would   never   be   beginning   with   January    1966,    up    to   problems   of   cancer    in    the    Regional
                        treating   him   any   more.   Why    have    so   able  to  get  the  health   care   system   at   the  present  time.  We  did   get   as   close   Program.  I  think  it  is   quite   clear   to
                        many   of   us   over-used   the   Blue   Cross?   several  levels  at  which  it   functions   to   as  we  could,  but  we  still  didn't  ao   to   vou  that  all  of  us  will  leave  this  room
                        It  is  not  because  we  are   careless   about   cooperate in such a program.                      the practicing physician's office.                IomeNvhat    dissatisfied     because     there
                        the  Blue  Cross;  it  is   because,   in   many     Dr.   SMART.   Dr.   Baylor   of   the    Na-      This   was   a   very   efficient    method,   are  so   manv   probleriis   that   we   would
                        instances,   we   recognize   that   the    hos-   tional   Cancer    Institute    is    presently   and  we  were  able  to   survey   in   a   pe-   like  to  have  discussed.  If  -,ve  can  con-
                        pital   is   the   only   existing    acceptable   undertaking,      again,      beginning      in   riod  of  8   weeks   4t   hospitals   in   the   vcA,  this   to   Dr.   Marston,   perhaps   we
                        facility in  which,  in  the  totality  of  this   January   1969,   a   3-'ear   study   of   ten   State  of  Utah  and  36   hospitals   in   the   can   have   another   session   in   the   not
                                                                                                   y
                        patient's   situation,   we    can    reasonably   cities  and  of  two  States  to  try  to   de-   State   of   Wyoming   with    ei,ht    medical   too   distant   future   @vitli    much    more
                        say  he   should   stay.   This   is   a   great   te=ine   the   incidence   by   having    every   students  in  a  period  of   8   weeks.   That   time   allotted   for   the    discussion    of
                        problem.                                           physician   pick   up   every    single    case   is one way of -ettln,- at this thing.             i-nariy  other   problem,,   which   are   con-
                           Dr. S'I'ORI-"%'. Storey,                        %vitillil their                                                                                                               ii) tli(-
                        I A,otilct likt@ to @LSI@ a ([Lit'.';tlOll tii@tL is Now, flow IIILICII tll(!          Is to  (10    1)1'0@L(711. 'I'll(@y Said, "W)ILL %V(@ Otil@lit
                        related  to  the  discussion  t@iat  has   'List   that  in  all  areas  of  the  country,  I   am   to do is         it  t  law."  And  they   just                             I                I
                                                                  i                                                                                                                            @i few points I %vc)tilcl I'k(!
                        gone  on,  but   I   would   specifically   like   uncertain.   But   I   would   say   that    in   passed   the   law   in   Wyoming   that    all   to  make  here  because  I   think   thev   are
                        to  ask  it  of  Dr.  Smart.  Specifically,   it   Utah  and  also  in   Montana   and   also   in   pathologists    must    send    a     duplicate   of    some    importance    to     our     work
                        is   whether   or   not    you    consider    it   Idaho,  it  is  a   reportable   disease,   and   report  of  the   histology   of   every   case   wlii(@ii  will  go  on  bt@foi-c   tli(,   next
                        practical   to   make   cancer   a    reportable   they  are  getting  reporting   of   about   IO   of   malignancy    to    the    Stite    health   (-otif(,r(-nc@(@.
                        disease   in   any   given   region.   What    I   percent  of   the   cases.   And   the   reason   c](@I)artriierit.   And   in   the   last    :3      Mc,nLion  was  made   bv   Dr.   Breiiii@iii
                        have   in   mind   with   that   is   that   @ve   that   they   are    getting    reporting    of   months,   even   though   it   has    been    a   of   that   important    segi-nent    of    the
                        don't   have   too   much   difficulty   getting   only  10  percent   of   the   cases   is   be-   reportable   disease    by    physicians    for   population   which   is   less   favored   than
                        information   on   mortality    and    we    are   cause    they    aren't     giving     anythin-   several  years,   in   the   last   3   oi-   4   others.  Of   course,   we   are   all   deeplv
                        able     to     get     morbidity     statistics   back   to   the   physician.   They   are   re-   months,    they    have    picked    up    more   concerned  in   seeing   to   it   that   even,
                        through   tumor    registries    of    hospitals   questing   more   and   more   work   of   him,   cancer   cases   than   they   have   in    the   man,   woman,   and   child   in   the    coun-
                        which   have   tumor    registries,    but    we   but   they   are   giving   nothing   back   in   entire  3  years  previous.  And  that   is   a   try  has  access  to   as   fine   methods   of
                        have   great   difficulty   in    finding    out   return.                                           pretty efficient way of doing it.                 cancer   diagnosis   detection    and    dia@--
                        what   the   true   incidence   of   any    form     And  the   answer   is   that   the   reports     Dr.  FARBI-',R.  If  you   will   permit   me   nosis  and  then   treatriient,   and   finallv
                        of   cancer   is   and   what   the   prevalence   have  simply  been   filed   on   a   desk   in   to make    a    few    concILiding     remarks.   rehabilitation,    as    anv     other     man,
                        of  the   disease   is.   And   we   also   have   the    health    department     and     nothing      First,   I   do    want    to    acknowledge   woman, and child in tile COLintn.
                        great   difficulty   in   finding    out    what   has   ever   been   done   with    them.    The   the     distinguished     leadership      which      But I would emphasize that           if   N@,e
                        the  stage   of   cancer   is   in   any   given   only   incidence   figures   they   have   ever   Dr.   Robert   Marston   has   given   to   his   did  no   more   than   carrv   on   the   kind
                        community   at   the    time    that    it    is   come  out   with   are   the   incidence   fig-   staff  and  to  the  country   in   this   very   of    cancer    diagnosis     and     treatment
                        diagnosed.                                         ures   that   have   come   from   the   Cancer   great   and   important    program.    It    is   available   todav   to   patients   -,vho   are
                           It  seems  to  me  this   is   critical   in-   Society   where   they   say    285    patients   one   of   the   most   important   moves,    I   in  the  favored  group  able   to   pa@r,   we
                        formation,   and   we    have    got    to    be   per   100,000   are   doing   to   develop    a   believe, in  the  historv  of  i-fieclicine  in   N,,,otild  not   be   dome   Our   job.   There
                        able   to   get   this.   And   we   have   dis-   malignancy.                                       this  country.   We   arc   grateful   to   him   are two more 'ohs to be done.
                        cussed   the   possibility    of    the    mech-     We took      the    approach    of     hiring   and  to  the  splendid  staff   that   he   has      The first  is  to  see  to  it  that  evenr-
                        anism   of   making    cancer    a    reportable   eight    medical    students    and     sending   brought   to   work   with    him    in    this   one,,   inc]Lidin,   the    private    patient,
                        disease  as  being   a   way   of   getting   at   them  out  so  survey  all  of  the   hospitals   important program.                                recci ,vcs  everything   that   medicine,   sur-
                        this  kind  of   information,   but   the   gen-   of  the  State.  We  went  into   every   re(@-     We arc grateful        to    our    panelists          and   laboratory    science    has    to
                                                                                                                                                                                                                   a
                        eral  feeling   among   our   people   is   that   ord   room;    we    pulled    every    record,   here   for   their   contributions    to    the   off(@r  todav  for  their   prolong   tion   of

                        88





                          life  and  hopefully  for  their  cure.   I       is  a  much  abused  term.  I  have   used         the disciplines  of  biochemistry  or  in-        Programs  were  created   for.   We   must
                          lia%@e figured and  I  am  willing  to  de-       another     term-the     conception     of         ternal  medicine  or  surgery  or  pathol-        not  be  content  Nvith  years  and  years
                          fend these statistics, that if  we  applied       total care of  the  patient  which  brings         ogy.  It  should  detract  from  none   of        of   application   to   the   base    upon
                          everything   that   is   known   today   to       in  everyone,   every   discipline,   that         them,  but  brin--   additional   strength        which  we  are  goin-  to  build   because
                          every  Patient  in  the  country,   includ-       might be of aid  to  the  patient.  I  was         to every one of these disciplines.                there is  so  much  that  is  known  today
                          incl,  those  in  favorable  economic  cir-       pleased  with  this  question  about   who           If  we  do   that   in   every   medical        that  we  can  use  for  the  benefit   (>
                          cumstances   and   those   who   have    no       is the leader  of  the  team.  The  leader         school,  we  will  turn  out  doctors  who        those  who  do  not  have  what  is  known
                          private  doctors  at  all,  we  could  save       could  be  any  one  of  the   specialists         are  already  accustomed  to   an   inter-        to those  who  are  most  expert  in  this
                          100,000   patients   this   year   of   the       mentioned and one more.                            disciplinary    approach     no     matter        field. I would  hope  that  we  will  have
                          300,000   who   are   going   to   die   of         There  is  one  speciality  that   could         what  field  the  new  doctor  may  enter.        in  the  near   future   another   confer-
                          cancer.                                           be  added,  Dr.  Brennan.  There   was   a           I  would  say  one  final   word   here.        ence of  those  interested  in  the  prob-
                            I  think  this  should   be   our   imme-       man   named   James   Ewing,   and   there         We  have  -one   through   a   period   of        lems of cancer  related  to  the  Regional
                          diate  goal  in  the   Realonal   Programs.       was   a   man    named    Dusty    Rhoads;         discussion  of  continuing  education,   a        Medical  Programs,  and   that   we   will
                          We   must   be   certain   that   when   we       both  of  them  were   pathologists,   and         matter    of    tremendous     importance.        talk   about   more   specific    programs
                          initiate  these  programs,  Nvc  must   not       they   were   leaders.   What    is    important   We   have   also   -one   through   a    period   which   can    be    instituted    today    and
                          pen-nit    Gresham's    law    of     economics   is   that   in   this   interdisciplinary    ap-   of    data    collection,    plannlnl-,     and   which   hopefully   will    have    been    in-
                          to   operate.   We   must   not    have    poor   proach   to   the   entire   problem   of   can-   study.  There  is   no   question   that   this   stituted  by  those   of   us   wh   are   here
                                                                                                  I                                                                                                               0
                          work   pushing   out   good    work    in    an   cer    treatment    and     cancer     research,   is   a   field   of   great   importance.   But   today  to  report  on  at  the   next   confer-
                          attempt   to   spread   this    to    everyone.   there   must   be   someone   who   is    highly   these  are   supporting   structures   of   the   ence.
                          We   must   raise   the   standard   for   pri-   skilled  -in  his   own   discipline,   who   by   program  that  will  lead  us  to   the   final
                          vate  patients  as  well  as  for  those   wfio   his   nature   and   interests   has   a   broad   goal   of   these   Re--ional   Medical    Pro-
                          are less favored.                                 view of the            field  of  canc@er,   and   grairls. That  is  the  care  of  the  patient.
                             I think there     ai-(.-  a  few   delusions   awat,(,ii(,ss of what  it  ii@ictns  to  achieve   We  must  get  to  the  patient  as  i-al)icllv
                          under which @v(,- have ol)(@,r@it(!(l in  tli(-   goals of  I)i@(@v(@iition  and  goals  of  cure.   as  possible  \without  waltiii,@  for  5   oi-
                          past.  One  is  that  every   doctoi"s   office   That   man   can   come    froi-n    any    dis-   10 years of study and planning.
                          is  a  cancer   detection   center.   That   is   cipline.   We   must   not   permit    any    of     We   Must   hell)   them    and    we    must
                          impossible.   We   must   not    impose    that   the  rules  of  craft  unionism  or   the   spe-   help    the    continuing    education     peo-
                          load   upon   a   eneral   practitioner,    who   cialty   boards   to    determine    who    will   ple.   But    -,vith    knowled@e    and    re-
                          is  not  equipl-)cd   by   training   or   with   be tfic  Icaclei-  of  a  ,roul)  interested  in   sources of medicine in        this      countiT
                          tfic   proper   instritment@ttlc)n   or    with   tli(,, 1)@iti(,iit with c,-Ln(@cr.                 today, we call  apl-)Iy  w)i.-it  is  known  by
                          tlif-- I)t-ol)(@i- hospital        to                W(@ li;lv(@ to 'go           ]lot   only   to   those Who         illol.(" (Ixl)('I't, illol'(, (,N-
                          the   responsibility   of   telling   a   given   tl)c    hospital,    but    to    the    medical   periciiced,  in   caiicet-   than   those   who
                          person  that   he   has   or   has   not   evi-   school    to    bring    into    the     medical   have  not  worked  in  the  field,   to   every
                          dence of cancer.                                  school  the  word  "oncoloa                                                     i
                                                                                                             ,,y"   as    an   patient  of  every   doctor   n   the   country
                             To  follo@v  this  along,  I  am  glad  that   honorable    temi,    rcprescntinc,    a    pur-   and  to  every  person   who   is   sick   with
                          this  A7as   brought   out   by   Dr.   Robbins   suit  that   brings   in   people   from   every   cancer,   whether   he   has   a   doctor    or
                          that  no  one   doctor   can   take   care   of   discipline   represented    on    the    faculty   not.
                          any   one   patient    with    cancer.    There   of   the   medical   school.    And    such    a     I   would   fire   that   we    push    ahead
                          never  was  a  time   when   any   one   doctor   division    of    oncology    in    a    medical   with  I)Iannin,,-  which  leads  to  the   care
                          could do that.                                    school  must  be  so  created   that   it   will   of  the   patient.   That's   the   goal,   and
                             This  team   approach   is   essential.   It   not   interfere   with   the   development    of   that's    what    the     Re--ional     Medical
                                                                                                                                                                                                                              89












                              PANEL         DISCUSSION          ON-     (ICD    330-334),    rank    third    among     States and the  lowest  rates  are  in  the        Unfortunately,   not    enough    infor-
                                                              STROKE    leading  causes  of  death  in  the  United     Southwestern    and    Mountain     States.     mation  is  available   on   incidence   of
                                                                        States;  they   are   outranked   only   by     It  should   be   noted   that   the   geo-     cerebrovascular   disease    in    -,encral
                                                                        arteriosclerotic    heart    disease    and     graphic   clustering   of   cerebrovascular     populations.   Those   data    which    are
                                                               Panel:   malignant neoplasms.                            disease  mortality  in  the  United  States     available are difficult to compare.
                        Nemat     Borhani,     M.D.     (Chairman)         In  1965,  a  total  of  201,057  persons    does  not,  in  general,  conform  to  geo-        The     Middlesex     County,     Conn.,
                        Professor   of   Internal   Medicine   and      died   of   cerebrovascular   diseases,   a     graphic    distribution    of     mortality     study   reported   an   annual    incidence
                                    Chairman,     Department     of     rate  of  104   per   100,000   population.     from arteriosclerotic heart disease.            rate of 2.3 per  1,000  population  of  all
                                            Community        Health     The  age-specific  death   rate   increases        The  findings  of  the   recently   con-     ages.   This   incidence   rate   increased
                             University   of   California   School      with  age,  from  15.4   per   100,000   in     ducted    National    Cooperative     Study     tremendously  with  age,   from   4.1   per
                                                     of     Medicine    the  age  group  35  to  44  to   430   per     on    Mortality    from     Cerebrovascular     1,000 in the age  group  55  to  64  to  50
                                                     Davis, Calif  .    100,000  in  the  age  group   65   to   74     Disease   indicate   that   the    observed     per  1,000  in  the  age   group   85   and
                                     Clark   H.   Millikan,    M.D.     and  1322.2  per   100,000   in   the   age     geographic  variations  in  mortality   are     over.
                                     Consultant    in     Neurology     group 75  to  84.  Death  rates  also  vary     real  and  not  due  to  statistical  arti-        In     Framingham,     Mass.,      among
                                                    Mayo      Clinic    among  the  races  and  between   the   two     facts.                                          5,106  men  and  women  aged   30   to   62
                                               Rochester,      Minn.    sexes,  96.3  for  white  males,  108   for        More  specifically,  analysis   of   the     years  who  were  found  to  be   free   of
                                                                        white   females,   113.5    for    nonwhite     death ccrtificttes foi- wl)lte iiial(@,s arid   both coronary  heart  disease  arid  (7cre-
                                        James   F.   Toole,    M.D.     males    and     115.9     for     nonwhite     females, age 45  to  69,  from  nine  areas     I)rovasculai-  disease  during  the   initial
                                      Professor     and      Chairman   females.                                        of    the    United    States,    representing  examination,   there   occurred   90    cases
                                    Department      of      Neurology      Cerebrovascular    diseases    impose    a   high,   intermediate,   and    low    reported  of  cerebrovascular  diseases  in  12   years
                        Bowman    Gray     School     of     Medicine   multibillion  dollar  burden   on   the   Na-   cerebrovascular    disease    death     rates,  of  observation,   an   incidence   rate   of
                                          Winston-Salem,         N.C.   tion's   economy   each   year.   The    most   showed  that  the  difference  in   rates   do  less  than  2  per   1,000   per   year.   In
                                                                        recent  data   from   the   National   Center   not seem to be due to:  .                       Framingham,     thrombotic     brain      in-
                                   William    A.    Spencer,     M.D.   for  Health  Statistics  indicate   that   in         1.   Coding   differences   in    selec-  farction  was  by   far   the   most   common
                                Director, Texas Institute
                                                                  for   1962  the   loss   from   the   labor   force      tion  of  the  underlying      cause     of  type   of   cerebrovascular   disease,    ac-
                                 Rehabilitation     and      Research   reached   177,700   man-years   at   a   cost      death on certificates that     list   cere-  countin@  for  63   percent   of   all   such
                                                  Houston,       Tex.   of  $701.8  million.  The  direct   and   in-      brovascular disease diagnosis,               events.    Hemorrhage    into    the    brain
                                  Richard    L.     Masland,     M.D.   direct  estimated  cost  of  stroke  in  1962         2.    Differences    in    certification  was   the   least   common    (4    percent),
                              Director,   National    Institute    of   amounted to $1,147 million.                        practices   by    coroners    or    medical  but  most  lethal   type   of   cerebrovascu-
                        Neurological    Diseases    and     Blindness      Nearly  50  percent  of  the  direct  cost      examiners,                                   lar disease.
                               National   Instt'tutes    of    Health   of   $211.6   million   was   for    hospital         3.    Use    Of    Vague    terminology,     As   far   as   prevalence   of   cerebro-
                                                                        care;  more  than  half   of   the   indirect      and                                          vascular   disease    is    concerned,    the
                                                                        cost   or   $468   million   was   associated         4. Large   number    of    deaths    at-       'lable  data  leave  much  to   be   de-
                             R.  BORHANI.   The   first   item   that   with    morbidity    from     cerebrovascular      tributed   to    cerebrovascular    disease  aval
                        Dwe    will    cover    this    morning    is   diseases.                                          in nursing homes and outside             of  sired. By  and  large  it  is  believed  that
                        the   epidemiology   and   early    detection      The  analysis  of   mortality   data   re-      hospitals.                                   total  prevalence  of  this  disease  in  the
                        of   cerebrovascular    diseases    in    the   veals   that   there    exists    a    marked      The  findings  of  this  study   bring   to  United   States   is   between   I   and    2
                        United States.                                  clustering   in   mortality   from   cerebro-   focus   the   need   for    a    comprehensive  million.  It  should   be   emphasized   that
                          Disorders   of   the   cerebral    circula-   vascular   diseases   within    the    United   morbidity  study  to   further   explore   the  accurate    data     on     prevalence     of
                        tion,    grouped    together    under     the   States.  The  highest  rates  are  found   in   reasons   for   the   geographic   differences  cerebrovascular  disease   are   not   avail-
                        category    of    Cerebrovascular    Diseases   the  South   Central   and   South   Atlantic   in mortality.                                   able and are much needed.

                        90






                       In   summary,   the    available    data        3.  Ascertain   the   true   incidence   tent   have   current   advances   in   the   called   the    RMP    approach    to    the
                    suggest  that  there  is   no   appreciable      and   prevalence   as   well   as    the   field  become  known  to   the   practicing   stroke    program.
                    sex   differential    in    cerebrovascular      magnitude   of   disability    resulting   physician?   What   rehabilitation    serv-      So  we  start  also  with  the   presump-
                    disease,  that  Negroes   experience   more      from each type, and                        ices  arc  available,  are  they  adequate,   tion that for  a  given  region  there  will
                    cerebral    and     subarachnold     hemor-        4. Accurately      assess     existing   and how are they being utilized?              be centers of excellence,  or  a  center  of
                    rhage  than   Caucasians,   that   increas-      therapeutic   and   rehabilitative   re-      It is evident  that  there  is  a  great   excellence,  which   must   interrelate   in
                    ing   age   and    blood    pressure    are      sources  and  measures,  as   they   may   need for  b@isic  reliable  information  to   terms  of  the  original  law  to  all  por-
                    (@l(@@irly       to Lll(-. (I(-v(-Iol)ii)(-rit of :Ilt(!I- tll(. natural history of  v@ll-lot";            'I'lits must 1)('  (]one  1)(@- tiotis  in(i  all  (-oniiyiiiiilties  tiid  all
                                       (lisca.S(.-, tll;tt liyl)(,.I-- tyl)(--S of tl)is clisc,as(-, in the (,orit- foi-c   any   meaningful   I)i,cveiltiv(l   01' persons of the region.   I   am   going   to
                    cholesteroicinia   is    associated    with      munity.                                    control ii-icasure  could  be  applied.  To   start with the   theoretically       optimum
                    the  risk  of   developing   this   disease      Once   cerebrovascular    disease    has   me,  these  questions  pretty  well   chart   center   setting    to    demonstrate    the
                    only  in  the  age  group  30  to  49,  and   become  manifest,  its  treatment  is   es-   the way  for  the  activities  of  the  Rc-   complexity   of   the   problem    we    are
                    not  thereafter  and  that  there  is  some   sentially  limited   to   either   surgical   gional    Medical    Programs    throughout   talking about,   what   kinds   of   persons
                    evidence  relating  cigarette  smoking   to   procedures,  or  acute   supportive   medi-   the country.                                  or   disciplines   should   be   represented
                    cerebrovascular disease.                      cations.   Also   with   modern   medicine,      I think  we  can  leave  the  epidemiol-   a, far as the center is concerned.
                       Major  deficits  in  our  knowledge   of   many   patients    anticipating    cercbro-   ogy  at  this  point  and  hear  from   our      Now,   the   word   "should"   was   used
                    the   occurrence   and   the   nature    of   vascular  disease  can  be  treated  cffcc-   distinguished   panel.   The   first   mem-   advisedly. This is in a  sense  a  theoreti-
                    cerebrovascular   disease   are    evident.   tively   to   avert    catastrophe;    and,   ber of the  panel  who  is  going  to  dis-   cal  concept,   and   you   will   see   not
                    Many  aspects  of   the   epidemiology   of   among  those  who  have   suffered   severe   cuss the  subject  of  various  aspects  of   many fulfill the criteria  as  the  criteria
                    cerebrovascular   disease    need    urgent   attack,  treatment  can  reduce   or   pre-   management   of   the   acute   phase    of   are elaborated. Here is a list:
                                  tudies.    Furthermore,    as   vent chronic  disability.  It  is  commonly   cerebrovascular  disease  is   Dr.   Clark-      One,    Neurology.     Now,     neurology
                    systematic s
                    was  reported  by  the   President's   Com-   believed   that   all   new   and    modern   Millikan.                                     might   handle   EEG,   brain   scans,   and
                    mission   on   Heart    Disease,    Cancer,   techniques  of  therapy   and   rehabilita-      Dr.  MILLIKAN.  If  we  start  with  the   encephalography   in   a   given    setting,
                    and   Stroke,   many   fundamental    prob-   tion  could,   and   indeed   would,   pro-   presumption   that   the   Regional   Medi-   but  often  different  personnel  Nvill   be
                    lems  of  physiology,  pathology,   neurol-   vide  benefit  to  the  patient,  when  in-   '                                             involved with some of those items.
                                                                                                                cal  Program  is  going   to   attempt   to
                    ogy,   neuropathology,   circulatory    dy-   telligently   applied.    What    is    not   do   something   about   stroke   patients,      Two,   Neuroradiolo,@y,   for    contrast
                    namics,  and  blood   clotting,   to   name   known,   however,   is   information    re-   it seems  wise  at  least  to  discuss  the   studies.  In   some   instances   this   in-
                    only  a  few,  need  to  be  studied   with                                                                                               volves  scanning,  or  they   handle   echo,
                                                                  garding  utilization  of   current   knowl-   matrix  into  which   we   may   mold   the
                    respect   to   development   of    cerebro-   edge   in   the   medical   community   and   stroke setting.                               or may not, of course.
                    vascular diseases.                            how   judiciously   these   measures    are      I  am  going  to  begin  in   terms   of      Three,   Medicine,    including    Cardi-
                       If  intelligent   programs   aiming   at   being  applied   to   the   cerebrovascular   personnel  and  facilities  because,  after   ology,  the   inspection,   diagnosis,   and
                    the  prevention  and  control  of  cerebro-   disease  patient  population  as  a  whole-   all, the core issue  has  to  do  with  the   therapy   of   hypertension,    and    hema-
                    vascular  disease  are-to  be  established,      Indeed,  questions  arise  as   to   how                                            to   tology  in  reference  to  blood   constitu-
                    it is vital to:                               effectively  the   medical   community   is   kinds of people that are going                ents.  Now  we  have  the  business  of  the
                          1.  Be  able   to   distinguish   be-   utilizing    the    information     already   address  themselves   to   the   individual   high  hemoglobin  raising  its   head,   and
                                                                                                                care  of  individual  stroke  patients,  or   Nvhat  the  meaning  of  this  is  going  to
                       tween  various  types   of   cerebrovas-   available  with  respect   to   ccrebrovas-                                                                   1
                       cular  disease  and  their   precursors,   cular  diseases.  Are  the  high  risk  in-   the  prevention  of  stroke   in   individ-   be  remains  to  be  seen;   obviously   the
                          2.   Know   accurately    the    mor-   dividuals  being  identified  and  to  what   uals, plus facilities, meaning all  of  the   diagnosis    and    long-tenti    care    of
                       tality  and   case   fatality   of   the   extent the risk  being  altered?  Are  ade-   physical   components,   the   two   molded   diabetes.
                       various  types  of  untreated   cerebro-   quate   diagnostic   procedures   and   fa-   together  into   an   organizational   com-      Four,  Su@,,ery,  vascular   and   neuro-
                       vascular disease,                          cilities  being  utilized?  To   what   ex-   plex  which  might  in  this  instance   be   surgery.    Although    there    has    been


















                                                                                                                                                                                                                                                      verv-
                                                                                                                                             persons    involved    in    the    social     setting    ology is becoming a part of our e
                                                                                                                                             of a particular patient's problem.                        day life.
                                                                                                                                                Number      eight,       Clinical       Patholo,@y.      Number   15   is    a    collection    of    items
                                                                                                                                             This    is    the    type    of    professional    in-    Linder     so-called     Basic     Scicnce,      and
                                                                                                                                             dividual       who       heads       the        backup    here    is    experimental    patholo@    ,     ph@-
                                                                                                                                                                                                                                               ,,Y@     I
                                                                                                                                             laboratory     services     which      are      manda-    sics,     mathematics,      electronics,      neuro-
                                                                                                                                             tory    for    the     research,     training,     and    chemistry-a     whole     host     of      different
                                                                                                                                             the    actual    practical    care     of     patients    kinds   of   people   who   well   may    need    to
                                                                                                                                             in    this    setting.    Now,     recall     I     am    be   involved   in   the   mix   of   research   in-
                                                                                                                                                                                                       vestigation   at   the   level    of    the    cere-
                                                                                                                                             discussin-     the     most      sophisticated      of
                                                                                                                                                                                                       brovascular research center.
                                                                                                                                             patients'    setting,    the    center,    the     hub      And    finally,    16.    I    have    put    down
                                                                                                                                             of    the    wheel.    Clinical     pathology,     and    other    administrative     types     of     persons
                                                                                                                                             here    we    see    individuals    who    must    'in    having    to    do    with    Fiscal     Arranl(,,c-
                                                                                                                                             some    instances    look    after    brain     scans,    ments,      the      accomplishment      of      the
                                                                                                                                             and   others   must   of   course   take    care    of    attaining    of    various    kinds    of     space,
                                                                                                                                             the   clot   lysis   phases    of    tti(!    problem;    its   remodeling,   and   that   sort    of    that.
                                                                                                                                             chemistry    in    general,     and     in     certain      You   see    how    ridiculous    this    is    in
                                                                                                                                             instances,  tissue pathology.                             terms   of    taking    care    of    Mr.    Average
                                                                                                                                                I   have    put    down    the    next    one    as    American   with   a    stroke.    As    Dr.    Endi-
                                                                                                                                             the    general    area    of     Secrctarial.     This    cott   said   yesterday,   $25   million   for   one
                                                                                                                                             is    the     kind     of     supporting     personnel    cancer   center    that    can    handle    a    few
                                                                                                                                             that   is   mandatory   to   the   filling   Out    of    hundred    patients    is    not    a     rcallstl('
                                                                                                                                             the   various    kinds    of    fori-ns,    transcrib-    look   at   the   problem   of   cancer    in    the
                           considerable     emphasis     on     the      surgery    itation   may    have    to    be    subdivided,    as   iii(y reports, et cctera.                                 United States.
                           of    occlusive    disease    in     the     cervical    far     as     personnel      is      concerned-physi-      We    go    on     to     number     10,     Neuro-      So let's chanue cut-                a   bit    and
                           portions     of     the     cerebral     circulation,    cal     medicine,      speech,      and      lancua(TC   patholo(7                                                 sav  what  is   possible   in   a   coLintN,   corn-
                                                                                                                                                       "Y-
                           we   must   reflect    that    differential    di:kg-    pathology.                                                  Then    I    put    Epz'demiolo,,ay.     We     are    m,,nity   in   Illinois,   or   in    Missouri    or
                           nosis     obviously     includes     other     condi-                      and    @ill     tli(,     supporting                                                             .n   Florida,   outside   t]-i(@   irnii    c    iate
                                                                                                                                             t@ilkiiig  about  tli(.,  (,enter  now,   foi-   tli(,    1   .
                                                                                                                                                                                                       settlii-    of    the    @reat    medical    center.
                           tions    inside    the    head,    and    when     we    @trLICtLll'C.;   that    go    around    liLti-sltl(',   study   of   the    impact    of    the    disoi-clei-
                           get     to     the     subject     of     hemorrhage,    either    in    terms     of     prevention,     prou-                                                               We     might   look   at   it    from    a    dif-
                                                                                                                                      0      on    the    community,     the     collection     and
                           whether       subarachnoid       or        intracere-    nosing    stroke,    or    the    completed     stroke                                                             ferent  standpoint   and    sav    if    we    tal@c
                                                                                                                                             analysis    of    data    in    reference    to    the                                      I
                           bral,   we    have    a    situation    that    falls    setting-this      kind      of      personnel      ob-   spread of it and its possible meanina                     the    temporal    profile    of     cerebrovasci-i-
                           into     the     province     of      the      neuro-    viously is mandatory to the setting.                                                                         s.    lar    disease    where    can    we     make     an
                                                                                                                                                Number 12, Neuro-ophtlialmolo,
                           surgeon.    In    some    settings     the     neuro-       The   next   oi)c    I    have    put    down    is                                                      'Y-    impact   as    we    begin    to    structure    or-
                           surgeon     has      become      accomplished      at    @oclal,Yc?@7)lce:.          l@in(I  of  1)(@rsorill(@l      Number  13,  N@,7irop,@ycliolo,,,I!,                   gaiijzatiotiil  iiiatr-l(-(,s  foi,  ,iii  itt;i(,K,
                           doing    peripheral    vascular    sut-(,(@rv.     So    ii(,(@clecl to tli(@  return  of  Fail  liiclivicltltl      Ntilill)(,I- 1/1@, for tl)ig            kind  of
                           number four is surgerv.                                  to     the     community,      the      interrelation-   business,       Computer        Methodology.        It      Well,    of    course,    as     Dr.     -%Iasland
                               The     next     one      is      Rehabilitation.    ships   between   the   cost    structure    of    the   is   fairly   obvious   as   we   get   further    in-    ei-nphasized   yesterday,    we    turn    to    the
                           And    in    the    setting    of    the     research    patient     and     the      patient's      family-all   to   the   20th    century    that    the    use    of    matter    of    prevention    and     what     kinds
                           center    the    whole    concept     of     rehabil-    of    this    must    be    worked     out     through   computer       teclinolo,,ay        and        method-    of   personnel    might    be    involved    in    a

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                                                                                                                         'tiii(@,tion,  Consultation,  and  full  corn-   and  the  site  of  the  bleed'n-.   In   some
                       (@oxiiiriun'ty in screening and  ,itt(!rlil)t-   so-called  minimum  level   is   an   inil)or-
                       ing   to   do   something   about   1)i-evert-   tant  matter.  We  start  with   some   @-incl   itiunicatiori  with  some   kind   of   person   locations,  bleedin,  seems   to   stop   more
                       tion,  and  what  kind  of   physical   facil-   of    individual    who    knows     something   who     knows     something     about      the   quickly  than   others,   and   obviously   if
                       ity is necessary.                                about   the   brain-this   may   be   an   in-   brain.                                           the  clotting  is   abnormal,   as   in   leu-
                          I  have  written   down   here   that   one   ternist,  this  may  be  a  man   in   general      Perhaps   we   will    have    an    oppor-   kemia,  or  in   a   patient   on   anticoagu-
                       of  the  key  issues  sooner  or  later   must   iii(@dl(,lnc  who   has   had   some   special   tunity   later   on   to    come    back    to   lants,    the    bleeding    may     continue,
                       1)(@ tli@it a I)fiysician be in t@i(@ iiilx wfio training                         if   we   are   further CIISCLISSion of the matrix  be-          when it would c@e in nonnals.
                       knows  something   about   tfic   brain.   For   goin(,   to   discuss   practical   prevention   cause  there  is  a  great  deal  more  to  be      Even    though     head     injury     rep-
                       the   moment   let's    temporarily    discard   in  terms  of  screening,  then   action,   we   said about this.                                 resents  a   major   cause   of   intracranial
                       the  concept  of   the   formal   disciplinary   have to get action.                                 Dr.   BORHANI.   Dr.   James   Toole   will   bleeding,  I  have  decided  today   to   con-
                       distinction.    There    have    been    argu-      Before  closing   I   want   to.   make   a   talk    about     intracranial     hemorrhage.   Sider  only  bleeding  due   to   disease   of
                       ments   among   some   of    us    at    times   comment   about   this.   We   have   to   get      Dr.   TOOLE.   Those   of   you   who   are   the     vessels,     so-called     spontaneous
                       about   what    kind    of    a    discipline-   inclusion     of     someone     who     knows   experts   will   have   to   bear   with    me   hemorrhage,    with    a    very    occasional
                       oriented  physician   could   r(,,@illy   know   soiTi(@thin,,,   @ibout   vascular    surgery,   while  I  -lve   you   what   I   would   con-   allusion    to    the    traumatic    injuries
                       something   significant   about   the   brain,   %whether  titled   a   nCLirosurg(@on   or   a   Sider   a    basic    talk    on    hemorrhage   which   are   such   a   great   problem    as
                       but it  has  been  a  belief  of  some  of  us   general   surgeon   with   special    training   within   the   head.    Intracranial    hemor-   causes of hemorrhage.
                       that  we  can  train  individuals  in   short-   in vascular surgery.                             rhage   within   the    head    occurs    when      As   mentioned   earlier,   bleeding    may
                       term   training   experience   to   at   least      I  want  to  make  a  plea   before   clos-   an  artery,  a  capillary,  or  a  vein   rup-   be  arterial,  capillary,   or   venous.   Ar-
                       become   knowledgeable   of   some   of    the   ing-I  don't   know   whether   I   will   get   tures,  allowing  blood  to  spill  into   the   terial    blood,    being     under     higher
                       practical    aspects    and,    theoretically,   strenuous  ob'ection   from   the   panel   or   surrounding    tissues.     Depending     upon   pressure,  usually  results   in   more   mas-
                                                                                       i
                       evcrv    physician    should     have     this   the  audience  or  not.   I   want   to   make   the  site  of  the  rupture,   this   Spillane   sive  bleeding  with  a  more   rapid   evolu-
                       knowledge,   or   should   have   some   abil-   a   plea   that   we    do    not    construct   may  result   in   the   accumulation   of   a   tion   of   events   than    does    capillary
                       itv  in  this  regard,   updated   from   time   matrices  for  the  approach   to   the   pre-   blood  clot  which   can   act   as   a   mass   or     venous     bleeding-obviously      with
                       to  time   by   (@ntinuing   education   tech-   vention   of   stroke   in   which   we    put   compressing   and   displacing    the    adja-   some      exceptions.      Hemorrhage      can
                       niques.  So  that  some  sort  of   physician,   vascular  surgeons   in   an   isolated   set-   cent    structures    and    tissues    and/or   occur   from   any   site    or    from    any
                       whether    called    formally    and    board-   ting  to  do  the  whole  'ob.  I  think  that   spasm  of   the   arterial   tree   in   which   artery   or   vein   within    the    head-for
                                                                                                 i
                       certified  in  neurology  is  not  the   issue   as   we   see   referred   problem   patients,   the  rupture  occurs,  and  lastly   a   reac-   example,  vessels   may   rupture   into   the
                       at the moment.                                   that  one  of   the   commonest   sources   of   tion to the  blood  itself  as  in  the  chem-   pituitary  gland   but   some   vessels   rup-
                          III the first pla(:c, it  is  not  possible   problem   patients    come    from    settings   ical    meningitis    which    occurs     when   ture  more  frequently   and   as   a   result
                       foi, all the (Communities.                       where  tli(@re   has   been   a   very,   very   there   is    a    subarachnoid    hemorrhage.   some    structures    are    involved     more
                          Dr.   Masland,   how    many    are    cer-   vigorous    surgical    operative     approach   Vessels  may   rupture   because   the   walls   often than others.
                       tified in neurology now?                         to  the  clotted  arteries  in  the  neck   by   are   weakened   by   disease,   occasionally,      Again  I   want   to   emphasize   that   I
                          Dr. MASLAI;D. About 1,200.                    people   %vho   have   not   yet   had   their   because   the   intraluminal    pressure    is   am  addressing   this   talk   to   those   of
                          Dr.  iMILLIKAN. Close  to            1,500.   lifetime    medical    experience     enriched   excessive,  or   because   of   trauma   which   you   who   have   not   studied   the   anat-
                       You get the complexity of the            prob-   by   finding   out    anything    about    the   tears the vessels.                               omy   of   the   skull,   the   menin-es,   or
                       lem  and  the  impossibility  of   the   prob-   brain.   And   I   personally   believe   that      In   many   instances    two,    or    even   brain.
                       lem  in   terms   of   distrll)utin,,,   these   IL  is  highly  important   that   this   sur-   three,  of  these   factors   may   occur   in      First,  I  would  like  for  you  to   con-
                       people   to   make    even    adi-ninistrative   @,cry   not   only   be   conducted   by   in-   combination   with         one        another.   sider    the    venous    anatomy    of    the
                       contact   with   every    citizen    in    the   dividuals   who   are    technically    expert   Whether the resulting clot            enlarges   brain.
                       United States.                                   at  handling   the-   problems   of   vascular   depends   upon   many   factors,   only    two      (Slide)  You  can  see   that   the   brain
                          The matter     of  the   surgery   at   the   surgery,  but  who   are   working   in   con-   of   which   are   the   clotting    mechanism   is   covered    by    meninges,    the    dura

                                                                                                                                                                                                                      93










                       mater,   the   arachnoid,   and   the   pia    bral  spinal  fluid,  up  over  the   hemi-   is   another   type   of   aneurysm   which   therapy  for   each   is   dependent   upon
                       mater.  Outside  the  dura  you   can   see    spheres   and   down   around   the   brain   seems to  develop  in  patients  with  sus-   having  a   properly   trained   group   of
                       the  middle  meningeal  artery  and   vein.    stem   into   the   spinal   theca.   Local   tained  hypertension.  These   are   micro-   people available, as was discusse          y
                       Rupture  of  one  or  the  other  of  these    blood  clots  accumulate,  and   this   can   aneurysms  which  occur  in   the   arteri-   Dr.   Millikan,   with   adequate    equip-
                       two   vessels   causes    epidural    hema-    act as a  mass  lesion,  but  most  of  the   oles  which  penetrate  the  substance   of   ment   for   the   rapid   management   and
                       toma-almost   always    the    result    of    systemic  signs  are   secondary   to   the   the  brain.  These  aneurysms  are   micro-   initiation of the steps  necessary  to  re-
                       trauma   to   the   overlying   skull.   At    reaction   to   blood   in   the   cerebral   scopic  in  size  and  appear   to   be   a   lieve the condition.
                       times  a  barely  preceptible  skull  frac-    spinal  fluid.  This   results   in   acute   tortuosity  of  vessels,  beads   of   out-      Dr.   BORHANI.   Dr.   William   Spencer
                       ture causes  rupture  of  artery  or  vein,    headache,  stiff  neck,   and   change   in   pouching.  In  some  cases,  these   micro-   will talk  about  the  various  aspects  of
                       with   the   rapid   accumulation   of    a    level  of  consciousness.  About  half   of   aneurysms   rupture    and    produce    an   rehabilitation in stroke.
                       blood clot,  which  presses  on  the  brain    the   patients   with   subarachnoid   have   intracerebral    hemorrhage    which    de-      Dr.    SPENCER.    I    approached    my
                       like  a  tumor.  Evacuation  of  the  blood    a  ruptured  aneurysm.   The   others   are   stroys  the  parenchyma   of   the   brain.   part of this perhaps a little  differently.
                       clot  removes  the   tumor   and   ligation    of unknown cause.                             Most  people  have  felt  there   is   very   We  might  entitle  it   "A   Tale   of   a
                       of  the  vessels  cures  the  patient,  but      Most    aneurysms    arise    from    the   little to be done about  these  clots  once   Noncategorical   Approach   to   a    Cate-
                       delay  even  for  an  hour   or   two   may    arterial circle of Willis or  the  artcries   the  rupture  has  Occurred,  for  it   de-   gorical   Problem,"   because    I    think
                       be fatal.                                      which  feed  or  arisc   from   it.   Aneu-   stroys  structures,  many  of   which   are   there  is  some  question  in  your   minds
                          Beneath  the  dura  is  the   pia-arach-    rysms  are   thought   to   be   congenital   vital  to  normal  function.   Most   occur   on  the  relationship   of   rehabilitation
                       noid   and   between   them    are    veins    and to be  the  result  of  herniations  of   in the  region  of  the  internal  capsule,   to  RMP,  either  as   physicians   or   as
                       which,  when  ruptured,  result   in   sub-    intima  through   congenital   defects   in   or  in  the  thalamus-areas  of  the  brain   administrators  or  as   people   concerned
                       dural   hematoma,    which    is    another    the   media.   This   herniation   may   be   which  arc  both  very  difficult  for  the   with   the   administration   of   Regional
                       mass  lesion  within  the  head  caused  by    brought  about   by   elevation   in   sys-   neurosurgeon to aliproacti.                   Medical Programs.
                       a blood  clot.  Bleedin  in  this  instance    temic arterial libad pressure.                  The  point  to  citiphasize  about   all       What is the  relationshil)  of  rehabil-
                                               9
                       is  almost  always  venous  so   that   the      Unfortunately,   the    development    of   of these  forms  of  intracranial  licinor-   itation  as  a  method  of   patient   man-
                       evolution  of  events   is   usually   more    an   aneurysm   cannot   be    inticipited.   rliagc is that all @ir(@ I)ett(@r 1)rcvciit(@cl a,reirierit to  these  various  categorical
                       chronic,   often   with   insidiously   pro-   They   hardly   ever   produce   localizing   than   treated.   Identification   of   pa-   problems?  I   suppose   stroke   is   prob-
                       gressive signs and symptoms.                   signs   or   symptoms   which   one   could   tients  who  might   suffer   subaraclinoid   ably  the  most  evident  one,  simply   be-
                          (Slide)  Here  is  an   example   of   an   utilize  in  mass  screening  programs   to   or    intracerebral     hemorrhage     from   cause   the   person   with   a    completed
                       accumulation   of   blood    clots    beside   decide   whether   or   not    one    might   either  form  of  aneurysm  is  partly  the   stroke   very   often   has   problems    of
                       the  temporal  lobe.  You   can   see   that   eventually   have   a   subarachnoid   hem-   identification  of  hypertensive   patients   mobility  or  movement,   and   it   is   in
                       it  presses  up  on  the  brain,  displacing   orrhage.  However,  in  the   majority   of   and  it  is  hoped  that  the  control   of   the   disturbances    of    movement    that
                       the  structures  which  are  ordinarily   in   people   who   have   ruptured   aneurysms,   hypertension   would   reduce   the   inc'-   phv  ical  rehabilitation,  at  least  in  a
                                                                                                                                                                      s
                       the  midline  and  resulting  in   displace-   hypertension   is   found,   which    gives   dence of    these  tragic   diseases.   The   medical  sense,   has   had   reat   utility
                       ment  of   the   hemisphere   and   compres-   some  hope  that   control   of   hyperten-   traumatic    forms    of    hemorrha-e-epi-   and development.
                       sion  of  the  midbrain   which   ultimately   sion   might   result   in   reduced   fre-   dural    and    subdural     hematomata-are      Unfortunatelvl   however,   this   leaves
                       caused the patient's death.                    quency of this disaster.                      also better prevented than treated.           in your mind a    ,residue  which   is   not
                          (Slide)   The   nexf   form   of   intra-     The  next   type   of   hemorrhage   that     In    summary,    the     most     common   consistent  with  what   is   happening   in
                       cranial    hemorrhage    which    we    will   I would like  to  discuss  is  hypertensive   forms  of   intracranial   hemorrhage   are   rehabilitation   medicine,   and   that   is
                       discuss   briefly   is   the    subarachnoid   intcrc@ci-ebral  hemorrhage.  Recall   that   those   secondary   to   trauma   to    the   i i-e@ilization that  rehabilitation  offers
                       hemorrhage.  In   this   disease,   bleeding   we  have  just   discussed   aneurysms   of   head   afid   hypertensive   exti'acerebral   a  way   of   plannina   for   the   manage-
                       occurs   within   the   pia-arachnold    and   the  circle  of  Willis   and   the   major   hemorrhage.   Each   of   these   can    be   iiient of  an  individual  so  that  on  the
                       blood  flows  freely   throu-h   the   cere-   arteries at the base of  the  brain.  There   prevented  at  least  in  part,   and   the   one hand it is possible  to  limit  the  de-

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                       velopment   of   those   conditions   that   gor'es-disease    categories,    we    arc     In  the  rehabilitation  context,   what   ticipate the  consequences  of  the  long-
                       will lead to  his  inability  to  function   discussing.                                  this means  is  that  we  are  seeing  im-   term situation, to  a  greater  extent  in
                       in  a  life  responsibility,  and  on  the     What  are  the  trends  in  this  field?   proved  ability  to  prognose  what   will   stroke   perhaps   than   in   anv   other
                       other  hand  there  arc  developing   pro-   These  suggest  that   aspect   of   rcha-   happen  to  an  individual  as  a   conse-   condition.
                       cedures   and    precise    methods    for   I)IIltation as a model  of  extended  care   qucnce of stroke in the  totality  of  his    We   have   learned   from   studies   of
                       better,   more   integrated   use   of   a   which has  as  its  focus  ultimately  not   situation.  We  are  learning  better  how   ideally  healthy   men,   simply   immobi-
                       variety of health services,  health  serv-   only   personal   life   adjustment    but   to  say  whether  the  realistic   outcome   lized   under   bed-rest    circumstances,
                       ices which  help  the  individual  achieve   management     of     those     conditions   is  going  to  be  cure  through   natural   that there is rapid deterioration  of  the
                       life adjustment.                             which  will  threaten  the  life  of   the   recovery    or     improvement     through   physiological capacity  to  adapt  to  the
                         There  is  another  trend  in  rehabili-   individual  and  his  ability   to   adapt   usage  of  some  definitive   medical   or   physical    environment,    and     indeed
                       tation   which   has   particular   impor-   and adjust.                                  surgical  procedure,  or  whether  it   is   even   to   the   psychological   environ-
                       tance  to  Rc,,ional   Medical   Programs,     First, in stroke we are seeing  an  lin-   likely  that  with  a  comprehensive   and   iiieiit. Irregardless  of  the  pathology,
                       and  that  is:  We  are   bccominu   aware   proved ability to predict stroke  I)roiie-   extended  program  of  a   highly   inten-   the  consequences  of  our   circumstances
                       more  and   more   of   the   anticipatory   iicss,  as  we  have  heard,  by  advances   sive kind we can  help  tl-iis  individual   of care, if they produce  inactivity,  im-
                       elements  of  care  of   the   individual.   in  the  quality  of   the   mathemathical   to  adapt  and  adjust  to   nonresolvable   mobility,  and   deprivation   of   senson
                       The   movement   of   early   care   which   predictive models,  as  they  are  called,   neuroanatomical     impairments.      For-   and   motor    input    or    experiences,
                       considers  the  individual  from  a  point   that  are  being  developed  for  estimat-   tunately  these  may  not  be   paralleled   problems  will  be   created   Nvhich   we
                       of  view  of  disability  potential,  from   in- the likelihood  of  these  conditions.   by   identical   functional   impairments,   call    the    immobilization    syndrome-
                       a point of  view  of  the  impact  of  his   I think this  @vill  improve  increasingly   because the brain is  so  plastic.  Alter-   leading  to  the  disabilities  which  are
                       characteristics is a  person,  his  living   'In the near future  so  that  right  away   natively  we  may   predict   Nviietli(,.r   equally  as  great  and   devastating   as
                       situation, his  natural  life  space  upon   we will  be  forced  into  having  a  pro-   maintenance  of  life,  just  simply  sus-   the or'izinal disease  process  and  these
                       what happens  to  him  in  terms  of  sur-   cess or a procedure  to  care  for  people   tenancc of life is all that  is  going  to   can be offset.
                        IV        1                                                                                                                             The impact  of  this  on  care  is  that
                       v al  and  in  terms  of  prognosis.  This   who have a high  risk  of  increased  lia-   happen,  or  whether  there  will   be   a
                       is  something  we  have  to  be  concerned   bility to these conditions.                  continuing  regression   and   dissolution   the  reorganization  of   community   hos-
                       @vith right from the very beginning.           Let  me  illustrate  what  I  mean.   On   of the person.                               1)ital services to prevent disability,  to
                         Most  of  you  probably  think  of   re-   the one hand,  in  society  we  have  pro-     This is  very  important  to  know.  Al-   prevent  the  effects  of  immobility  and
                       habilitation   as   a    "Flurnpty-Dumpty"   I)oscd    advanced    automated     health   though  we  don't  presently  have   these   itiactivity is an  essential,  realizable,
                       operation,  which  is   to   put   Humpty-   screening.  Now,  RMP  is   one   of   our   distinctions  in  those  aspects  of  mor-   early ingredient of  what  we  can  do  in
                       Dumptv  back  together  again  after   you   few possible solutions to  having  a  pro-   bidity statistics,  these  should  be  the   our   RMP   programs.   We   should    put
                       have   a   catastrophic   dissolution   of   cedure  or   process   to   do   something   basis  for  our  planning  and  our  basis   this up  as  a  requirement  of  a  satis-
                       every   aspect    of    human    behaviors   about    those    discovered    once    we   of deciding what can ,ve  do  at  a  local   factory  operational  stroke  program   if
                       physical,   personal,       psychological,   identify   the   people   who   have   in-   community  level  or  for  us   to   coii-   we  are  going  to  make  an   impact   on
                       emotional,  social,   economic   catastro-   creased risk. It  is  one  thing  to  know   sider at a central level  of  organization   the complete stroke situation.
                       phe. This is the  way  rehabilitation  es-   it is  going  to  happen.  It  is  another   of health  services.  The  implication  of     The next thing that this will do  is  to
                       tablished itself  in  medicine.  That  was   thing  to  be  prepared  to  do  something   such  studies  is  going  to   have   tre-   force us into  a  posture  of  haviii-  to
                       the  meaning  of   the   so-called   third   about  it,  and  I  suspect  that   people   mendous  impact  on   the   organizational   define better  triage  and  prediction  of
                       phase  of  medicine,  and  I  think,  too,   believe we are  giving  attention  to  the   structure of health services.                those who       benefit   from   intensive
                       perhaps this  is  the  reason  that  reha-   latter more than  the  former,  that  they     Offsetting  disability  must  be   added   rehabilitative  services  and  those   who
                       bilitation  was  usually  considered  late   will  assume  we  will  do  better   diag-   to medical care as a  part  of  the  acute   will  be  adequately   managed   and   can
                       in the course of  disease  and  disability   noses  and  hope  that  this  is   matched   care  process.  The  acute  care   process   benefit    from    available     community
                       and  didn't  fit  into  the   neat   cate-   by an adequate backup of care.               has to have built  in  procedures  to  an-   service.  We  just  have  to  face  up  to

                                                                                                                                                                                                      95










                       this because  there  are  not  enough  pro-  will affect  greater  life  adjustment  suc-  distant  goal  and  yet  a  realizable  goal  complished   at   home.,   in   the    local
                       fessionals   for   restorative    services.  cess of the stroke person.                    for  our  citizens  who  have  stroke,   in-  (@ommun't@,  or  ultimately  in  the   long-
                       There are only  600  I)Iiysiatrists.  There     Fiii@illy, I think we are seeing -,t       (@lticlirig ours(-Ives.                       terrii (@ar(! institution.
                       are  probably  fewer   people   than   that  mand  for  a  high   rate   of   application     Dr.  BORHANI.  I  will   ask   Dr.   Mas-     We   have   indicated    the    resources
                       with  any  substantial  training  and  con-  of  research  findings  in  this  evaluative  land   to   emphasize    and    expand    on  @vlilch  the  institute  has  deveoped   for
                       cern  about  this  rehabilitation   manage-  prognostic  process,   and   in   this   or-  what  he  presented   yesterday   in   terms  this.  I  should  point  out  that,  as  Dr.
                       ment process in other specialities.          oanizational  aspect  of  care.   The   bar-  of  resources  and   activities   throughout  Mill'kan   has   so   ablv   outlined,   the
                         The next thing  is  that  we  are  seeing  riers  are  on  the  one   hand   that   ad-  the country in the field of stroke.           neurologist  per  se  is  onlv  one   member
                       an  evolution  of  institutionalization  in  vances  in  molecular   biology   are   less     Dr.   MASLAND.   just   to   recapitulate  of   a   much   broader    team.    Somehow,
                       rehab  medicine.  If  you  define   broadly  applicable  to  this  situation   of   opti-  briefly:  I  have  urged   that,   recogniz-  however,   there   must   be   brought    to
                       "institutionalization," it is  the  organi-  mizing   and   providing    better    health  ing  that  we  must   start   with   limited  bear  on  the  stroke  problem,   especially
                       zation of  collective  human  effort  in  a  care   than   we   had    hoped    in    our                        Itimate      objective  at  the  phase  of   diagnosis   and   acute
                                                                                                                  programs,  our  u
                       physical setting. In  rehabilitation,  this  original  planning  in  bridging   the   gap  should  be  a  total  program  for   stroke.  therapy,  the   capabilities   of   individ-
                       is  essential,  because  if  vou  need  the  between  research   and   its   application.     Such   a   program   comprises,    first,  uals   who   have   knowledge   and   under-
                       assistances  of   -many   professions   and  Paralleling  a  reorganization   of   health  facilities  for  the  recogn'  ion  o  t   e  standino,  of  the  function   and   s-,,mp-
                                                                                                                                               it                                        1
                       many  disciplines   you   have   to   inte-  care   services   for   stroke   and   other  stroke-prone  individual,   and   for   pre-  tomatolooy of the nervous svstem.
                       -rate  and  coordinate   -,vhat   they   do  problems    that    have    produced     ex-  ventive  measures  applied   to   such   in-     Fig. I)* Here is our list     of   stroke
                       around  the  patient's  needs,  and  as  he  tended  needs  for  care  is  the   require-  dividuals,  highlighting        particularly  research centers. Some of       them     are
                       changes.                                     ment   that    we    must    very    rapidly  those  with  hypertension,   with   diabetes  rather specialized:
                         This   means   that   the   institutional  understand   these    organizational    fea-  and   with   certain   biochemical    abnor-        Berkelev  Center  is         primarik@
                       pattern  of   the   intensive   care,   ex-  tures  through  health  services   research.  malities.   I   mentioned   yesterday   that     working   with   the   epidemioloav    of
                       tended  care  of  the  severely   disabled,  This  has  not  had   in   any   sense   the  evidences  of  vascular   disease   may   be     stroke.
                       is  going  to  increase   in   the   future  attention it  needs,  if  we  are  going  to  observed  in   conjunctiva,   and   it   has        'ne Baltimore  Center  is  also  pi-l-
                       rather  than  decrease  if  these  accruing  be in  a  position  to  have  good  alterna-  been   mentioned   today   that    a    high     marily epidemiology.
                       numbers  are   to   be   diminished.   Some  tives to  suggest  to  one  another.  And  I  level   of   hemoglobin   appears   to    be        The center  in  Boston  is  (,on(,cii-
                       kind  of  model  of  relationships  has  to  mean  to  one  another,   as   I   hope   we  found   more   commonly   in   the   stroke-     trating    on    the    manaacnient    of
                       be   developed   between   these   institu-  will  find   out   what   every   group   is  prone individual.                                aphasia.
                       tional  resources  and  the  classic  corn-  doing  in  rehab   aspects   of   comprehen-     Secondly,  we  need   centers   for   the        The others, I think,    are    dealing
                       munity resources of the hospital.            sive patient management.                      sophisticated  diagnosis   of   the   stroke     with  one  or  another  aspect   of   the
                         I  don't  think  there  are  enough  pro-     In conclusion,  I  think  that  rehabili-  patient    and    centers    within    which
                                                                                                                                                                   clinical characteristics  of stroke.
                       fessional   people   or   that   there   is  tation  medicine  in  some  elements,   par-  there (,an be applied  the  mocl(@rii  stir-
                       enough  money  to   model   intensive   re-  ticularlv in  the  processes  of  evaluation  gical  and   medical   methods   of   treat-     (Fig. 2)  *  These  are  individual  r(--
                                                                                                                                                                search  projects.  These   we   have   indi-
                       habilitation  centers  in   every   commun-  of   disturbed   human   function   and   in  ment of the acutely ill patient.
                                                                                                                                                                ('ated only  to  point  out  that  here  are
                       ity  hospital  as   we   have   done   with  development   of   knowledge    about    how     Next we must provide for pro          @pt  individuals  A,ho  have   an   interest   in
                       surgical  suites.  Not  for  a  long  time.  to   understand   adaptive    behavior    of  mobilization    and    effective    remeoia-  some   aspect   of   the   stroke   problem.
                       Therefore,   the   teaching   function   of  the  human  in  the  situation  of  disease,  tion in  an  effort  to  achieve  the  maxi-
                       these  specialized  resources  has  to  ex-  particularly   these   chronic   conditions,  mlim  restoration   of   function   in   the  However,   many   of   these   are   of    t
                       pand  out   of   proportion   unfortunately  will  offer  to  you  in  lzcgional  Medical  stro c- isa  c   Ill 1VI Lia .                fLiti(larii(,iit@il research n@itur-(-,  @iti(I
                       to the research  and  the  care  activities  Programs  a   useful   teaching   and   dem-     Finally  we   have   the   loii(---terT-n  th(@v  may  have  little  relevance  to  the
                       that they are cloin,, if    are goiii@@  to  olisti-ational iiiod(@l of (,oiiil)i-(!Ii(-nsiv(, I)t'01)1('tll 01' tll(@ life @l(ljtlStTll(@Ilt  Of  SLI('Il f)t-obl(-rii of N@-itli tli(-
                                                                                                                                                                stroke I)at'
                                                                                                                                                                           ient.
                       mount   any  kind  of   a   I)roaram   that  and  extended  care  which  we  see  as  our  individuals,  whether  this  is  to  be  ac-
                       96                                                                                                                                          *See pages 60-65.








                                                                                                                                                                                         I      Dr.    ?\4ASLAND.    In    a    coi-nmun'ty    of
                            (Fig.  3)l-  This   slio@@,s   tli(@   (-(-ntcrs    Manpower,    fellowships     are     be'n,     pro-    and foi- patients, fi-oi)i a real I)i-act'                                                       I
                               l                                                                           I           I  I                          I                                 ica
                         @vhci-c@  tli(@i-c  Is  a  stucl@@  of  the   sul)-    veered  for  nurses   to   be   trained   in   ncu-    standpoint?                                            100,000    there    would    be    a     tremendous
                         araclino'd   h(,morrh-,i                                                I                                        Dr.    ToOLI,',.    One    thing     I     would
                                                     g(@  and       iiiti-a-    i-olo,,I(-.al  nursing  A,Ithin   these   (@enters.                                                           opportunity     for     such     an      individual
                         (@rai-iial aii(@ui-N,sriis. And @,,,oit  will  ))O-    ff   You   @@,aiit   Lo    have    some    iitii@es    point  out  to  you  is  t   c   -u'dc   for   set-    ,NIio    had    received    even    that     rather
                         tl(,-e  in  each  of  these   maps   there   is   a    trained  in   the   specifics   of   neui-olo,,Ical    tlii(l@   til)   a   stroke   pro-ram   which   has    modest     amount     of      additional      corn-
                                       p@ttz(!Itv of a(!tlvlt@,  N@,(@st  of    i-it-irsin,,,  tli(@  liureatt   of   Health   Man-    'List   been   distributed    by    the    American    1)ctciice.     You     might     even      consider
                         the  -.%Ilssisslpl)l.                                  po%vcr  can   be   helpftil.   The   officials   to    Heart       Association.       Dr.        Millikan,    taking     two     people-a     medically      ori-
                            (Fl<,,-.   4)*   Here   is    the    cooperative    contact   are   Dr.   Jessie    M.    Scott,    Di-    Chairman    of    the    Council    on     cerebro-    ciated   and    a    surgically    oriented    per-
                         stud@    of    the    value    of    livpoterisi@,c    rector,     Division     of     Nursing,     Bureau    vascular   disease,   and   a   variety   of    ex-    son.    Train'                     e      available
                                                                                                                                                    1                      1                               ing programs ar
                         agents    in    the    prevention    of     stroke.    of     Health     Manpower,     or     Dr.     Faye    perts   have   worked    to    put    together    a    for   each   within   which,   in   a    relatively
                         This   is   a   study   in   which   a   group   of    Abdellali,       Chief,       Research       Grants    manual    for     just     such     a     community    brief   period   of   time   of    practical    ex-
                         patients    with    hyl)(@rt(.-nsion    are    man-    Branch, Division of Nursin-.                           as    you     describe:     How     to     mobilize    I)c-rience,     they     can     become     kno@vl-
                                                                                                                    0                                    1                                                 -
                                                                                      'ondly, within our train'                                                                               cdgeablc     in    the    newest     methods     of
                         a,,ed.    They     are     being     ,Ivcn     hypo      Se(,                                 ing      pro    community   activity,          what     to      do,
                                                                                crrams, a number of centers            are      pro                                                      e    diagnosis    and        management.        Stipends
                         tensive    agents    to    see     whether     they                                                           whom   to   recruit,   and   how   to   get    som,                              ZD
                         will   in   fact   reduce    the    frequency    of    viding special postgraduate               training,    action    started.    This     is     called     "A    are   available   to   make   it    possible    for
                         stroke.   We   are   hopeful   that    this    will    in   the   management    of    stroke.    If    you    Guide    for    Affiliates    and    Chapters    in    a   person   to   do   this    without    a    com-
                         prove to be the case.                                  have    a    man    in    your    community     who    the Stroke Program."                                   plete financial loss.
                            (Fig@   5)   -@   This   is   the   studv   sup-    wants   to    become    more    expert    in    the       Dr.   MILLIKAN.   I    would    like    to    et      Dr.    HUNT.    Hunt,    Virginia.    I     think
                         ported   by   the    Heart    Institute,    focused    diagnosis     and     management     of     stroke,    in   on    that    hypothetical    question.    Was    1-nany    neurologists     in     many     communi-
                         primarily    on     the     surgical     management    he   can   receive   a    3-    or    6-month    or    one   of    the    conditions    no    neurologist?    ties,   because   of   the    manitude    of    the
                         of   stroke   throuch   surgery    of    the    in-    1-year    fellowship-in     effect,     a     resi-       Dr. HEUSTIS. No neurologist.                        problem,    are    really    unwilling    to    be-
                         tracranial art(.@rl(@s,  It  is  no%%,  a  randoii)    clency--w'thin   @vliicl@i   lie    can    rc(@c'vc       Dr. MII,LIKAN. I would put               in    a    (-in   the   task.   Where   can   be    a    focal
                         studv   in   which   some    are    treated    sur-    special    training    in    the    problei-n    of    strong I)Iug, then, for having                 some    point?   Or   what   is   a   --ood   focal   point
                         gicail@, and some medically.                           stroke.                                                                                                       Nvherc    the    neurologist    in    the     corn-
                                                                                                                                       person   in   the    groupina    that    you    did
                            (Fig.   6)   *   I   should    have    mentioned                                                                                                                  niunity    can    be,in     to     approach     the
                                                                                   Dr.   BORHANI.   I   would    like    to    open    presume     would     go     some     place     for                        n
                         @,estei'dav   that   there   are   two   types   of    the   floor   to    discussion    and    questions.    some      short-term      training       experience    I)roblem    Nvithotit    this     total     commit-
                         trainin(,   I)ro(,,r,ains.   We   do   have   seven       Dr.   fff-USTIS.   A.   E.   I-Icustis,   Micli-    specifically referable to stroke.                      merit?
                         pro-rams     specifically     directed      to%vard    iff  an.  The  panel  has   told   us   about   the       I    don't    know     how     other     members      Di-.    SPENCER.    Well,    what    was     pro-
                         the   problem   of   stroke.    Most    of    these    things   we   ini,ht   expect   in    the    larger    of   the   panel   would   feel   about    t    is.    posed   in   the   question   before    was    what
                         are   general    neui-olo,,ical    training    cen-                                                                                                                  (-an   be   done   in    a    community    hospital
                                                                                centers.    But    I    have     a     hypothetical    I    would     guess     that     an     internist-      I .
                         t(@rs    whose    men    will     (.ertainly     be                                                                                                                  vilich   has    some    arrav    of    specialists,
                                                                                case,      ,cntlcmen,      a      community      of    type   individual   might    be    the    one.    I
                         knowledgeable      and      helpful      regardin,,                                                                                                                  and which has some           interest,       appar-
                                                                                100,000,    a    good    cadre    of     board-spe-    Nvouldn't    want    to    fully    earmark    this
                         the    differential    diagnosis     and     treat-    (-ialized    internists    and    sur,eoiis     and    as     a     disciplinary     requirement.     Some    entlv, in looking at         the     problem     of
                         ment    of    stroke.                                                                                                                                                stro@e in that community.
                                                                                 o     neurologists,     an     orthopedic     sur-    individual   might   be   selected   for    3,    6
                            1   also    failed to      mention      yesterday   "                                                                                                                On   the   one   hand,   a   great    deal    of
                         two         important elements    in    this    pro-   .'eon    with    a    yen    toward     rehabilita-    months    of,    experience    on     an     active    attention   has   been    given    to    how    you
                         (tram    of    trainin,.    Within    several    of    tlon,  a  special   part   of   a   hospital   with    stroke   demonstration   unit    or    an    active    would    build    up    the    diagnostic     capa-
                         out-   stroke   research   (Tnt(@rs    xv(@    have    an     interest     in     rehabilitation.     What    stroke   service.   Then    that    person    could    bility   for   this   arotip.   And    I    a(,,rce
                                       iitirs(-s %vlio        skillful   ]In    i-(-ally (-;in this         do,   both   for    the    I)ccoiti(! tli(,.         for   developer)    tic('    tliit  %,vitli  short-term      ti-ainln,,,   tli(-
                         neurological   riLirsin(,,,   and   in    (@ollal)-    physicians    in    the    (Community    and    for    on-goin(,    activity    in    your     comiflunit@                    tcd    and    susceptible    1)liy-
                                                                                   I                                                                                                     ,    most   iriteres
                         oration    with    the     Bureau     of     Health    the   physicians   in    the    surrounding    area    of 100,000.                                            sician    and    physicians     may     be     cap-
                            *See pages 60-65.                                                                                                                                                                                                  97









                   tured  to  do   this   kind   of   functional    ing   bond   between   heart   and    stroke.   ing,  social  work,  visiting  nurses   asso-    "Our  problem  is  lack   of   optimal   tim-
                   evaluation     and     comprehensive      pa-    I  would   suggest   that   you   can   whomp   ciations   and   community    health    orga-    ing of physician referral."
                   tient      management      planning       and    up   the   hypertension   bit   and   get   a   nizations,   their   involvement?   This   is      Dr.    EVANS.    And    continued    super-
                   guidance.                                        screening    program    going.    You     are   not just a hospital situation.                   vision.
                      But  I  think  the  problem   is--@vli.,tt    probably aw;ti-(! of  tti(,  I(-,tivitics  of      Dr. Si@l,'NCT:.R. I  w@is  going  to  say,      Dr.  Sll[:NCT--R.  I  think  realistically,
                   emphasis   should   the   diagnostic   train-    one   Joseph   Wilber,   who   has   had   an   the third  elciii(@rit  that  you  definitely    too,  we  have  to  look  at   the   adequacy
                   in,   or   educational    experience    have?    interesting   experience   in   Atlanta    in   could  consider  is  what   we   would   call    of  our  various  care  sponsors'   i-nethods
                   Should  it  be  in  respect  to   triage   or    a   smaller   community   in    the    south-   out-of-hosl)ital    extended    care.     And    of  reimbursement  for  services   to   allow
                   sorting  of  those  people  that   will   re-    east,  where  they   have   done   a   hyper-   here   the   visiting   nurse   associations-    this to happen.
                   quire  very  elaborate   and   complex   sur-    tension   screening.   This   is   now    re-   in a  community  of  that  size  I  will  bet      Dr.  BORHANI.  I  see   in   the   audience
                   gical procedures,    for   instance,   versus    ported   in   the   literature.   The    idea   there is one or-                                 we  have  Dr.   Carroll   Quinlan,   who   is
                   those  that  can  be  probably   quite   well    being  to  find  out  those  individuals   in      Dr. EVANS. Probably four.                     the   chief    of    the    Stroke    Control
                   managed in that institution itself?              the    community    who    have     hyperten-     Dr.   SPENCER.   All   right,   four.   Un-    program.
                      Now,  I   think   you   have   to   there-    sion  and  to  get  them   into   the   hands   fortunately,    what    has    happened    in      Dr.   QUINLAN.   I   am   sure   many    of
                   fore   assess   each   individual    institu-    of    their    local    physicians    without   these  is  that  the  physician  is  not  ex-    you  are  familiar  ivith  the   Heart   Dis-
                   tion's capabilities as,,vell is  their  goals    changing  the   @vhole   forrnat   of   prac-   perienceci  in  how  to  use  them,   so   it    ease   Control   program.   For   those    of
                   in  coming  tip  with  a  plan  of  education    ti(@e in that situation.                        is not  a  part  of  his  treatment  decision    you %viio  are  not,  we  ti,e  an  operating
                   which  is  acceptable  to  the   people   in-      We  all  realize,  even  if  you   have   a   making.   But   capability,   @vith    proper    branch   of   the   National    Center    for
                   volved.  I  think  you  have  also   got   to    neurologist,  individuals   vary   in   terms   planning   for   this   functional    evalua-    Chronic   Disease,   and    we    have    re-
                   parallel  this  with  a  functional   evalua-    of   their   professional    disease-oriented   tion   and   the   inclusion   of   community    cently   changed   our    name    to    Heart
                   tion  unit  in  a  community   hospital   di-    interest,   and   you   may   or   may    not   agencies    in    this    planning    process    Disease   and   Stroke    Control    program,
                   rected  by   a   physician,   perhaps   part-    have  someone   who   is   considerably   in-   around    individual     patients,     should    more  or  less  to  emphasize  our   interest
                   time,   in   a   community,   a    practicing    terested  in  the  problem  of   stroke,   or   allow   the   development   of   proper   us-    in the problem of stroke.
                   physician    who     is     supported     and    someone  who  has  a   bit   of   time.   But   age  of  such  things   as   can   be   done.      It might  seeti-i  confusing  to  you  @vho
                   trained   for   a   period   of   perhaps   a    if you  use  a  larger,item  such  as  hyper-   And  there  are   many   things   which   can    perhaps   are   new    in    Recional    Pro-
                   month   in   an   intensive    rehabilitation    tension-and   I   am   relating   this    now   be  done  in  the  home  setting  also.   But    grams,  honv   we   may   differ   from   the
                   center   so   he   learns   the   methodology    to     prevention     and     screening-Nvhy,   I  think  the  problem  is  what   he   said-    National   Institutes    of    Health.    The
                   of functional evaluation.                        you   can   begin   a   prooram   with    ex-   how  do  you   get   this   going?   I   sug-    Institutes  by  and  large,   as   Dr.   Mas-
                      Probably  you   will   find   a   physical    isting     personnel,     training     laymen   gested    that    concept    of    evaluation    land  pointed  out,  are   working   in   the
                   therapist  in  that  hospital,  and   develop    and   other   individuals   to   do   screen-   units.   Physicians   are    familiar    with    area   of   fundamental    basic    research.
                   such  an  evaluation  unit  as   a   support-    ing  as  far  as  blood   pressure   observa-   and   accept   laboratories,    heart    sta-    Our  laboratory   by   and   large   is   the
                   ive  service  to  the   physicians   and   to    tion  is  concerned,  the   initial   takin-z                                                    community.   We   are    working    in    the
                   the   hospital   so   you   can   begin   the    of  blood   pressure,   and   act   something   tions,  and  things  of  this  sort.  Can  we    same  areas  in  which   you   are   working.
                   triage process.                                  going.                                          sneak   in   consideration    for    function      Our  purpose  is   to   do   research   and
                      Dr.    MILLIKAN.    The    question    had      Dr.  EVANS.  I  would   like   to   address   and  @ave it under a physician,      so   you    development  on   ways   to   put   to   work
                   to do  with  how  to  get  going  in  a  com-    this   question   to   Dr.   Spencer.   Bill,   can    'lave    physician-to-physician    re-    those  discoveries   made   by   the   Insti-
                   munity.  I   would   like   to   sug,est   as    I  -,vould  suspect  that  there   are   more   ferral  of   consultation?   Then   you   may    tlt,s  and   other   areas   of   fundamental
                   soon  as  you  get   home   you   get   going    people  in  the   home   and   other   insti-   gradually   introduce   the   other    disci-    r ...  arch.  There  are  certain  activities
                   on  this;   and   this   does   not   require    tutions-not     in     hospitals-the     kind   plines  that  are   concerned   ,vith   corn-    in  which  Nve  are  presently  enga-ed,   in
                   elaborate  personnel.   There   is   a   neat    you   are   talking   about-so   @vould   you   prehensive    patient    management,     that    %vhich  I  think  perhaps  you   might   have
                   cross-over-hypertension  as  a  cross-           address yourself to the role of  nurs-          exist and are continually telling  us,           a direct interest.

                   98




                   We  are  at  the   present   time   inaugu- form  the  various   activities   in   which ho@v  you  can  really  involve   the   kind Then   the   next   thing   that   may   be
                 rating   a   national   system   of    stroke we  engage.   We   would   be   very   happy of  planning  that  is  taking  place  on  apractical  is  to  back   up   these   func-
                 registries.  We  are  doing  this  for   sev- to  work   with   any   of   you   in   your local level,  because  each  of  the  social tional  units  -,vith   live   communication
                 eral   different   reasons.   One,   we   are rcg'on'n  planning  in  any  way   that   we workers  in  the  public  agency  now   will links  with  the  resources  that  can  give
                 interested   in   the   nature   and   extent can.                                        have  bracketed   into   its   name   every- the   more   sophisticated   decision   sup-
                 of  the  stroke   problem.   This,   as   you Dr.    SPARKMAN.     Would     Dr.     Mas- thing    that    comes    from    Washington portive  service,  at  least  to  help   the
                 know,  is  very  poorly  defined,  both   na- land   comment   on   the   nurse   training and from the  State  office  of  rehabilita- staff  in  these   units   to   define   the
                 tionally   and   locally,   and    I    would programs, please?                           t'on.  There  is  a   tremendous   army   of patient  that  is  beyond  their  scope   of
                 commend  the  idea  of  a   stroke   registry                                         -   helpers,   and   I   was   wondering   about management.  That  is   @oing   to   require
                                                               Dr. MASLAND,      This   is   a   new   pro
                 to  each  one  of  you,  because   it   seems gram which is '    getting       underway.  your   experience,   or   your    proposals- two-way   video    and    audio    linkages.
                                                                             Just
                 to  me  that  if  you  are   not   aware   in Several  of  the  stroke  clinical  research how to involve them?                       This   isn't   as   expensive   as    people
                 your   own   region   of   the   nature   and centers   have   very   competent    nursing Dr.   SPFNCER.    People    get    involved think.  On  a  line-of-sight  basis  we  can
                 the  extent  of  the   stroke   problem,   it staffs.  We  have  felt  that  these  people best around  an  effort  to  solve  a  prob- do  it  now   for   $4,000   per   terminal,
                 is going  to  be  a  very  difficult  one  to who    are    recruited    and    maintained lem  which  is  of  larger  scope  than  any and  we   have   done   it   experimentally.
                 attack.                                      primarily  to  support  the   research   ac- one  of  them  can  handle.  I  didn't   get I   am   talking   about    two-way    video
                   Now,    as    pointed    out    by     Dr. tivities  should  also  be  made   available to  detail  further  this   concept   of   aand two-way audio.
                 Lilienfeld  yesterday,  registries   have   afor  the  training  of   other   nurses   in functional  evaluation  unit  in  a   hospi-  It  can  be  done  now.  There   are   al-
                 number    of    different    purposes,    and the    techniques    and     problems     of tal.  It  certainly   should   include   the ready    netnvorks    for    visual     com-
                 very  valuable  ones.  First  of  all,   they neurological  nursing.  In  order   to   ac- vocational   counselor   and   the   welfare munication     developing     rapidly     by
                 arc    most.important    in    planning    and complish  this   we   have   established   aworker   from    that    community    hospi- industry   and   by   national   educational
                 programing.    Secondly,    they    are     acollaboration    with    the    Bureau    of tal   concerned   with   these   kinds    of television. We have  even  got  a  satellite
                 very    good    instrument    for     manage- Health Manpower         1
                                                                                  ,  which   is   provid-  problems.     The     evaluation     process kicked  out  by  NASA   which   the   Inter-
                 ment.  And  thirdly,   and   perhaps   i-nost ing  fellowships  for  nurses   to   receive and   the    commitment    process,    which national   Radio   Relay    League    built.
                 importantly,   they   are   very    important training  in   a   well-organlzcd   training has to  follow  up  what  services  are  go- We  don't  have  anything   like   this   in
                 in   evaluating   the    effect    of    your program  of   the   stroke   research   cen- ing  to  be  committed  by  whom,   is   the medicine  for  medical   care   and   scien-
                 program,                                     ters.  The  place   for   you   to   contact place  for   their   participation.   Again, tific   communication   which   is    ridic-
                    All  of  you  are   beginning   to   start                                                                                   into        1
                                                                  Id  be  the  Bureau   of   Health   Man- the problem is how you get this '           tilous in the space age.
                 (,oriimunity  programs.  I  think   that   it power,                                      our  system  of  medical  care   under   the  If    you    support    these    community
                                                                Dr.   SOI,OWA-,'.   Dr.   Faye   AI)dellah physiciaii's  direction   and   coordination institutions as, already, experim
                 is well to soiind a not(,, of  (@auLlon,  and                                                                                                                               ents
                 tfiat 1.1; this- --that sooner or     per-   would be  the  one  to  contact  on  this.   and   integration.   This   is   precisely  are showing  you  can,  ,vith  tNvo-,,va),
                                                  c    going    Dr. I,]-'.V[N. David  l,ev'n,  C(-n,Lral   what lie is not trained t
                 hal)s in  several  years,  you  ar                                                                                   o  do.  So  all  (,oiiiiiiuni(-ation  assistance,  so  that
                                                                                                                       is try to use
                 to be called upon  to  justify  your  pro-   N(nv  York  Advisory  l@oard,  School   of   you can do '             this   evaluative  when  they  have   problems,   they   have
                 gram,  and  I  think  if  you   have   in-   Social  Work.  I   wanted   to   make   an   consultative  device  or  something   that  somebody  to  see  and  talk  to,  present
                 augurated  this,  and  know   the   nature   observation  that  all  of   the   changes   is  familiar  to  the  doctor.  The  diag-  their  problems  to,  then  you  have  the
                 and  extent  of  the  problem,  you   will   that  are  taking  place  which   we   see   nostic  evaluative   process   which   ex-  beginning  of  next  element   in   educa-
                                                  ur   pro-   here, social and  rehabilitation  services   pands  his  activities   and   which   in-  tion. I think this  is  a  valid  concept.
                 be able to see what  eff(,@(-t  yo                                                                                                               I
                 grain has had.                               divisions,  in  ten-ns  of  welfare  plan-   cludes  in  terms   of   human   function,  We  know  at  least  that  there  is  real
                    We  are  working   in   a   number   of   ning,  will  mean  that  you  have  a  re-   including  social   function,   may   give  interest in it on the part  of  the  corn-
                 other cliff                                                   communities.    One    of   him real help around a real p                   nity hospitals.
                            erent  areas.  N@'e   work   by   source in the              1                                                     atient  mti           1
                 contract and  by  assignees.  In  our  ex-   the questions  I  would  like  to  address   that is  his  responsibility  and  produce     And  the  other  thing,  as  Dr.  Evans
                             I                                                                         I   the desired res                                              eing realistic
                 hibit  upstairs  we  outlined  in  written   to  Dr.  Millikan  and  Dr.   Spencer   is                  ult.                         pointed out, b                  in   terms
                                                                                                                                                                                                99










                           of   the   problem,   the   first   is   to    identify    of   it   to   provide   as   much    of    what    we     should    not    go    on    and    develop     stroke     hope    that    the     Reolonal     Medical     Pro-
                           the    resources    we    have     got     by     real,    have    been    talking     about     as     possible.     I)ro,rams     kvithotit     really     taking     oui-     ,rarns   N@,111   direct   tlieni@cl\-cs    to    an-
                           indepth     analysis     of      communities      other    And   a   huge   emphasis    has    to    be    placed     time   and    sj)cndlnl-    as    much    tiriie    as     s%verill,,,    these    questions.    I     mentioned
                           than    our     own,     like     this     hypothetical    upon      the      methods      by      which      the     needed-and      this      will       differ       from     alreadv,     in     the     introductory      remarks
                           community     of     100,000.      You      may      be    people  are  taught.                                       (@or-niiitinitv     to     community     and      from     I    made,    the    variations    in    the     aeo-
                                                                                         Also,    another    as    ect    of    this    that     region  to
                           astounded   as   to   what    is    there    in    care                                                                              reg on-to  learn  what                is    ,ral)hlc mortality of stroke in \,at'
                                                                                                                  p                                                                                                                                          IOUs
                           resources,     and     their     susceptibility     and    I   have    been    interested    in    is    redesign     really needed in our region. I tl@ilrik              it    States in the (-ountr\,.     We    arc     I)Ianiiinu
                           willingness    to    change.     The     problem     is    of    the     home.     Very     seldom     does     a     is   essential   that   we   spend    enou(,Ii    time     to    pursue    further    activities    with     the
                           we      haven't      produced      or      demonstrated    physician     or     other      interested      person     and     develop      a      systematic      I)rograrii     Support      from       NINDB,       NHI,       Heart
                           visibly     enouh      successful      examples      or    actually  -o      into     the     patient's     ]dome     activity    that    we    know    exactly,    be    it     and     Stroke     Control,     and      the      Re-
                           methods,       orcanizational       methods,        and    and see him in his own setting.                            in      the      hypothetical       community       of     ,Ional    Medical    Pro-rams     and     all     the
                           of      procedures       which       these       people       These     two     aspects     we     should     not     100,000      that      Dr.      Heustis      mentioned     various      Federal      Government       a(,eiicies
                           can    use    and    need     that     they     haven't    foract.      Perhaps      the      most      practical     or     whatever     region     we     arc      working     that   can   help   us,   to    chart    some    kind
                           been trained in.                                           thing  is  stt(,Ii  a   simple   thing   as   a   good     in.     What     arc     the     resources      reallv     of   a    I)ro,ram    to    finallv    learn    about
                                  assure    you,    assessi-nent     of     fun(:-    ai-ciiitc(,t    or    someone    who     knows     how     available@)   What   is   the   n@iturc    of    tli(@     the   nature    of    the    disease    tliroliaho@it
                           tions   in    the    interpretive    sense    is    not    to   mal@c   a    person    mobil(!    and    prodtic-     problem     in     that     CO]IIITILlrllty?      Arid     the   country.   Finally,   I   think   in   e,,,erN,
                           simple.   I   can   give   you   a   sl)eci   ic    in-    tive in his own home.                                      what    kind    of     prevention,     control     and     re,,ion  it   is   important   for   Lis   to   learn
                           stance.    If    you    get    a    vital    cal)acit%@       Dr.   BoRilANT.    I    think    that    we    (,an     r(@liabilitation     program     is     already     in     what   the    proportion    is    of    the    stroke
                           value     expressed     as     a     percent      normaI   summarize        today's        session:         There     existence   there   that    we    call    build    on?     (@ases   Nvho   never   -et    to    the    hospital.
                           of    lung    capacity,    -,vhat    does    it    mean    are      two      issues      which      were      em-       Nbbodv      can      tackle      this      ldroblern     Di,.   Spencer  put         it     at     soi-nething
                           in   terms   of    that    pati(,,nt's    abilltv    to    1)hisiz(!cl,   tnci   they   are   not    intitt.ially     alone.  No   I)ro,i-@Liyi   (7@iii   do   it   alone,.     @ti,otincl 80 pei-(@ent.
                           tolerate  the  cii(,,r(Ity  (!xi)(-iicllttii-c  of  his    (@x(-Iiisi%-(..                                            Ali(],  as  @loii  li(@@ir(i                                 I  itilill@ it Is         iiiII)ol,t@tilt, if
                                       ]if(!                 Is  it  I   sigiiiii-       I,'list  ()I, ;III,    is (.Vi(It.ll(,  tll(!I,(.
                           (-,tiitly   declared   iiicaSLII-CII)Cllt   or   not':'    @t  gi,e@it  riceci  l'oi-  basic,  i,ellai)l(,,   In-     (!I,Illllcllt I)i-o,yi-aiiis,  St@it(,  1)i-ogr@tiris,
                           That    is    Nvhat    I     mean     by     functional    formation     on     the     magnitude     of      the     and    I    am    sure,    local     programs     that     death,    and    morbidity     from     this     dis-
                           evaluation.      You      have       to       interpret    problem     and      the      resources      available     are    already     in     existence.     There     arc     ease,   that   ,@,e    must    know,    because    if
                           measurements      in      terms      of      individual    in    the    community    for     systematic     plan-     manv      people      in      various      disciplines     xvc concentrate       in    our     hospitals     and
                           functional      capacities,      and      the       pa-    ning    of    effective    programs     of     preven-     of    health    already    doinol-     various     ac-     centers,   and   these    patients    nex,ei@    ffet
                           tient's    demands.    That     is     not     trivial,    tion    and    control     of     the     (@crebrovas-     tivities   in    this    particular    field.    There     to  the  hospital,  then   we   are   'List   IOSino,
                           but   this   can   be   done.   This   is   what    the    cular diseases.                                            are       organizations,       voluntary        health     the battle before it is started.
                           doctor   is    interested    in    as    an    antidote       And   secondly,   there   is   a   need    for    a     oran'zatioiis,      and       official       or,an'za-       Secondly,    we     must     know     about     the
                                                                                                                                                                                                                                                               in
                           to     the      laboratory      measurement      explo-    systematic     application     of      our      knowl-     tions,   public    agencies,    that    are    doinc,-     nature of    the   problem. I think a@-a'
                           Sion and the patient -,vill benefit.                       edge    and    resources    in    terms    of     pre-     certain th'n(ys.
                                                                                                                                                              I  ,                                          this  i-nust  be    done     on     the      regional
                              Dr.       TOOLE.       One       aspect        which    paration    of    the     community     and     build-       I think     it   is    incumbent    upon    us    to     basis, and    I    can    -uarantee     voti     that
                           hasn't     been     mentioned,     and      I      'ust    in,@     on     the     resources      already      in     bring    these    rhinos    into    focus    in    the     the national data on the cpidem'oto
                           throw   it   out,   is   education    of    the    fam-    existence in various Communities.                          region  where  we  would  like              to     de-     will     provide     Useful     data     and,     al-
                           llv    into    being    involved.    We    are    talk-       I  think  thit   tti(,s(-   two   istt(,,s   pretty     ,,(,Iol)  a  I)ro@,i-aiii  foi- sti-ol@,   an(]     to     tlioiif,li tli(,v (-@iii 1)(, helpful, tlie@@  x@,111
                           In,-  about   olti-   provision   of   care   to   this    \%,ell  (-heart  the  w@,iv   for   the   Rc,,,ioii@if     take   tclvatit@t,,,e    of    the    resources    and     not be as helpful as the. kind ol'
                           passive    person    and    his     passive     famllv.    Mecll(-al      Pi-o.-i-,iiiis      throughout      the     funds available.                                           that   voti   will   collect   in   your   own    rc-
                           My    attitude     is     involveriierat     of     the    country.                                                      I,\Vo sl)c(-'f'(@  (itic@st'oiis  Iran,,(,  i-eall@     'oil,  because  national   Cl@Lta   \%,'I]   d'fl'ei-
                           familv      and      mobilization      of       members       I    would    like    to    emphasize    that    we     bothered   me   for    a    Ion,,    time,    and    I     from   I)Iac(, to place.

                           100







                       I think it is  very  important  for  us
                     to  develop  a  systematic   program   of
                     sur%,eillance-call it registry  or  what-
                     ever    you    want-a    program    which
                       'II tell the people in  charge  of  the
                     wi                    1
                     re-ion 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-
                     inendous   opportunity   for   the    Re-
                     ,ional  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 I am sure this will be done.


























                                                                                                                                                                                            101












                                                   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.


                      292-414 O-GS-8                                                                                                                                                               103








                                                GROUP                        DISCUSSION    Health      Manpower"      of       pertinence       to   American         Medical         Association         and   is    questioned    in    vie@v    of    the    current
                                                                                                                                                                           1                  1                 1
                                                                    TOPIC            A:    his     specific     area     of      interest      and   other      medical      societies      have      assumed   trend    bv    these     institutions     to     remove
                                         "HEALTH                              MANPOWER-           ise.                                                         'bil'ty    for    the    (,eneral     improve-   the      education      of      such      professionals
                                                                                           expert                                                    response      I
                                                               REVIEW                OF      Dr.   Dwight       Wilbur       discussed        four   iiient   of    the    quality    of    iriedical    edu-   from their curricula.
                                          COMMISSION                      ]'XEIIOI'\'F"    issues  covered      in       the       ]@el)oi-t--tlie   (-@itioti.                    is   g(@n(@t-@illy   itii-     Dr.        Fenninger         comm(!ntecl         thit
                                                                                           supply     of      physicians,      relicensurc      of   aware   of   the    extent    to    which    the    peer   the     Report     addressed     itself     to      the
                                                                                           health  professionals,         foreign           physi-   i-ev-cw      process      is      already      underway.   need    to    improve     the     health     of     in-
                                                                    Discussants:                                                                         1
                                                                                                                                                        search is needed to formulate                           di%,iduals   and   of    patients    as    the    i,ea-
                                                                                           c    ans,    and    peer     review.     Dr.     Wilbur   Re
                                  James      C.      Cain,       M.D.       (Moderator)    1
                                                                                           supported        the        recommendation         that   teria     by     \N,Iilch      physicians'      perform-   son   for    a    system    of    care    and    health
                                                   Consultant      17z       Mc(ilcl'nc
                                                                                           the     numbers     of     medical     schools      and   @ince   arfcl     patient       (-arc     (@an      1)(@   services.      The       public       has       demands
                                                            The       Mayo       Clinic
                                                                                           of     students     should     be     increased.     He   measured.                                                  and    expectations    of    services    bN,     health
                                                            Rochester,            Minn.
                                                                                           a,,reed    that    Federal     funds     toward     the      Dr.        Ruhe        commented        on        two   personnel     beyond     what     can      be      sup-
                                                Leonard         Fennincer,         M.D.    support    of     medical     education     are     de-   points    in     regard     to     financial     support   plied.  The  Report pointed               to      lon@-
                                                                                                                                                     for students. Tli(@, n(@ecl for ,(-)in(, siii
                                                Director,   Bitri@azi   of   H(:(zltli.    sit-al)l(,,    provided     tti(-     (expansion     in                                                              Vince     short-term     issues      which      include
                                                                                                                                                     I)OI-L  ()I'               (-(Itl(';Ltioll    Is     now   (Itl;tlily @ll)(I (Ill;iiitity of            tls(.   ()I
                                                      Public   Hcaltli,    St,-?@vie:i:    filefiL  ill  the              of     (@(itic,.ttioiial   generally                                         still-   sl@ills,           (-Clti(@;ltioll, MIT)(]
                                                C.    H.     William     Ruhc,     M.D.    programs.                                                 I)Ort     by     the     Federal      Government      of   in      resources.
                                               Di.rector,     Division     of     Medical    On   the   issue   of    rell(TnsLire    of    health   medical      education       is       supported       by      During      the      question      and       an@vei-
                                                                              Education    professionals,      a      highly       c@ontrovei-sial   some    as    a    means    of    bringina    in    stu-   period    there    was    li%,clv    discussion     ori
                                         American          Medical          Association    one   over    a    period    of    veat-s,    it    was   dents    from    the    IoN,,,cr    economic     level-,   such issues      as     Regional      Medical      Pro-
                                                                    Chicago,       111.    noted    that     the     Report                          of   society.   This   is   a   controversial    issil(I   grairis and      their            review       Tn(@cti-
                                                                                           that    rcll(,enstti,c    be    further     (considered   which    current    statistic-    fall     to     stil)-   anisin,  the     improvement         of         medical
                                                        A.   N.    Taylor,    Ph.    D.
                                                                                           by        appropriate        or(,anizations         and   port.     The     implied     criticism      of      the   education        through        the         I)ro,ranis,
                                        Dean,     School     of     Related      Health
                                                                                           agencies.       The       public seems     to     cren-   medical     curriculum     in     the     Report      is   criteria to      'udge     quallt\,     of      medical
                                                                               Services                                                                                                                                          i                               I
                                                                                           erallv   support    the    (-.oncept    of    i-elicen-   not    3'ustified    in    view    of    the    constant   practice,     and      the      deteri-nination      of
                                                  Chicago        Medical         School    su re Ias
                                                                    Chicago,       Ill.               a     guarantee     of     good      quality   review     and     change     in     the      curriculum   medical      manpower      needs      and       bettei-
                                                                                           care.     A      review      of      current      State   conducted      by      medical      educators.       Re-   tit'li    'on of manpower,
                                                                                                                                                                                                                   1  zati
                                                      D@vi-ht       Wilbur,        M.D.                     Tloard    I)ro(-(,cltir(@s     %@,,,is   liccn.,;ure,    has    been     discussed     sl-)oracl-
                                                                   Presl(l(,,iit-Elt,ct    sti,(@sseci @is (@ssential siric(@ health                 ically     since     I()32.     The     Cli@il)liasil.1'
                                          American        Medical         Associatl'olz
                                                                                           power   is   a    national    asset,    and    mobility   should    be     on     motivation     of     physicians
                                                        San      Francisco,      Calif.    between      States       should       be       assured   through        appropriate        continuing         ed-
                                                                                           throu(,h reciprocity.
                                                                              Recorder:                                                              ucation       efforts       to       improve       their
                                                Veronica    L.    Conley,    Ph.     D.       Di-.      Wilbur       stressed       that       the   practice.      Only      then      should       relicen-
                                                        Educa      z'          I     is
                                                                  t   on   Spcc'al'   t    responsibility,    for    and    ititliority     ov(,t-   sure be seriously (-onsidercd.
                                            Divist'o?i      of       RcgioizalMt!(Ilcal    foreign    I)Iiysi(-iatis    should    r(@si(l(@     in       In     regard     to      the      Report,      Di-.
                                                                               Programs    educational      institutions.       These       physi-   'I'aylor    stated    that     the     title     implies
                                                                                           clans,    he    said,    should    be    required    to   equal    consideration    of     all     health     pro-
                                                                                           have    the    same     qualifications     and     pass   fessionals    when    in    fact    it    is     devoted
                                 '"-ch        discussant         reviewed         those    exams     comparable      to      U.S.      physicians.   primarily     to      I)hvsicians.      The      recona-
                                 @    aspects     of     the     "Report     of     the       The    iml)ortan(,e    of     peer     review     at   mendation  that          edification      of      health
                                 National        Advisorv         Commission         on    tli(@  local  level   was   (,Tiil)liasiz(,(I.   'I'h(,   personnel      be      assumed      by      universities

                                 104










                                      (,IZOUP                DISCUSSION
                                                       TOPIC         B:
                                                      "REGIONALIZATION"



                                                           Discussants:
                       Lester      13reslow,      M.D.      (Moderator)
                         Professor    of     Health     Adniinistration
                              and    Chairnzan,     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
                             University     of     Kentucky     Medical
                                                                 Center
                                                 Lexington,       IICY.

                                                              Recorder:
                                           Roland      L.      Peterson
                                     Chief,       Planning       Branch
                             Division    of    Regloitcil    Afc(ll'cal
                                                                         zation    was    particularly    stressed.    It      Mr.     McNerney     pointed     out     that   and   bLl'ldin-D   up    their    own    strength
                                                                                                               I                                            I                  @is  all   alternate   to   Iiiikin(l,   to-ether
                                                                         was  pointed  otiL  that  tfiei,(,,  might  1)(@           had been             failures   in   re-
                                                                         difrercrit   bases   of   regionalization    for    (,ionalization.  'I'lic   resistance   to   re-   %vitli others.
                                                                         differing    purposes.     Dr.     Si.)ai-kiiian    ,-Ioiializatioii     was     historical     and      Eco?iot?iic.-Thei-c     were     no     incen-
                           he   discussion    addressed    itself    to  said   that   "rc-lons"   for    patient    care    widespread,     and     included      libraries   t'
                     Tthe questions: IN'liat is re-'                     and    continuing    education    well     might    and  schools.  Speaking   froi-n   his   oN@,ii      Acii?iz7iistrative.-The            administra-
                                                                 onali-
                     zation?    What    problems    does    it    Pose?  differ.   Even   patient    care    might    re-    experience,   lie   cited   the   reasons   for   tl%,e   underpinnings    were    ad    hoc    and
                     11@v can it be achieved?                            (Itilre  different  "i-e@,lons,"   as   in   the    the  failure  of  an  attempt   in   the   past   iticidetital  i-atlict-  than  coiitinuin--   and
                        Regionalization   ",as   defin(@cl   by    Di-.  (@,ise  of  aCLItC   corollary   car(,,   versus    @it i-e,,-ioii@ilizatioii of hospitals in til)-   substantial.
                     l@'Illard  as   lml)lyiii(,   linka,,(,s   arnon,,  (-ancci-   therapy.   While    the    functional    Pei-  Miclil,,)an.  Some  of  these   z@easoiis      Sl)eakln,-   fi@oiii   the   audience,    Di-.
                     health   resources   and   as   a    Process    Of  asliect   was   clearly    recognized,    others    @vei-c:                                           Charles   I,cN%-ls   of   the   Kansas   Program,
                     gcttin,,r    people    involved    and    al)l)ro-  emphasized   that    geo,,ral)hy    and    J)eo-      Attitudi?2al.-,roo    often    the     insti-   saw   the   principal    problem    of    re-ion-
                     pi-late 1)lannin,, begun.                           ple    are    fundamental    to     regionaliza-    tLItions    involved    in     re-lonalizatioii   alization   as   one   of   social   enginerill(r
                        The    functional    aspect    of    regionall-  tion.                                               were    more     interested     in     autonomy   He   was   seconded   b@,   Nli-.   ,%@IcNernev.,

                                                                                                                                                                                                                             105









                     who  pointed  out  that  little  is   known    increasingly   sophisticated    technol-                GROUP               DISCUSSION of  the  problem  of  delivery  of   qualitv
                     about  the  social  engineering   and   ad-       ogy.                                                               TOPIC        C:  health  care   to   people,   and   defining
                     ministrative   aspects   of    regionaliza-                                                           "URBAN                PROBLEMS" the  pu  ose  of  the  session  as  focusing
                                                                                                                                                                  rp
                     tion.  The  medical  center,  he  observed,    Dr.  Willard  said   that   if   medical                                               on   the   contributions    that    Regional
                     is essentially  an  authoritarian  setting.  centers  and  other  institutions  see  Re-                                              Medical   Programs   can   make    to    the
                                                                                                                                             Discussants:
                     Regionalization   will   require   negotia-  gional  Medical   Programs   only   as   an                                              solution   of   the   urban   problem.   The
                                                                                                                           Paul Ward          (Moderator)                   ig
                     tion   and    compromise    and    entering  opportunity  or  additional   resource   to                                    .   .     following  are  h'   blights   of   comments
                     the realm of "brutal politics."              do   some   things   they    have    always                     Executive       Director by the panel members:
                           Dr.  Breslow  felt  that  involvement  wanted  to  do,   then   neither   Regional              California     Committee     on
                     might  prove  to  be   the   solution.   He  Medical   Programs   nor    regionalization          Regional      Medical      Programs Mrs. Anne Somers:
                     noted  that  getting   the   nontechnicians  will be successful.                                          San Francisco,        lif.     The     medical     establishment     has
                     and  nonprofessionals  to  come  to   grips                                                          Roger    0.    Egeberg,     M.D- both   the    opportunity    and    respons'
                     with  the   problem   is   perhaps   neces-                                                         Dean,    School    of    Medicine bility   to   make   significant   contribu-
                     sary, since  the  former  have   too   many                                                 University    of    Southern    California
                                                                                                                                                           tions to the  solution  of  the  problem  of
                                                                                                                                 Los   Angeles,    Calif.
                     vested and embedded interests.                                                                                                        urban health.
                           Mr.  McNerney  felt  that   regional-                                                                 Frank     Lloyd,     M.D.    We   kn6@   more    of    the    internal
                     ization  must  take  into   account   corn-                                                               Director    of     Research channels  of  the  heart  vessels   on   the
                     munity     needs    and     must      have                                                     Methodist   Hospital   of   Ind'   na  one   hand,   and   the   canals   on    the
                                                                                                                                                     za

                                                                                                                                               Zs,
                     structure.    Successful    regionalization                                                                   Indianapol'       Ind.  planet  Venus  on   the   other,   than   we
                     requires a delicate  balance  of  the  two.                                                                    Anne     R.     Somers do   about   the   back   alleys   of    our
                           Dr.  Breslow  was  optimistic   about                                                       Industrial  Relations      Section  gh'ttos-
                     the  future  for  health   regionalization.                                                                Princeton       University    Special   aspects   of   urban   problems
                                                                                                                                                           in New Jersey are:
                     He based this on-                                                                                                Princeton,      N.J.
                                                                                                                                                              Increasing    immigration    of     rural
                           reater  experience  in  this  regard,                                                             Ray  E.   Tr-usself,   I\I.D.      poor  from  the  South  to  city  ghet-
                           9particularly  with  regard  to  area-                                               Director,   School   of    Public    Health     tos.
                                                                                                                     and     Administrative     Medtcz'n(!
                                                                                                                                                              Outmigration of physicians.
                           wide  health   facilities   planning;                                                               Columbia        University     Vacuum   of   leadership   in    academic
                           agreater  commitment   to   the   con-
                                                                                                                                    New     York,     N.Y.
                                                                                                                                                                medicine.
                           cept of  and  need  for  regionaliza-
                                                                                                                                                 Recorder:    The   great   potential    and    promise
                           tion. At  the  time  of  the  passage                                                              Stephen J.         Ackerman       of    Regional    Medical     Programs-
                           of  Hill-Burton,  there  were  a  few
                           farsighted  individuals  but   little                                                  Associate   Director for Pla7i.7iz'".,a       "to build a  bridge  of  service  be-
                                                                                                                                     and       Evalual''071     tween  science   and   the   people."
                           widespread commitment;                                                                    Division  of    Regional     Medi.Cal    Hopeful     developments     in     New
                           physicians and others, and not                                                                                        Programs  Jersey:
                                                           Just
                           hospitals,  are  now  involved.   He
                                                                                                                                                              The   organization   of   the   Depart-
                           cited the  number  of  practitioners                                                                                                 ment   of   Community   Affairs   un-
                           who  had  become  involved  in   Re-                                                   he   moderator,    Mr.    Paul    Ward,       der  leadership  of  Paul   Ylvisaker
                           gional Medical Programs;                                                          Topened    the    session    by     pointing       which little by little  is  translat-
                           agreater  public  understanding   for                                             out  the   distinct   diftei-ences   between       ing  1)an,,-s  of  conscience   about
                           the need of regionalization;                                                      rural  and  urban  areas  in  the   solution       the needs  of  the  inner  citv  into

                     106












                                                                                                                           I
                              substantive action.                      them  in  finding  the  solutions  to  these   publicity if  persons  with  fiscal  control     personnel  in  positions   of   responsi-
                            Emergence  of  interests   and   leader-   problems.                                      arc to react.                                    bility.
                              ship  action   from   academic   medi-   Dr. Frank Lloyd:                                 Regional     Medical     Programs      can        How   can   Regional   Medical    Pro-
                              cine  through  the   stimulation   and      Regional     Medical     Programs     can   make  a  contribution   to   overcome   lack     grams   help    underprivileged    physi-
                              organization   of    Regional    Medi-                                                  of   understanding   on    urban    problems     cians  without   staff   privileges   be-
                              cal Programs.                            do  well  by  helping  to  plan  a   compre-     ,_ rough  participation  of  the   scientific  come part of the system?
                                                                       hensive  program  with   the   delivery   of   ...
                            Specific   move   in   New   Jersey   to   services in the urban area.-,.                 community   which   can    provide    scien-
                         have   its   program   develop   leadership      By     excluding     Negro     physicians   tific data to help public officials.
                         in   communitywide   planning    for    de-                                                    Neither     Regional     Medical      Pro-
                         livery   of   quality   medical   care   by   from hospital privileges,      and      from   grams   nor   any    other    program    can
                         bringing   together   the   leadership   of   educational programs in        the    health   bridge   the   gap    between    need    and
                         the   medical   establishment   with    the   professions (Indiana freshman        . class   service  without  major   public   decisions
                         leadership   of   the   urban    community,   has  two),  the  leadership   potential   of
                                                                       Negro   health    professionals    in    the   about what can be done.
                         including  the  inner  city,  throuah   the                                                    Some      problems      and      questions
                                                                       solution  of   these   urban   health   care
                         cooperation   of    the    Department    of   problems  is  removed.  It   is   of   prime   raised in floor discussion were:
                         Community       Affairs.                      urgency   that   these    deficiencies    be        How   can   ideas    and    information
                         Dr.    Roger    Egeberg:                      reversed.                                        be  gotten  from  people  in   the   ghet-
                            The  need  for   emphasis   on   availa-      We   are    wasting    health    manpower     tos  and  how  can  those  people  be  in-
                         bility of care rather than  a  priority  of   by     making     mandatory      unnecessary     volved in planning?
                         concern   for   quality.                      training.   Unskilled   personnel   can   be        Recognizing   the   need   to   involve
                            The  need  to  change  the  focus   from   trained  to  do  health  jobs  but  it  must     the    underprivileged    consumer,    how
                         the  provider's  standpoint  to   that   of   come from bottom up.                             can   leadership   be   developed    among
                         the   consumer's,   and   to   change   the   Paul Ward:                                       these groups?
                         patterns so  that  the  services  are  pro-                                                       The   problem   of   Negro    rejection
                         vided  as  the   people   want   them   and      To  secure   the   desired   changes   in     of    Negro    professional     leadership
                         can  really  use   them.                      the  delivery  of  health   care   and   the     puts  these  people  in   the   uncomfort-
                            Regional    Medical    Programs     must   utilization   of   nonprofessional    health     able  position   of   being   needed   but
                         be    concerned     with   regionalization,   aides, etc.,  requires  the  application  of
                                                                                                                        not wanted.
                         sub.regionalization,       sub-subregionali-  strong   pressure   behind   the    division        With   regard   to   the   Piel    Com-
                         zation,   and    perhaps,    sub-sub-subre-   of    Regional    Medical    Programs     in     mission  Report   in   New   York-   which
                         ,gionalization, in order to  fit  the  car,   Washington   and   State,   regional,    and
                         to  the  needs  of  the   persons   to   be   local health officials  in  the  field.  The     tended   to   preserve   two   care   sys-
                         served,  rather  than  force  people   into   built-in  resistance  of   multiple   vested     tems,  one  for  the  poor  and  one   for
                         the mold of the producers.                    interests  makes  progressive   action   un-     the  others,  the  problem  of   the   po-
                            All  of  the  concepts  about   develop-   likely   without    such    firm    counter-     litical realities  of  an  existing  large
                         merit  of  new  systems  of  care  and  the                                                    body   of   civil    service    employment
                         use  of  new  types  of   paramedical   and   pressure,                                        forces continues in city hospitals.
                         subprofessional   health   personnel    are   Dr. Ray E. Trussell:                                The   problem    continues    of    se-
                         within   the   scope   of   the   programs,      Problems  in   urban   areas   are   much     curing    professional    acceptance    of
                         where   resides   responsibility   to   use   greater  and  must  get  a  good   deal   of     the   use   of   subprofessional    health

                                                                                                                                                                                                             107











                                                GROUP                        DISCUSSION          ach       discussant       briefly       described    nitila      and      project       grant       mechanisms    -ind     the            Comprehensive             Health
                                                                    TOPIC            D:    Etlic      I)i,lncil-)al      prorams      and       ac-    on a noiicate,ori(,al basis.                                 Plannin,   Pro(,t,ani,   I)ai't'ctilai-l@,   at    tli(,
                                                "RELATED                        FEDERAL    tivitics    of     the     acnc@     he     represented,        Dr.    Cliaci@vick    described    the    role     of    lo(-al-rc,,Ional      level.       Several       persons
                                                                                                                                                                                                                                                     c
                                                                              PROGRAMS"    and    went    on    to    discuss     the     rclation-    the    National     Center     foi-     Chronic     Di,@-    i-(-I)oi-teci     on     the     d     vclopiiig     ex-
                                                                                           ship     between     that      agency      and      R(,-    ease   Control   as   13ciii(ly   of    most    iiiil3or-    1)(-rl(,nce    in    different    parts     of     tlif,
                                                                                           (,'onal Medical Pi-oo-rams.                                 tiiice      in      the       transition       I)ct@@!ccn    ('OLintrv     in     iniplemeiitin(,@     these      two
                                                                           Discussants:
                                                                                              Re,)-arclin-    the    programs    of     the     Di-    activities    of     the     catc(,oi-'cal     institutes    1) I-o (r
                                        Daniel  I.  Zwick                  (Nfoderator)                                                                                                                                  -i,anis in concert.
                                                    Associate       Director        for    vision      of      Medical      Care       Aclmlnistra-    of     the     National     Institutes     of     Heiltli
                                                                                  i        tion,      Dr.      Veverk-a       emphasized       that    and     the     operational     activities     of     Rc-
                                                    Prograt@z            Alanageiiicrit
                                                                                           the      division       and       Regional       Medical    alonal     I\Ieclic@al      Pi-o@rims.      As      such,
                                                    Health       Services        Office
                                                                                           Pro,,rams     shared     the      same      goal      of    its   role    his    been    one    of    deriioiisti-at-
                                          Coniniunity          Action          Prograni
                                                                                           bringinff     the     best     possible     care      to    itig     the     efficacv     of     neNvIv     developed
                                    Office       of        Econontic        Opportunity
                                                                                           c@,(,rN,one   in   need   in    the    most    effective    te(-bniqties   1),ISCCI   upon    the    @i,oN@,tli    of
                                        .Tames     H.     Ca%@anaiil,h,     Ph.      D.    incl     (,ffi(@i(,nt     niinncr.     The     division,    I)ioi-n(@(11(-,i] @,iiowl(-d(l,e.
                                 Dirt,clor,  ()ffice,  of  (I                                    iioL(,(I,  is  (,ool)(-i'atlii@',  \@-itli   tll(,        I))-.
                                                            Health          Pla?i?zz'ng    Dcl)at-tirietit     Of     11OLISiii,,     and     Urban    of   Health   Sci-%,](-(@s   as   the    fo(,@ll    point
                                      Office      of      the      Surgeon      General    Development       in       the       provision        of    for     the     organization     and     delivery      of
                                                    Public        Health        Service    mort(,a(,c      loans      for      rotil)      practice    health       services.       It,    thc@i-efore,       is
                                                                                           facilities.    Additionally,     the     division     is    (@oticernccl     N@@itli     the      development      of
                                          Donald        R.        Chadwick,        M.D.    concerned       with       both       health        man-    self-or(,aniziiio-    processes    to     effect     this
                                        Director,       National       Center       for    ])onver   and   facility    needs,    and    hopes    to    organization      and      deliver),      which      iii-
                                                Chronic        Dz'sease        Cent                                                                        .1
                                                                                  rOl      dovetail    these    concerns    with     the     activ-    clude     the      I)Iannin,      process,      (,onsLil-
                                        Bureau       of       Disease        Prevention    ities      of      Re,ional      Medical      Pro-rai-ns    tation,       and       certiin             certification
                                           and         Environi@iental          Control    in these same areas.                                        procedures.
                                                    Public        Health        Service       Dr.      Cavanati@h      described      the      five        Mr.    Zwick    in     dcsci-ibin,     the     Ncigh-
                                                  Carruth         Wa,,ner,         M.D.    i-najor      areas      of       the       Comprehensive    I)orhood      Health       Centel-       program       of
                                           Director,  Bureau          , of       Health    Health        Planning        legislation        (Public    tlic@    Office    of    E(,oiiornl(,.     01)1)ortiinitv
                                                                                                                                         0 1 1
                                                                                                                                                       ll'glllillllt('(1
                                                                                           I.,,ixv  @19-7@9)   and  i-el)ortc,c                I
                                                    Public        Health        @ervice    ])]-Offl,css   to   date.   The   first   three   se(,--    thit                  and     Reffioii.,il      Mc@clicil
                                                                                                                                                       Programs.      Specifically,      lie      noted,      it
                                                                                           merits    of    this     lc(,islation     deal     prin-
                                                             Eugene             Veverka                                                                is   the   pool-   Who   SLlffcr   the    most    is    a
                                              Divisz'oiz     of      AIedical      Care    cll)allv      with       State       and       areawiclc    result   of    the    gap    I-)et%vcen    k-iiowleciff(,
                                                                                           health'     planning.      These      in(@ludc      for-                                                        I   '
                                                                  Acl7tiz?zi'.@tratio?i                                                                ind      application.       Aclciition-.ill),,       li(,
                                                                                           ititil@i    (@ratits    to    States    for    (,oml)rc-
                                             Bureau     of     Health     Sci-t.,Ic(,.@                                                                clesc@l-']I)ecl   tile  (.ollllyloll   interest        of
                                                                                           11(@lisiv(,   li(@altli    I)],-tiinln,-,    pro'
                                                    Piibll(7  Ili-(iltli                                                                               I)otil                   it)
                                                                                           -i'@ints  foi, lo(,.,il ,iricl '11,C;Lwi(l(,                          iiiocl(@ls in tli(-  oi,ffaiilz,,itioti  @iti(I
                                                                        Recorder:          I)IAnniii(,,,    -,ind    I)i-o.'ect    gr,,iiits    for    delivery of health S(,I-vl('(,S.
                                                        Lerov (@.       Colcli-fian        ti-aitiln(,,,      studies,      and      demonstrations        I)urin(,,    the    cltiestion    incl     aiis%%,ei-
                                              Prograin  Polz'c),        Specialist         of health plannin,. The final t@vo
                                                                                                                                               scg-    portion     of     the     -,@sion,     the     principal
                                        Divisio?i     of     Regl'o?7al      ,Ifctlical    in(-nts    deal    N%,Ith     t]-ic     provision     of    focus            on     tli(,     relationships     I)(,-
                                                                        P?-o(,raiii.@      health   services,   tlii-oti,,,h    both    the    for-    t%veen

                              108







                                        (;IZOUP              T)ISC,'IjSSION               discussion   of   this    panel    fell    matical    i-nodel     and     appropriate     ma-    qti  isition,  availability  or   sources,   Corn-
                                                           '1'01'IC    l@":     T'ili(i'to  tli(,,  following   five   (1-cnet-al    iiil)Ltlatioii.  Health   services   research   is    prehensiveness,       validity,        timeliness,
                                                                         'S     11-(,.Is,  Miller  \V(,I.(..           in    this    @il)j)li(,cl i,(,s(,@ircii involving i  vit-l(!t@,    iii(I   use.   Cleirly,   the   qiiantitation   of
                                                       l@ P@' Sl,"A l@c: I                                                           ol'            @tncl social clis(@il)lliies  tii(i    health    set-vices    research     depends     on
                                                                                  Essential    nature    of    health    services    the    application    of     all     manner     of    the      validity      and       comprehensiveness
                                                               Discussants:          research.                                       methodologies     to     the     complex     prob-    of the data base.
                          Paul      Sanazaro,       \I.D.       (Moderator)       The    inherent     problems     and     strat-    lei-iis of health care.                                  A    data    base    has    five     character-
                              Director,     Division      of      Education          e,v of dat   a collection.                         Data        collectio7i,.-Major        problems    istics:   It    must    be    comprehensive;    it
                            Association      of      American       Medical       The problems of evaluation.                        in   health   services   relate   to   data   col-    must   relate   to    reality;    it    must    be
                                                                   Colleges       A   consideration   of   the   priorities    in    lection.    These     problems     include     ac-    timcly-I   it   must   be   available;   and    it
                                                       Evanston,       Ill.          establishing areas for research.
                                         Morris     E.     Collen,     M.D.       The     special      problems      and      op-
                            Director,      Department      of       Medical          portunities   in    health    service    re-
                                                 Methods           Research          search      presented      by       Regional
                            The       Perrnanente       Medical       Group          Medical Programs.
                                                     Oakland,        Calif.       Health          services          research.-The
                                                                                omponents     of     health     services      re-
                                   Caldwell     B.     Esselstyn,      M.D.     c
                                                 Associate         Director     search    have    been    identified    by    Dr.
                           New       York       Metropolitan       Regional     Kerr    White    as    descriptive,    analytical
                                                  Medical           Program     experimental,      and      evaluative.       The
                                                                                .n'tial   stage    is    reportorial    and    de-
                                                   New      York,      N.Y.     ' 1
                                                   John            Thompson     scribes  the  "health  system"  as   it   exists.
                              Professor    of     Public     Health     and     The     analytical     phase     depends     upon
                                Director,     Program      in      Hosbital     establishing    hypotheses    and    then     ap-
                                                                                propriatc    data     collection.     The     ex-
                                                             Administration
                              Yale     Univer.5ity      Medical      @chool     pcrimental     phase,     one     which     pres-
                                                                                ently    is    larely    undeveloped,     depends
                                               New      I-Iaven,      Conn.
                                                                                on    testing     models     and     manipulating
                                         John      N%Iilliainson,      M.D.     variables.  Finally,      evaluation,       which
                                      Division     of     Medical      Care     although   not   research   per   se,   is    in-
                                                       and        Hospitals     herent     in     research      and      requires
                               The      Johns      Hopkins       UniversitY     methodologies.
                                School    of     Hygiene     and     Public       Health   services    research    was    briefly
                                                                     Health     differentiated      from      operation       re-
                                                    Baltimore,          Md.     search       and       operations       research.
                                                                  Recorder:     Operation     research     depends     on     the
                                  Richard      F.      Manegold,       M.D.     collection   of   specific   data   for    estab-
                              Associate     Director      for      Progra?n     lishing    policy    and     management     deci-
                                   Development         and         Research     sion.     Operations     research     and     its
                                 Division     of      Rerional      Medical     component      systems      analysis      depends
                                                                  Progranzs     upon    the    development    of     a     mathe-

                                                                                                                                                                                                                                          109








                                                                         Although        long-term        evaluative    Regional    Medical    Programs     offer                GROUP                 DISCUSSION
                          must  be   used.   For   the   most   part,
                                                                                                Ities,    intermedi-  to the health  service  researcher  a  lab-
                          available  data  are   not   comprehensive.   goals pose time difficu                                                                                                  TOPIC         F:
                          Thus,  although  there  are  data  on   the   ate  goals  can  be   set.   These   include  oratory.   They    inherently    tend    to      "CON'I'INUING                    EDUCATION
                          incidence   of   diseases   (so   many/pop-   T-neastir(-,.; of  better  resource  alloca-  stimulate both the proper clticst'                                AND           I-RAININC,,
                            I                                                               -                                                                ions
                          ulation)   there   is   only    fragmentary   tioii, beLtci, utilizations, iiiil-)rov(,cl and Vince tli(! (Iti(-st for, til(@, Solutions.
                          information    on     "service       time."   more    relevant    educational    programs.
                          ("Service  time"  is  information  on   the     Conventional   wisdom    may    be    used                                                                                 Discussants:
                                                                                                                                                                     Patrick   B.   Storey,   M.D.    (Moderator)
                          number  of  patients  in  the  health  sys-   to   bridge   the   science   service   gap.
                          tem   with   a   given   condition.)    Our   Clearly,  not  all  "latest"  advances   are                                                              Professor     and      Chairman
                          present  data  lack,  therefore,   is   in-   advances   and   some   plainly   are    not                                                 Departnzent    of     Community     Medicine
                                                                                                                                                                            Hahnemann       Medical       Colleae
                          formation on prevalence.                      feasible.   Many   "new"    procedures    do                                                                                        I
                           Evaluation.-Evaluation     poses      spe-   not  stand  the   test   of   use.   Others,                                                                      Philadelphia,       Pa.
                          cial  problems.  What   should   be   eval-   "heart    transplants"     for     instance,                                                           Luther    Christman,    Ph.     D.
                          uated?  What  can   reasonably   be   eval-   clearly  are  not   when   first   developed                                                             Dean,    School    of    Nursing
                          uated?  What  are  the   regional   respon-   feasible  for   the   system.   Thus,   con-                                                                 Vanderbilt        University
                          sibilities  in  evaluation  and  what   are   ventional  @visdom  can  dictate   to   some                                                                       Nashville,       Tenn.
                          the national responsibilities?                degree  what  should   be   and   can   then                                                              George    E.    Miller,    M.D.
                           In    many    instances     end     result   be measured, evaluated.                                                                              Director,   Office    of    Research
                          evaluation   cannot   be    the    measure.     Research     riorities.-Certain      areas                                                                 in     Medical     Education
                          Regional     Medical     Programs     deals                p
                          basically  with   chronic   diseases   that   in  the  health  field  will  yield  greater                                                                  Universz'ty  of   Illz'nois
                          will  not  promptly  yield  to  changes  in   results  in  the   health   service   fie-Id.                                                                           Chicago,     Ill.
                          management.   Further,   because   of   the   Some     population     groups,      usually                                                                  A.  N.   Taylor,   Ph.   D.
                          annual   increments   in   the   population   upper   middle   class,   now   have    good                                                             Dean,    School    of    Related
                          at  risk  gross  mortality  and   morbidity   health  care   services.   Conversely,   the                                                                         Health      Services
                          statistics   may   not   show   significant   poor   and   many   rural   areas   do   not                                                              Chicago     Medical      School
                          changes.                                      have    adequate    health    care.    Thus,                                                                            Chicago,     111.
                            Evaluation  is  a  two   stage   process.   priorities  for  research  in  these   areas                                                                                    Recorder:
                          First  criteria  must  be  established  and   of  health   care   offer   obvious   prompt                                                        Alexander    M.     Schmidt,     M.D.
                          then   a   professional    judgment    must   payoffs.                                                                                       Chief,    Continuing     Education     and
                                                                                                                                                                                            Trainin,       Branch
                          be  made.  Were  the   criteria   attained?     Special    opportunities    for     health
                          In   these   terms   evaluation   can    be   service      research.-Regional      Medical                                                        Division    of    Regional    Medical
                          established  on   the   basis   of   expert   Proorams,   by   involving    the    various                                                                                  Progrr-.ris
                          judgment  of  what  should   be   the   ex-   components    of    the    health    system,
                          pected  mortality,   the   morbidity,   and   offer    special    research     advantages.                                                      r.  Storey   opened   with   a   -,,cry
                          the  cure  rate.   A   comparison   between   Health  service  objectives   may   be   es-                                                 D
                                                                                             i                                                                              brief  statement  listing  the  ptir-
                          expectation  and  reality  then  leads   to   tablished;    educational    and     service                                                 pose   of   Regional    Medical    Programs:
                          an examination  of  the  realities  of  the   programs    designed    to    serve    these                                                 To  improve  medical  services  in   a   re-
                          expectations,    the    deficiencies     in   ends;  finally,  evaluation  can  test   the                                                 gion  and  link  them  to   I)atients@   the
                          health care, or both.                         effectiveness of the innovation.                                                             Conference-Workshol):     To     allow     a

                          110







                     comparison    of    notes    among    regional   what    he    actually     needs.     Examples:   to    his    benefit,    medical     education   demic   peer   judgment   and   its   applica-
                     Medical       Programs        representatives;   A.NIA   national    plan,    etc.    What    is   should   give   to   a   physician   what   he   bility  outside   the   school   need   study.
                     and   the   Discussion   Groups:    To    help   needed   is    educational    diagnosis,    and   needs,  when  he  needs  it,  in   a   conven-      The    experience    of    the     American
                     each   other   with   specific   problems   of   not    treatment     (more     courses).     We   ient  way  and  at  a  convenient   time,   in   College   of   Physicians   with   the    phy-
                     making    continuing     education     efforts   have entirely too much treatment.                 a   palatable   form.   It    (the    content)   sician's    self-inventory    would    suggest
                     relevant to program goals.                          Q.    Can    a    physician    (or    other)   must  have   the   characteristic   of   being   that   physicians    aren't    reluctant    to
                        Dr.  Storey   asked   if   anyone   had   a   teach   himself?   What   is   the   role    of   applicable   to   what   the   learner   does,   find  out  about  themselves,  at   least   if
                     problem   for   discussion   of   the   group;   teaching machines, TV tape, etc.?                 and applicable the next day.                     they are fairly  sure  there  is  no  built-in
                     there     was     an     instantaneous     and      A.   The    problem    with    self-instruc-     One    major    problem    now    is    with   penalty.
                     vigorous   demand   for   the    floor.    The   tion  is  that  one  tends  to  study  what  he   basic   medical   education.    The    medical      Any  doctor  really  wants   to   do   what
                     next   hour    and    a    half    plus    was   is   most   comfortable   with.    Also,    his   student   spends   time   in   a   series   of   he  does  well,  or  at  least  as   well   as
                     occupied   by   an    exchange    among    re-   objectives   are    too    often    inappropri-   closed  systems,  each  with  a   finite   end   his peers.
                     source    persons    and    attendees,    num-   ate.  If  a  golfer  wants   to   improve   his   point,  usually  with  some   sort   of   exam      Perhaps    the    physician    is     over-
                     bering  more  than   100   and   filling   the   score,  he   can   read   and   work   out   by   passed  at  the  end.  The   practice   of   a   worked  and  tired,   and   a   bit   disillu-
                     room  beyond   its   seating   capacity.   The   himself,  but  he  will  get   little   or   no   profession   is   open-ended,   without    the   sioned.
                     following    summary    of    questions    and   better,  and   maybe   worse.   He   must   get   built-in   motivations    of    exams,    etc.      Q. Does the system interfere?
                     discussions reflect that exchange:               professional help from a golf pro.                Therefore,   the    medical    student    must      A. Yes,  indeed.  First  of  all,  most  of
                        Q.  Dr.  Miller   has   said   we   already      Self-education   in    medicine    is    the   be   indoctrinated    from    the    beginning   the  medical  system,   especially   the   ad-
                     had     enough      continuing      education,   same,  in  a  way.  At  some   point   a   pro-   of  his  medical  education  to  be  a   self-   ministrative   system,   is   19th    century.
                     and   that   we   didn't   need   any    more.   fessional   educator   must   help   set    ob-   motivated   learner.   He   must   be   taught   This interferes with everything.
                     What did he mean?                                jectives,  and  help   one   to   decide   what   to  use  the  various   self   teaching   aids      Secondly,   role   perceptions    interfere
                        A.  (Dr. Miller)       I   have   said   we   he  is  really  missing,  and  what  he  there-   available   like   books,   TV   tape,    etc-   all the  time.  A  study   of   patient   care
                             enough   iiiforitiatiori.    We    are   foi-c really  needs.  To  accoiril)llsli  this,   What   makes   us   think   that   our   prac-   was  done  at  the  University   of   Illinois
                     drowning    in    information.     What     we   the   student    must    reveal    his    igno-   titioners  know  how  to  use   these   things   (Dr.   Miller)   and   it   was   found   that
                     need  is  not   more   information   or   ways   rancc-this  is   often   a   painful   process.   now,    just    because    Regional    Medical   role    perceptions     and     misperceptions
                     of   disseminating   the   information,    but   TV  tape  is  like  a   book,   and   we   have   Programs   can   buy   them   and   put   them   effectively    blocked    team-oriented    ed-
                     a  method  of   establishing   priorities   of   books  now.  The   problem   is   really   what   out for use?                                     ucational   efforts.   The    doctor    always
                     what    a    physician    needs.    We    must   the content should be.                              Medical   students    should    be    taught   had  to  lead  the  team,  a  nurse   couldn't
                     help   a   learner   (physician,   etc.)    to      Q.   How,   then,   is   one   to   motivate   to  be  critical  self-learners,  perhaps   by   do this or that, etc.
                     want,  then  obtain,   and   then   use   what   a    physician    (or    other)    to    learn?   the   process   of   evaluating   what   their      Yet,   team   teaching,   based   on    the
                     he  actually  needs.   This   is   the   major   (About   three-quarters    of    the    discus-       I
                     issue.                                           sion   revolved   around   this   one    point,   professors believe and know.                     care  of  a  patient,   is   probably   vital.
                        Studies  have  been   done   as   to   what   motivation.)                                        It  is  commonly   said   that   the   medi-   Too  little  of  this  is  done   any   place,
                     a  physician  thinks   he   needs,   or   what      A.  Motivation   is   tied   to   need.   If   cal   school   atmosphere   of   peer    judg-   and   probably   must   be   begun   in   med-
                     he  wants;  but  such  are,  by   and   large,   one   discovers   what   he    really    need.s,  ment  is   healthy   and   should   be   taken   ical  schools.  But   if   the   "For   what?"
                     invalid,  as  they  are  based  on   his   own   motivation  should   not   be   too   great   a   out  to  the  community.   But   the   fallacy   is for the  care  of  the  patient,  then  the
                     opinion.   This    often    represents    what   problem.   We   use   what   is   known   about   here  is  that   while   the   academic   sur-   education    must    be    centered     there,
                     he  is  comfortable  about,   or   even   what   the  learning  process  all  too  little  (psy-   geon    may    accept    the     give-and-take   and  the  real  needs  must  be  the   patient
                     li(! knows @ilrea(ly.                            (@liology  of  learning,   etc.).   I,Ikc   the   i,(!g@ir(Iii)g surgery, lie gets  pretty  il'-   needs,  in(i  this  must  be   the   oriciita-
                        .Soiric  attempts   have   been   made   to   golfer,  who  gets  from  a   golf   pro   what   ritated   about   being   (luestioiicd   about   tioii,  not  what   a   physician   wants   or
                     help  a   physician   discover   for   himself   he   needs   and   applies    it    immediately   biochemistry.    The    validity    of    aca-   what a teacher wants to teach.

                                                                                                                                                                                                                    ill














                                GROUP               DISCUSSIONS
                                                TOPIC        G:
                                 "DATA               COLLECTION
                                     AND            REGISTRIES"


                                                   Discussants:
                          Abraham    M.    Lilienfeld,     M.D.
                                                    (Moderator)
                                 Professor     and     Chairman
                        Department    of    Chronic    Diseases
                                                     Un'vcrsity
                          The Johns Ilopkl?IS         z
                                   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,    111.
                                John    E.    Wennberg,    M.D.
                                     Program        Coordinator
                       Northern    New     England     Regional
                                         Medical        Program
                                            Burlington,     Vt.
                                                                                                                     IL
                                                      Recorder:
                                      Maurice    E.     Odoroff  as a basis for planning; the use  of  can-   nity  to  obtain  information  useful  for     to  special   social   research.   These
                                 Assistant  to   the   Director  cer registries  for  planning  and  evalu-   regional   medical   purposes    by    ag-     data  also  permit   deteri-ninin-   the
                                          for    Health    Data  ation; and  data  collection  for  use  in   ,regatin,,  small  areas'  data  for  such     political jurisdiction.
                           Division   of   Re,,ional    Medical  evaluation.                                  relevant   items   as   the    demographic        It  permits  matching   health   data
                                                       Programs     Use  of  1970  census  data   for   Rc-   characteristics   and        socioeconomic     to   census   data   and   thus   record
                                                                 al. onal   Medical   Pro,7ram    plannin(,.- data. There  are  three  general  uses  of     linkage   between   health   data    and
                                                                 The  Census  Bureau  is  now  testing  its   these census data:                             social   and   economic    chai-acteris-
                         he  panel  organized  its  clisci-i-,-  procedure  in  Nc@v   Haven,   Conn.,   in        Use  for  definlnl-  population   and     tics as a basis for pro-,,idin-  sen7icc.
                    Tsion   around    the    following    three  preparation  for   gathering   1970   ccn-      their characteristics to  isolate  con-        It   permits    selecting I   special
                    areas:  The  use  of   1970   census   data  sus  data.  This  presents   an   opportu-      centratioii   of   problems    amenable     samples  to  do  intensive  studies  bN@

                     112






                                  matching        infon-nation        from         local    met;       and       evaluation        of        specific                     GROUP                          DISCUSSION     developed,      although      there      were       dis-
                                  sources        between         health         agencies    projects.                                                                                          TOPIC             H:     senters,    that     in     general     hospital     ad-
                                  and    with    other    local    data,     such     as        Evaluation      is      essentially      a      value                                                   "HOSPITALS"     ministrators    as     a     profession     were     not
                                  housing,           economic            characteristics    'Lidgment     and     relates     to     criteria     de-                                                                   sufficiently     involved     in      the      prograxns
                                                                                            i
                                  and social unrest.                                        veloped      for      these      objectives.       Objec-                                                                   in      their      re-ions.      Consideration       was
                                                                                                                                                                                                                                       0
                                                                                                                                                                                                       Discussants:
                                  (I.@e of re,z"@tries      for       planning       and    tives      are      expressed      in      terms       of                                                                   Liven    to    the    proper     methods     for     in-
                                                                                                                                                               D.         Eugene         Sibery         (Moderator)     -
                               evaluation.-Cancer        registries        are         a    evaluation       procedures.       The       art       of                                                                   xrolvement    of    hospitals     and     the     proper
                               tool    for    planned    data    collection     on     a    evaluation     involves      discovery      of      indi-                               Executive              Director     involvement        of        hospital        administra-
                                                                                                                                                                  Greater       Detroit        Area        Hospital     .
                               continuing      basis.      The      primary       objec-    cators     or     measures     which     allow      their                                                                   tors      in       Re-lonal       Medical       Programs
                                                                                                                                                                                                            Council
                               tive    of    a    cancer    re,istr-y    is     improved    assessment.        These        requirements         pre-                                                                   aL the regional and national level.
                                                           I'D                                                                                                                             Detroit,           Mich.        The      following      are      directions       the
                               patient     care.     The     registry     must      meet    sent     difficulties     in     defining      objectives
                                                                                                                                         i
                               this   criteria   or   else   it   is   A,orthless.   The                            iblc    to    analytic    assess-                          Pearl      R.      Fisher,      R.N.     discussions       went       and       areas        thev
                                                                                            in terms suscept
                               two     major     types     of     cancer      registries    mcnt     because     objectives     must      be      ex-                                                 Administrator     covered:
                               are         hospital-based         registries         and    pressed     in      terms      of      mortality      and                                   Thayer             Hospital           The goal of the pro-ram                   is    to
                               I)opulation-based           central           registries.    morbidity      and      efficiency       of       medical                                Waterville,              Maine        improve         patient         care          through
                               'I'he    aim    of    the     hospital-based     registry    care.   The    major    problem    is    to    find    or                                                                      cooperative            arrangements.            These
                               is    follonvul)    of    cancer    patients,     defined    develol)       indicators       which        sufficiently                             John         W.          Kauffman        arrangements        will,        if        effective,
                                                                                                                                                                                                      Administrator        change    the     behavior     of     the     provid-
                               as     returning     for     examination     to      dis-    measure       morbidity.       The       problem       of                               Princeton              Hospital        ers   of   care,   and   thereby    the    goal    of
                                              ible    spread    to    new    sites    or                'ng    morbidity     is     further     corn-
                               cover poss                                                   measurl                     I    I                                                            Princeton,           N.J.        the      program      will       be       approached.
                               for      concurrent      disease.       The       central    1)llcated    by    the    fact    that    certain    dis-
                                                  idemiolo,,lc        in        emphasis    eases  give   rise                                                                    Edward         H.         Norolan
                               registrv is ep                                                           I        1     to       several        morbid                                                                         The    hospital     is     the     major     corn-
                               @iLirii(,cl at (I(,t(-Yriilriln@t                  @izicl    conditions.               (](@v(@lol)ii-iciit   of    in-                               Execiitiz)e            Director        iiiLiiiity    institution    with     the     poteii-
                                                                                                                                                                                                                           ti@il   of   focLisin(,-   the   enc@(,ics   of   the
                                                       SLII-%'I','@Ll I'.It('S fOl'                     indicators                  S(@ll('Ille  foi-          Presbyt(@riaii       Uiizvcrsit5@           Hospital
                                                                                                                 ;Ill(l L S(@ll('Ill(' FOI'                                                                   I,(I.        J)I-Ovi(let-  of  (-are.  I-lo,,;I)itils,   in   this
                                                                          @@'ILli  ill(-    t,il'ylli@ll @iii(I                oii(t (!oll(l't'                                                                                                                       I)el,ccl)-
                                                                                                                                              I  loll                                                                      S(.Ilse,
                               tl-(@11(i  within  ill(,.                                                tli(,.   otli(,i,,   @iii(I   the   develol)-                                                     Recorder:        tioiis    from     episodic     care     to     corn-
                               1'rogi-aiiis     foi-      estal)llslilji(l,      central             of    @t    summary    set     of     indicators               Richard      F.      Maiie,,-Old,       1\1.1).        11ILinity       and        comprehensive        care.
                               registries.     The      concentration      needs      to    of "net morbidity."                                                 Associate       Director       for        Progra?ii        For    this    latter     role     hospitals     have
                               be   at   the   local    level    because    a    central        The      requirements       to       define       the                 Development           and            Research        unique strengths.
                               rec,istr@@   is    no    better    than    the    quality    tv              unts,       and        interrelationshil)              Division       of        Re-zonal        Medical           These      stren-ths       are       several-fold.
                                                                                                I)es,     amo
                               of      data      received      from      liospital-based    of    morbidity    is     a     major     problem     in-                                                      Programs        First,    the    hospital    represents    one     of
                               registries.    Moreover,    there     needs     to     be    %,ol\,,Ing    a    research     effort     beyond     the                                                                      the        community's        major         resources
                                     'd(@                                                       I               of    l@e,,Ional              Medical
                               c,onsi    @rable    iriotivatiori    at     the     local    c-    i)acity                                                                                                                  for        organized         and         personalized
                               level    for    good    quality     data     to     1)(@,    l'i-of,i-aiiis.                                                     iiii)liasis  ill  the  (IiS(@LISSIOTI   was   first        licaltli   care.   As   such,   there    is    neces-
                               achieved.                                                        Mortality     and     efficiency      of      medical     EJ     placed     on     the     basic     purpose     of        sarily      a      community      concern.      There
                                  Data        collection        for         evaluation.-    care     are     more      easily      measured.      The     Regional        Medical         Programs.         Follow-        is,   if   not   always   the   reality,   at   least
                               Evaluation      was      defined      as       evaluation    failkire  to   de-,,elol)   a   full   set   of   indica-     in@     this,     attention     was      directed      to        the     potential         for           professional,
                               of    medical    care    to     determine     gaps     in    tors    for    morbid    states    implies    that    the     the     changing      role      of      hospitals      in        paramedical,        and         health         educa-
                               riied'Ical     care:     evaluation     of      lzeglonal    (complete   set   of    issti(@s    involved    in    the     health     care     and     the     hospitals'     unique        tiori.    There    is,    also,    the     experience
                               Medical     Programs     in     terms      of      stated    obj'c(@tives   of    the    program    are    not    con-     advantages      for      fulfilling      this       role.        ill    organizing    the    providers     of     care
                               I)ro(,raiTi    objectives    and     how     they     arc    sidered in the analysis.                                      With      this      back,,i-ound,       a       consensus        into    effective     teams.     There     is     the














                                                                                                                                               GROUP DISCU                                                     arced    that     com-
                           economic    focus    for    developing     the   Equal   recognition   was    given    that    the                                               SSION   T t being generally a@
                           necessary   resources.   Finally,    in    the   reasons   for    this    seemingly    poor    at-                                    TOPIC         I:   JL     munity     or     consumer     involvement
                           hospital        administrator,        himself,   tendance   might    be    explored.    If,    in-                                          "COMMUNITY   is   indispensable   to   success    in    promo-
                           there     is     the     management     compe-   deed,    the    low    census     of     hospital                                        INVOLVEMENT"   tion   of    a    Regional    Medical    Program.
                           tence      experience      in       developing   administrators    was    symptomatic    of    in-                                                       the    following    issues    rapidly     emerged
                                                                                                                                                                                                up's    discuss'
                           plans   and   putting   them    into    opera-   adequate     involvement      of      administra-                                                       in the gro                 ion:
                                                                                                                                                                     Discussants:
                           tion.                                            tors,   correction   of    the    causes    would             Robert     M.      Cunningham,      Jr.      Community      involvement      for      what?
                           In   spite   of    these    significant    re-   strengthen      Regional       Medical       Pro-                                                          Community      involvement      of       whom'
                                                                                                                                                                      (Moderator)
                         sources,    the    participants    were     gen-    rams.                                                                                                     Who   is    the    consumer?    Patients    or
                                                                            0                                                                                              Editor
                         erally    concerned    that     hospital     ad-      In   closing   the   session,   the   interest                                                             physicians?
                                                                                                                                            Modern       Hospital        Magazine
                         ministrators      were      seemingly       only   of   the   division   in   establishing   greater                                   Chicago,     Ill.      Do     the      community      representatives
                         marginally     involved.     Several     strate-   liaison   with   national   and    State    orga-                                                             really   rel)r(-sent   the   (@onsui-ners'.
                         gies    for    involvement    were    suggested.   nizations     representing     hospitals      was                                 Alan    C.    Davis      The   difficultv   of   identifying    qtiall-
                         These    included     the     development     of   voiced and noted.                                                                Science       Editor         fied lay leaders.
                         local   advisory   groups    as    in    Georgia                                                                      American      Cancer       Society      The    difficulty    of    explaining,    what
                         and   the    coincident    need    to    develop                                                                                  New     York,     N.Y.         Regional     Medical     Programs      are.
                         areawide planning councils.                                                                                              Howard      Ennes,       M.P.H.      Howard     Ennes     asked      for      "con-
                           One    somewhat     thorny     problem     rc-                                                                                                           sumer     modulation,"      later      translated
                         lated   to   institutional    vested    interest                                                                   Assistant      Vice      President'/or  as   "comniunity   healtfi    citizenshil)"    in
                         arose.   On   the   one   hand,   some    agreed                                                              Com?nunity    Servz'ces     and     Health   application.    "The    times,"    Ennes    said,
                                                                                                                                                                        Education   "demand      intensified      'consumer      mod-
                         that   these   interests   should   be   diluted                                                        TheEqiiitableLifeAssuranceS                 I.et                I
                                                                                                                                                                         oc     y
                         for   the   total   community    concern.    New                                                                                                    r  v   ulation'   of   health   care   activities,   in-
                         mechanisms    of    financing     using     for-                                                                                  New  York,  A.   @   .   cluding   those    related    to    goal-setting,
                         mulas   for   reasonable   cost   and    charges                                                                                   Pierre   C.    Fraley   resource    allocation,     priorities     deter-
                         -,vill  mitigate   some   of   the   competitive                                                                         Director  of  Iizfori??.(itz'on   iiiination  .  .  .   in   short,   all   aspects
                                  On   the   other    1),in(l,    several                                                           Gre,,ati!r              Valley  I?o,,glortell   ()f tll(- (I(-Iiv(,I-y of- II(.;Ilt 11 S(,r VI(-(.S, ()I(-il-
                         urged   that   vested   interests    were    in-                                                                                Medical          Program   (-osts,  and  related  corriiiiunity
                         deed   the   source   of    institutional    and                                                                                 Philadelphia,       Pa.   cisionmaking."
                         professional   excellence.    At    best,    one                                                                                                              Health  care        programs      for      the
                         could   hope   to   coordinate   these    inter-                                                                           Marc    J.    Musser,    M.D.   community   must   pass   a   "4-A    test,    he
                         ests   but    should    hesitate    to    dampen                                                                           Program           Coordinator   said.    "Are    they:    Appropriate,     Avail-
                         them.                                                                                                       North     Carolina     Regional      Medical   able, Accessible, Acceptable?"
                           Finally,   the   poor   attendance   at    the                                                                                                 Program      "I   suggest,"   said    Ennes,    "the    ur-
                         Conference-Workshop     and     the      discus-                                                                                    Durham,         N.C.   gent   need    for    a    nationwide    partner-
                         sion  itself  were  discussed.  The   fact   was                                                                                               Recorder:   ship   to   create    a    concept    of    'com-
                         that  fewer  than  2  percent   of   the   total                                                                         Edward      M.      Friedlander   munity     health     citizenship'-an      effort
                         conferees   at   the   meeting    were    hospi-                                                                         Assistant  to   the   Dz'rector   to   be   joined   in   by    Governmental    and
                         tal     administrators.     Recognition      was                                                              for     Communications     and      Public   private sectors, by        professional       and
                         given  to  the   fact   that   greater   attend-                                                                                           Infor77zation   lay  groups,   by   all   levels   of   activitv-
                         ance  at   both   the   panel   discussion   and                                                               Division     of     Regional      Medical   Federal,    State,     local."     The     object
                         the     Conference     might     be      proper.                                                                                                Programs   would  be  to   focus   on   the   responsibility

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                    of  the  individual  to  know  and   make   His  personal  interest  and  drive   were  out that  the  chosen  representatives  do               GROUP              DISCUSSION
                    the most of himself,  to  utilize  health   contagious   among   the   various    area  not  necessarily  represent   the   actual                              TOPIC       J:
                    services,   and   to   participate   con-   leaders, and .  .  .  he  worked  success-  consumers.  Musser  put  in  a  plug   for                                "OPERATIONAL
                    structively  in  community   health   de-   fully  with  them  in   establishing   the  the political science  book,  "Rulers  and     PROGRAM                    DEVELOPMENT"
                    cisionmaking.  In  this   direction,   "we  State   of   Franklin   Health    Council,  Ruled,"  as  a  good  source  of  informa-                                Discussants:
                    have    (literally)   done      next   to   Inc. . .  .  the  first  organized  health  tion on the  nature  and  complexities  of
                    nothing."                                   planning   group."   This   effort    pre-  forming    working    relationships    be-  @rlarles  E.   Lewis,   M.D.   (Moderator)
                      Pierre   C.   Fraley    introduced  the   ceded   the   North   Carolina    Regional  tween  what  someone   called,   "Us   and                  Program        Coordinator
                    "for  what?"  Fraley   pointed   out  that  Medical     Program,     and      involved  all them."                                  Kansas    Regional     Medical     Program
                    "the means need  to  justify  and  accom-   4,000  persons  in  seminars   on   commu-    From   her   experience   with    promo-                    Kansas    City,    Kans.
                    plish  the  desired  end."  Fraley  cited   nity health problems.                       tion of citizens' health groups  in  west-              C.   Hilmon    Castle,    M.D.
                    the  example  of  Pap  smear  testing  in     Alan  C.  Davis,  discussing  the   dif-  em   Pennsylvania,   Sister   M.    Ferdi-                  Program        Coordinator
                    New   York   City.   Whether   the   free   ficulty  of  explaining  what  a  Regional  nand advised:  "At  their  first  meeting,     Intermountain     Regional      Medical
                    screening  station  was  installed  in  a   Medical  Program  is,  described   it   as  they  don't  know  what  they  want.   Let                                    Progranz
                    midtown   department   store   or   moved   the first public  program  in  the  health  them  get  rid  of   their   frustrations.                  Salt   Lake   City,   Utah
                    up to Harlem, it tended  to  attract  the   care  field  to  involve  the   practicing  Then you have them involved."                                   T.    A.     Duckworth
                    same   intelligent,   highly   motivated,   physician.    Davis     warned     against    Whether    Regional     Medical     Pro-  Chairman,    Regional    Advisory    Group
                    not-so-poor  class   of   women,   mainly   bringing  in  professionals  only:   "It's  grams are designed  to  help  patients  or          Wisconsin     Regional     Medical
                    white  and   mainly   Jewish.   He   sug-   the   consumers    we    are    ultimately  help   doctors   help   patients,    there                                     Program
                    gested  that  the  goals   of   community   aiming  at,"  and  advised   against   su-  seemed  to   be   no   disagreement   with                           Wausau,      Wis.
                    involvement   should   be   to   increase   perimposing  concepts  or  set   standards  the  unidentified  voice  from  the   back              Albert E.   Heustis,      M.D.
                    knowledge,   to   change   attitudes   or   from on high,  "Let  the  people  do  it."  of  the  room:  "The   program   will   be                  Program        Coordinator
                    motivation,  and  to   change   behavior.     In the  discussion,  Fraley,  joined  by  judged   by   improvement    in    medical          Michigan     Regional      Medical
                      Describing  "the  successful   applica-   Dr.  Stanley  W.  Olson  from   the   aud-  care."                                                                         Program
                    tion of  a  public  information  program"   ience,  protested  the   assumption   that                                                               East    Lansing,    Mich.
                    in the  "State  of  Franklin,"  a  seven-   the  patient  is  the  consumer   in   Re-
                    county  rural  area  in  southwest  North   gional   Medical   Programs.   "The   phy-                                                       Donal   R.     Sparkman,     M.D.
                    Carolina,  Dr.  Marc  J.  Musser   empha-   sician  is  the  consumer,"  said  Fraley.                                                              Program        Coordinator
                    sized the "right man"  principle  in  ob-   Olson   pointed    out    that    Regional                                                      Washington-Alaska         Regional
                    taining    community    involvement.        Medical    Programs    emphasize     work-                                                                  Medical        Program
                      "The   initial    public    information   ing   through   established   groups   and                                                                      Seattle,     Wash.
                    program  was  carried  on  by   virtually   does not provide direct  service  to  con-                                                                               Recorder:
                    one   man,    on    a    person-to-person   sumers, i.e., patients.                                                                       Richard    B.    Stephenson,    M.D.
                    basis,"  said  Musser.  "This  man  is  a     From  the   audience,   Dr.   Henry   T.                                                Associate   Director   for    Operations
                    psychologist  and  member  of  the   fac-   Clark  discussed  the  problem  of   iden-                                                    Division   of    Regional    Medical
                    ulty  of  Western   Caroline   University   tifying quality  in  lay  leaders.  "Those                                                                                Programs
                    at Cullowhee. .  .  .  It  was  clear  to   who  may  get  involved  often   have   no
                    him  that  the  seven  counties  .  .   .   knowledge  of   the   processes   involved
                    working  together,  could  do  far   more   in   community   organization   and    ac-                                                  he  discussion  was  opened   by   the
                    to  solve  their  mutual  problems   than   tion," he said.                                                                        Tpanel   participants    briefly    review-
                    each   county   working    independently.     A   New   Jersey   discussant    pointed                                             ing   their   own   regional    experiences

                                                                                                                                                                                               115











                       with   developing   operational   status.     There  was  also  general  reconitioii
                       The  meeting   was   then   thrown   open   of the importance  of  acquiring  either
                       for  general  questions  and  discussion.   a critical mass or of reaching a  criti-
                          The  eneral  area  of  how  to  handle   cal point in the  planning  process  to-
                               g
                       both the generation and  review  of  ol)-   gether  with  the  neecl  for  concorni-
                       crational   proposals    was    discussed   tant  evaluation  as  an  ongoin-   part
                       from  several  aspects,  beginning   with   of planning.
                       the   involvement   of    legal    action     Additional points touched      on  in-
                       groups  of  various  kinds  through  dif-   cluded the usefulness of the  fruits  of
                       fering levels of technical or  scientific   previous  planning  activities  such  as
                       review   to   final   regional   advisory   Hill-Burton  and   similar   activities;
                       group  action.   Althou   h   there   was   the desirability of involving  early  in
                                               9
                       considerable variation  in  the  detailed   the planning process  persons  with  ex-
                       approach, there was     general    agree-   pertise outside the  medical  profession
                       ment  as  to  the   overall   methodology   itself; and the fact that the regions as
                       of handling  and  the  necessity  of  in-   identified for the purposes  of  initial
                       volvement at the different levels.          planning  grants  would   in   fact   be
                          The relationship of planning  to  ol)-   made  to  regions  and  not  to  indivi-
                       erttional activities  was  explored  from   vidtial institutions within the  region.
                       several  different  angles.   The   ques-     Finally,  it  was  reemphasized   that
                       tion  was  raised  as  to  whether  plan-   "there  were  many   roads   to   Rome,"
                       ning   should   be   directed   primarily   and that it was neither the  intent  nor
                       toward  regionalization  or  toward   the   the desire at either the  local  or  the
                       categorical   objectives   of   improving   national level for there to be  uniform-
                       care of health disease,  cancer,  stroke,   ity  or  conformity   to   some   master
                       and  related  diseases.  It  was   agreed   scheme  for  regions  to  become  opera-
                       that  planning  should   do   both,   but   tional, but that  diversity  and  flcxl-
                       that  the  primary  thrust   was   toward   bility were clearly in order.
                       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.
                         Reeni  hasized  in  a  number  of  dif-
                                p
                       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  contrast(.,cl
                       with the purely planning grant.

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         I
                           A NONPROFESSIONAL LOOKS AT                     Irving J. Lewis
                           REGIONAL MEDICAL PROGRAMS










                                                REMARKS                   Honorable Melvin R. Laird










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                              A               NONPROFESSIONAL   demand which  for  me,  and  indeed,  all  not  only   your   hard-earned   personal   neither clear cut  nor  infallible,  and,
                                             LOOKS         AT   of  my  colleagues  who  have  been   ex-  income  but  also  the   way   in   which   as  I  have  indicated,  our   analytical
                               REGIONAL               MEDICAL   posed to it in depth,  has  meant  a  re-  society  utilizes  its  people  and   its   techniques  are  still  probably  not  as
                                                     PROGRAMS   orientation  of  thinking,  a  new  level  natural or physical resources 'and    the   solid as we would like.
                                                                of objectivity, and above  all,  a  last-  services   or   social   purposes   which    Still,  I  hope  you  will  accept  that
                                          Irving   J.   Lewis   ng  respect  for  a   much-maligned   and  these  resources  produce.  The   alloca-   this budgetary effort is  no  simple  ac-
                              Deputy    Assistant    Director   little  understood   executive   agency."  tion   process   is   never    ending-the   counting task, but  one  in  which  after
                                   Bureau   of   the   Budaet    I  quote  Ivan  at  length  so  that   I  larger the  Federal  budget  the  greater   we  fall   back   exhausted-incidentally,
                                                        -       may  publicly  accept   his   compliments  the   responsibility   that    Government   that will occur for  1969  very  shortly-
                                  Oflice  of  the   President   while at  the  same  time  deny  that  we  assumes to channel  and  direct  its  re-   we  have  helped  the  President  find  a
                                                                are  beady-eyed,   and   hope   that   we  sources according  to  rational  choices.   balance   first,   among   the   national
                                                                are better understood as a result of  his    I have no crystal ball to tell  me  how   goals of national security,  foreign  af-
                       am  pleased  to  have  this   opportu-   efforts. Also, despite  our  passion  for  large  the  level  of  Federal   spending   fairs,  education,  health,  abolition  o
                       nity  to   be   at   the   Conference-   anonymity,   we   now   find   that   the  will be or ought  to  be.  I  would  only   poverty,  environmental   quality,   rec-
                     Workshop  on   Regional   Medical   Pro-   stageIon  which   Federal   programs   are be  speculating,  and  I  would  be   es-   reation,  housing,  transportation,  sci-
                     grams.  I  always  welcome  an  occasion   played  has  become  so  vast   that   we  pecially  speculative  if  I  engaged  in   ence  and  technology,  and  so  on;  and
                     to show to an  unbelieving  public  that   do have to  allow  for  a  few  occasions  the game of "what  if  we  had  no  Viet-   second,   among   the    programs    most
                     the men in  the  Budget  Bureau  do  not   which permit us to  see  local  interests  nam?"  The  level   will   remain   high,   likely in action  to  give  him  progress
                     wcar  green  eye  shades  or  sit   upon   at work, or, as we  say  at  the  Bureau,  however,  and  the  competition  for  the   toward  these  goals.  There   is   never
                     high stools in  their  counting  houses.   the real world. For  it  is  to  help  in  dollars increasingly acute.  This  acLite   enough to go around,  and  it  is  little
                     In a recent talk  at  this  same  hotel,   shaping  this  real  world  that   presi-  competition  means   that   we   in   the   wonder   that   Maurice   Stans,   Presi-
                     Dr. Ivan  Bennett,  Deputy  Director  of   dential goals,  policies,  purposes,  and  Budget   Bureau   must    concern    our-   dent  Eisenhower's  last  budget   direc-
                     the Office  of  Science  and  Technology   proposals  are  eventually   fused   into  selves  with  the  goals  and  objectives   tor, called budgeting the  unifon-n  dis-
                     and  one  of  my  principal  mentors  in   what  is  termed  "the  program  of   the  and  the  hoped-for  results  of   health   tribution of dissatisfactions.
                     the health field, described us in  these   President."  It  is  the  translation  of  and other  programs.  We  try  to  refuse     There   is   ample   room   to   demon-
                     words:                                     that  program  into  dollar  terms  which  to  go  along  with  the  proposals  that   strate   that   the   worth   of   social
                      "Some  of  you,  I   know,   have   had   leads us in the  Budget  Bureau  to  pur-  'shoot from the hip.                        investment  is  subject  to   qualifiable
                     experience  with  the  Bureau   of   the   sue the facts, to question  the  purposes    What I  am  saying  is  that  while  we   assessment. There is  rather  a  -,vi  e-
                     Budget, where, since the       multiple-   of programs,  to  analyze-alas,  all  too  in the  Budget  Bureau  have  no  special   spread effort  today  in  the  Government
                     crack system does not  exist  and  there   imperfectly-their  costs  and   benefits,  wisdom  or  formulas  for   sorting   out   to  produce  these   assessments,   going
                     are no fissures  that  allow  for  pene-   so   that   the   decisionmaker-in    our  our  budgetary  goals   and   priorities,   Linder such  names  as  systems  analysis
                     tration of local interests into national   case,  the  President-can  look  at   al-  the President wants  his  program  to  be   or  program   planning   and   budgeting.
                     policy decisions to influence  decision-   tematives  and  evaluate  relative   pay-  tuned to  the  problems  of  our  society   Thus, investment  in  education  is  said
                     making  and  allocation  of   resources,   offs from different kinds of  public  in-  and the  need  for  developing  solutions   to be more than socially   4c      good"-we
                     one has recourse  only  to  putting  to-   vestments.                                 to   those   problems.   He   wants   his   say it is  economically  productive,  and
                     gether  a  balanced,   persuasive,   and     As availability  of  public  funds  for  final  choices  to  be  not   only   good   we  can  even  say  by   how   much.   We
                     factual argument. It is  with  real  re-   public  purposes  becomes  tighter,   the  choices,  but  better  than  other   pro-   can, by better analysis,  show  that  the
                     spect and admiration  that  I  say  that   need  for  questioning   is   heightened.  posals  to  accomplish  the   same   end,   rehabilitation  of  the  handicapped   is
                     here  are  the  beady-eyed,   hard-nosed   Our thirst  for  knowledge  is  quickened  and  to  show  better  returns  for   the   not  only  socially   useful   but   eco-
                     skeptics, receptive to opinion  but  de-   as  we  understand   that   when   budget  same  investment  of  public  funds.   To   noriiically  advantageous.   In   medical
                     manding  iron-clad   factual   details-a   decisions  are  made  we  are   affecting  be  sure,  the   budgetary   process   is   science,  similar   reasoning   can   and

                     118








                                                         to    Show    f;kvol-;Il)](@     fol-(@ll)IY ilill)t-(,Ss  ill)oll  you  tl-l(,.  SWC(',I)
                                                                                                                                                                                                                    qovernmcnts.            Unfortunately,                for
                                                                                                                  ;I(,t,ivjty ill  1,11    so(!I;ll                                                                 tlios(-    who    @ij)l)t-oa(-.h    governmental     i-c-
                                                                                                                                                                                                                    lat'ons     simply,     no     one     has      contrived
                             ratios     foi- (@,xaiijl)l(-, it li@is 1)(!(,f) (loti(!     II(-](I.                                                                                                                     I        I
                             in    studies    in     tile     I)cl)artjii(@iit     of        'I'tic   use   of   tile    phrase    "liui-nan    rc-                                                                 a    simple    formula    for    the     execution     of
                             I-lealth,      Education,      and      Welfare       of     sources"      has       become       fashionable       in                                                                 these    programs.     n     t     c     contrary,     we
                             the   health   of    the    poor    and    the    health     today's      intellectual      parlance,      but       I                                                                 have       adopted,       probably       not       always
                             of children.                                                 think     it     signifies     that     the      programs                                                                 consciously,      the       approach       of       prag-
                                But   let    me    cltiickly    hasten    to    clis-      roLiped     Lindet-     this      banner      constitute                                                                 matic      experimentation.      There       is       not
                                                                                          9
                             abuse   You   of   any   i(le@i    that    I)Lid@,(-ting     a     new     type      of      governmental      effort,                                                                 always    time    to     wait     for     the     perfect
                             and     its     associated      decisionrriaking      is     not    to    be    compared    with     social     lcgis-                                                                 solution.    So,    we    grope    toward     it,     ac-
                             strictly     for     budget     professionals.      This     lation     of     the      I)ast-cither      the      New                                                                 cepting    some    risks.     We     place     a     high
                             is     no     system     of     push     buttons      or     Freedom     of     Wilson     or     the     New     Deal                                                                 premium     on     close      cooperation      and      a
                             ivhlrrln,-     magnetic     tapes.      Public      pol-     of        Roosevelt.        That         legislation-fair                                                                 flow       of       information       among       equals,
                                       ill   made    in    the    political    arena,     labor    standards,    child     labor     laws,     food
                             icy is st                                                                                                                                                                              and,   above    all,    we    are    willing    to    see
                             and   it   is   in   this   arena   that    the    budg-     and      drug      controls,       unemployment       in-                                                                 institutional      change       come       about       in
                             (@tary decisions are made.                                   surance,    social     security,     to     mention     a                                                                 many    forms.    We    have    had     to     try     to
                               A   better   grasp   of    the    role    of    public     few-reflectcd     a      simpler      social      philos-                                                                 move       more       and       more       decisionmaking
                             expenditures     in     creating      social      assets     ol)hy       that       Government       should       pro-                                                                 out   into    the    field,    recognizing    that    co-
                             does   not   by   itself   tell   us   when   to   spend     vide      a         basic         underpinning         by                                                                 ordination     of     programs     cannot     all      be
                                                                                                                                                                                                                    achieved     by     Federal     action.     The     bene-
                             or    how    much    to    spend.    Our     pluralistic     interdicting       various       behavior        patterns
                             society      responds      to      pluralistic       de-     or     by     providing     certain      minimum      in-                                                                 fits     of     decentralization,      however,      must
                             niands    whether    they     ai-(@     supported     by     come      guarantees.      Today,       the       revolu-                                                                 be    accompanied    by    the     costs     of     anom-
                             a     dispassionate     array     of     facts      arid     tion    of    rising    expectations    in    the    less                       MR. LEWIS                                 alies,        diversity,        inconsistency,        and
                             figures     or      not.      Many      human      needs     developed     world     is     paralleled     by      un-   the     professional     specialists.      Too      often,    even       downright       error.        But        deep-
                             clamor      for      passionate      attention,      and     rest    in    our    own     society,     and     Govern-   the      professional       insists       on       assump-    rcoted      social      and       economic       problems
                             many    1)robl(-,ins    (-r-y    out    for    solutions     iiient     is     responding     by     provision      of   tions,     approaches,      I-)rograms,      or      tech-    are    complex    in     nature     and     cannot     be
                                ll(-gi(@(.t(-(l @tj'(.;Is of ])III)]'                                                                                 liology   of   iiiilv(@i-s;tl   @ii)l)lical)ility.   L(@st    ;ttt@L(-.ke(I       by       simple-minded,       single-
                                                                    i(@ ('011(,(Ir,]).    "(@l'Vl('(,S oil ;t V(lr-y I)I-o@t(I  fi@olit.
                             Certainly,     our      planning      and      atialyti-     89th     Congress     alone     produced      21      new   we          "dehumanize"          human           resource    shot approaches.
                             cal    capability    is    not    Treat    enough     to     health      programs,      17       new       educational   prograi-ns,    may    I    stress    that     the     pn'-       In    his    report    to    the     President     and
                             have    given    us    in    so     short     a     time     programs,      15       new       economic       develop-   mary      focus      of      Government      in       man-    the       Congress       on       Regional        Medical
                             rationality      to      clevelol)      our      present     iiicnt     programs,     12     new      programs      to   a@ing     this      array      of      programs      ou,ht    Programs,       the       Surgeon       General       set
                             array     of     Federal     human     resource     pro-     meet    problems    of    cities,    and     four     new   to   be    on    the    individual    no    matter    Nvho    forth   at   length    a    number    of    issues    and
                             grams.     About     459     sti(@h     programs     are     manpower programs.                                          he        is-Lindcrprivileged,        I)<)or,        aged,    problems       which       face       the        Regional
                             des(@i-ll)c(l    in    the    annual    (7atalo(,     of        l,rorri   OLII-   early   clays,    we    Arr)ericatis   migrant,      veteran,      child,      mothers      noii-    Medical      Pro-rams.       Some       derive       from
                             I-'cderal        assistance        programs         pro-     have     been     a     "practical"      people.      And   white,      retarded,      rural,      uneducated,      or    characteristics      of      the      general      health
                             dtice,c]  by  tfl(@  Offi(@(!  of   I"Collortl'(@   Ol)-                     '(,,ty  t(                                                                                                settiii,,     in      this      country-for      example,
                                                                                          So  oui-  so(:l           -,jicls    to    bring     into   other statutory category.
                             ])Ortunity.    I    (@oillilicti(I     tills     catalog     being      human       resource       programs       that       'I'hese    programs,     and     I     include     Re-    its      essentially      voluntary      and      private
                             to    your    attention.    It     may     hear)     You     are    targeted     to     specific     action     areas.   gional       Medical       Programs,       have       cre-    nature,      the       magnitude       and       complex-
                             not   only   to    find    out    whether    there    is     These    may    be    categories    of     disease     or   ated      a      new      dimension      for       Federal    ity   of   what   is   often   termed    a    $43    bil-
                             a      grant      program      to      finance      your     specific         population         groups,         and-I   management       and       for       relations        with    lion        industry,        manpower        limitations,
                             favorite   pro'ect,   but   it   Nvill    also    rather     may     adcl-arc     too     often     controlled      by   the    private    sector    arid    State    and     local    and    rising    medical     costs.     Others     relate
                                             i


                                     292-414 0-68-9










                             to  the  law  itself-definition  of  a   re-   public     controversy-such      as      bio-  of  us  needs   to   be   an   economist   to  medicine"    may    become    not    disease-
                             gion, significance  of  disease  categories,   medical      research      and       academic  know    that    when    more    funds     are  oriented,  but   the   area   of   organizing
                             use  of   advisory   groups,   dissemination   science-   and   new   activities    designed  poured   into   the   arena   for   purchase,  the  system  of  care.  Of  course,   another
                             of   information   relating   to    advances   to   finance   and   make    available    the  the  selling  system   must   be   more   ef-  impact,   still   only   seen   in    general
                             in    diagnosis    and    treatment,     and   medical    knowledge    we     have.     How-  ficient  or  its  supply  must  be   enlarged  terms,  will  be  seen  in   the   need   for
                             others.                                        ever,  it  is  also  clear   that   extremely  or  the  infusion   of   funds   may   simply  production   of    more    doctors    faster.
                                In time,  these  and  other  issues  will   high  on  the  health  agenda  is  the   dis-  be  eaten  up  by  price  inflation.   Debate  The     President's      Health      Manpower
                             be dealt  with  in  the  public,  executive,   tribution   of   our    medical    knowledge-  continues-and     I     am     no     expert-  Commission      recommended      that      we
                             and  legislative  forum.  But,  as   I   see   what   we   call   the    organization    and  on  the  extent  to   which   medicare   con-  develop   economic   incentives    to    make
                             Regional    Medical    Proorams    in    the   delivery problem.  I  think  that  it  is  in  tributed  to  rising   medical   costs,   but  this    possible.    Oliver    Cope     wrote
                             context   that   I   discussed   earlier-our   solving  this   problem   and   in   bringing  the rising  costs  are  with  us  and  there-  somewhat   despairingly   of    this    prob-
                             problem   of   allocating    resources    of   medical  care  to   people   that   the   Re-  fore  spur   us   to   examine   our   system  lem    of    medical    education    a    few
                             men,   money,   and   materials-its    prime   gional     Medical     Programs     potential  of medical care.                               months   ago   in   Harpcr's   Maaazt'ne.   I
                             worth to our society  will  be  in  its  ca-   lies.                                             Many speak      of    Regional     Medical  would   hope   that   in   time   we    could
                             pacity   for   improvement   of   our   sys-      Medicare   and    medicaid    alone    ac-  Programs as a     unifying  focus   for   the  overcome   his    despair    bv    responding
                             tem-or   systems-of   medical    care    for   count   for   over   $8   billion   of    the  health  resources  of   a   region,   linking  to the prod of the Commission.
                             the  people  served.  Let  me   stress   the   Federal   expenditures   of    $15    billion  patient,     physician,     hospital,     and     Through   the    National    Center    for
                             word  "medical"   because   too   often   in   for  health  programs.   They   have   virtu-  medical  centers  to   provide   the   latest  Health   Services   Research    and    Devel-
                             the  past  in  this  country  we  have  used   ally  eliminated   financial   barriers   for  advances   of   knowledge   to   the   people  opment,     Regional     Medical     Programs
                             "health"  as   a   euphemism   for   medical   the  aged   and   have   made   it   possible  in  this   region.   But   health   functions  will  get  invaluable   assists   through   a
                             in  view  of  our  unwillingness   to   con-   for   poor   and    near-poor    in    three-  are     a     continuum,     and     Regional  rising   level   of   supporting   investiga-
                             front on a  public  level  the  problems  of   fourths  of  our   States   to   receive   an  Medical   Programs   will   have   to    con-  tions      and      experiments.      Another
                             medical care.                                  increasing  volume   of   medical   services.  sider   the   problems    of    distribution,  significant  actor  on  the  scene   is   the
                               By  now  it  is  established   that   Gov-   These  landmark  laws   of   1965   arc   ac-  cost  and  organization   of   health   care.  "Partnership  for  Health,"   and   I   guess
                             ernmcnt has  set  its  face  in  the  direc-   companied   by   others   in   maternal   and  I  would   think   that,   because   of   the  we  still  have  to   establish   with   more
                             tion  of  tackling  the  problem  of  assur-   child health.                                  tremendous   scope    of    heart    disease,  clarity   how   we   want   this   experiment
                             ing to  all  its  citizens  the  access  and     Ironically,     many     people-and     es-  cancer,   stroke,   and   related   diseases,  to  tie  in  with   Regional   Medical   Pro-
                             availability   of   high   quality   medical   pecially      medical       professionals-are  the   task    of    improving    organization  grams.  There  is  a   tendency   to   regard
                             care.  I  regard  as  idle  the   discussion   troubled    over    this    outpouring     of  and  delivery   of   medical   care   through  this   program   as   just   another    State
                             whether  we  mean  such  care  is  a  right,   Federal   funds   to   diminish    the    fi-  Regional   Medical   Programs   has   to   be  support  program.  This  is   an   error   in
                             like  public  education,  or  a   privilege.   nancial  burden   of   paying   for   medical  viewed   in   the   context   of   comprehen-  judgment,  and  you  will  find  that  it  is
                             The goal is clear, and  if  we  are  serious   care,  and   they   are   rightly   troubled,  sive  health  services  and  not  in  a  nar-  regarded   here   in    Washington    as    a
                             about   it,   we   must   constantly    make   because    with    demand     for     medical  rowly based disease approach.                  pilot  program  of  some   significance.   It
                             painful  choices  as  to   where   we   will   care  now  effective,   as   the   economists    This task  will  have,  in  the  long  run,  is   a   major   breakthrough   in   changing
                             put   our   moneys   and   equally   painful   say,  the  pressure  is  on  the   profession  serious   implications   for   medical   cen-  the   proclivities   of   professionals   and
                             decisions  on  how  to   arrange   our   in-   to   deliver.   In   addition,   of   course,  ters   and   medical   schools.   The    com-  their   executive   and   legislative    sup-
                             stitutions.                                    there  is  the  vocalized  but  as  yet   not  fort   of   biomedical   research   and   in-  porters    to    opt    for    narrowly-based
                               I  do  not   anticipate   that   we   will   effective  demand   of   citizens   not   yet  dividlial   case   treatment   or    tcaching  categorical  programs.  There  is   a   seri-
                             experience   major   trade-offs   in    Gov-   covered-for    example,     the     disabled,  may  be  replaced  for  many  by   the   rag-  ous effort  afoot  in  this  town  to  create
                             ernment    spending    between    previously   the  migrants,  or  the   rural   and   urban  ing   controversies   over    medical    care  more      manageable      packages      which
                             well-f unded activities that  were  of  less   poor  not   eligible   for   medicaid.   None  costs,  doctors'  fees,   etc.   "Interesting  permit   the   local   private   and   public

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                          .,(,I to], to ;I( I (](.(.I@@lv(.Iv wall(. I)?(-S(-IV- foI-(.V(.I-:t II(-W('t.ofwoo(I       :t (11."Iw(.I.  (.1-is'.@()f III(! (@'ti(@s 's;t litlill;tll          itl(,Ilt. lz(,g,oll;tl M(!(]'(@:tl  Pi-ogl.;Illls
                          irig tli(@ right of tli(.-             (;()v(!t-ii-    (-)f watei- - it is the despair of            uii-   crisis  and  the   cities   are   where   we   will   ti-ics  to  develop,  on   the   basis   of   local
                          merit   to    establish    priorities    of    na-     able  to  aspire  to   the   expression   of   his   find   most   starkly   the   poverty   of    which   initiative,    new    institutions    and     tech-
                          tional significance.                                   potential  as   a   human   being;   it   is   the   Colin McLeod spoke.                                   niques    to    solve    health    problems.     In
                            In   the   Budget   Bureau    we    have    read     despair    of    having    no    future     except      For   too   long    our    society    has    in-   a    sense,    Model     Cities     is     Regional
                          with    considerable     interest     the     Sur-     that    of     mean     survival     in     misery   vested   resources    in    only    the    physical   Medical     Programs      writ      large      upon
                          gebn    Gencral's    priority    statement     for     loaded     enclaves     surrounded      by      an   aspects   of    the    city,    but    the    Model   the total human resources scene.
                          Partnership   for    Health    issued    in    No-     opulent society."                                    Cities     program     is      ampic      testimony      The    Model    Cities    program    has     an-
                          vember.     This     priority     statement     is      There     has     now     been     mounted     in   that   human   and    social    needs    are    the   other     lesson     for      Regional      Medical
                          very  topical,  and  I   suggest   that   it   has     the     Office     of     Economic     Opportunity   dominant       theme       today.       Sixty-three   ProgFams-the       necessity       of       citizen
                          great   meaning   for   many    of    you.    This     a   program    by    the    "medical    radicals,"   cities    have    been    selected    for     first   participation       in       program       develop-
                          statement      establishes      three       budget     as    Marion    Sanders     calls     them,     of   generation     grants      under      this      top   ment   and   his   access    to    the    decision-
                          priorities    that    are    relevant    to    Re-     Neighborhood       Health       Centers.       To-   priority     program,     designed      to      im-   making    process.    There    are    many    roles
                          gional Medical Programs:                               day,    46    centers     are     in     operation   prove   the   quality   of    urban    life,    de-   which    we    can    attempt    to    define    as
                               First:                                            or   to   be   funded,   and   medical    s(,hools   clarcd   by   Congress   to    be    the    ii-iost   being    logical    and    effective    for     the
                            prehensive   health    (:are,    dlre(,tcd    to     at  all  levels  are   in   the   business.   This   critical    domestic     problem     facing     the   private   citizen   in   health    affairs.    Hos-
                            individuals    and    families,     not     dis-     is   more   than   an   incidental    change    in   United    States.    These    63     cities     now   pital    trustee    or    planning    body     mem-
                            eases;                                               attitude.  It  is   recognition   that   the   Na-   have   the   initiative   by   law    to    develop   ber   are   obvious   roles.   Not    so    obvious
                               Second:       Improvement       of        the     tion's   health   business    lies    in    making   programs,      for      selected      neighborhoods   and      perhaps      somewhat      more      nebu-
                            health   status    of    the    indigent;    and     medical   care   available   to   all,   and   the   so   as   to   remove   or   arrest   blight    and   lous  is  the  role  of   the   private   citize.11
                               'I'filr(]:   Us(,   @.tri(I    training    of     rol(, of rri(!(Ilcal s(-Iiools  ar)cl  centers  is   decay,    to    make     marked     progress     in   is   a   member   of   the    board    of    dircc-
                            n(@igfil)orlioo(i   r(,sl(l(!nts    an(]    it)-             in   this.   May   f,   as    a    layman,   i-(-dii(@itig   social   @ind   educational   (Its-   tors    of    a    regional    medical     program.
                            volvement      of       neighborhood       resi-     suggest   that   heart,   stroke,   cancer,    and   advantages,      ill      health,      underemploy-   I    know    many    of    you     are     thinkin-
                            dents    in     planning     and     implementa-     related       diseases-significantly       related   ment,    and    enforced    idleness,    and     to   about   this   role   of   the   citizen    which@,
                                                                                                                                      provide       educational,       health,        and   incidentally,    would    parallel     the     con-
                            tion of health projects.                             or     not-will     be     found     among     the
                            I    would    only    bore    you     were     I     poor   in    the    neighborhood    health    cen-   social   services   necessary    to    serve    the   sumer     representation     found      in      the
                          to   recite   statistics    about    the    health     ters.       Undoubtedly,       many        medical   poor    in    the    Model    City    area.     You   Partnership     for     Health     program.      In
                          status   of   the   poor.    The    evidence    of     schools   are   or   will   be   deeply   involved   should   be   aware   that   this   is    a    pro-   any   case,    the    nonprofessional    role    in
                                                                                 n     both     Regional     Medical      Programs.   gram    run    through    the     Department     of   planning     a     regional     medical     program
                          unusual    disease     and     high     prevalence     I
                          of  ill  health  identifies  them   as   a   high-     and     neighborhood     centers     and      both   Housing        and        Urban        Development,   warrants      expansion      and      the      com-
        s                 risk   population.   While    the    middle    and     programs     should     profit      from      each   but    that    HUD    places    primary    reliance   munity    members,    to    play     this     role,
        a                                                                        ther.                                                on    other    agencies    for    evaluating    the   will   have   the   responsibility    for    asking
                          upper   classes   in    this    opulent    society     0
        t                 have   a    malaise    and    uncertainty    about      If   I   am    right    that    Regional    Medi-   human       resources       program       proposals   a     number      of      unpleasant      questions
        9                 their   own   lives,   the   health   status    of     cal   Programs   has   not    been    sufficiently   of these Model Cities plans.                          about   the   quality   of   the    medical    care
        d                 the   poor   is   part   and   parcel   of    that     concerned   thus    far    with    the    problems     The    Model    Cities    program,    born     in   in  a   region,   the   availability   and   acces-
                          complex     called      poverty      which      is     of  the  poor,  I  can   extend   this   lack   of   the   inspiration   of   a   few,   dealing    with   sibility    of    comprehensive    health    serk--
        d                 much   greater   than    'ust    lack    of    in-     concern   to    the    cities    generally.    Not   the    institutional    arthritis    of    Federal,   ices,    or    the    usefulness    of     Regional
        i-                come.   It    is    what    Colin    McLeod,    in     that   I    ignore    the    rural    poor.    The   State,     and     local     bureaucracies      and   Medical     Programs     in     inhibiting      the
        Le                his    recent     AAMC     address,     eloquently     Breathitt       Commission       reminds        us   frustrated    by     the     professionalism     in   rate   of   cost   increase   in   medical    care.
        @h                called  "the   lack   of   hope   that   one   can     most   forcibly    that    urban    poverty    has   health,     education,     and     welfare,     may     May    I    suggest,    however,    that    there
        ic@               ever   rise   beyond   the   despair   of    being     deep   roots   in   rural   poverty.    But    the   yet  turn   out   to   be   our   boldest   experl-   is    another    consumer    role    which     must

                i                                                                                                                                                                                                                           121











                              be considered. It is  an  inevitable  role     Not  too  long  ago  Public   Broadcast
                              if  human  resources   programs   are   to  Laboratories   televised    the    sharply
                              reach  the  people  whom  they   are   de-  polarized views  of  the  police  and  the
                              signed  to  serve.  I  am  speaking   here  militant   Black   Power   advocates   re-
                              of the citizen  in  the  neighborhood  who  -arding  law  enforcei-nent   by   police.
                              will not be satisfied with  past  patterns  It was a fairly  chilling  experience  for
                              of    consumer     representation,     but  the  advocates  of   moderation.   But   I
                              wishes   rather    through    neighborhood  found   provocatively    thoughtful    the
                              organizations   to    make    his    views  minister   from   Atlanta    who    calmly
                              known.   The   requirement   of   partici-  told  a  nationwide  audience   that   all
                              pation of the citizens  in  the  neighbor-  our  social,  education,  and  health  ef-
                              hood   in   determining    the    programs  forts  were  hampered  by  an  essentially
                              which  serve  them   is   found   increas-  ne-ative   attitude   of   Americans   to-
                              ingly  in  Federal   law,   Model   Cities  ward  the  poor  and  the  Negro.  If   we
                              and   Office   of   Economic   Opportunity  expect    human    resources     programs,
                              being   only   highlight   examples.   The  including    Regional     Medical     Pro-
                              prescription  of  the  participation   may  -rams, to  realize  their  investment  Po-
                              vary in  differing  statutes  as  may  its  tential  to  serve   human   beings,   the
                              administration  in   practice.   But   one  professional's  attitude   must   be   one
                              thing  is  certain:  The  voice   of   the  that  not  only  permits   him   to   help
                              citizen consumer  will  be  heard  at  the  the poor and  Negro,  as  he  did  in  the
                              grassroots  level  in  the   deliberations  past eras of social legislation, but  also
                              affecting his future.                       motivates  him  to  urge  their   involve-
                                The   need   of    community    involve-  ment and  give  them  access  to  the  de-
                              ment  and  citizen  participation  is  un-  cisionmaking   process.   That   is    our
                              familiar  to   the   medical   profession,  -oal  in  Model  Cities,  Office  of  Eco-
                              which  has  survived  a   long   time   in  nomic   Opportunity,    and    Partnership
                              this  country  under  the   slogan,   "You  for  Health.  It  should  be  no  less  in
                              are  the  doctor."  But   Paul   Ylvisaker  Regional Medical Programs.
                              very astutely pointed out at  last  year's     May  I  tha'nk  you   for   this   ol)-
                              conference  in   this   hotel   that   the  portunity  to  be  present  at  this  Con-
                              Regional   Medical   Programs   has    too  ference,  and  wish  you  well   in   your
                              narrow  a  professional   base,   and   he  endeavors.
                              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
                              tliit (!xl)ericiic(-."

                              122








                                                                      REMARKS    to    see    that    medical    services    in     the   saw    for    the    decades    of    the     seventies
                                                                                 hands    of    a    very    limited    medical    man-   and eighties.
                                                                                  on@,er   ,roul)   could   get    to    patients    in       And    I    think    the    pro,ress    that    has
                                 Honorable      Melvin       1Z.       l,aird                         g'oiis     of     our     country   )-)ccii   made    that    has    coomc    from    these
                                          Meniber,    U.S,     Ifou.@e     of    Ltic  various  i,c  i
                                                                                 ,iricl the  us(-,  of  this  iriccl'(!al  iiianl)onver   discussions      and       your       report,       Dr.
                                                     Re/) r(.-.5 e! ?i I(it z    (-otilci  be  2i ftill(!i-        f(illei-  titili7.a-   Co,,Ilesliall,   on   the   work    that    has    gone
                                                                                                                                          or)          it this                   shows       that
                                                                                                 as                fol.@v:ll.(l    into   this                is  fliially,,,ettlii,,,   started.
                                                                                 tll(! future, @VC (@OLII(l SC(@   tlllt  it   Nv@isn't   It   has   got   a   long   way   to   ao,    but    at
                           caryi(@   here    to    learn,    and    I    have    'List   a    CILI('Stion    of    doctor    shortages,   least,    you     are     defining     the     problem.
                           been    listening    to    the    morning     ses-    but   it was   a    cluestion    of    shortages    in
                       sions   with    a    great    cical    of    interest.    every    area       of        medical        manpower.
                       It    is    true    that    I    have    served     on    And     tli(,                 l'i-ograiri        could
                       the     I-lealtli,      Education,      and      W(@l-    "love   in  tli(,   (tir(-(@t'oii   of   making   bet-
                       fare       Appropriations        Committee        ever    tcr    use    of    the    limited    supply     which
                                                                                      had    on    hand    and    which    we     fore-
                       since      this      department      was      created,    we
                       working    very    closely    with     the     gentle-
                       man   on   the    other    side    of    the    aisle,         IT
                       John    Fogarty,    who    was    my    closest    and
                       dearest     friend     in     the     Congress.     We
                       had    a    very    great     association     together
                       for some 16 years.
                           I   know   that   he    would    be    proud    of
                       the    1)rogr(-ss    that    the    lzcglonal    Medi-
                       (@;ll I'l-ogl-@illi ll;IS lll;t(](! it) ;L Vf'l-y ';I)Ot-t
                       period    of    time.    And    the    fine     report
                       on   this   conference    which    I    @vas    privi-
                       lcgcd    to    hear    from     you,     Doctor,     I
                       think    speaks    -,vell    for    tfiis     pro@ram.
                           When    we    made     the     first     appropri-
                       ation   for   this    program,    of    course,    Nve
                       ,@,cre    concerned    about    the    delivery     of
                       the     research     benefits     which     we     had
                       funded   at    an    ever    increasing    rate    'or
                       a   period   of   some   12   to   13    years,    the
                       dcli%,cry   of    these    research    benefits    and
                       research    findings    to     a     limited     iium-
                       her    in    the     medical     manl)onver     field.
                       But    the    purpose    of    this    program     was           HONORABLE MR. LAIRD

                                                                                                                                                                                                                                                     123













                                    APPENDICES ....             1. CONFERENCE-WORKSHOP
                                                                    PROGRAM

                                                                2. COORDINATORS' STEERING
                                                                    COMMITTEE

                                                                3. REGISTERED PARTICIPANTS

                                                                4. REVIEW COMMITTEE AND
                                                                   NATIONAL ADVISORY COUNCIL

                                                                5. DIVISION STAFF

                                                                6. REGIONAL MEDICAL PROGRAMS
                                                                7. PUBLIC LAW 89-239

                                                                8. REGULATIONS
























                                                                                             1 25














                                                                                                                           APPENDIX              I            Panel:       RAY E. TRUSSELL, M.D.,
                                                                                                                                                                           Director, School of Public Health and Administrative Medicine,
                                                                                                                               CONFERENCE-WORKSHOP                         Columbia University,
                                                                                                                                           PROGRAM                         New      York,       N.Y.
                                                                                                                                                                           FRANK P. LLOYD, M.D.,
                                                                                                                                                                           Director, Medical Research,
                                                                                                                                                                           Methodist Hospital,
                                  THEME:  ISSUES  FOR  REGIONAL  MEDICAL  PROGRAMS                                                                                         Indianapolis,        Ind.
                                              IN THE  IMPROVEMENT  OF  HEALTH  CARE
                                                                                                                                                                           AMOS JOHNSON, M.D.
                                                                                                       WEDNESDAY,            JANUARY            17                         Garland, N.C.

                             8 a.m.  REGISTRATION                                                                                        Concourse            12           Noon-6           p.m.           DI-"MONSTRATIONS-EXI-IIBITS                                   Terrace
                                                                   FOCUS ON THE ISSUES                                                                        Special   demonstrations   and   exhibits    which    reflect    regional    and    other    related    activities
                             8:30-10:30 a.m.  PLENARY SESSION                                               International      Ballroom       West            have been irranged and will be opened and iTianned during this period.
                                                                                                                                                              See   Appendix   A   of   this   printed    prograiri    for    listing    of    demonstrations    and    exhibits
                             Chairman: STANLEY W. OLSON, M.D.,                                                                                                and their locations.
                                              Chairman, Coordinators' Steering Committee and
                                              Coordinator, Tennessee Mid-South Regional Medical Pro.-rarn                                                     1:30-3:30       p.m.       SERIES       I-PAPEI@S       ON       REGIONAI,       ACTIVITIES       AND        IDEAS
                                              Quality   and   Availability   of   I-Tealth   Care   for    Heart    Disease,    Cancer,    Stroke,
                                                and Related Diseases in the l,uture as l@lated to:                                                            Selected    15-minutes    papers    presenting     highlights     of     regional     activities     and     ideas
                                                o Science and Service                                                                                         now   being   devclop(@ci   in   the   regions   will   [)(-   presented   on   the   following    schedul(-    in
                                                      CARLETON CHAPMAN, M.D.,                                                                                 adjacent    rooms    permitting    and    encouraging    conferees    to    develop    it    projected    schedule
                                                      Dean, Dartmouth Medical School,                                                                         so that they can move      from   room   to   room   at   20-n-dnute    intervals    to    hear    those    papers
                                                      Hanover, N.H.                                                                                           in  which   they   have   the   most   related   interest:
                                                9 Regionalization                                                                                             Starting
                                                      LESTER BRESLOW, M.D.,                                                                                     lime                         Afeeti@q  room.@  on  concourse   level
                                                      Professor of Health Administration  and Chief,                                                            1:30           I'@il)(,rs          1         7         1 li        11)         25           :role
                                                        Division of I lc@iltli Services,                                                                        1:50           I'@tl)crs           2         it        1 4         20          2(i          :@o(:
                                                      UCLA School of Public Ifealth                                                                             2:10           Papers              :i        9         1 5         2 1         27
                                                      Los Angeles, Calif.                                                                                       2:30           Papers              4        10         1 6         22          28
                                                o Development of Personal Health Service                                                                        2:50           Papers              5      1  1         1 7         23          29
                                                      DWIGHT L. WILBUR, M.D.,                                                                                   3:10           Papers              6      1  2         1 8         24          30A
                                                      President-Elect,                                                                                        See   appendix    B    for    detailed listing of papers, s@ers and room location.
                                                      American Medical Association,
                                                      San Francisco, Calif.
                                                                                                                                                              3:45-5:15          SESSION I-I)ISCUSSION GROUPS
                             II a.m.-12 Noon  PLENARY SESSION (continued)                                 International      ]3allrooin       West
                                                                                                                                                              Insofar   as   possible,   discussion   subjects   ue    related    to    preceding    papers    and    in    Some
                                              Quality   and   Availability   of   Health    Care    for    Heart    Disease,    Cancer,    Stroke,
                                                and Related Diseases in the Future @ Related to:                                                              cases paper presenters are included as discussants.
                                                                                                                                                                TOPIC A          "Health         Manpower-The         Commission         Report"
                                              o The Population                                                                                                  TOPIC B          "Regiori;tliz@ition"
                            Cli@iirni.iii:    IZOGEI@ 0.

                                                                                                                                                                                 "I                vi,-,-s
                                              Los Angeles, Calif.                                                                                             See     Appci)(lix (:  lot-  listing  of'p@Li-ticil)@ttits  and   room   location.

                              126









                                                                                                                                                 RICHARD F. MANEGOLD, M.D.,
                                                                                                                                                 Associate Director for Program Development and Research,
                                                                                                                                                 Division  of  Regional  Medical   Prograrm.
                                                                                                                                            9 Operations Research
                                                                                                                                                 ROBERT    BUCHER,     M.D.     (presenter),
                                                                                                                                                 Dean, Temple University School of Medicine and
                                                                                                                                                 Consultant to the Division of Regional Medical Prograrm.
                                                                                                                                                 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
es                                                                                                                                               Consultant to the Division of Regional Medical Programs.
                                                                                                                                                 MAURICE E. ODOROFF,
ts                                                                                                                                               Assistant to the Director for Health Data,
                                                                                                                                                 Division  of  Regional  Medical   Programs.


                                                                                                                            10:30-12:30 p.m.  PLENARY SESSION                              International   Ballroom    West
                                                                                                                                                    (continued)
as                                                                                                                          Chairman: JOHN A. GRONVALL, M.D.,
                                                                                                                                         Co-Chairman, Conferencc-Workshop on Regional Medical Programs,
                                                                                                                                         Associate Director and Associate Dean,
rs                                                                                                                                       University of Mississippi Medical Center,
                                                                                    THURSDAY, JANUARY 18                                 Jackson, Miss.
                                                                                                                                         A National View of New Developments in:
                                      REGIONAL MEDICAL PROGRAMS INTO ACTION                                                                 0 Heart Disease
                                                                                                                                                 DONALD      S.      FREDRICKSON,      M.D.,
                                                                                                                                                 Director, National Heart Institute,
                       8:30-10 a.m.  PLENARY SESSION                                  International Ballroom West                                National Institutes of Health.
                                                                                                                                            0 Cancer
                       Chairman: ROBERT G. LINDEE,                                                                                               KENNETH M. ENDICOTT, M.D.,
                                    Co-Chairrnan, Conference-Workshop on Regional Medical Programs,                                              Director, National Cancer Institute,
                                    Assistant Dean, Stanford University School of Medicine,                                                      National Institutes of Health.
                                    Palo Alto, Calif.                                                                                       0 Stroke
                                                                                                                                                 RICHARD L. MASLAND, M.D.,
                                    Division of Regional Medical Programs Reports on:                                                            Director, National  Institute  of  Neurological  Diseases  and  Blindness,
                                         Progress and Issues                                                                                     National Institutes of Health.
                                            ROBERT Q. MARSTON, M.D.,                                                        12:30-6 p.m.  DEMONSTRATIONS-EXIIIBITS                                                  Terrace
                                            Associate Director, National Institutes of Health, and
                                            Director, Division of Regional Medical Programs.                                  Special demonstrations and exhibits which  reflect  regional  and  other  related  activities
                                          A New Emphasis                                                                    have been arranged and will be opened and manned during this period.
                                            ALEXANDER M. SCHMIDT, M.D. (presenter),                                           See  Appendix  A  of  this  printed  program  for  listing  of  demonstrations  and  exhibits
                                            Chief, Continuing Education and Training Branch,                                and  their  locations.
                                            Division of Regional Medical Programs.

                                                                                                                                                                                                                       127












                            1:30-3:30     p.m.     SERIES     II-PAPERS      ON      REGIONAL      ACTIVITIES      AND
                                                 IDEAS                                                                      3:45-5:15 p.m.  SESSION 11-DISCUSSION GROUPS
                                                                                                                              Insofar as possible, discussion subjects are related to preceding  papers  and  in  some
                             Selected 15-minute papers presenting highlights of  regional  activities  and  ideas  now      cases paper presenters are included as discussants.
                            being developed in the regions will be presented on the  following  schedule  in  adjacent
                                                                                                                                TOPIC      F  "Continuing Education and Training, For What?"
                            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          TOPIC      G  "Data Collection and Registries"
                            they have the most related interest:                                                                TOPIC      H  "Hospitals"
                                                                                                                                TOPIC      I  "Community Involvement"
                              Sta),Iing                                                                                         TOPIC      j  "Operational Program Development"
                                time                  Meeting rooms on concourse level                                        See Appendix C for listing of participants and room location.
                                1:30        Papers        31       37        43       49        55
                                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
                                                                                          'Ti                               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 sc c    e

                                                                                                                            HEART DISEASE                                                              Lincoln    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. Fbx III, 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, M D,
                                                                                                                                        Medical Director,
                                                                                                                                        American Heart Association,
                                                                                                                                        New York, N.Y.




                              128







                         CANCER                                                                Thoroughbred Room                                 SUMMING UP AND LOOKING AHEAD
                         Chairman: SIDNEY FARBER, M.D.,
                                      President-Elect,
 c                                                                                                                           10:30 a.m.-12 Noon  PLENARY SESSION                           International   Ballroom   West
                                      American Cancer Society and Director of Research,
                                      Children's Cancer Research Foundation,
                                      Boston, Mass.                                                                          Chairman:    PAUL     D.     WARD,
                         Panel:       MICHAEL J. BRENNAN, M.D.,                                                                           Incoming  Chairman,  Coordinators'  Steering Committee,  and
                                      Scientific and Medical Director,                                                                    Coordinator, California Regional Medical Program.
                                      Michigan Cancer Foundation,
                                      Detroit, Mich.                                                                                        9 Conference-Workshop Summary of Issues
                                      JUAN DEL REGATO, M.D.,                                                                              LOWELL T. COGGESHAf,f,, M.D.,
                                      Director,                                                                                           Vice President Emeritus,
                                      Penrose Cancer Hospital,                                                                            University of Chicago.
                                      Colorado Springs, Colo.                                                                               & Address by .  .  .
 9                                    KENNETH M. ENDICOTT, M.D.,                                                                          IRVING         LEWIS,
                                      Director,                                                                                           Deputy Assistant Director,
                                      National Cancer Institute,                                                                          Bureau of the Budget,
                                      National Institutes of Health.                                                                      Office of the President.
                                      GUY F. ROBBINS, M.D.,
 d                                    Director of Planning,                                                                                 o Closing Remarks by .  .  .
 s-                                   Memorial Hospital for Cancer and Allied Diseases,                                                   PHILIP R. LEE, M.D.,
 Is                                   New York, N.Y.                                                                                      Assistant Secretary for Health and Scientific Affairs,
                                                                                                                                          U.S. Department of Health, Education, and Welfare.
                         STROKE                                                                  Hemisphere Room
                         Chairman: NEMAT BORHANI, M.D.,                                                                      12 Noon  ADJOURNMENT
                                      Professor of Internal Medicine and Chairman,
                                      Department of Community Health,
                                      University of California School of Medicine,
                                      Davis, Calif.
                         Panel:       RICHARD L. MASLAND, M.D.,
                                      Director, National Institute of Neurological Diseases and Blindness,                                                      APPENDIX A
                                      National Institutes of Health.
                                      CLARK H. MILLIKAN, M.D.,                                                                              LISTING OF DEMONSTRATIONS AND EXHIBITS
                                      Consultant in Neurology,                                                               WEDNESDAY, JANUARY 17, 1968
                                      Mayo Clinic,
                                      Rochester, Minn.                                                                       THURSDAY, JANUARY 18, 1968
                                      WILLIAM A. SPENCER, M.D.,
                                      Director, Texas Institute for Rehabilitation and Research,                             12 Noon-6 p.m.  DEMONSTRA,riONS-EXHIBITS
                                      Ilouston,'I'cx.
                                      JAMES TOOLE, M.D.,                                                                      Special demonstrations and exhibits which reflect  regional  and  other  related  activities
                                      Professor and Chairman,                                                                have been  arranged  and  will  be opened  and  rnanned  during  this  period.  The  following
                                      Department of Neurology,                                                               list  indicating  location  on  Terrace  Level  or  in  Park  Suite  Rooms  includes   number
                                      Bowman Gray School of Medicine,                                                        or letter of exhibit, the name   of  the  exhibitor,  and  some  descriptive  information  on
                                      Winston-Salem, N.C.                                                                    each  exhibit.



                                                                                                                                                                                                                      129













                                                                                                       TERRACE             LEVEL         [Exhibit  No.)  and   exhibitor                Description and (exhibit contact)
                              [Exhibit No.] and exhibitor                     Description and (exhibit contact)                            [8-91
                                                                                                                                      Rochester     Regional     Medical    Models  of  various   available   types   of   coronary   care
                                                                                                                                      Program in Conjunction With              units,  including  that  in  operation  in  this   Regional
                            Greater Delaware Valley               Maps   and   charts   depict   the   need   and   method   for      the Heart Diseise Control                Program. (Mrs. Jane Hansen)
                            Regional     Medical     Program        subregionalization   of   a   "mega-region."    (Mr.    Ward      Program   of    National    Center
                                                                    Bentley)                                                          For   Chronic   Disease    Control

                                [21
                            Western New York                      A 4-panel display  of  how  a  region  is  acting  to  improve      Cancer    Control    Program    of    Entitled  "Stop  Oral  Cancer,"  this  visual  exhibit   high-
                            Regional     Medical     Program        patient care. (Mr. Anthony Zerbo)                                 National   Center   For    Chronic       lights  special  forms  of  detection  and   treatment   of
                                [31                                                                                                   Disease Control                          this type of cancer. (Dr. Richard L. Hayes)
                            Missouri Regional                     A   dual   display.   One   includes    photographic    panels           [I 1]
                                                                                                                                      Rehabilitation Services               A  4-panel  display  describing  the  services  of  vocational
                            Medical Program                         illustrating  various  operational   projects   now   under-      Administration                           rehabilitation. (Mr. Tom Brubeck)
                                                                    way  in  this  region.  The  other  is  a  scale  model   of
                                                                    the  comprehensive   medical   cire   facility   now   being           (121
                                                                    built  in  Smithville,  Mo.,  the  site  of   one   project.      Nationil Heart Institute of           Detailing   somc   related   programs   of   the    Institute,
                                                                    (Miss Annette Eberley)                                            the National. Institutes of              this exhibit  will  emphasize  its  coronary  drug  project
                                                                                                                                      Health                                   to  evaluate  lipid-lowering  drugs   in   acute   coronary
                                [41                                                                                                                                            disease. (Mr. Donald Bradley)
                            Tennessee Mid-South                   3-panel  display  of  nursing   care   showing   how   efforts
                            Regional     Medical     Program        of  physicians  and  nurses  for  superior   care   can   be           [13]
                                                                    achieved  by  vertical  organization  as  opposed   to   the      Washi@gton-Alaska         Regional    An  exhibit  designed  to  explain   this   program   and   by
                                                                    fragmenting    effects    of    horizontal     organization.      Medical Program                          a  special  device  provide  the  opportunity  to  identify
                                                                    (Dr. Stanley Olson)                                                                                        the  mortality  rate  in  the  three  categorical  diseases
                                                                                                                                                                               in the  various  parts  of  the  State  of  Washington  and
                                [5]                                                                                                                                            compare   them.   Also   included    is    an    arrhythmia
                            North Carolina Regional               A  cooperative  exhibit  indicating  data   on   acute   core-                                               simulator  which   permits   physicians   to   test   them-
                            Medical Program and                     nary  occlusion  from  44  hospitals  in   North   Carolina.                                               selves  in  diagnosis  and  treatment  of   acute   cardiac
                            Commission    on    Professional        (Dr. Virgil Slee)                                                                                          problems. (Mrs. Marion Johnson)
                            and Hospital Activities                                                                                        [I4]
                                                                                                                                      North Carolina Regional               An  exhibit  detailing  the   stroke   control   program   now
                                [61                                                                                                   Medical   Program   in    Conjunc-       underway   at   the   Bowman-Gray   School   of   Medicine.
                            Colorado-Wyorriing Regional           A  dual  exhibit.  One  section  is  an  exhibit  which  indi-      tion With the National                   (Dr. James Toole)
                            Medical Program                         cates   development   of   this   program.   Combined   with      Institute of Neurological
                                                                    this  will  be  a   videotape   presentation   showing   how      Diseases  and  Blindness  of   the
                                                                    this  program  plans  to  use  videotape  units   for   con-      National  Institutes  of  I-Iealth
                                                                    tinuing education. (Mr. Robert Vestal)
                                                                                                                                           [151
                                [7]                                                                                                   Intermountain Regional                A   7-part   exhibit   including   a   description   of   this
                            Heart Disease Control                 A dual exhibit. One is  a  descriptive  display  of  the  type      Medical Program                          program;   description   of   use   of   highly    portable
                            Program   of   National   Center        of  work  done  in   the   Standirdization   and   Reference                                               videotape   recording   system;   illustration   of    this
                                                                                                                                                                               rcgioii's effort to estal3lish ;i  "regen(-r@itiv(-"  coii-
                            For  Chronic   Disease   Control        Laboritories  of  this  progriiii  and   location   of   the                                               tiiiuiiig education program;  cx@iiiiples  of  orgiiniz@  -
                                                                    laboratories   participating   in    standardization    pro-                                               tionzil planning; visualization of importance of        two
                                                                    grams  for  drugs  used  in  treatment  of  heart   disease.                                               types   of   data   collection;   and   demonstration    of
                                                                    The  other  is   a   display   of   computer   analysis   of                                               scope  and  method  of   this   Region's   two-Nviy   ridio
                                                                    electrocardiograms. (Dr. Gerald Cooper)                                                                    network. (Mr. Charles Akerlow)

                            130









                                                                                                                                          [Exhibit No.] and exhibitor                        Description and (exhibit contact)
                                                                                                                                             [211
                                                                                                                                        American Heart Association                 Materials detailing the activities of this Association as
                                                l@PJ REC,"AL                                                                                                                       they   relate   to   Regional   Medical   Programs   and    an
                                                  m@            P@                                                                                                                 example  of  how  a  State   association   is   working   with
                                                                                                                                                                                   one  Regional   Medical   Program   will   be   available   in
                                                                                                                                                                                   this exhibit area. (Miss Placide Schriever)
                                                                                                                                             [221
                                                                                                                                        Iowa Regional Medical                      Diagrams   showing   interrelationship   between   this   pro-
                                                                                                                                        Program                                    gram   and   health   planning   groups   in    the    region.
                                                                                                                                                                                   (Dr. Willard A. Krehl)

                                                                                                                                             [231
                                                                                                                                        Louisiana Regional Medical                 Dispiiy includes  original  drawing.,;  for  slide  pre-scnti-
                                                                                                                                                                                   tioll              the (ICVC[ol)sllcllt ;Ill(l  activities  of
                                                                                                                                                                                                            A. S4i[);itict-)

                                                                                                                                             [241
                                                                                                                                        Office of Program Planning                 This   exhibit   of   maps   developed   by   computer   shows
                                                                                                                                        of the Surgeon General                     census  data  by  small  geographic  area  for  possible   use
                                                                                                                                                                                   in     Regional     Medical     Program     planning.     (Mr.
                                                                                                                                                                                   James King, Jr.)
                          [Exhibit No.] and exhibitor                       Description and (exhibit contact)                                [251
                                                                                                                                        Mountain States Itcgion;il                 A  visual  description  of  the  use  of   questionnaires   to
                                                                                                                                        Medical 1'rogrLrii                         gain  planning  information   and   data   from   the   region
                        National Institijt(! of N(@tir(j-        I-'Ixliil)it consists of iiiforiii;itioti ;iii(i ;t iii;i[)   indicating                                          for   use   in   developing   this   program.   (Dr.    Alfred
                        logical I)ise@@ and liliridncss           the  location  of  Stroke   l@esciircii   C(-,ntcr,   Training                                                   Popma)
                        of the National Institutes of             Programs    and    Aneurysm    Studies     established     and
                        Health                                    underway    throughout    the     country.     (Mr.     Robert             [261
                                                                  Hinkel)                                                               West Virgi@a Regional                      A  visual  explanation  of  initial  activities   and   people
                            [17]                                                                                                        Medical Program                            concerned  in  the   development   of   the   planning   phase
                        National Cancer Instittit(, of           An exhibit  (](!rnonstr;iting  the  activities  ;laid  location                                                   of this program. (Dr. C. L. Wilbar)
                        tli(- N@itiori;tl Isistittit(-s of        of                        (:(-iit(:rs ;iii(i
                        I J(!altl)                                'I'r@iiiiiiig  Centers  cstal3lishcd  and  underway   through-             [271
                                                                  out the country. (Mrs. Pauline Wall)                                  Division of Medical Care                   A3-panel    exhibit    visualizing    automated     multiphasic
                                                                                                                                        Administration of the Bureau               screening   ranging   from   patients   themselves   to    the
                            [181                                                                                                        of Health Services                         use of the computer. (Miss Grace Osgood)
                        Bureau of Health Manpower                A  3-panel  exhibit  describing  the   organization,   function
                                                                  and  activity  of  this  Bureau  and   its   relationship   to             [281
                                                                  the  delivery  of   health   care.   (Mr.   Wayne   M.   Bard)        American Medical Association               Exhibit visualizes  the  areas  of  responsibility,  available
                            [19]                                                                                                                                                   resources,    and    other    health    organizations     that
                        American Cancer Society                  A  visual   display   of   professional   educational   printed                                                   should   be   involved   with   Regional   Medical   Programs.
                                                                  materials  related  to   various   types   of   cancer.   (Mr.                                                   (Dr. Howard Doan)
                                                                  Walter James)                                                              [291
                            [20]                                                                                                        Division of Regional Medical               The  standard  exhibit   currently   being   used   at   large
                        Chronic Respiratory Disease              Materials  describing   diagnosis,   treatment,   and   related        Programs                                   national   meetings   and   a    newly    developed    smaller
                        Control Program of the                    activities  in   emphysema   and   chronic   bronchitis   will                                                   easily  transportable  and   usable   replica   to   be   made
                        National Center for Chronic               be displayed and av@iil;iljic. (Mrs. Shclic l,engcl)                                                             available   for   smaller   local,    area,    and    regional
                        Disease Control                                                                                                                                            meetings on request. (Mr. Frank Karel III)

                                                                                                                                                                                                                                            131










                                  [Exhibit No.] and exhibitor                       Description and (exhibit contact)                                [F-,xhibit letter] room exhibitor                    Describtion and (exhibit contact)
                                  [30)                                                                                                                 [F] Farragul Room
                              Veterans Administration                     This   exhibit   visualizes   the    long-range    VA    hospital       National Library of Medicine              A   demonstration   of   the   medical    television    system    in
                                                                          replacement      and      relocation      program,      providing                                                    operation    from    the    Audiovisual     Center     of     the
                                                                          some  idea  of  future  facilities  that   should   be   included                                                    National  Library  of   Medicine   in   Atlanta   to   affiliated
                                                                          in regional planning. (Mr. I-Toward Armstrong)                                                                       hospitals   in   various   parts   of   the   city.   (Mr.   John
                                  [311                                                                                                                                                         Argyle King)
                              Michigan      Regional      Medical         Describing    "Project    Echo"    (Evidence    for     Community            [GJ,7ackson Room
                              Program                                     Health   Organization),    this    exhibit    visually    details       National Naval                            A    demonstration    of    the    development    and     use     of
                                                                          an    on-going     environmental     appraisal     and     inter-       Medical Center                               audiovisual      materials      in    medical          education.
                                                                          views  to  assess  current  health  status  and  needs   of   the                                                    (Ensign T. Galbreath)
                                                                          population of this region. (Mrs. Betty Tableman)                             (H) Kalorama Room
                                                                                                                                                  Clinical Center of the                    A    15-rriinute     film      demonstrating      the      automated
                                                                                                                                                  National Institutes                          computerized    clinical    laboratory    of     the     clinical
                                                                                                         PARK          SUITE          ROOMS       of     Health                                center  and  the  possible   application   of   such   a   system
                                  [Exhibit letter) room exhibitor                   Description and (exhibit contact)                                                                          to   hospitals   on   a   regional    basis.    TO    BE    GIVEN
                                                                                                                                                                                               ONLY      AT      3      P.M.      WEDNESDAY      AND      THURS-
                                  [Al Bancroft Room                                                                                                                                            DAY.    (Dr.    George    Z.    Williams     and     Dr.     John
                              California     Regional     Medical         Display  portion  portrays   the   development   of   this   pro-                                                    Otis)
                              Program                                     gram  in   the   new   University   of   California   School   of
                                                                                                                                                       [I] Independence Room
                                                                          Medicine   at   Davis.   The    demonstration    section    shows
                                                                          the   medical   television    programs    being    carried    out       L)ivision of Nursing                      Preliminary     information     and     examples     of     instruc-
                                                                          at  the   University   of   California,   Los   Angeles.   (Harry       of Bureau of Health                          tional   systems    for    training    nurses    for    intensive
                                                                          0. Bain and Dr. Donald Brayton)                                         Manpower                                     coronary   care   units   and   open   heart    surgery.    Based
                                                                                                                                                                                               upon   educational   projects   sponsored   by    the    Division
                                  [B] Chevy Chase Room                                                                                                                                         of    Nursing    at    Presbyterian-University    of     Pennsyl-
                              Kansas Regional Medical                     Specially  selected  slide  presentation  of  elements  of   this                                                    vania   Hospital    by    Dr.    Laurence    Meltzer    and    at
                              Program                                     program  designed  to   be   used   to   inform   and   encourage                                                    Ohio   State   University   by   Rita   Chow.   (Miss    Florence
                                                                          cooperation   of   various    groups    within    this    region.                                                    Reynolds)
                                                                          (Dr. Charles Lewis)
                                  [C] Chevy Chase Room
                              Oklahoma      Regional      Medical         A   demonstration   of   the    U.S.    Air    Force    Computer-                                                    APPENDIX B
                              Program                                     Based     Worldwide     System     for     Continuing     Medical
                                                                          Education-as     adapted     to     the     Oklahoma     program.                                           LISTING  OF  15-MINUTE PAPERS
                                                                          (Col. Owen G. Birtwistle)                                                                        ON REGIONAL ACTIVITIES AND IDEAS
                                  [DI DuPont Room
                              Greater Delaware Valley                     A   presentation   of   the   systems   analysis   approach    to       PAPERS BY ASSIGNED NUMBER
                              Regional Medical Program                    planning   as   utilized   in   this   region.   TO    BE    PRE-
                                                                          SENTED       ON       THURSDAY        ONLY.        (Dr.        G.       WEDNESDAY, JANUARY 17, 1968
                                                                          Angelides)
                                  [El Edison Room                                                                                                 Paper
                              Wisconsin l@(.),ioll;ll M('(Ii(-;Il         (I    (li@il,l;ly                                                          N(,.
                                                                          lis@-(l if) this          ;Is @t 1)@isis  lol-  (](.(:isiollill;lliilig
                                                                          on  elements  of  opcration;)l  programs.   (2)'I'li(@   deinoii-         I        "I       ],'evaluation  Studi(-s   Utilizing   ;I   Multiphasic   Screen-  1:30 p@m.
                                                                          stration   portion    covers    the    Dial    Access    Mcdic@il                   ing   Center   Operating   in   Coopcr@ition   with    a    Cornprclicn-  Lincoln Room
                                                                          Library   Service   now   in   operation    in    this    region.                   sive  Health  Care   Program   for   Persons   in   an   Urban   Poverty  East
                                                                          (Mr. Roy Ragatz)                                                                    Area." LLOYD ELAM, M.D. (Tennessee Mid-South)
                              132







                                  Paper                                                                                                                             Paper
                                  NO.                              Title, author, and (region)                                  Time and location                   NO.                                Title, author, and (region)                                  Time and location

                                  2      "Provision     of     Optimum     Clinic@il      1,@iboratory      Services      for   1 :50 P.  Ill.                      16       "Complementary          Relationship          Between          Iowa          Regional  2:30      p.m.
                                             :;,(100,00()     I'(-oi)lt!."     I)AVII)     SI-"[.IGSON,      M.D.      (Cori-   l,iiicoll)  l@()t)lll                           M(-(Iic;tl                                         II(-.iltli   lll;iiining    and  Military
                                             iiccticut)                                                                         East                                            Voluntary     Comprehensive     I     le@iltli     I'laiining:     A     Necessary  Room
                                  3      "Biochemical      Screening      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                           (Iowa)
                                                                                                                                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." jOf IN D. 'I'HOMPSON (Connecticut)                                        Lincoln          Room                           LARKIN, M.D. (New York Metropolitan)                                                Room
                                                                                                                                East                                18       "The Role of a School of Public Health in                                  Developing    :     p.i-n.
                                  5      "Flanner       House       Multiphasic       Screening       Program."       IIAII,-   2:50    p.i-n.                                  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      Adrriinistra-  1:50    p.i-n.
                                  7      "The    Use    of    a    Multi-Media    Approach    to    Enhance    the     Learn-   1:30    p.iTi.                                  tors." JOSEP14 J. MASON, JR. (Alabama)                                              Hemisphere
                                             itig      of       Health       Science       Personnel."       WILLIAM       G.   Lincoln          Room                                                                                                               Room
                                             COOPER, M.D. (Colorado-Wyoming)                                                    West
                                                                                                                                                                    21       "Development  of Relationship Between the                         Medical         As-  2:  1  0  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        RooiTi                           Regional       Medical       Program."       J.       0.       FINNEY,        M.D.  Room
                                                                                                                                West                                            (Alabama)
                                  9      "Communication          Research          Unit."          WILLIAM           STEPHEN-   2:  1  0  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  He@pherc
                                                                                                                                West                                            SEIPP, M.D. (Connecticut)                                                           Room
                                  I I    "Development      of      Receptive      Attitudes      Toward      New      Ideas."   2:50      p.m.                      24       "Regional         Advisory         Group         and         Review         Process."  3:10      p.m.
                                             JOI IN S. GILSON, M.]-). (Intermountain)                                           Lincoln       l@ooiii
                                                                                                                                                                                CFIARLES E. LEWIS, M.D. (Kansas)                                                    1-1@pherc
                                                                                                                                West                                                                                                                                Room
                                  12     "The     Impact     of     RMP      on      Hard      Core      Poverty      Arcas."   3:10      p.m.
                                             PAUL D. WARD (California)                                                          Lincoln          Room               25       "A    Proposed     Circuit     Postgraduate     Program     in     Heart     Disease,  1:30      p.m'
                                                                                                                                West                                            Cancer,     Stroke     and      Related      Diseases      in      the      Oregon  Thoroughbred
                                  13     "The   Role   of   the   Voluntary   I   fcalth    Agencies    in    the    Regional   1:30      p.m.                                  Region." M. ROBERTS GROVER, M.D. (Oregon)                                           Room
                                             Medical      Program       in       Iowa."       WILLARD       A.       KREI-IL,   Military                            26       "The      Information      and      Education      Resource      Support       Unit."  1:50      p.m.
                                             M.D. (Iowa)                                                                        Room                                            JOHN N. LEIN, M.D. (Washington-Alaska)                                              Thoroughbred
                                                                                                                                                                                                                                                                    Room
                                  14     "Small      Coiritnunity      lllaiining."'I'ASKI,"I@       K.       IkOlilNE'l"ri",   1:50      p.m.
                                             (Wastiington-Alaska)                                                               Military                            27       "Uhusual     Programs      for      Continuing      Education      of      Physicians  2:10      p.m.
                                                                                                                                Room                                            at    Grassroots     Level."     C.     L.     WILBAR,     JR.,     M.D.     (West  Thoroughbred
                                  15     "Coordination       of        Comprehensive        Health        Planning        and   2:  1  0  p.m.                                  Virginia)                                                                           Room
                                             Regional     Medical     Program      Activities      in      Western      Penn-   Military                            28       "Community-Ccntercd            Continuing             Medical             Education."  2:30      p.m.
                                             Sylvania,       1967."       E.       WAYNE        MARTZ,        M.D.        and   Room                                            C. HILMON CASTLE, M.D. (Intcrnmoutain)                                              Thoroughbred
                                             If OWARD I-IOUGIF (Western Pennsylvania)                                                                                                                                                                               Room

                                                                                                                                                                                                                                                                                        133













                                pap-                                                                                                                                PAPERS BY ASSIGNED NUMBER
                                  /VO.                              Title, author, and (regior)                                  Time and
                                                                                                                                                                    THURSDAY, JANUARY  18,  1968
                                29        "Survey     of     Continuing     Education      of      the      Physicians      in   2:50    P.M.  red                  Paper
                                            MetropolitanWashington."THOMASW.                                        MATTINGLY,   Thoroughb
                                            M.D.,       LEONARD       CHIAZZE,        JR.,        SC.D.,        and        MAL   Room                               No.                                Title, author, and (region)                                   Time   and    location
                                            XAVIER (Metropolitan Washington, D.C.)
                                30A       "Approaches    to     Evaluation     of     a     Regional     Medical     Program."   3:10 p.m.                          31       "A    Study    of    Physician     Office     Practice     in     the     Connecticut   1:30     p.m.
                                            CALDWELL       B.       ESSELs,rYN,       M.D.       (New       York        Metro-   'I'liorouglibr(!d                               l@egion." I-)ONALI)                         pH.     1),     ,ind     ORVAN     W.   Lincoln        l@ooiyl
                                            politan)                                                                             Room                                            HESS, M.D. (Connecticut)                                                            East
                                30B       "Systems       Approach       to       Planning."       ANGELO       P.       ANGEL-   1:30 p.m.                          32       "Consumer       Health       Care       Survey."       LAWRTNCE       J.       SHARP,   1:50     p.m.
                                            IDES,         M6D.,         LARRY          McGOWAN,          M.D.,          ARTHUR   DuPont                                          pH. D. (Washington-Alaska)                                                          Lincoln           Room
                                            STANKOVICH (Greater Delaware Valley)                                                 Room                                                                                                                                East
                                30C       "Informal      Discussion      on      Systems      Analysis."      HERBERT       P.   1:50 p.m.                          33       "Continuum    of    Long    Term    Care     in     a     Local     li@th     Service   2:10     p.m.
                                            GALLIHER,      JR.,       pH.       D.       (Professor,       University       of   DuPont                                          Area."        E.        RICHARD        WEINERMAN,         M.D.         (Connecti-   Lincoln           Room
                                            Michigan)                                                                            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 IIARI@OW, M.D. (Georgia)                                         East
                                                                                                                                                                    35       "The    Regional     Medical     Program     as     a     Means     of     Increasing   2:50     p.m.
                                                                                                                                                                                 the    Morale     of     the     Fimily     Doctor."     ROGER     BOST,     M.D.   Lincoln           Room
                                                                                                                                                                                 (Arkansas)                                                                          East
                                                                                                                                                                    36       "Community        Hospital        Learning         Centers."         FRANK         M.   3: 1  0  p.m.
                                                                                                                                                                                 WOOLSEY, JR., M.D. (Albany, N.Y.)                                                   Lincoln           Room
                                                                                                                                                                                                                                                                     East

                                                                                                                                                                    37                            with     a     Stroke     Car(-,      Demonstration      [Jnit."   I:'iO  p.TTi@
                                                 INUFEO@                                                                                                                                        l@. SMI'l@ll,  M.1). (Mississil)13i)                                 jeff(!rsoti    Itootii
                                                                                                                                                                                                                                                                     I-'ast
                                                                                                                                                                    38       "System     for     Clinical      Data      Collection      and      Analysis      in   I':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 EnglancD                                                              Jefferson         Room
                                                                                                                                                                                                                                                                     East
                                                                                                                                                                    40       "CotTipreliciisiv(!       Cardiovascular       Care       Unit."       GLENN       0.   2:30     p.m.
                                                                                                                                                                                 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       "l,xperi(!iice.     with     tli(-.     WARMII     Mock-tip     Coronary      C@ir(-.   'i:  IO  p.m.
                                                                                                                                                                                 Unit."                        YAI@NAI,I.,            M.D.            (Washington-   J(-fl'(7rsoll IZ()olll
                                                                                                                                                                                 Alaska)                                                                             E,@  t
                                                                                                                                                                    43       "Nursing      in      the      Regional      Medical      Progrinis-Alliance      for   1:30    pairs
                                                                                                                                                                                 Better       Patient       Care."       I-TESTER       TF-IURSTON        (Kansas)   Military
                                                                                                                                                                                                                                                                     Room


                                134









                            Paper                                                                                                          Paper
                            NO.                         Title, author, ani (regior)                          Time    and                    No.                           Title, author, and (regior)                          Time    and

                            44      "Continuing  Nursing  I,-,clklc,@ition   Using   University   Hospital   1 :50  p.m.                   58      "Cancer    Training     and     Continuing     Education     and     Com-   2:30   p.m.
                                    Nursing      Servicc'l'raining      Facilities."      (Mrs.)      MARGARET Military                               puterized     Tumor      Registry."      CHARLES      SMART,      M.D.   Thoroughbred
                                    SOVIE (Central New York)                                                 Room                                     (Intermountain)                                                          Room
                            45      "f-lealth   Manpower   Survey   of   Western    New    York."    Harry   2: 10  p.m.                   59      "Assurance    of    Adequate    Therapy    Following     Detection     of   2:50   p.m.
                                    A.      SUL'I'Z,       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.irl.                   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: 1 0 p.m.
                                    Research."      WILLIAM       H.       McBEATH,       M.D.       (Ohio   Military                    WEDNESDAY, JANUARY 17, 1968
                                    Valley)                                                                  Room
                            4@)     "An   Experimental   Model   in   Organization    of    a    ltcgional   1:30   p.m.                                                                                             Paper
                                    Medical     1'rograrn."     L@ICIIAIZD     F.     HAGLUND      (Intcr-   I   lcmisphcrc              Starting time                 'Title, author, and (region)                  No.            Location
                                    mountain)                                                                Room
                            50      "Multi-Projcct       Planning."       WILLIAM       R.        THOMPSON   1:50   p.m.                 1:30 p.m.        "Health     Evaluation     Studies     Utilizing      a      I       Lincoln      Room
                                    (Washington-Alaska)                                                      Hemisphere                                     Multiphasic      Screening      Center      Operating              East
                                                                                                             Room                                           in     Cooperation     with      a      Comprehensive
                                                                                                                                                            Health   Care   Program    for    Persons    in    an
                            51      "A   Systems   Approach   to   Regional    Medical    Program    Plan-   2: 1 0 p.m.                                    Urban      Poverty      Area."      LLOYD       ELAM,
                                    ning." DAVID II. GUSTAFSON, Pi 1. D. (Wisconsin)                         Hemisphere                                     M.D. (Tennessee Mid-South)
                                                                                                             l@oom
                                                                                                                                                          "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-Wyo@ng)
                            )3      "Clinical    Data    Collection     with     a     Purpose."     HOMER   2:50   p.m.                                  "The   Role   of   the   Voluntary   Health    Agencies    1 3       Military
                                    WARNER, M.D. (Intermountain)                                             Hemisphere                                     in    the     Regional     Medical     Program     in              Room
                                                                                                             Room                                           Iowa."       WILLARD       A.       KREHL,       M.D.
                            54      "The   Design   and   D@c@nation   of    Data    Collecting    Instru-   3:10   p.m.                                    (Iowa)
                                    ments.,, LAURA G. LARSON, R.N. (Mountain States)                         Herrdspherc                                  "Watts-Willowbrook      Regional      Medical      Pro-    19        Hemisphere
                                                                                                             Room                                           gram."      DONALD       J.       BRAYTON,       M.D.              Room
                            55      "A  Cooperative  Project  for  the  Care   of   Cancer   Patients   by   1:30   p.m.                                    (California)
                                    Memorial    Hospital    for    Cancer    and     Allied     Diseases."   Thoroughbred                                 "A    Proposed     Circuit     Postgraduate     Program    25        Thoroughbred
                                    GUY F. ROBBINS, M.D. (New York Metropolitan)                             Room                                           in   Heart   Disease,   Cancer,   Stroke,   and   Re-              Room
                            5(@     "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: 1 0 p.m.                                    P.       ANGELIDES,       M.D.,       LARRY       Mc-              Room
                                    SON, M.D. (Albany, N.Y.)                                                 Thoroughbred                                   GOWAN,         M.D.,          ARTHUR          STANKO-
                                                                                                             Room                                           VICH (Greater Delaware Valley)

                               292-414 0-68-10                                                                                                                                                                                               135








                                                                                                                                                                                                                                                                                                                          Paper
                                                                                                                                                          Ilaper          Location                         Starting  tiriie                           'I-itle, author, and (region)                                         No.              I,oc(2tioll
                                        Starti"  tirtir                            Title, author, and (r@@ion)                                               No.
                                        1: 50 p. iii.                   @pl.c)visioti      of      Optiiiiulil      Clinical       1,@iborLttot-y              2     Lincoln Rooiii                        2::iO p.iii.             "A        RegionLtl        Litiliz@itioll,         P@ltiel't         fliforiiia-          4         I,iiicolli  l@ooiii
                                                                        S(!rvic(.s         for         :3,000,000         People."         ])AVID                    Etst                                                                   tioii       and       Statistics       Systciii."        jOliN        D.                    East
                                                                        St,-,I,TGSON, NI.D.  (Connecticut)                                                                                                                                  1111 I()MPSON                          (Connecticut)
                                                                        "LJscofii          Tel(@l)lioiicNetwork          for           Continuing              8     Lincoln Rooiii                                                 "Coiliiiiuiiity            Iiiforittation                        Coordii-iator."          10        Lincoln Rooin
                                                                        ]'(Itic@ktioji."                                                                                                                                                    \VAlkl)      I,.      OI,IVI'l@,       M.D.       (Albztr)y,       N.Y.)                    Nvc.@t
                                                                                             l@l('IIARI)               11.                1,YONS,                    Nvcst
                                                                        M.I-).  ((@cntr@it New York)                                                                                                                                '@CC)IIIPI(-Ill(.Iltllyl@(-Iiltiotisftip                          B(.tweclllow;l          I         Military
                                                                        "Slii@ill          Coiiililuiiity           Planning."           'FASKEI@              14    Milit@irv                                                              l@cgioiiil    MC(ii(:@il                           1'rogi-aiii-Cojiiprc-                    R(@oll-I
                                                                        K.  lkoI@INETTE  (NNI@isfiiiigtoii-Al@isk@i)                                                 Rooiii                                                                 liciisiv(-        II(--altli        Planning        and        Voluntary
                                                                        "Council         of         lkcgiorial         Planning         Directors              20    1 Icii-Lispli(-i-(@                                                    (@oillpl-(.Ilcll@iV('     I     I(-@titti     Planning:     A     Ncces-
                                                                                 Adiiiiiiistrator,;."                JOSEPI I
                                                                        and                                                                                          Rootii                                                                 ,;iry       Accoii-iplisliiiiciit."       J014N       (@'.       BAR'I'-
                                                                        MASON, JR.  (Al;ib@tiiiii)                                                                                                                                          1,E'l"l',     M.A.,     Lf,.     B.      (Iowa)
                                                                        "Tli(@    Itiforiii;itioii     @iii(i     I"(ILI(@;itiorl     R(,sotirc(-                                                                                                SLII)-l@CgiOll@ll          (ioncept           and           Liaison          22        1 ]('Illispll(-I-(-
                                                                                                                                                               2(i   Thorokiglibr(!(l
                                                                        Support       tJnit."        JOIIN        N.        l@l,"IN,        M,I).                    Roo[ii                                                                 St;,tfl'."        NVII,I,I.%M        (I.        SI'IkINC@,         ji@.,                    lkoolli
                                                                        (W@isliingtoii-Alaskii)                                                                                                                                             M.D.         @iii(I         \,VARI)         ]IFN'FLEY          (Gre@iter
                                                                        "Tnforiiial       Discussion       on       Systciii,;       Aii@tlysis."              :iOc  I)Iipoiit                                                              I)el@iw@tr(,        Valley)
                                                                        I     IEIKBER'I'     P.     GAf,l,li]Elk,     jlk.,     Pi     1.     1).                    Ikoolli                                                         "(',Olllllltlliity-(:Cllt(-rC(i  Continuing   M('(IiC;ll                                 28
                                                                        llrofcssor,  University of' Micliig@iii                                                                                                                             E(lu(@ittioii."               IIILMON                         CAS'I'I,L,                    Roolli
                                                                                                                                                                                                                                                   (Ilit(.I-Illollllt@iiii)
                                         2: 10 p.iii.                   "Biocliciiii(:,il Screening in Missouri."                                              @i    l,iii(@olii Rooiii                                                                I loLls(.                          Scr(.(-Ilillg         Pro-                    Lincoln  l@oolli
                                                                        @IAMES           T.                I'A(]Kt,,R,    M.D.                and                    l@@ist                                                                 gi-@iiii." I IARVI@IN'                                             M.1).                    l,"@ist
                                                                        IIUBER'I'   J.    VAN    PEI,"NEN,                                   M.D.
                                                                        (Missouri)
                                                                        "C'oiniiiiinic@itioii Research Unit."                                                  0     l,ill(:Olll l@ooiii                                                                             of                   @\ttittid(-s         'I'o-          I I       I,iiicolll Roolli
                                                                        WII,I,IAM                   STI@llill-"NSON                    (Missouri)                    West                                                                   witr(i       New       1(1(,;is."       J()IIN       S.       ('@11,SoN,
                                                                        "(,'oor(iiii@Ltioji       of        Cotiipr(-l
                                                                                                                     ,I(-Ilsive        II(-;iltfi              15    Milit@irv                                                                                                                                                17        Milit@ti@  l@oolli
                                                                                                    -giOn@tl       M('(IiC@@l        I)T-Ogr@till                    l@oolli
                                                                        ])I;tllllitlg ;Ill(i  lk(                                                                                                                                           S(@llools ill  @t R(.@ioii;tl Nl(-(Ii(-;il
                                                                        Activities      in      W(-,;t(-rii      I'ciinsyl%,@iiii@i,      10(i7."                                                                                           VIN(@l,,Nl'           (I(-I'ALJI,           I,.%I@KIN,            Ni.1).
                                                                        I,'.    WAYN l@'                       MAIKTZ,     M.1).           @111(i                                                                                           (Ni-w York  %I(,trol)oiit;tii)
                                                                        ll()NIVARI)                                                  ['(-iiiisyl-
                                                                                                                                                                                                                                                                        of                                II(.;Iltil          2@;       1
                                                                                                                                                                                                                                            S(-i-%i(-(-  Ai-(,@is as @@  l@@LSiC @St('I) ill                                            l@ooll)
                                                                        "I)cvclopiil(-Ilt        of        l@(.1@itioiisllil)         li('tWc(,Ii              21    1                                                                      M(-(Iic;il        I)I@tiiiiitig."         (:()NI@:\I)         Sl,lll)l),
                                                                        the     Medical     Asso(-i;itioii     of      til(-      St@tt(.      of                    Roolli                                                                          ((@olill(.Ctictit)
                                                                        Al@it)@iiii@t      @Lll(l      tli(-      Altl)illll@L      l@(-,@ioiizii                                                                                           "S'lii-%(-y   of,  (]()Iltiiitlitig                         of     ill(.
                                                                        Medical 1'rogritiii."                        l-'INNI@@N',            M.D.                                                                                           I'liysici@ilis      ill      \I(,tl.ol)olit;iii         itsiiiil@'toll."
                                                                        "LJiiiisii;tl    I)zogi@iiiis   for   (@olitilitlill@                                  27                                                                           1,1"()N@\l@D (@IiIAZZI@, Jl@                                      ;iiiki
                                                                        ii(-;itioll                         ;it (;I@ISSI'oot;                                        l@oolli                                                                Nll.\I,             X.\Vll:'1,







                                              l'i6









                                                                                                                            Paper                                                                                                                             Paper
                                    ,$'Iartin@q time                  'title, author, and (r@,ion)                          No.               Location                             time                   Title, author, and (region)                           No.              Location

                                                       "l@"xr)(-rirri(,nt  to  'I'(-st  ;iii(i                                        Lincoln        l@oolli            1:50 Join.          "Consumer       Health        Care        Survey."        LAW-      32        Lincoln          Room
                                                          Mo(i(-l  of                                                                 I,";tst                                                                                                                             East
                                                          1,U'I'Ifl-'It Clf]tIS-I'MAN, I'll. 1).                                                                                               Alaska)
                                                          nessc(., Mid-South)                                                                                                               "System     for     Clinical     Data      Collection      and      38        Jefferson          Room
                                                       "'I'hc    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    in    a     18        Military                                              "Continuing      Nursing      Education       Using       Uni-      44        Military           Room
                                                          I)cvcloping        lzcgional        Medical         Program."               Room                                                     vcrsity     Hospital     Nursing      Service      Training
                                                          EDWARD           COIJART,            M.D.            (Conncc-                                                                        Facilities."         (Mrs.)         MARGARET          SOVIE
                                                          ticut)                                                                                                                               (Central New York)
                                                       "Regional        Advisory        Group        and         Review     24        Hemisphere                                            "Multi-Project         Planning."          WILLIAM          R.      50        Hemisphere
                                                          Process."        CHARLES        E.        LEWIS,         M.D.               Room                                                     THOMPSON (Washington-Alaska)                                               Room
                                                          (Kansas)                                                                                                                          "Cooperative        Community         Health         Program."      56        Thoroughbred
                                                       "Approaches      to      Evaluation      of      a      Regional     30A       Thoroughbred                                             EDWARD        L.        BURNS,         M.D.         (North-                Room
                                                          Medical           Program."            CALDWELL            B.               Room                                                     western Ohio)
                                                          ESSELS-1@YN,       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, JANUAI@Y  18,  1968                                                                                                                              BERG, M.D. (Northern New England)                                          East
                                                                                                                                                                                            "Health     Manpower      Survey      of      Western      New      45        Military
                                                                                                                            Ilaper                                                             York."      HARRY      A.      SULTZ,       JOHN       FOR-                Room
                                    Starting time                     Y'itle, author, and (region)                          NO.               Location                                         TUNE,            JOSEPH            FELDMAN,             and
                                                                                                                                                                                               SPERO           MOUTSATSOS           (Western           New
                                    1:30 p.m.          "A   Study    of    Physician    Office    Practice    in    the     31        Lincoln           Room                                   York)
                                                          Connecticut         Region."          DONALD          RIEDEL,               East                                                  "A     Systems     Approach      to      Regional      Medical      51        Hemisphere
                                                          pH.      D.      and      ORVAN      W.      HESS,       M.D.                                                                        Program       Planning."       DAVID       H.       GUSTAF-                Room
                                                          (Connecticut)                                                                                                                        SON, M.D. (Wisconsin)
                                                       "I-'xp(@ri(@nc(@s witli;tStrok(@                1)(!tiiotistr;t-        7      Jcfr(@rson    ltooti@l                                                                                                    57        Thoroughbred
                                                                                                                                                                                            "Community         Cancer          Coordinator."          WIL-
                                                          tiori Unit."                     l@.    SMI'I'L    1,    M.D.               I-l;ist                                                  LIAM        P.        NELSON,         M.D.         (Albany,                Room
                                                          (Mississippi)                                                                                                                        New York)
                                                       "Nursing     in     the     Regional      Medical      Programs-     43        Military          Room
                                                          Alliance    for    Better    Patient    Care."    II    ESTER                                                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      Organization      of     49        1 lemisplierc                                            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      0.      TURNER,       M.D.,       CECIL       R.                East
                                                          Cancer      and      Allied      Diseases."      GUY       F.                                                                        AUNER,      M.D.,      and      JOHN      J.      McKINSEY,
                                                          ROBBINS,       M.D.       (New       York       Metropolitan)                                                                        M.D. (Missouri)

                                                                                                                                                                                                                                                                                             137














                                                                                                             Paper                                                                             APPENDIX C
                              Starting time                Title, author, and (region)                       ivo.          Location                i,js,i'ING Ol,' I'Ai@'ricli'AN't'S ANI) I,OCA'I'l               ON Ol-' DISCUSSION GI@OUI'S

                              2:30 p.rii.       "Gu(@st   lzcsident   1'rogr@iiii."           GI-"OIZGI"     4(;      Milit@it-y                   Wl,"I-)NI@SI)AY, JANUAI@Y  17
                                                   IZO]31@"IZTSON, M.]). (N4;iine)                                    Izooril
                                                "Development    of    a    l@giotial    Medical     Pro-     52       1 I(,-inispliere             SI-',.SSION I-DISCUSSION GL@OUI'S                                                         3:45-5:15 p.m.
                                                   grant    Data    Source    Book."    LOUISE     BELI,              l@oorn
                                                   (Western Pennsylvania)                                                                                                                                                               I.incoln l@oom East
                                                "Cancer     Training     and      Continuing      Educa-     58       Thoroughbred                 'I'OPIC A         "Health Manpower-lZcview of Commission Report"
                                                   tion    and     Computerized     Tumor     Registry."              Izoom
                                                   CHARLES        SMART,        M.D.         (Intermoun-                                           Moderator:        *JAMES C. CAIN, M.D.,
                                                   tain)                                                                                                             Consultant in Medicine,
                              2:50 p.m.         "The   Regional   Medical    Program    as    a    Means     35       Lincoln ]@oorn                                 The Mayo Clinic,
                                                   of   Increasing   the   Morale    of    the    Family              East                                           l@oclicster, Minn.
                                                   Doctor."      ROGER       BOST,       M.D.       (Ar-                                           Discussants:      LEONAIZD FENNINGER, M.D.,
                                                   kansas)                                                                                                           Director, Bureau of Health Manpower,
                                                "Dataphone      EKG      Consultation:      A      Model     41       Jefferson Room                                 Public I-Icalth Service.
                                                   for   Extension   of    Medical    Center    Services              East                                           ELEANOR LAMBERTSON, ED.D.,
                                                   to      Community      Hospitals."      JOHN       B.                                                             Director, Division of Nursing Education,
                                                   HERMANN  (Nebraska-South  Dakota)                                                                                 Teachers' College,
                                                "Continuing      Education       Performance       Dcfi-     47       Military                                       Columbia University,
                                                   cits.11         CLEMENT          BROWN,          M.D.              Room                                           New York, N.Y.
                                                   (Greater Delaware Valley)
                                                                                                                                                                     C. l@l. WILLIAM RUIIE, M.D.,
                                                "Clinical   Data    Collection    with    a    Purpose."     53       Hemisphere                                     Director, Division of Medical Education,
                                                   HOMER        WARNER,         M.D.         (Intermoun-              Room                                           American Medical Association,
                                                   tain)                                                                                                             Chicago, Ill.
                                                "Assurance     of     Adequate     Therapy     Following     59       Thoroughbred                                   *DWIGHT WILBUR, M.D.,
                                                   Detection    of     Cervical     Carcinoma."     JOHN              Room                                           President-Elect,
                                                   B.    PHILLIPS,    M.D.    (Albany,     New     York)                                                             American Medical Association,
                              3:10 p.m.         "Experience      with      the       WARMP       Mock-up     42       Jefferson Room                                 San Francisco, Calif.
                                                   Coronary     Care      Unit."      STEPHEN      YARN-              East
                                                   ALL, M.D. (Washington-Alaska)                                                                   Recorder:         CECILIA CONRA,rij,
                                                                                                                                                                     Assistant to Chief,
                                                "Community       Hospital       Learning       Centers."     36       Lincoln Room                                   Continuing Education and Training Branch,
                                                   FRANK       M.       WOOLSEY,        JR.,        M.D.              East                                           Division of Regional Medical Prograrm.
                                                   (Albany, New York)
                                                "Skeleton     Program     in      Continuing      Educa-     48       Military Room                   *Members of the National Advisory Commission on Health Manpower.
                                                   tion     and     Clinical     Research."      WILLIAM
                                                   H. McB EATH, M.D. (Ohio Valley)
                                                "The    Design     and     Dissemination     of     Data     54       Hemisphere
                                                   Collecting       Instruments."        LAURA        G.              Room
                                                   LARSON, R. N. (Mount-,tin States)
                                                "Coordinating     High     I,"n(!rgy      lt;tcli;ttiori     (;o      'I'liorOLlglil)r(-d
                                                   Therapyfor35Gcncralliospit;ils."JO]IN                              ltoor-n
                                                   IVES (Connecticut)





















                                                                                           Military Room                                                                                  Lincoln Room West
                        TOPIC B        "Regionalization"                                                                    TOPIC C        "Urban Problerm"
                        Moderator:     ROBERT SIGMOND,                                                                      Moderator:     PAUL WARD,
                                       Executive Director,                                                                                 Executive Director,
                                       Hospital Planning Association of Allegheny County,                                                  California Committee on Regional Medical Programs,
                                       Pittsburgh, Pa,                                                                                     San  Francisco,   Calif.
                        Discussants:   LESTER BRESLOW, M.D.,                                                                Discussants:   ROGER 0. EGEBERG, M.D.,
                                       Professor of Health  Administration  and  Chairman,                                                 Dean, School of Medicine,
                                       Health  Services Division,                                                                          University of Southern California,
                                       School of Public Health,                                                                            Los Angeles, Calif.
                                       University of California at Los Angeles,                                                            FRANK LLOYD, M.D.,
                                       Los Angeles, Calif.                                                                                 Director  of   Research,
                                       WALTER J. McNERNEY,                                                                                 Methodist Hospital of Indiana,
                                       Executive I)ir(@-ctor,                                                                              Indianapolis, Ind.
                                       Blue Cross Association,                                                                             ANNE     R.      SOMERS,
                                       Chicago, 111.                                                                                       Industrial Relations Section,
                                       WILLIAM R. WILLARD, M.]D.,                                                                          Princeton    University,
                                       Vice President,                                                                                     Princeton, N.J.
                                       University of Kentucky Medical Center,                                                              RAY TRUSSELI,, M.D.,
                                       lexington, Ky.                                                                                      Director, School of Public Health and Ad@nistrative Medicine,
                        l@ecordcr:     ROI-AND PETERSON,                                                                                   Columbia     University,
                                       Chief, Planning Branch,                                                                             New York, N.Y.
                                       Division of 1-tcgional Medical Programs.                                             Recorder:      STEPHEN ACKERMAN,
                                                                                                                                           Associate Director for Planning and Evaluation,
                                                                                                                                           Division of Regional Medical Programs.













                                                                                                                                                                                                                     139




















                                                                                          Hemisphere Room                                                                                         Thoroughbred Room
                         TOPIC D         "Related Federal Programs"                                                                 TOPIC E         "Health Services Research"
                                                                                                                                    Moderator:      PAUL SANAZARO, M.D.,
                         Moderator:      DANIEL      1.       ZWICK,                                                                                Director, Division of I'citicttion,
                                         Associate Director for Program M;tii;tg(@rn(-.rit,
                                         Health   Services   Office,                                                                                Association of American Mt!(Ii(:;tl (,'oll(-g<-s,
                                         Community Action Program,                                                                                  l,"v@iiistoli, 11).
                                         Office of Economic Opportunity.                                                            Discussants:    MORRIS E. COLLEN, M.D.,
                         Discussants:    JOHN W. CASHMAN, M.D.,                                                                                     Director,
                                         Director, Division of Medical Care Administration,                                                         Department of Medical Methods Research,
                                         Bureau of Health Services,                                                                                 The Permanente Medical Group,
                                         Public  I-leiltli  Service.                                                                                Oikian(l, Calif.
                                         @JAMI,'S 11. (:AVANAU(;] I, I'] I. 1).,
                                                                                                                                                    Associate I)it-(@(@tor,
                                         Director, Office of Comprehensive I le-.iltli Planning,                                                    New York Metropolitan Regional Medical Program,
                                         Office of the Surgeon General,                                                                             New York, N.Y.
                                         Public   Health    Service.
                                         DONALD R. CHADWICK, M@D.,                                                                                  JOHN THOMPSON,
                                         Director, National Center for Chronic Disease Control,                                                     Professor of Public Health and Director,
                                         Bureau of Disease Prevention and Environmental Control                                                     Program in Hospital Administration,
                                         Public  1-teiltli  Service.                                                                                School of Public I-le@ilth,
                                                                                                                                                    Yale University,
                                         CAIZI@tJ'I'll %VA(;Nl-"It, M.1),,                                                                          N(-w I I:iv(-ii, (:o[iii.
                                         I)ir(-ctot-, Iiiit-(-;iti of I [,-;title S(-rvi(-4-.%,
                                         I,ul)lic  Health   Service.                                                                                J()I IN Wil.1,IAMSoN, M.D.,
                                                                                                                                                    Division of Medical Care and Hospitals,
                         Recorder:       LEROY              GOLDMAN,                                                                                The Johns Hopkins University School of Hygiene and Public Health,
                                         Program Policy Specialist,                                                                                 Baltimore, Md.
                                         Division of Regional Medical Programs.                                                     Recorder:       RICHARD MANEGOLD, M.D.,
                                                                                                                                                    Associate Director for Program Development and Research,
                                                                                                                                                    Division of Regional Medical Programs.














                          140















                      THURSDAY, JANUARY 18

                      SESSION 11-DISCUSSION GROUPS                                                     3:45-5:15 p.m.


                                                                                                Jefferson Room East                                                                                      Thoroughbred Room
                                I-'   "(-:ontiriiiinc,, F@"cltj(7;itioi) ;if)(I  l@'or Wll;it@"                                                        ('oil(-(7tioii ;iii(I IZ(,gistri(-s"
                                                                                                                                               Alt]ZAI IAM  NI. [,[ I,l



                                                              (:oll(.g(.,                                                                      Scliool of I lygiciie, @iii(i I)tiblic I lealtli,
                                      Philadelphia, Pa.                                                                                        Johns Hopkins University,
                      Discussants:    LUTFIER CHRISTMAN, Ph. D.,                                                                               Baltimore, Md.
                                      Dean, School of Nursing,                                                                 Discussants:    JAMES F. KING, JR.,
                                      Vanderbilt University,                                                                                   Office of Program Planning and Evaluation,
                                                                                                                                               Office of the Surgeon General,
                                                                                                                                               Public Health Service.
                                      f)it(--(,t(jr, Offi(:(!         in M(-(Jic;il l-'Iduc@itioii,                                            ANI)I@l@'W     MAYI,'R,      M.D.,
                                      University of Illinois,                                                                                  Assistan; Director,'
                                      Chicago, Ill.                                                                                            American College of Surgeons,
                                                                                                                                               Chicago, Ill.
                                      A. N. TAYLOR, Ph. D.,                                                                                    HARVEY     SMITH.     Ph.      D.,
                                      Dean, School of Related Health Services,                                                                 Director, Research, Survey and Evaluation,
                                      Chicago Medical School,                                                                                  University  of   North   Carolina,
                                      Chicago, Ill.                                                                                            Chapel Hill, N.C.
                      Recorder:       ALEXANDElk M. SCHMIDT, M.D.,                                                                             JOHN E. WENNBERG, M.D.,
                                      Chief, Continuing Education and Training Branch,                                                         Coordinator,
                                      Division of Regional Medical Programs.                                                                   Northern New England Regional Medical Program,
                                                                                                                                               Burlington, Vt.
                                                                                                                               Recorder:       MAURICE        E.         ODOROFF,
                                                                                                                                               Assistant to the Director for Health Data,
                                                                                                                                               Division of Regional Medical Programs.










                                                                                                                                                                                                                            141














                                                                                      Military Room                                                                              Lincoln Room East
                     TOPIC H        "Hospitals"                                                                       TOPIC j       "Operational Program Development"
                     Moderator:     D. EUGENE SIBERY,                                                                 Moderator:    CHARLES E. LEWIS, M.D.,
                                    Executive Director,                                                                             Coordinator,
                                    Greater Detroit Area Hospital Council,                                                          Kansas Regional Medical Program,
                                    Detroit,   Mich.                                                                                Kansas City, Kans.
                     Discussants:   PEARL FISHER, R.N.,                                                               Discussants:  C. HILMON CASTLE, M.D.,
                                    Administrator,                                                                                  Coordinator,
                                    Thayer Hospital,                                                                                Intermountain Regional Medical Program,
                                    Waterville, Maine.                                                                              Salt Lake City, Utah.
                                    JOHN W. KAUFFMAN,                                                                               T. A. DUCKWORTH,
                                    Administrator,                                                                                  Chairman, Regional Advisory Group,
                                    Princeton Hospital,                                                                             Wisconsin Regional Medical Program,
                                    Princeton,  N.J.                                                                                Wausau, Wis.
                                    EDWARD      H.       NOROIAN,                                                                   ALBERT E. HEUSTIS, M.D.,
                                    Executive Director,                                                                             Coordinator,
                                    Presbyterian University Hospital,                                                               Michigan Regional Medical Program,
                                    Pittsburgh,  Pa.                                                                                East Lansing, Mich.
                     Recorder:      RICHARD MANEGOLD, M.D.,
                                    Associate Director for Program Development and Research,                                        DONAL R. SPARKMAN, M.D.,
                                    Division of Regional Medical Programs.                                                          Coordinator,
                                                                                                                                    Washington-Alaska Regional Medical Program,
                                                                                          Hemisphere Room                           Seattle, Wash.
                     TOPIC I        "Community       Involvement"                                                     l@ecorder:    RICHARD STEPHENSON, M.D.,
                     Moderator:     ROBERT M. CUNNINGHAM, JR.,                                                                      Associate Director for Operations,
                                    Editor,                                                                                         Division of Regional Medical Programs.
                                    Modern   Hospital   Magazine,
                                    Chicago, Ill.
                     Discussants:   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.    @USSER,    M.D.,
                                    Coordinator,
                                    North Carolina Regional Medical Program,
                                    Durham,     N.C.
                     Recorder:      EDWARD M. FRIEDLANDER,
                                    Assistant to the Dircctorfor Communications and l'ublic Information.
                                    Division of Regional Medical Programs.

                     142








                                                      APPENDIX 2                                                                                      APPENDIX 3            ANDERSON, Philip C., M.D.
                                                                                                                                                                            Special Assistant to the  Director
                                                                                                                                                                            National Institutes  of  Health
                               COORT)INATORS'                    STEERING                                                       RI'GISTERED                    CONFERENCE   ANDREWS,    Neil    C.,    M.D.
                                                                COMMITTEE                                                                          I'AIZ'rlCll"AN'I'S       Coordinator
                                         REGIONAL                 MEDICAL                                                                                                   Ohio Valley Regional Medical Program
                                                         PROGRAMS                                                                                                           ANGELIDES, Angelo P., M.D.
                                                                                                                            ABDELLAH, Dr. Faye G.                           Director  of   Medical   Education
                                                                                                                            Chief, Research Grants Branch                   The Lankenau Hospital of Philadelphia
                                                                                                                            Division of Nursing                             Greater Delaware Valley Regional
                             STANLEY W. OLSON, M.D.,                        J. MINOTT STICKNEY, M.D.,                       Public  Health   Service                          Medical Program
                             (Chairman)                                     Program Coordinator,
                             Program Coordinator, Tennessee                 Northlands    Regional                          ADAMS, Wright, M.D.                             ARBONA,     Guillermo,     M.D.
                               Mid-South Regional Medical Program             Medical     Program,                          Executive Director                              Professor  of  Preventive  Medicine  and
                             Professor of  Medicine,                        Rochester, Minn.                                Illinois  Regional  Medical   Program             Public Health
                                                                                                                                                                            School of Medicine
                             Vanderbilt  University,                        PAUL D. WARD,                                   AKERLOW, Charles W.                             University of Puerto Rico
                             Nashville, Tenn.                               Program Coordinator,                            Director, Media Services
                             C. HILMON CASTLE, M.D.,                        California Regional                             Intermountain   Regional   Medical    Program   AREND, William P., M.D.
                                                                                                                                                                            Medical Consultant
                             Program    Coordinator,                          Medical     Program,                          ALEXANDER, Chauncey A.                          Heart Disease Control Program
                             Intermountain Regional Medical                 San Francisco,  Calif.                          Assistant Director for Program
                                                                                                                                                                            Public Health Service
                               Program,                                                                                       Development-Area IV
                             Associate Dean and Chairman,                                                                   University of California, Los Angeles           ARRINGTON, Clifton W., M.D.
                             Department of Postgraduate Education,                                                          California Regional Medical Program             Meharry Medical College
                             University of Utah,                                                                            ALLRED,  J.   D.,   M.D.                        Mid-South Tennessee Regional Medical
                             Salt Lake  City,  Utah.                                                                                                                          Program
                                                                                                                            Assistant    Coordinator
                             JAMES T. I IOWEI,L, M.D.,                                                                      Maryland Regional Medical Program               ARTZ, Invelda M.
                             Member, National Advisory Council                                                              AMOS, James R., M.D.                            Nurse Consultant
                                                                                                                                                                            Heart  Disease   Control   Program
                               on Regional Medical Programs,                                                                State  Health  Department  of   North
                                                                                                                                                                            Public Health Service
                             Executive Director,                                                                              Dakota
                             Henry  Ford   Hospital,                                                                        North Dakota Regional Medical                   ASTON, Lydia S.
                             Detroit, Mich.                                                                                   Program                                       Public Health Advisor
                             MARC J. MUSSER, M.D.,                                                                          ANDERSON, Elmer A., M.D.                        Regional    Medical     Program
                                                                                                                                                                            West Virginia University Medical Center
                             Program    Coordinator,                                                                        Medical Director
                             North Carolina Regional Medical                                                                John   Wesley   Hospital                        ATCHLEY,    William    A.,    M.D.
                               Program,                                                                                     Los  Angeles  County  Department   of           Assistant   Area    Coordinator
                             Durham, N.C.                                                                                     Hospitals                                     California Regional Medical Program
                             WILLIAM C. SPRING, JR., M.D.,                                                                  ANDERSON, H. William                            University of California School of
                             Program    Coordinator,                                                                        Assistant Director                                Medicine
                             Greater Delaware Valley                                                                        Arkansas Regional Medical Program               ATTIS, Bari
                               Regional Medical Program,                                                                    ANDERSON,    Ivan     D.                        Information Specialist
                             Wynnewood, Pa.                                                                                 Director of Research                            National Institute of Neurological
                                                                                                                            Kansas Blue Cross-Blue Shield                     Diseases and Blindness
                                                                                                                            Kansas   Regional   Medical   Program           National Institutes  of  Health
                                                                                                                            ANDERSON, Otis L., M.D.                         BACASTOW,    Merle    S.,     M.D.
                                                                                                                            Assistant Manager                               President
                                                                                                                            Washington, D.C., Office of American            Medical Care Development, Inc.
                                                                                                                              Medical    Association                        Maine Regional Medical Program

                                                                                                                                                                                                                   143













                                BAILEY, David R.                                   BATES, Roswell P., D.O.                            BERRY, Albert G.                                   BOQUIST, William
                                Program Analyst                                    Executive      Director                            Instructor                                         Information Coordinator
                                Program Planning and Evaluation                    Maine Osteopathic Association                      Department   of   Oral    Pathology                California Regional Medical Program
                                Office of the Surgeon General                      Regional       Advisory Group                      Meharry Medical College
                                Public    Health    Service                        Maine Regional Medical Program                                                                        BORHANI, Nemat O., M.D.
                                                                                                                                      BERSON, Robert C., M.D.                            Professor of Medicine and
                                BAIN, H. 0.                                        BAUMGARTNER, Leona                                 Executive Director                                 Chairman, Department of Communitv
                                                                            is)    Professor of Social Medicine                       Association  of   American   Medical   Colleges       Health
                                Community        Relations, California (Dav  .
                                   Regional Medical Program                        Harvard Medical School                             BINGHAM, Fletcher H.                               School of Medicine
                                University of California at Davis                  BEASLEY, Steven E.                                 Assistant Director                                 University of California at Davis
                                BAKER, John G.                                     Science Writer                                     Council   of   Teaching   Hospitals                BORLAND, Jack
                                Public Relations Counsel                           National Institute of Neurological Diseases        Association  of   American   Medical   Colleges    Manager, Services Department
                                Wisconsin Regional Medical Program                    and Blindness                                   BIRCH, Larry H., M.D.                              Smith, Kline and French Laboratories
                                                                                   National Institutes of Health
                                BARD, Wayne M.                                                                                        Program Director                                   BOST, Howard L., Ph. D.
                                Information Officer                                BECI-IILL, Williirri D.                            Michigan Regional Medical Program                  Ohio   Valley   Regional   Medical    Pro    ram
                                                                                   Commissioner                                                                                                                                  9
                                Bureau of Health Manpower                          Administration on Aging                            BLACK, Louis A., M.D.                              Assistant Vice President for Program
                                Public    Health    Service                        Social and Rehabilitation Service                  Assistant    Program    Coordinator                   and Policy Planning
                                BARNES,      Donald      R.                        U.S. Department of Health, Education,              Northwestern Ohio Regional Medical                 University of Kentucky
                                Medical Systems Development                           and Welfare                                        Program                                         BOST, Roger B., M.D,
                                   Laboratory                                      BEDWEI,I,, Maj. Gen. T. C., Jr.                    BI,AKE,     Thomas     M.                          I)ir(-(@tor
                                Heart Disease Control Program                      I3irector of StifT                                 (,i,or(liriator for Heart                          Ai-k;irisas Rr-gionil M(,(Ii@il Program
                                National Center for Chronic Disease                Assistant Secretary of Defense                     Mississippi IZ(@gi<)nal M(,(Ii(-ii] I)rogy-@tiii
                                   Control                                         Health   and    Medical                            13LAKI-'Y,   Thelma    M.                          liOUCIIARD, Richard E., M,D@
                                Public    Health    Service                                                                                                                              Assistant Professor of Medicine
                                                                                   BELL, Louise M.                                    Ilea] tli I-dLicator                               University of Vermont
                                BARNHART, Gilbert R., M.D.                         Research      Associate                            American Cancer Society                            Director of Coronary Care Program
                                Bureau of Health Services                          Western Pennsylvania Regional                      BLASINGAME, J. T., Jr., M.D.                       Northern   New   En   land   Regional    Medical
                                Public    Health    Service                           Medical      Program                            Member Advisory Group                                 Program          9
                                BARR, Daniel M.                                    BENJAMIN, Clement                                  Georgia Regional Medical Program                   BOWMAN, C. W.
                                University   of    Missouri                        Assistant Chief                                    BLAZER, Mrs. Rexford S.                            Program Representative
                                   School    of    Medicine                        Educational  Studies      and  Development         Vice   Chairman,   Regional   Advisory    Group    South   Carolina   Regional   Medical    Program
                                BARROW, J. Gordon, M.D.                               Section                                         Ohio Valley Regional Medical Program
                                Director                                           National Medical Audiovisual Center                                                                   BOYDEN, George M.
                                                                                   Atlanta, Ga.                                       BLESS,   Stuart   R.,   M'D,                       Chairman, Education Committee
                                Georgia  Regional Medical Program                                                                     Assistant Chief, Coronary Section                  New    Mexico    Regional    Medical     Program
                                                                                   BENTLEY, Ward                                      Heart   Disease   Control   Program
                                BARTLETT,      John      C.                        Chief,   Area   Liaison                            National  Center  for  Chronic          Disease    BOYLE, Richard E., M.D,
                                Assistant Program Coordinator                      Greater Delaware Valley Regional                     Control                                          Department of Continuing Education
                                Iowa Regional Medical Program                         Medical      Program                            U.S.   Department   of    Health,    Education,    Colorado-Wyoming Regional  Medical
                                                                                                                                                                                            Program
                                BASALYGA, R. G., M.D.                              BERNSTEIN, Arthur, M.D.                              and Welfare
                                Chief, Program Development Section                 Cardiac Program                                    BLOOM, Cliarlotte                                  BRAUNSTEIN, Norman W.
                                Heart Disease and Stroke Control                   New Jersey Regional Medical Program                Information    Specialist                          Public Health Advisor
                                   Program                                                                                            Bureau of Health Manpo%%-er                        Chronic Respiratory Disease  Program
                                Public    Health    Service                        BERNSTEIN, Lionel, M.D.
                                                                                   Acting Assistant Chief                             Public   Health   Service                          Public Health Service
                                BATES,    Barbara,     M.D.                        Medical Director for Research and                  BOHANNON, Richard L., M.D.                         BRAWNER, Donald L.
                                Rochester (New York) Regional Medical                 Education                                       Former Surgeon General                             Chairman,    Tulsa     Subregional     Committee
                                   Program                                         Veterans Administration                            U.S. Air Force                                     Oklahoma Regional Medical Program

                                144






                              BRAYTON, Donald, M.D.                               BROWNING, Levi M., M.D.                              CALDWELL, Dale                                      CHAMBERS, J. W., M.D.
                                                                                  Coordinator for Alaska                               Director of Information                             Program        Coordinator
                              Coordinator-Area IV
                                                           at Los Angeles         Washington-Alaska Regional Medical                   Oregon    Regional    Medical    Program            Georgia Regional Medical Program
                              University   of   California
                              California    Regional    Medical    Program          Program                                            CALLAHAN,      Thomas      E.                       CHAMBLISS, Cleveland R.
                                                                                  BRUCE, Dr. Harry                                     Regional    Advisory    Group                       Office of Program Planning
                              BRENNAN,     Michael     J., M.D.
                              Ilresident, Michigan Cancer Foundation              Chief, Manpower and l@"ducation                      Western     Pennsylvania     Regional     Medical   Office  of  the   Director
                                                                                  Division of Dental Health                              Program                                           National Institutes of Health
                              Professional    Advisory    Committee     on
                                                                                  Public Health Service                                CAMPBELL, Guy D., M.D.                              CHAPMAN, Carleton B., M.D.
                                Cancer
                              Regional    Advisory     Board                      BRYAN, James E.                                      Coordinator                                         Dean
                              Michigan    Regional     Medical     Program        Executive Secretary                                  Mississippi Regional Medical Program                Dartmouth University Medical School
                                                                                  American   Federation   for   Clinical   Research
                              BRESLOW,     Lester,      M.D.                                                                           CANNON,   Wilson   P.,    Jr.                       CHASE, Beatrice A.
                              Professor of Health Administration                  BUCCI, Barbara Echols                                Chairman, Regional Advisory Group                   Director,     Services     Community     Planning
                              Chairman, If(--attli Services Division              Research Assistant                                   Hawaii    Regional    Medical    Program               for Nursing
                              S(@llool of Ptll)li(: ll(!@lltli                    'I'lic Johns I lol)kins University                   Senior   Vice   President                           National League for Nursing
                              Uriivf-rsity of                                     I)ef)artni(!rit of Medical Care Hospitals            Bank of Hawaii                                      CFIATTERJEE, Manu, M.D.
                              BRICKER, Sandra                                     BUCHER, Robert, M.D.                                 CARPENTER, Robert R., M.D.                          Program        Coordinator
                              Editorial Assistant                                 Dean, Temple University                              Institutional Liaison Officer                       Maine Regional Medical Program
                              Ohio Valley Regional Medical Program                School of Medicine                                   Baylor University College of Medicine               CHRISTMAN, Dr. Luther
                                                                                  BURK, Lloyd B., Jr., M.D.                            CARSON, Bruce F.                                    Dean, School of Nursing
                              BRINKLEY, Sterling B., M.D.                         Metropolitan Washington, D.C.                        Chief,   Legislative   Reference   and    Liaison   Vanderbilt      University
                              Chief Medical Officer                               Regional Advisory Group                                Branch                                            CICARELLI, Sara Marie
                              Rehabilitation Services Administration              BURNEY, Anita W., M.P.1-1.                           Office of Program Planning
                              U.S. Department of Health, Education,                                                                                                                        President-      ect
                                and Welfare                                       Health Services Advisor                              National Institutes of Health                       American   Society   of   Medical   Technologists
                                                                                  U.S.   Department   of    Housing    and    Urban    CASELEY, Donald J., M.D.                            CLAMMER, George R., M.D.
                              BROIDA, Joel H.                                       Development                                        Vice   Chairman,    Regional    Advisory    Group   Associate   Coordinator   for   the   State    of
                              Physical Therapy Consultant                         BURNS, Edward L., M.D.                               Illinois   Regional   Medical    Program               Pennsylvania
                              Heart Disease and Stroke Control                    Chairman, Regional Advisory Group                    Medical Director and Associate Dean                 Greater Delaware Valley Regional
                                Program                                           Northwestern      Ohio      Regional      Medical    University of Illinois Hospitals                       Medical Program
                              Public Health Service                                 Program                                            CASTLE, C. Hilmon, M.D.                             CLARK, Henry T., Jr., M.D.
                              BROOKS, Fredrica                                    BURTON, Marvin H.                                    Program       Coordinator                           Program        Coordinator
                              Public   Relations    Director                      Physician Education Coordinator                      Intermountain    Regional     Medical     Program   Connecticut     Regional     Medical      Program
                              New York Metropolitan Regional Medical              New Jersey Regional Medical Program                  CAVANAUGH,    James    H.,    Ph.     D.            CLARK, John Kapp, M.D.
                                Program                                           BUTLER, Josephine                                    Director of Comprehensive Health                    Chief,   Regional   Medical    Program    Activi-
      n                       BROWN, Charles E., M.D.                             Washington, D.C., Tuberculosis                         Planning                                             ties
                              President                                             Association                                        Office of the Surgeon General                       University of Pennsylvania
                              Charles Drew Medical Society                        BYRON, T. X., M.D.                                   Public   Health   Service                           CLARK, Sister M. Ferdinand
                              California    Regional    Medical    Program        Medical Representative                               CAZORT, Ralph J., M.D.                              Chairman,     Subcommittee      on      Community
                                                                                  Postgraduate Programs                                                                                       Involvement
                              BROWN, Charles R.                                   California Regional Medical Program                  Dean                                                Regional    Medical    Program     of     Western
                              Administrative     Assistant                        CAIN, James C., M.D.                                 Meharry    Medical    College                          Pennsylvania
                              Indiana University Medical Center                   Consultant in Medicine                               CHADWICK, Donald R., M.D.                           Administrator of Mercy Hospital of
                              BROWN, Clement R., Jr., M.D.                        The Mayo Clinic                                      Director,    National    Center    for    Chronic      Pittsburgh
                              Director of Medical Education                       CALDWELL, Charles W.                                   Disease Control                                   CLEMENT, Edward C.
                              Chestnut Hill Hospital                              Director,   Program   Development    and    Field    Bureau of Disease    Prevention      and            Administrative Services Department
                              Greater Delaware Valley Regional                      Services                                             Environmental       Control                       North Carolina Regional Medical
                                Medical Program                                   Iowa Regional Medical Program                        Public   Health   Service                              Program
                                                                                                                                                                                                                                        145










                                  COBB, Alton B., M.D.                                   COOK, Ernest W., Ph. D.                             CROCKETT, Charles L., Jr., M.D.                       DAVID, Wilfred, M.D,
                                  Chairman, Regional Advisory Group                      Medical Care and Education Foundation               Consultant,  Continuing  Education  and               Deputy Director
                                  Mississippi Regional Medical Program                   Rhode Island Regional Medical Program                 Regional Planning                                   National Center for Chronic Disease
                                  Director, Division of Chronic Illness                  COOLEY, George W.                                   Virginia Regional Medical Program                        Control
                                  State Board of Health                                  Medicil Society of the District of                  Roanoke Memorial Hospital                             liur-(-@iu of Discis(@ 1'revcntion tnd
                                  COCCESFIALL,    Lowell     T.,     M.D.                Columbia                                            CROSS, l,'Idwai-d B., M.D.                               Environmental Control
                                  Vice President                                                                                             Chief, Adult Heart Control Section                    Public Health Service
                                  University of Chicago                                  COOPER, Gerald R., M.D.                             Heart Disease Control Program                         DAVIES, Dean F., M.D.
                                                                                         Chief, Heart Disease Control Standardi-             Public Health Service                                 Memphis Regional Medical Program
                                  COHART, Edward M., M.D.                                zation Laboratory
                                  Professor of Public Health                             National  Communicable Disease  Center              CROSWHITE, Margaret D.                                DAVIS, Alan C.
                                  Yale University Department of Epidemi-                 in Atlanta                                          Office of Communication                               Science Editor
                                  ology and Public Health                                COOPER, Henry R., M.D.                              Alabama Regional Medical Program                      American Cancer Society
                                  COHN, Roy, M.D.                                        Member, Regional Advisory Group                     CROUCH, Boyden L.                                     DAVIS, Burnet M., M.D.
                                  Chairman, Stanford-Area III                            Florida Regional Medical Program                    Coordinator of Communications and                     Research and Training Division
                                  Regional Medical Programs                              COOPER, Theodore, M.D.                                Continuing Education                                National Library of Medicine
                                  Stanford University Medical Center                     Associate   Director                                Arizona Regional Medical Program                      Public Health Service
                                  COLE, Clifford H., M.D.                                National Heart Institute                            Research Assistant, University of Arizona             DEAN, C. Robert, M.D.
                                  Chief, Neurological and Sensory Disease                National Institutes of Health                         School of Medicine                                  Associate Regional Health Director-
                                  Control Program                                                                                            CROW, Harry R.                                           Region II
                                                                                         COOPER, William G., M.D.                            Sales Manager                                         New    York    Metropolitan    Regional     Medical
                                  Public Health Service                                  Director, Unit Teaching Laboratories                Wilson Gill, Incorporated                                Program
                                  COLEMAN, James Walker, III                             University of Colorado Medical Center
                                  Program Representative                                 COPELAND, Murray M., M.D.                           CROW, Richard S., M.D.                                DEARING, W. Palmer, M.D.
                                                                                                                                             Medical Officer                                       Executive Director
                                  South   Carolina    Regional    Medical                Associate   Director                                National  Center  for  Chronic  Disease               Group    Health     Association     of     America,
                                  Program                                                M.D.  Anderson  Medical  Hospital  and                Control                                                Inc.
                                  Medical  College  of   South   Carolina                Tumor      Institute
                                                                                         Texas Medical Center                                Public Health Service                                 DEBAKEY, Michael E., M.D.
                                  COLLEN, Morris E., M.D.                                                                                    CUGLIANT, Anne                                        Professor    and    Chairman,     Department     of
                                  Director, Department of Medical Methods                CORNELY, Paul B., M.D.                              Staff Coordinator, Data and Research                     Surgery
                                  Research                                               Head, Department of Preventive                      New York Metropolitan Regional Medical                College of Medicine, Baylor University
                                  The Permanente Medical Group                           Medicine                                              Program                                             Division    of    Regional     Medical     Programs
                                  COLLINS, William T., M.D.                              Howard    University                                CULBERTSON, James W., M.D.                               Advisory Council
                                  Secretary, Regional Advisory Group                     CRAYTOR, Josephine K., R.N.                         Program Coordinator                                   DeGRASSEi Richard V.
                                  Northwestern Ohio Regional Medical                     Rochester (New York) Regional Medical               Memphis Regional Medical Program                      Program Manager
                                  Program                                                Program                                                                                                   Northern    New    England     Regional     Medical
                                  Lima Memorial Hospital                                 University of Rochester                             CUNNINGFIAM, Robert M., Jr.                              Program
                                                                                         CREVASSE, Lamar, M.D.                               Editor, Modern Hospital Magazine
                                  COMBS, Robert C., M.D@                                                                                     Chicago, 111.                                         Del GUERCIO, Marie T., R.N.
                                  Area   Director,    Irvine@Area    VIII                North Central Florida Subarea                                                                             Health Education Coordinator
                                  California Regional Medical Program                    Coordinator                                         DAITZ, Bernard D., M.D.                               New Jersey Regional Medical Program
                                  CONNOLLY, Eleanor C.                                   Florida Regional Medical Program                    Special Assistant to the Chief                        Del REGATO, Juan A., M.D.
                                                                                         College of  Medicine                                Division of Medical Care Administration               Director, Penrose Cancer Hospital of
                                  Consultant                                             University of Florida                               Ptil)li(: Health Service                                 Colorado Springs
                                  National Tuberculosis Association                                 K(@ritictli ]@., M.D.                    I)ANI-'Olt'I'll, William 11., M.D.                    National Advisory Carit:t-r Council
                                  CONNOLLY, J<)Iin'l'.                                   Meiril)(!r, l@'xecutive Committee                   Vice Cliaii(@elloi- for Medical Affairs               DEMARIA, William J., M.D.
                                  Staff Co-)rdinator, Program Development                Virginii Regioriil Medical Program                  Wisfiington University, St. Louis                     I)irt,(@tor, Continuing Education
                                  New York Metrol)olitin Regional M(-(Iicil                   University  of  Virginia  Medical              l'i-ogriiii Coordinator                               North Carolina Regional Medical
                                  Program                                                School                                              Bi-State Regional Medical Program                        Program
                                  146







                  DENTON,  I  larriet   A.                         I-DDINGER, John W.                                 ESCOVITZ, Gerald I-I., M.D.                       FEARN, James A.
                                                                   I)ir(@(:tor of Information                         Acting  Chief,  Continuing  Education             Field Representative
                  Public  Health   Service                         Maryland Regional Medical Program                    Branch                                          Susquehanna     Valley     Regional     Medical
                  U.S.    Department    of Health,     Education,  I-"Dl,"N, Raymond I,.                              Division of Physician Manpower                       Program
                    and lvclfare                                   California Regional Medical Program                Bureau of Health Manpower                         FEIGENBAUM, Harvey, M.D.
                  DIE]@'ENBACH, Viron L., 1).D.S.                                                                     Public   Health   Service                         Indiana Regional Medical Program
                                                                   Regional    Advisory    Groul)
                  Director, Division of Dental Health              I-'Ixccutive   Director,   California  Heart       ESSELSTYN, Caldwell B., M.D.                      Associate Professor
                  Public  Health   Service                            Association                                     Associate Director                                Indiana University Medical Center
                  DIETZ, J. Herbert, Jr., M.D.                                                                        New   York   Metropolitan   Regional    Medical   FENNINGER, Leonard D., M.D.
                                                                   EDWARDS, Jesse E., M.D.                              Program
                  Consultant in Rehabilitation Mcclicine       ,   President                                                                                            Director
                  Ne@%,  York  University  Medical  Center  anci   American Heart Association                         ESTES, E. Harvey, Jr., M.D.                       Bureau of Health Manpower
                    Memorial Hospital Center                                                                          Director, Community Health       Sciences         Public   Health   Service
                  DOAN, Howard W., M.D.                            Charles  T.  Miller   Hospital                     Duke University Medical Center                    FETTER, Franklin C., M.D.
                  Director                                         EGEBERG, Roger O., M.D.                            ETHRIDGE, Clayton B., M.D.                        South Carolina Regional Medical
                  Colorado-Wyorning Regional Medical               Dean                                               Chairman, Regional Advisory Group                    Program
                    Program                                        University of Southern California                  Associate Dean, George Washington                 Dean,  Medical  College   of   South   Carolina
                  DRISCOLL, Dr. Edward J.                          School of Medicine                                   University     Hospital                         FIELDS, Cleo
                  Associate Director for Extramural                EHRLICH, Frank                                     EVANS,    Lester,    M.D.                         Rochester,   New    York    Regional    Medical
                    Programs                                       Chief, Budget Management, Section 11               Associate Director (Education)                       Program
                  National Institute of Dental Research            Financial Management Branch                        Connecticut Regional Medical Program              Heart  Disease  and  Stroke   Control   Program
                  American Society of Oral Surgeons                Office of Administrative Management                EVANS,    Lloyd,     M.D.                         Public   Health   Service
                  DitBEAU, Normand                                 National Institutes of Health                      Office  of  the  Dean,  College   of   Medicine   FINNEY,   J.   O.,   M.D.
                                                                                                                      Ohio   State   University                         Associate Director
                  Assistant  Director,  Information  and   Corn-   ELAM, Lloyd, M.D.                                  EYMANN, Carolyn                                   Alabama Regional Medical Program
                    munications                                    President                                          l,nfon-nation    Services                         FISHER, F. David, M.D.
                  Missouri Regional Medical Program                Meharry    Medical     College                     Kansas Regional Medical Program                   Office of the Dean
                  DUCKWORTH, T. A.                                 ELDER, Jerry 0.                                    FAHS,  Ivan  J.,  Ph.  D.                         College of Medicine
                  Chairman, Regional Advisory Group                Assistant Director, Survey and Planning            Medical Sociologist                               Ohio   State   University
                  Wisconsin Regional Medical Program               Oregon Regional Medical Program                    Minnesota Regional Medical Program
                  Employers Insurance of Wausau                                                                       FALK,  Leslie  A.,   M.D.                         FISHER, Pearl R., R.N.
                  DUKE, Arnold                                     ELLWOOD, Paul M., Jr., M.D.                        Tennessee    Mid-South     Regional     Medical   Administrator
                  Planning Assistant                               Executive Director                                   Program                                         Thayer Hospital of Waterville, Maine
                  Oklahoma Regional Medical Program                Aineric;tn Rehabilitation I,'oundation             Chairman,     Department      of      Community   FISK, Shirley C., M.D.
                  i@AS'I'WOOD, ]Zi(@tiar(l,r., I)li.D.             I-,NI)ICOTI', K(@rinctli M., M.D.                    Health                                          New   York   Metropolitan   Regional    Medical
                  I                                                                                                   Meli;irr-y Medical College                           Program
                  Executive Vice President                         Director
                  Texas Medical Center, Inc.                       National   Cancer    Institute                     FARBER, Sidney, M.D.                              Columbia  University  College   of   Physicians
                                                                   National   Institutes of Health                    President-Elect                                      and Surgeons
                  EBERLY, Annette                                                                                     American Cancer Society                           FITZ,    Reginald    M.D.
                  Assistant  to  the  Assistant   Director   for   ENNES,     Howard,      M.P.H.                     Director of Research                                                I
                    Public Education Information                   Assistant  Vice President                          Children's Cancer Research Foundation             Program       Coordinator
                  %lissouri Regional Medical Program               I-'Iquitable Life Assurance Society                FAUBER, John, D.D.S.                              New Mexico Regional Medical Program
                                                                                                                      Secretary,   Council   on    Hospital    Dental   Dean, School of Medicine
                  ECKBERG, D@vain L., M.D.                         ERICKSON, Frederick K.                               Service                                         University of New Mexico
                  Scientist Administrator                          Acting Director
                  Division of Research Facilities and              Division of Allied Health Manpower                 American Dental Association                       FLAGLER,    Philip     B.
                    Resources                                      Bureau of Health Manpower                          FAZEKAS,    Joseph     F.                         Service Manager
                  National Institutes of Health                    Public Health Service                              New    Mexico    Regional    Medical    Program   Smith, Kline and French Laboratories

                                                                                                                                                                                                                   147














                           FLANDERS, Sarah E., M.D.                                  FRANCIS,       John       O'S.                             GILSON, John S., M.D.                                     GREEN, Jerome G., M.D.
                           Assistant     Visiting     Physician                      Executive Office of the President                          Associate Coordinator                                     Associate Director for Extramural
                           Goldwater Memorial Hospital                               Bureau    of    the     Budget                             Intermountain Regional Medical Program                       Programs
                           New York University Medical Center                        FREDRICKSON,       Donald        S.,        M.D.           University of Utah Medical Center                         National Heart Institute
                           FLANNAGAN,        William         H.                      Director, National Heart Institute                         GLOVER, Homer B.                                          National Institutes of Health
                           Member, Executive Committee on                            National Institutes of Health                              Area  Liaison  Officer                                    GREENE Charles R., M.D.
                              Regional Medical Programs                              FRIEDRICH,       Rudolph       H.,        D.D.S.           Greater Delaware Valley Regional                          Goordinatr, Downstate Medical Center
                           Roanoke Memorial Hospitals                                Chairman, Department of Oral Surgery                          Medical Program                                        State University of New York
                                                                                                                                                                                                          New     York     Metropolitan     Regional      Medical
                           FLEISHER, Daniel S., M.D.                                 Columbia University                                        GOLDSMITH, Katherine I,.                                     Program
                           Associate Professor of Pediatrics                         American    Society     of     Oral     Surgeons           Assistant Director - Area VII I                           CRIFI-'I'I'll,   John   1-1.
                           Temple University School of Medicine                      Chairriian,      Committee      on      Regional           California Regional Medical 1'rograrn                     Research Associate
                           FLEMING, George M., Ed.D.                                    Medical Programs                                        GOODHART, Robert S., M.D.                                 Commission     on     Professional     and     Hospital
                           Director/Coordinator, Allied          Health              FULLARTON, Jane Evalyn                                     Coordinator,  New  York  Academy  of                         Activities
                           Texas Regional Medical Program                            Assistant     Chief,     Legislative     BrLncli              M(-.di(@iri(!                                          C;RTZZLE, Claude O., M,D,
                           Methodist Hospital                                        Office of Progrztrn I)Ianning                              New York Metropolitan Regional Medical                    I)irt-i7tor, Wyoming Division
                           Baylor University College of Medicine                     Natiori;tl   Itistittit(-s of Ife@tIL]i                       1'rograrri                                             Mountain     States     Regional      Medical      Pro-
                           FLORIN, Alvin A., M.D.                                    GAINES, Barbara, R.N.                                      COTO, Unoji, M.D.                                            gram
                                                                                     Assistant Director
                           Acting Coordinator                                        Continuing           Education                             Chairman, Heart Advisory Committee                        GRONVALL, John A., M.D.
                           New Jersey Regional Medical Program                       Oregon      Regional       Medical       Program           President, Hawaii Heart Ass(>ciation                      Associate Director and Associate Dean
                                                                                                                                                                                                          University of Utah Medical Center
                           FOLEY,     Joseph      M.,      M.D.                      GALLIHER,    Herbert    P.,    Jr.,    Ph.    D.           GOTTOVI, Daniel, M.D.                                     Co-Chairman,           Coordinators'           Steering
                           Coordinator of  Postgraduate  Medical                     Professor     of     Industrial      Engineering           Medical Consultant                                           Committee
                             Education     and     Professor     of     Neurology    The University of Michigan                                 Heart Disease  and        Stroke  Control  Pro-           Conferencc-Worksh<)p      on       Regional       Medi-
                           Case     Western     Reserve     University     School    GANZ,      Aaron,       D.D.S.                                gram                                                      cal Programs
                             of Medicine                                             Chief, Program Planning Office                             Public Health Service                                     GROVER, M. Roberts, Jr., M.D.
                           FOLLMER, Hugh C., M.D.                                    National Institute of Dental Research                      GRABER, Mrs. Joe Bales                                    Program          Coordinator
                           Associate Director for Nevada                             National Institutes of Health                              Special Assistant to Director                             Oregon Regional Medical Program
                           Mountain States Regional Medical                          GARCIA-PALMIERI, Mario R., M.D.                            Bureau of Disease Prevention and                          GRUBB, Donald A.
                             Program                                                 Professor of Medicine                                         Environmental Control                                  Assistant Program Coordinator
                           FORBES, Charles M.                                        School of Medicine                                         Public Health Service                                     Northwestern Ohio Regional Medical
                                                                                     University of Puerto         Rico                                                                                       Program
                           Vice President                                                                                                       GRAEBER, Fred O., M.D.
                           Memorial      Sloan-Kettering      Cancer       Center    GARVEY, Henry T.                                           Assistant Director of the Idaho Study                     GUSTAFSON, David H., Ph. D.
                           FORDHAM, Robert A.                                        Information Officer                                        Mountain States Regional Medical                          Planning         Coordinator
                           Coordinator of  Federal  Programs                         Heart Disease and Stroke Control                              Program                                                Wisconsin Regional Medical Program
                           University of Vermont                                       Program                                                  GRAHAM, William D., M.D.                                  GUTHRIE, Eugene H,, M.D.
                                                                                     Public Health Service                                      Deputy Director                                           Associate Surgeon General
                           FOX,   Samuel    M.,    III,    M.D.                      GETZ, Richard R.                                           Hawaii Regional Medical Program                           Public    Health     Service
                           Chief, Heart Disease Control Program                      Executive Director                                         Leahi Hospital, Honolulu                                  HAGLUND, Richard F.
                           National Center for Chronic Disease                       Medical Television       Network                                                                                     Program Manager
                           Bureau of Disease Prevention and                          GILLESPIE, Guy T., M.D.                                    GRANDON, Raymond C., M.D.                                 Intermountain      Regional       Medical       Program
                             Environmental Control                                   Cancer Coordinator                                         Chairman, Regional Advisory Group                         University of Utah Medical Center
                           Public Health Service                                     Mississippi Regional Medical Program                       Susquehanna  Valley  Regional  Medical
                           FRALEY, Pierre C.                                         University Medical Center                                     Program                                                HAGOOD, William J., Jr., M.D.
                                                                                                                                                                                                          Speaker, Congress of Delegates
                           Director of Information                                   GILLESPIE,       John       W.                             GRANING, Harold M., M.D.                                  American Academy of General Practice
                           Greater    Delaware    Valley     Regional     Medical    Planning Officer                                           Assistant Surgeon General                                 Member, Executive Committee
                            Program                                                  Alabama      Regional      Medical       Program           Public Health Service                                     Virginia Regional Medical Program

                           148






                    HALL, Jack, M.D.                                  HASEGAWA, Masato M., M.D.                         HENNINGS, Arthur G.                               HOHMANN,      Thomas      C.,      M.D.
                    Director     of     Medical     Education         Senior Member, Steering Committee                 Member,    Regional     Advisory     Group        Chairman, Regional Advisory Group
                    Methodist     Hospital,      Indianapolis         Hawaii Regional Medical Program                      Steering        Committee                      Subcommittee on Stroke
                    IIAMMERSLEY,      Don      W.,       M.D.         HATCH,      Charles      L.                       Coordinator, University Health Center of          Western     Pennsylvania      Regional      Medical
                    Chief, Professional Service                       Field        Representative                          Pittsburgh                                        Program
                    American     Psychiatric      Association         Susquehanna          Valley Regional        Medical HENRY, Barbara Whitmore                         HOLBROOK, W@rd C.
                    HAMPTON, H. Phillip, M.D.                            Program                                        Area     Liaison     Officer                      Executive Director, Health and Welfare
                    Chairman,       Executive       Committee         HATCH,      Thomas       D.                       Greater    Delaware    Valley     Regional        State of Utah
                    Florida    Regional    Medical    Program         Executive Officer                                    Medical       Program                          HOLLAND, Charles D.
                                                                      Division of Allied Health Manpower                HERMANN,       John       B.                      Assistant Director
                    HANSEN, Jane                                      Bureau of Health Manpower                         Planning    Director,    The     Creighton        West    Virginia    Regional    Medical     Program
                    Information Specialist
                    Heart   Disease   and   Stroke    Control         Public    Health    Service                          University                                     HOLLOMAN, John L., M.D.
                       Program                                        HAYES,      Donald      M., M.D,                  Associate        Coordinator                      Past President
                    I)ublic ff(-alth Service                          Assistant   Professor    of Medicine              Ncbraska-South Dakota Regional                    National Medical Association
                    I IAI'Pl-',I,, Roderick                           l@owriian   (;ray    School of Mcdi(@in(@            Medical       Program                          Mcinlier,    Regional    Advisory    Group
                    Assistant (,(@r(iiii;ttor                                                                           III-"US'I'IS, All)(@rt E., M.D.                   New    York    Metropolitan    Regional     Medical
                    (@reater  Delaware  Val   I(!y   Regional         IIAYI,"S, Ioliri J.                               Director                                             ProgranL
                                                                      I)ir(!(:Lor, Hospital Division                    Michigan    Association    for    Regional
                       Medical Program                                North  Carolina  Regional      Medical      Pro-                                                    HOLMBERG,    R.    Hopkins,     Ph.     D.
                                                                                                                           Medical Programs, Inc.                         Director
                    HARDIN, Neal H.                                      gram
                    Head, Continuing Education and Health             HAYES, Richard L., M.D.                           HILDEBRAND, Paul R., M.D.                         Health   Systems    Science    Division
                       Professions                                    Assistant to Chief                                Program          Coordinator                      American Rehabilitation Foundation
                    Oklahoma Regional Medical Program                 Cancer Control Program                            Colorado-Wyoming Regional Medical                 HONICKER, Franklin, Jr.
                    HARE, Edgar                                       National Center for Chronic Disease                  Program                                        Liaison Officer
                    Dcl;iwar(@  Liaison   R(@prc,,(@nt@ttiv(!            Control                                        1-1 I 1,1,, David B.                              Greater    Delaware    Valley     Regional
                    Greater    Delaware    Valley    Regional         l'ul)li(@  Health   Service                       1'rofcssor Of  COrIlITILinity  Medicine              Medical Program
                       Medical Program                                HAYES, Robert H., M.D.                            University   of    Vermont                        HORENSTEIN,Simon, M.D.
                    HARRIS,    John    H.,    Sr.,     M.D.           Associate      Coordinator                        HINE,    Maynard     K.                           Associate  Professor   of   Neurology
                    Chairman, Special Board Committee                 Nebraska-South    Dakota     Regional             Chairman, Research Committee                      Case   Western   Reserve   University
                    Susquehanna  Valley  Regional  Medical               Medical Program                                American Dental Association                       HORTON, Odell
                    Program                                           HELLER, William M., Ph. D                         American Association of Dental Schools            Director  of  Hospitals  and   Health
                    HARRISON,     Donald      C.,      M.D.           Director, Department of Scientific                IIINKEL, Robert                                      Services
                    Chairman,   Subcommittee    on    Heart              Services                                       Information     Specialist                        City of Memphis
                       Disease                                        American  Society   of   Hospital   Pharmacists   National  Institute of Neurological Dis-
                    Stanford-Area III                                                                                      eases   and   Blindness                        HOUGH, Howard E.
                    California Regional Medical Program               HELLMAN, Louis P., M.D.                           National Institutes of Health                     Associate   Director   for    Community
                                                                      Program Planning and Evaluation                                                                        Involvement
                    HARTFORD,     Thomas      J.,      M.D.           Maryland Regional Medical Program                 HISCOCK, William McC.
                    Vice President, Area Medical Programs             University  of  Maryland  School   of             Deputy Director                                   Western Pennsylvania Regional Medical
                    Arri(-ri(!ari  Cancer   Society,   Inc.              Medicine                                       Office of Program Planning and Evalua-               Program
                    HARVEL, Alvin E.                                  HENDRYSON,     Irvin     E.,     M.D.                tion                                           HUBBARD,   William   N.,   Jr.,    M.D.
                    Assistant Representative for Regional             Associate Director                                Office of the Surgeon General                     Dean, School of Medicine
                       Organization                                   New Mexico Regional Medical Program               Public   Health    Service                        University of Michigan
                    Office   of   the    Surgeon    General           HENNESSEY, Florence D., R.N.                      HOHMAN,     Robert      J.                        Chairman, Regional Advisory Group
                    Public Health Service                             Chief,   Nursing    Service                       Executive     Secretary                           Virginia Regional Medical Program
                    HARWOOD, Theodore H., M.D.                        Veterans Administration Hospital                  American Heart Association                        HUBER, Warren V., M.D.
                    Program Coordinator                               Member, Regional Advisory Group                   Program Planning Committee                        Metropolitan    Washington,    D.C.    Regional
                    North Dakota Regional Medical Program             Ohio   Valley    Regional    Medical    Program   Northlands Regional Medical Program                  Medical Program
                                                                                                                                                                                                                     149










                                        HUDSON,       Charles       R.                              JENSEN, John L.                                                 Kl,"NNI,'It, Harris M., M.D.                              KNOX, Van W., III
                                        Assistant to the Coordinator                                Art Director                                                    Assistant  Director,                          Programs    Research Analyst
                                        Mississippi Regional Medical Program                        Department of Communication Services                            Section                                                   Health    I-'Iconomics     Research     Section
                                        HUGHES,       Gerald        E.                              University of Kansas Medical Center                             I   feart   Disease   Control   Program                   Smith, Kline and French Laboratories
                                        Secretary     for     Meetings                              JOHNSON, Amos N., M.D.                                          Public Health Service                                     KORNFELD, Jack P.
                                        American Academy of Pediatrics                              Garland, N.C.                                                   KENNEY, Howard W., M.D.                                   Director of Data Analysis
                                        HUNT, Andrew D., Jr., M.D.                                                                                                  Medical    Director,    John    A.    Andrew    I-los-    Washington-Alaska Regional Medical
                                                                                                    JOHNSON,       Marion       1-1.                                pital                                                        Program
                                        Michigan Regional Medical Program                           Director of ConirnLinic@itioris                                 rtiskeg(-e I iistititte
                                        Dean, College of Human Medicine                             Washington-Alaska Regional Medical                                                                                        KOWALEWSKI,       Edward        J.,        M.D.
                                        Michigan State University                                      Program                                                      KENNEY, John A., Jr., M.D.                                National Review Committee
                                        HUNT, William B., Jr., M.D.                                                                                                 Professor and Head                                        American Academy of General Practice
                                        Chairman, Medical School Committee                          JOHNSON, Robert O., M.D.                                        Division    of     Dermatology
                                        University of Virginia Hospital                             Assistant Regional Coordinator                                  Froward University College of Medicine                    KRAMER, M. A.
                                        Virginia Regional Medical Program                           Wisconsin Regional Medical Program                              Metropolitan Washington, D.C. Regional                    Field Representative
                                                                                                    Cancer Study Group                                              Medical Program                                           American Medical Association
                                        HUNTER, Oscar B., Jr., M.D.                                 University     of      Wisconsin
                                        President                                                                                                                   KENRICK, Margaret, M.D.                                   KREHL, Willard A., M.D.
                                        College of American Pathologists                            KAISER, Raymond F., M.D.                                        Delegate                                                  Program Coordinator
                                        HUSTON,       Samuel        R.                              Deputy Regional Health Director                                 American     Academy     of     Physical      Medicine    Iowa Regional Medical Program
                                                                                                    Region IX-San Francisco                                         ,iri(i Rehabilitation                                     Director, University Hospitals
                                        Associate Director for Institutional                        Ilublic Health Service                                                                                                    University of Iowa
                                          Affairs                                                                                                                   KING, James C., M.D.
                                        Northern New England Regional Medical                       KASSEL, Henry W., M.D.                                          Associate    Regional        Health           Director    KRYSTYNAK, Leonard F.
                                          Program                                                   Regional Health Director                                        (Chicago)                                                 Research Assistant
                                        HUTCHISON, Dorothy J., R.N.                                 Region VIII-Denver                                              Bureau of Health Services                                 University of Michigan
                                        Chairman, Nursing Committee                                 Public Health Service                                           Public Health Service                                     KUMMER, Theodore G.
                                        Wisconsin Regional Medical Program                          KAUFFMAN,        John         W.                                K ING, James F., Jr.                                      Special Projects Administrator
                                        INGALL, John R. F., M.D.                                    Administrator                                                   l'ul)lic I fealtli Analyst                                Smith, Kline and French Laboratories
                                        Program Director                                            Princeton Hospital                                              Office of Program Planning and                            KUTTNER, Dena
                                        Western New York Regional Medical                           KEAIRNES, Harold W., M.D.                                       Evaluation                                                Exhibit Officer Cancer Control Program
                                          Pz-ogrwn                                                  Assistant  Coordinator  for  Research  and                      Office of the Surgeon General                             Public Health Service
                                        INGERSOLL, Ralph, Ph. D.                                      Evaluation                                                    ijl)llc Health Service
                                        Director of Research in Medical                             University of Kansas Medical Center                             KISSICK, William L., M.D.                                 LAGACE, Arthur E., Jr.
                                          Education                                                 KELLER, Martin D., M.D.                                         Director                                                  Health Administration Specialist
                                        Ohio State University College of                            Office of the Dean                                              Office   of   Program   Planning    and                   Colorado-Wyoming Regional Medical
                                          Medicine                                                  Department of Preventive Medicine                               Evaluation                                                  Program
                                        IVES, John E.                                               Ohio State University                                           Office of the Surgeon General                             LAMBORN, Emiley
                                        Director                                                                                                                    Public Health Service
                                        University of Connecticut, McCook                           KELSO, John H.                                                  KITCHING,      William      M.                            Director of State-Federal Relations
                                          Hospital                                                  Executive Officer                                               Field   Services    Consultant                            National       Rehabilitation       Association
                                        JANEWAY, Richard, M.D.                                      Public Health Service                                           Adult    Health    Protection    Branch                   LARKIN, Vincent depaul
                                        Assistant Professor of Neurology                            KEMP, Marguerite W.                                             Division of Medicil Care Administration                   Director
                                        Program Aclministritor, Cerebral                            Staff Assist;iti 1, I          ion OfFi(-(-                     lltli-l-;ili of I f(,;Illll                               N(-w York Mi-ir(tl)oli(;tti                 M(-(Ii(-;tl
                                          Vascular Iti-si-;tr-i-li I @tiit                                    ,( I
                                        ltowiii.iii (;r@ty School of M(-(Ii(-iiii-                          I         Si-I vi(.(@                                   KNI,'],', Cli;tr-](-s W., Jr.                             1,Al@SON, Carol M.
                                        JEFFERS, James R.                                           KENNI-"DY, Paul K.                                              Office of Pul)li(@ Relations and                          Nursing       Consultant-Cor<)n-,iry       Care
                                        Coordinator, Economics Section                              I-)(-I);trttiietit of Planning and Goorclin;iti(-n              Communications                                            Heart Disease Control Program
                                        Iowa Regional Medical Program                               Alabama Regional Medical Program                                South Carolint Regional Medical Program                   Public Health Service

                                        150






                               LARSON,      Laura      G.,       R.N.                            LEWIS, Charles E., M.D.                                            LYLE,   Carl    B.,    Jr.,    M.D.                               McFADDEN,          Catherine          L.
                               Associate Director                                                Coordinator                                                        Associate Professor of Medicine                                   Heart Disease Control  Program
                               Mountain        States        lt(!giori;il         Medical        Ktris;ts Itegiori@kl Medical          1'rogr;iiii                  University  of  North  Carolina              School  of           iltil)lic   fic@ilLh    S(,rvice
                                   l'i-(iFi,r@iiii                                                                                                                    M(.(ii(,ill(@                                                   M(:(;II.I., iteiiry C@., Jr., M.D.
                                                                                                 1.1" W I S, I I-vi lig J.                                                                                                            institutional Coordinator
                               LAWRENCE, Clifton F., Ph. D.                                      Deputy Assistant Director                                          LYNCH, George                                                     Texas Regional Medical Program
                               Associate Secretary                                               Bureau of the Budget                                               Audio-Visual              Coordinator
                               American Speech and Hearing Association                           Office of the President                                            Bowman Gray School of Medicine                                    McGOWAN, Larry, M.D.
                               LAWTON, Robert P.                                                 LEWIS, Sandra E.                                                   LYNCH, Richard V., Jr., M.D.                                      Greater Delaware Valley Regional
                               Associate Dean                                                    Executive Assistant to            the Director                     President,                                                           Medical Program
                               Yale University School of Medicine                                Northern       New       England       Regional        Medical     West Virginia State Medical Association                           McKENZIE, Richard B.
                                                                                                    Program                                                         Chairman, Regional Advisory Group                                 Program              Coordinator
                               LAYTON, Margaret                                                                                                                     West Virginia Regional Medical Program                            Susquehanna          Valley          Regional          Medical
                               National       Cancer        Institute                            LIKOFF, William, M.D.                          ardiology           McBEATH, William H., M.D.                                            Program
                               National Institutes of Health                                     President,     American     College     of     C
                                                                                                 Hahnemann       Medical       College       and       Hospital     Program Coordinator                                               McLAUGHLIN,                     Margaret
                               LEARNARD,          William          E.                                                                                               Ohio Valley Regional Medical Program                              Chief Nurse Officer
                               Associate Director                                                LILIENFELD, Abraham M., M.D.                                                                                                         Public      Health       Service
                               Health and Welfare Activities                                     Professor and Chairman                                             McCALL, Charles B., M.D.                                          McNERNEY, Walter J.
                               Smith,      Kline      and       French       Laboratories        Department       of       Chronic       Diseases                   Associate Professor
                                                                                                 Johns  Hopkins  University  School                  of             University of Tennessee College of                                President
                               LEE,    Lyndon    E.,    Jr.,     M.D.                               Hygiene and Public Health                                         Medicine                                                        Blue     Cross     Association,     Inc.
                               Director of Surgical Service
                               Chief,        Extra        Veterans         Administration        LINDEE,      Robert      G.,       M.D.                            McCARTHY, Dr. Thomas                                              McNULTY, Matthew F., Jr.
                                   Research                                                      Assistant Dean                                                     Office of the Director                                            Director,      Council       of       Teaching       Hospitals
                               Veterans              Administration                              Stanford University School of Medicine                             Bureau     of     Health     Services                             Associate      Director,      Association       of       Amer-
                                                                                                                                                                    Chief, Grants Review Branch                                          ican Medical Colleges
                               LEE, Dr. Marina D.                                                LINDSLEY,        George        A.,        M.P.H.                   Public Health Service                                             McPHAIL,      Frank       L.,       M.D.
                               Chief,       Medical        Division                              Assistant Executive Director                                                                                                         Director, Montana Region
                               Science Information Exchange                                      Illinois Regional Medical Program                                  McCONNELL, Thomas S., M.D                       '
                                                                                                                                                                    New Mexico Regional Medical Program                               Mountain       States       Regional       Medical        Pro-
                               Smithsonian              Institution                              LLOYD, Frank P., M.D.                                              School of Medicine                                                   gram
                               LEE, W. Boyd                                                      Director of Research                                               University     of     New      Mexico                             MACER, Dan J.
                               Dental Consultant                                                 Methodist Hospital of Indiana                                      McCORMICK,                   Calvin                               Director
                               Cancer        Control        Program                                                                                                                                                                   Veterans Administration Hospital
                               National      Center       for       Chronic       Disease        LOBUE, A. J., M.D.                                                 Senior Project Coordinator
                                                                                                 Member, Regional Advisory Group                                    Kidde       Construction,        Inc.                             Chairman, Regional Advisory Group
                                   Control                                                       California Regional Medical Program                                                                                                  Western         Pennsylvania         Regional          Medical
                               Public Health Service                                                                                                                McCUNE, William S., M.D.                                             Program
                               LEEDS, Dr. Alice A.                                               LOGSDON,       D.       N.,        M.D.                            President                                                         MACLAGGAN, James, M.D.
                               Special        Consultant         on         Comprehensive        Chief, Professional Service Section                                Medical Society of the District of                                Vice Chairman
                                   Planning                                                      Division of Medical Care Administration                               Columbia                                                       California Regional Advisory Group
                               National  Institute of Mental Health                              Public Health Service                                              McDANIEL,         Valcta         K.                               MACON, N. Don
                               Public Health Service                                             LUKEMEYER,          George           T.                            National Communicable Disease Cente@                              Planning Director
                               LEIN, John N., M.D.                                               Program Coordinator                                                Heart  Disease  Control  Standardization                          Texis Regional Medical Program
                               Associate Dean                                                    Indiana Regional Medical Program                                      Laboratory                                                     Program       Coordinator       for       University        of
                                                                                                                                                                     ublic Health Service                                                Texas
                               University       of       Washington       School       of        Associate      Dean,      Indiana      University       School     p
                                                                                                    of Medicine
                                   Medicine                                                                                                                         McDONALD,         Byron          A.                               MAGRAW,                  Richard
                               LEVINE,      Dr.      David       L.                              LUMMIS, Wilbur S., Jr., M.D.                                       Systems Engineering Consultant                                    Assistant Director
                               Associate        Dean,        School of Social  Work              Deputy Director                                                    Northern New England Regional Medical                             Bureau of Health Services
                               Syracuse University                                               Hawaii State Department of Health                                     Program                                                        Public      Health       Service
                                                                                                                                                                                                                                                                                              151
                                         292-414 0-68-11









                                    MAMIYA, Richard, M.D.                                              MAYER, William D., M.D,                                           MITCHELL, John A., M.D.                                            MURBACH, Edwin R., M.D.
                                    Leahi Hospital                                                     Dean   and   Director                                             President                                                          Northw@t District Chairman
                                    Hawaii Regional Medical Program                                    University of Missouri Medical Center                             Charles L. Drew Society                                            Northwestern  Ohio  Regional  Medical
                                    MARKEY, William A.                                                 MEEK, Peter G.                                                    MIYAMOTO, Robert M., M.D.                                              Program
                                    Deputy Director, USC-Area V                                        Executive    Director                                             President Elect                                                    MUSSER, Marc J., M.D.
                                    California Regional Medical Program                                National Health Council                                           I I-,iwaii Medical Association                                     Executive Dire(@tor'
                                    University  of  Southern   California   School                                                                                                                                                          North Carolina Regional Medical
                                       of Medicine                                                     MELICK, Dermont W.,                     M.D.                      MOOLTEN, Sylvan E., M.D.                                              Program
                                    MARTIN, Samuel P., M.D.                                            Program Coordinator                                               GI)-,IirT-naii,  Task  Force  Committee  on                        MYKY'I'EW, Marion, M.D.
                                                                                                       Arizona Regional Medical Program                                     Medical l,ducation
                                    Program Coordinator                                                University of Arizona College of Medicine                         I\/Iiddlesex G",Ieral Hospital in New Jersey                       Assistant Coordinator
                                    Florida Regional Medical Program                                                                                                                                                                        Wisconsin Regional Medical Program
                                    Provost, J. Hillis Miller Medical                    Center        MELTON, William K.                                                MOORE, Charles W.                                                  Marquette School of Medicine
                                    MARTZ, E. Wavne, M.D.                                              Director of Education                                             Associate Coordinator, Administration                              NADEL, Eli M,, M.D.
                                                                                                       The American College of Radiology                                    and Institutions
                                    Associate   Director,   Continuing   Education                                                                                       Kaiists Regional Medical Program                                   Associate Dean
                                    Western    Pennsylvania    Regional    Medical                     MERRITT, Betty L.                                                                                                                    St. Louis University School of Medicine
                                       Program                                                         Communications and Iiiforryiatiori Officer                        MOORE, George                                                      NJ,-@1,LIGAN, William D.
                                    NIAR'I'Z, Dr. Heleri E@                                            Georgia Regional Medical Program                                  Deputy Regional II(-altli Director                                 Executive    Director
                                    Staff Assistant for Planning                                       Ml,TCAI,FE, Robert M., M.D.                                       Region 111-Charlottesville                                         Ariicrican College of Cardiology
                                    Medical Assistance Administration                                  Associate Director
                                                                                                                                                                         Public He@iltli Service
                                                                                                                                                                                                                                            NELSON, Kinlcch, M.D.
                                    Social tnd Rehabilitation Service                                  Tennessee Mid-SoLith Regional Medical                             MORGAN, Harold S., M.D.                                            Program Coordinator
                                    Public Health Service                                                Pr(@grani                                                       Program (Coordinator                                               Virginia IZ(@giOtial Medical Program
                                    MARY,  Charles  C.,  Jr.,  NI.D.                                                 'I'lioriias    C.,     M.D.                         N(@I)i-;tskt-Soittli Dikot;t Regional Medical                              M(@(licil College of Virginia
                                    Associate Director                                                                                                                      Program
                                    Charity  I-lospitil  of        New  Orleans                        Cliairiiiin,  l'ostgra(Itiatc! Education C@orri-                                                                                     Nl-',I,SoN, Willi@iiii 1'., 111, 'v[.D.
                                                                                                         mittee                                                          MORGAN, Robert J., M.D.                                            Professor of Postgraduate Medicine
                                    MASLAND,  Richard  L.,  M.D.                                       University of Wisconsin Medical S(@liool                          Chairman, Regional Advisory Committee
                                    Director                                                                                                                             Nebraska-South Dakota Regional Medical                             Albany Medical College
                                    National      Institute       of       Neurological       Dis-     Mfl,I,ER,      George      E.,       M.D.                           1'rogriiii                                                       NEMIR, Paul
                                      cases  and  Blindness                                            Director,  Office  of  Research  in  Medical                                                                                         I)ir(,(@tor, Division of Graduate Medicine
                                    National Institutes of 1-fealtli                                     I,'dLication                                                    MORRISSEY, Edward F.                                               University of Pennsylvania
                                    MASON, Joseph J., Jr.                                              University of Illinois College of Medicine                        Assistant Director
                                    Associate  Director  for  Administration                           Division  of  Regional  Medical  Programs                         Connecticut Regional Mcclicil 1'rogi-arii                          NEWELL, Agnes M.
                                                                                                         National  Review Committee                                                                                                         Nursing          Consultant
                                    Alabama Regional Medical  Program
                                                                                                                                                                         MOSES, Cimpbell, M.D.                                              Stroke Progri
                                    MASSEY  Dr. Robert U.                                              MILLER,      Winston       R.,       M.D.                         Medical Director                                                   Heart DiscasemControl Section
                                    Lovelace    Foundation        for        Medical        Educa-     Program  Director                                                 American Heart Association                                         Public Health Service
                                      tion and Research                                                Northlands Regional Medical  Program
                                                                                                                                                                         MOU,'I'homas W., M.D.                                              NEWMAN, T. R.
                                    Nc%v       Mexico       Regional        Medical        Program     MILLIKAN,  Clark  El.,  M.D.                                      Assistant to the Coordinitor                                       %(Iministrative Officer
                                    MATOREN, Gary M.                                                   National  Advisory  Council  on  Regional                         Central   New   York   Regional   Meclicil                         Ohio Villev Regional Medical Program
                                    Associate  Coordinator                                               Medical         Pro
                                                                                                                           grams                                           Program
                                    New Jersey Regional             Medical  Program                   Consultant  in      Netirology                                                                                                       NIGAGLIONI, Adan, M.D.
                                    MATTINGLY, Thomas W., M.D.                                         Mayo  Clinic                                                      MOU'I'SATSOS, Spero                                                Program Coordinator
                                    Program  Coordinator                                                                                                                 Project Director, Heilth Manpower                                  Regionil Medical Proqriiii of Puerto Rico
                                    N,fetropolitan       @Vasliingtoti,       D.C,,       Regional     MITCHF',I,f,,       l@'rank  L.,  M.D.                            Western   New   York   R(-,gioii;il   M(,(Ii(-;il                                  Mi-cli(-:tl
                                                                                                       D(@l)tity (:Iiif-f, Office                                                                                                                        of I'il(-l  to
                                    MAYER,  Andrew,                                                    I)i%-isi,,il,)f I)il,e(.t I                                       M U 1, 1, I", IZ, J;l 11                                           NILSON,
                                    .Nssistaiit      Director,       Professional       Activities     liLit-t@;iti of I l(@altli Services                               Assisttzit Director  -Wisliijigtoii Office                         .Assistant Program Coordinator
                                    .,American  College  of  Surgeons                                  Public Health  Services                                           Ain(-ric@iii Nurses Association                                           Regional Medical Program
                                    152







                                   NOROIAN, Edward II.                                                PAREI,IUS, M. Ronald                                              PAYNE, W. Fixon, M.D.                                             PETERSON, Stanley S., M.D.
                                   Executi%-c Dire( Lor                                               Oregon                  Medical Ili-ogi,aiii                      Acting       Director,       1161)kitis%,ille,        Kentucky    District           Consultant
                                   Presbyterian University Ilosl)it@il                                PAI@Kl-'R,           f,orraine                                        Area                                                          Missouri  Regional  Medical  Program
                                   Western                                            M(.(Ii(-;Il                                                                       Tennessee       Mid-SOLItli        Regional        Medical        Sriiith-GI),n-C-.Lllaway Clinic
                                       Prograrii                                                      Communications and Information                                        I'vogi-ani                                                    PETIT,  Donald  W.,  M.D.
                                   NORTON,       Joseph        A.,        MD.                         North       Dakota       Regional       Medical        Program    Jennie  Stuart Memorial  Hospital                                 Director,  USC-Area V
                                   llr(@sid(-nt,    Arkansas     NI(@di(-@il     Society                              Itill)li  C.,  Jr.,  M.D.                         PEARSON,         David         A.                        ranch    California Regional  Medical  Program
                                   ?vlcziil)cr, Rcgion@il Advisory Board                              l'i-ogi-iiiii          Coordinator                                Deputy Chief, Health Econoiriics                  B
                                   Arkansas       Regionil        Medical        Program              Rocii(@stcr (New York)  Regional                       Medical    Division      of       Medical       Care       Administration    PHILLIPS, John B., M.D.
                                   O'DOHERTY, Desinoiid S., M.D.                                         Program                                                        Bureau  of Health  Services                                       Assistant Professor of Postgraduate
                                   Chairman, Regional Advisory Committee                                                                                                Public       Health       Service                                     Medicine
                                   Metropolitan         Washington,         D.C.         Regional     PARKS,  Raymond  E.,  M.D.                                        PECHMANN,  David K.                                               Albany Medical College
                                       Nfedical Program                                               Associate  Dean                                                   Administrative            Officer                                 POLLEY, Donald B.
                                   Professor       and       Chairman,       Department        of     University     of     Mixiiai     School      of      Medicine    Virginia Regional  Medical  Program                               Television Coordinator
                                       Neurology                                                      I'ARRE'I'I'E,  Robert  N.                                         PECK,  Cecil  P.                                                  Bowman Cray School of Medicine
                                   (;corg(@t(,%@,i) University I li'SI)it@ll                          Physical  'I'li(-r@tl)y  Consultant                               American  Psychological Association
                                   OGDI,'.N, Michael, iNI.1).                                         llul)lic      Health       Service                                Chief,  Psychology  Division                                      POPMA, Alfred M., M.D.
                                                                                                                                                                                                                                          Program Director
                                   Chief, Professional Assignment                    and              PASCASTO, Anne,  Ph. D.                                           Department       of       Medicine       and       Surgery        Mountain States Regional Medical
                                       Research                                                       Associate Research  Professor                                     Veterans  Administration  Central  Office
                                   Office of Program Services                                         University  of  Pittsburgh                                        PEREZ,  Eugene  R.,  M.D.                                             Yrogram
                                   Division of Indian Health                                          Member,       Division       of        Regional        Medical    Program  Director                                                 POSKANZER, Charles N., Ph. D.
                                   Public Health Service                                                 Programs  Review  Committee                                    Virginia Regional  Medical  Program                               Professor of Health Education
                                   OLIVER, Ward [,., M.D.                                             I'ATE,  James  W.,  M.D.                                          PERKINS,  Miles            L.,  M.D.                              State University of New York
                                   Assistant       Professor       of       Postgraduate              Chairman,  Professional Committee                                 Director                                                          College      at      Cortland
                                       Medicine                                                       Memphis  Regional  Medical  Program                               Bureau  of Medical  Care                                          Central New York Regional Medical
                                   Albany Medical Collcg(--                                           Professor, University of Tennessee                                Maine      Department      of      Health       and       Wel-        Program
                                   Albany,     Nc%v     York     Regional      NIcdical      Pro-        College       of       Medicine                                    fare                                                          POTTER, Jacobus L., M.D.
                                       gram.                                                          PATTERSON, John  W.  M.D.                                         PERRY,  Frank  A.,  M.D.                                          Coordinator
                                   OLSON Edith V., R.N.                                               Dean                                 I                            Coordinator      for       Meharry       Medical       College    New     York      University      School      of      Medicine
                                   Nursing birector                                                   University of Connecticut School of                               Tennessee        Mid-South        Regional         Medical
                                   Rochester  (Ne%v York)             Regional            Medical        Medicine                                                           Program                                                       POTTER, John, M.D.
                                       Program                                                        PAUL,        Oglesby,         M.D.                                PERRY,  Lowell  W.,  M.D.                                         Associate Professor of Surgery
                                   OLSON, Stanley W., NI.D,                                                                            Regional             Advisory    Chief,  Pediatric  Section                                        Georgetown University Hospital
                                                                                                      Chairman      ,       Illinois                                                                                                      Metropolitan        Washington,         D.C.,         Regional
                                   Director                                                              Group                                                          Heart Disease  Control  Program                                       Medical           Program
                                   Tennessee Mid-South Regional Medical                               Professor       of        Medicine                                Public       Health       Service
                                       Program                                                        Passavant  Memorial  Hospital                                     PETERS,        Richard         C.                                 POWERS, Helen K.
                                                                                                                                                                        Assistant             Coordinator                                 Chief, Health Occupations Education
                                   PACKER, James T., M.D.                                             PAYNE,  Ethel                                                     Maryland         Regional         Medical          Program        Bureau     of     Adult,      Vocational      and      Library
                                   Associate Director                                                 Nursing             Consultant
                                   .VfisSoLiri Regional Medical             Program                   Heart Disease  Control  Program                                   PETERSON,  John  F.,  M.D.                                            Programs
                                   University of %Iissoiirii%l(@(li(-al Center                        public     Fl(,@iltli      Service                                Director,  Loma  Linda Area                                       Office      of      Education
                                                                                                                                                                        (',,tliforiiia Regional  M(-clical               Pz-ograni        U.S.       Department       of       Health,        Education,
                                   I'AINTI@'R,     ]Robert     C.,      M@1).                         I'AYNE,       Gerald        H.                                    Loma      Linda      University      School      of      Medi-        and Welfare
                                   North Dakota Regional \I(@cii(-al llr(,graiii                      Chief,       Adult       Hetrt   Preventive           Programs        cinc
                                                           I-"iliil                                      S,.(Ii,)Il                                                     I'],''    'ItSoN,  Osl(-i,  I,.,  M.D.                            PRICE, Derck W.
                                                                                                      II(';Ir'L  I)is(-@ist'  ;III(]   Stroke     Control     I)j-o-    Associate  I)ii-ectot-                                            Survey Dirc(-Lor
                                   Region        III          Charlottesville                            grani                                                          'rri-State        Regional         Medical         Program        University of California at San Diego
                                             1-fealtli                                                Public       Health        Service                                Harvard  Medical  School                                          California Regional Medical Program

                                                                                                                                                                                                                                                                                                     153








                             QUINLAN, Carroll B., M.D.                         RICE, Walter G., M.D.                           ROBERTO, Edward A.                                  RUHE, C. H. William, M.D.
                             Deputy Chief                                      Dean, School of Medicine                        Administrator                                       Director, Division of Medical Education
                             Heart Disease and Stroke Control                  Medical College of Georgia                      Brown County General Hospital                       American Medical Association
                             Program                                           Georgia Regional Medical Program                Chairman, Committee on Community
                             National Center for Chronic Disease               RICH, Susan, R.N.                                  Hospitals                                        RUTH, William E., M.D.
                             Public Health  Service                            Assistant Director                              Ohio Valley Regional Medical Program                Representative Councilor
                             RAKITA, Louis, M.D.                               Survey and Planning                             ROBERTS, Dean W., M.D.                              American Thoracic Society
                             Associate Professor of Medicine                   Oregon Regional Medical Program                 Chief, Regional Medical Program                     SABATIER, Joseph A., Jr., M.D.
                             Cleveland Metropolitan General                    RICHARDS, Carol                                    Activities                                       Program Coordinator
                             Hospital                                          Staff Assistant                                 Hahnemann Medical College                           Louisiana Regional Medical Program
                             Western Reserve University                        Carnegie Corporation of New York                Greater Delaware Valley Regional                    SADLER, Alfred M., Jr., M.D.
                             RAMSEY, Lloyd H., M.D.                            RICHES, Roger J.                                   Medical       Program                            Office of the Director
                             Department of Medicine                            Assistant Operations Officer                    ROBERTS, Frank                                      National Institutes of Health
                             Vanderbilt  University                            Heart Disease and Stroke Control                Administrative Assistant to the Director            SADLER, Blair L.
                             Tennessee Mid-South Regional Medical              Program                                         Louisiana Regional Medical Program                  Program Analyst
                             Program                                           Public Health Service                           ROBERTSON, George J., M.D.                          Office of the Director
                             RANBERG,   Robert   A.                            RIDGES, J. Douglas, M.D.                        Medical Director                                    National Institutes of Health
                             Research Director                                 Medical Officer                                 Bingham Associates Fund                             SAGEN, Oswald K., Ph. D.
                             Susquehanna Valley Regional Medical               Medical Systems Development                     ROBERTSON, Julius D., D,M.D.                        Assistant Director
                             Program                                           Laboratory                                      Institutional    Liaison                            National Center for Health Statistics
                                                                                                                                                                                   Public Health Service
                                                                               National Center for Chronic Disease             Texas Regional Medical Program
                             RAPAPORT Elliot, M.D.
                                                                               Control                                                                                             SANAZARO, Paul J., M.D.
                             Area Coordinator-Area I                                                                           ROBINETTE, Tasker K.
                             California Regional Medical Program               Public Health Service                           Director, Health Care Planning                      Director, Division of Education
                                                                                                                                                                                   Association of American Medical Colleges
                             Cardiopulmonary Laboratory                        RIEDEL, Donald C., Ph. D.                       Washington-Alaska Regional Medical
                             San Francisco General Hospital                    Associate Professor of Public Health              Program                                           SAPPENFIELD, Robert W., M.D.
                                                                               Yale University Medical School                  ROBINS, Edith G.                                    Assistant Director
                             READER, George G., M.D.                                                                                                                               Louisiana Regional Medical Program
                             Coordinator for Cornell Medical School            RIKLI, Arthur E., M.D.                          Information Officer
                             New York Metropolitan Regional Medical            Chief of Operations                             Division of Medical Care Administration             SARACHEK, Norman S., M.D.
                             Program                                           Missouri Regional Medical Program               Public  Health   Service                            Medical Consultant
                                                                                                                                                                                   Heart Disease Control Program
                             Professor of Medicine                             RINGLER, Robert L., Ph. D.                      ROBINS, Morton                                      National  Center  for  Chronic  Disease
                                                                               Chief, Institutional Research Programs          Chief,  Statistics   and Analysis Program           Control
                             REDING,  Mary   josita                            National Heart Institute                        Heart Disease Control Program                       Public Health Service
                             Director, Executive Board                         National Institutes of Health                   Public  Health   Service                            SASULY, Richard
                             American Association of Medical Record            ROBBINS, Guy F., M.D.                           ROCK, James A., M.D.
                             Librarians                                                                                                                                            Coordinator of Program Development
                                                                               Director of Planning                            Vice Chairman, Regional Advisory                    California Regional Medical Program
                             RENTHAL, Gerald, M.D.                             Memorial Hospital for Cancer and Allied          Committee                                          SCHACHTER, Joseph
                             Director                                          Diseases                                        Western Pennsylvania Regional Meuicai
                                                                                                                                Program
                                                                               New York Metropolitan Regional Medical                                                              Statistician
                             joint Committee on Medical Care                   Program                                         Director, Laboratory Services                       Heart Disease and Stroke Control Program
                             Education                                                                                                                                             Public Health Service
                                                                                                                               Lee Hospital in Johnstown
                             American Public Health Association                ROBBINS, Lewis C., M.D.                                                                             SCHATZ, Irwin J., M.D.
                             REYNOLDS,     Florence                            Special Assistant to the Chief                  ROGATZ, Peter, M.D.                                 Wayne   State   University   School   of
                                                                               National Center for Chronic Disease             Director, Long Island Jewish Hospital               Medicine
                             Chief, Information and Reference                  Control                                         ROSS, Mabel, M.D.                                   Michigan Regional Medical Program
                             Services                                          Bureau of Disease Prevention and                Regional Health Director                            SCHELLPEPER, William L.
                             Division of Nursing                               Environmental Control                           Region I-Boston                                     Nebraska-South Dakota Regional
                             Public Health Service                             Public Health Service                           Public  Health   Service                            Medical Program
                             154








                        SCHIEVE, James F., M,D.                            SHELLEY, Roger                                   SKELLEY, Thomas J.                                SOVIE,    Margaret    D.
                        Assistant Dean                                     Director of Public Relations                     Chief,  Division  of   Disability   Services      Director of Nursing Education
                        Office of Continuing Medical Education             Rutgers University Medical School                Rehabilitation    Services    Administration      State University Hospital
                        University  of  Cincinnati  College  of            SHIELDS, George S., M.D.                         U.S.  Department   of   Health,   Education,      Central New York Regional Medical
                           Medicine                                        Associate Professor, Department of                  and Welfare                                       Program
                        SCHMIDT, Roland E., M.D.                             Internal Medicine                              SLEE, Virgil N., M.D.                             SPARKMAN, Donal R., M.D.
                        Associate Professor of Pediatrics                  Cincinnati General Hospital                      Director                                          Program      Coordinator
                        West Virginia University Medical Center            Ohio Valley Regional Medical Program             Commission   on   Professional   and   Hospital   Washington-Alaska Regional Medical
                        SCHNAPER, H. W.                                    SHINE, Patricia A.                                  Activities                                        Program
                        Associate Director                                 Director of Nursing Affairs                      SLEETH,    Clark    K.,    M.D.                   SPARKS, Robert D., M.D.
                        Alabama Regional Medical Program                   Western New York Regional Medical                Dean,   School   of    Medicine                   Assistant Director
                        SCHNEIDER, Aleene                                    Program                                        West   Virginia   University   Medical   Center   Louisiana Regional Medical Program
                        Tumor Registry, Data Collection                    SHOREY, Winston K., M.D.                         SMART, Charles R., M.D.                           SPENCER, William A., M D.
                        Bi-State   Regional   Medical   Program            Program Coordinator                              Intermountain    Regional    Medical    Program   Texas Regional Advisory Group
                                                                           Arkansas Regional Medical       Program          University   of    Utah    Medical    Center      Director
                        SCHOOLMAN,     Harold     M.,      M.D.            Dean, University of Arkansas      School    of                                                     Texas  Institute  for  Rehabilitation  and
                        Director, Education Service                          Medicine                                       SMITH, Patricia Ann                                  Research
                        Veterans Administration Centra          cc         SHULER, Virginia                                 Coordinator Planning for Library and
                        SCHOR, Stanley, M.D.                               Special Assistant for Program                       Information Services                           SPICER, William S., M.D.
                        Temple University School of Medicine                                                                Oklahoma    Regional     Medical     Program      Program      Coordinator
                                                                             Development                                                                                      Maryland Regional Medical Program
                        Greater   Delaware   Valley    Regional            Heart Disease and Stroke Control                 SMITH, Robert, M.D.
                           Medical Program                                   Program                                        Stroke Coordinator                                SPITLER, James D.
                                                                                                                                                                              Assistant Planning Director
                        SCOTT, Ralph M., M.D.                              lltil)lic I I(-aitli S(-rvi(@(-                  Mississippi   Regional   Mccli(@al   Program
                        Professor of Radiology                             SIBI"Ity, 1).  l,'Itigeil(@                      SMITH, Robert li. W., Col.                        University of Texas Medical Branch
                        University of Louisville                           1.  '                                                                                              Texas Regional Medical Program
                                                                           executive Director                                  U.S. Air Force
                        Ohio Valley Regional Mcdi(@;il llrograin           Greater Detroit Area Hospital Council            Deputy  Director   of   Professional   Services   SPRING, William C., Jr., M.D.
                        SEIPP, Conrad, Ph. D.                              Michigan Regional Advisory Group                 Office of the Surgeon General                     Program      Coordinator
                                                                                                                                                                              Greater Delaware Regional Medical
                        Associate Director, Research and                   SIDEL, James, M.D.                               SMITH,    Robert    R.,    M.D.                      Program
                           Evaluation                                      Medical Consultant                               Associate Director
                        Connecticut Regional Medical Program               Heart  Disease  and  Stroke  Control   Program   Georgia Regional Medical Program                  STANKOVICH, Arthur
                        SELIGSO                                            Public Health Service                                                                              Director  of  Management,  Information
                                   N, David, M.D.                                                                           SMITH, Robert Ray                                    Systems
                        Professor of Clinical Pathology                    SIDES, Jerry D., M. Sgt.                         Stroke Program                                    The Lankenau Hospital
                        Yale  University  School  of   Medicine            Continuing    Education    for     Paramedical   Mississippi   Regional    Medical    Program      Greater Delaware Valley Regional
                        SEMINGSON, Howard                                    Personnel                                      SMYTHE, Cheves M.                                    Medical Program
                        President, North Dakota Hospital                   Gunter    Air Force Base, Alabama                Associate Director                                STAPLETON, John F., M.D.
                           Association                                     SIEBER, Harry F., Jr.                            Association   of   American   Medical   College   Associate Dean and Professor
                        Administrator, Trinity Hospital                    Instructor,    Temple    University    Medical
                                                                             School                                         SOFFER, Alfred, M.D.                              Department of Medicine
                        SHANHOLTZ, Mack I., M.D.                           Greater  Delaware  Valley   Regional   Medical   Director, Scientific Activities                   Georgetown University School of Medicine
                        State Health Commissioner                            Program                                        American   College   of   Chest   Physicians      Heart Coordinator, Georgetown
                        Virginia State Department of Health                                                                                                                      University   Hospital
                                                                           SIEBERT, Dennis F.                               SOLOWEY,      Dr.      Mathilde
                        Virginia   Regional   Medical   Program            Information Officer                              Chief,   Program   Projects   and   Clinical      STAUFFER, Lee D.
                        SHARP, Lawrence J., Ph. D.                         Heart Disease Control    Program                    Center Grants                                  Assistant Director
                        Research  Associate  and   Sociological            Public Health Service                            Extramural Programs                               Department of Continuing Medical
                           Consultant                                      SILVER, David                                    National  Institute  of  Neurological  Diseases      Education
                        Washington-Alaska Regional Medical                 Director                                            and Blindness                                  Assistant Professor of Public Health
                           Pro.-ram                                        Diabetes Detection Program                       National Institutes of Health                     University of Minnesota Medical School

                                                                                                                                                                                                                       155











                     STEARNS,      Norman       F.,       M.D.                    STRAUSS, William T., M.D.                                    TAPP, Jesse W., Jr., M.D.                                    TITTLE, C. Robert, Jr., M.D.
                     Acting Director                                              Assistant       Professor       of           Postgraduate    Associate  Professor of  Community                           Program Coordinator
                     Tri-State Regional Medical Program                              Medicine                                                     Medicine                                                  Northwestern       Ohio       Regional        Medical
                     STEARNS, Perry, M.D.                                         Albany Medical College                                       University of Kentucky                                          Program
                     Assistant          Coordinator                               Albany Regional Medical Program                              Institutional Coordinator
                                                                                                                                               Ohio      Valley      Regional      Medical       Program    TOKARS      Jerome      I.,      M.D.
                     Maryland R(-,gionil Medical 1'rogr-.ini                      SUIIRLAND, George, M.D.                                                                                                   I@Llfl'@110  (@t!%v  York)  Regional  Nledical
                     STEINICKE, David G.                                          Department of Medicine                                       TAYLOR, A. N., Pli. D,                                          Program
                     Regional       Medical       Program       Representative    Michigan State University                                    Dean,    School    of     Related     Health     Sciences
                     Michigan     Commission     on      Professional      and                                                                 University of Chicago Medical School                         TOLLMAN, James P., M.D.
                                                                                  SULLIVAN, Dean                                                                                                            Program Director
                        Hospital         Activities                               Washington, D.C., Office                                     TEWART, Braxton E.                                           Nebraskt-South Dakota Regional ),Iedical
                     STEPHENSON,          Dr.          William                    Smith     Kline     and     French     Laboratories          Program Associate                                               Program
                     School      of      journalism                               SULLIVAN, Jaiti(-s 11.                                       New Jersey Regional Nledical Program                         University of N(,I)riski
                     University     of     Missouri                               Assistant (:ooi@(iiii;ttor-                                                                                               'I'OMI'KINS, l@ol)t-r-L (;., M.D.
                     project Director                                             Wis(@orisiri  Rt-giori2il  M(,di(!@il   I)rogr;itii          Stisclu(-Ii@Liiiia Valley l@(-giotixl Medical                Coordinator    for     Tulsa     Area
                     Missouri Regional Medical Program                            SULLIVAN, W. Albert, M.D.                                       Program                                                   Oklahoma       Regional        Medictl        Program
                     STEWART,      Donald       E.,       M.D.                    Director                                                     THOMAS, John F., M.D.
                     President, Minnesota Cancer Society                          Department          of    Continuing              Medical    Chairman,       Regional       ,\dvisory        Committee    TOOLE, James F.
                     Executive Committee, Northlands                                 Education                                                 Texts      Regional       Medical       Program              Chairman, Neurology Department
                        Regional        Medical        Program                    University      of      Minnesota       Coll(-gc       of    'I'IIOMPSON, DtriL                                           Ilowrnari Gray School of %fcdicine
                     S'I'ICKNEY,     J.      Minott,      M.D.                       m(@(ii(-iiic                                              Aciriiiiiistr@itor                                           TOOMI,'Y, l@ol)(-rt 1".
                     Pro.gr-,ir@i      Cof)rdinitor                               SU l,'I'Z, I lat-i-y A.                                                 Maine                I losi)it@ll                                                            liosl)iLtl
                     Nortlil@inds      Regional      Medi(:@il 1'rograni                                                                                                                                       System
                                                                                  Associate Professor                                          THOMPSON, John D.                                            South  Carolina Regional Medical
                     STITH, Marion C.                                             Department of Preventive Medicine                            Department     of      Epidemiology      iiid      Public       Program
                     Administrator                                                State University of New York                                    Health
                     C. S. Wilson Memorial Hospital of                                                                                         Director,  Program  in  Hospital                             TORGERSON jean T.
                        Johnson     City,      N.Y.                               SUMMERALL,     Charles      P.,      III,      M.D.             Administration                                            Chronic         RespirIatory      Diseases      Control
                     STOKES, Joseph III, M.D.                                     Program Coordinator                                          Yale University                                                 Program
                     Coordinator, San Diego-Arca Vii                              South     Cirolina     Regional      Medical      Program                                                                 Nitiorial     Center     for     Chronic      Disease
                     California Regional Medical Program                          SU'I'ER, James 'I'.                                          'T'IIOMIISON, Julia C.                                          Control
                     STONE, Lily M.                                               Res(tarcli Consultant                                        Director, Washington Office                                  Public flealth Service
                     American Cancer Society                                      Division of Hospital and Medical                             Artierican Nurses Association
                                                                                     Facilities                                                THOMPSON,        Spencer        G.,        M.D.              TOWNSEND, Thomas E., M.D.
                     STONEHILL, Robert B., M.D.                                   Public Health Service                                        Associate Coordinator                                        Chairman, Regional Advisory Board
                     Program Director                                                                                                                                                                       Arkansas Regional Medical Program
                     Indiana Regional Medical Program                             SUTHERLAND, John                                             Texas      Regional       Medical       Program
                     STORER,       Edward       H.,       M.D@                    President                                                    THOMPSON, W. R.                                              TRENT, George T,@
                     (@liairiii;iii,                                                                                                                                                                                      Assistant  to tlii- I)irt-(-t<,r

                                                                                                                                                                                                               Ilrogr@tin
                     Associate I)rof(-ssor                                        SYPHAX, Oricanna C.                                             Program
                     University      of       Tennessee       College       of    Chief, Institutional Programs               Section          THORPE, Thomas                                               TRUSSELL,      Ray      E.,      M.D.
                        Medicine                                                  Division       of       Manpower        Development    and   Director,  Communications and  Public                        Associate         Dean
                     STOREY, Patrick B., M.D.                                        Training                                                     Information                                               School   of   Public    Health    and
                     Professor of Community Medicine                              Office of Educition                                                                                                          Administrative            Medicine
                     Hahnemann         Medical         College                    U.S.     Department     of      Health,      EdLIC@ition.    North      Carolini      Regional       Medical
                     Chairman.      Task       Force       on       Continuing       and Welfare                                                  Program                                                   Columbia University
                        Medical           Education                               TABLEMAN, Betty                                              THURSTON, Hester                                             TUCKER, Norman
                     Greater     Delaware      Valley      Regional      Medi-    Planning and Administration                                  Assistant     Coordinator      for      Nursing              Division of Physician NIanpoN%-er
                        cal Program                                               Michigan       Regional       Medical       Program          Kansas      Regional      Medical       Program              Public Health Service

                     156








                        TUF)OR, @V. J.                                                  VOI,I,AN, DOLlgli.9 D., M.D.                                   WELD, Francis Minot, M.D.                                       WILLARD, William R., M.D.
                        l@i-St@Lt(-              M(!(Ii(-itl Program                    Coordinator, UC@-D@i%,is-Ar(@a II                              Medical Consultant                                              Vice      President
                        Southern Illinois University                                    California    Regional    Medical     Program                  Heart Disease Control Program                                   University of Kentucky Medical Center
                                                                                        WA(;Nl-'R, (:itri-titti J., M.D.                               lltil)lic Health Service                                        WILLIAMS, James D.
                        So( ial Work  CoitiL.Itaiit                                                                                                    WELLS, Benjai-nin B., M.D.                                      Chief, Planning Assistance Section
                        .,ktlan(aR(@gitinalOffi(:c-  l@egionIV                          liLIrC@ILI of Health Services                                  Director                                                        Office   of   Comprehensive    Health    Planning
                        I'Lll)li(! II('altfl Service                                    l'ul)lic Health Service                                        Alabama       Regional Medical Program                          Public Health Service
                        TURNER, Glenn O., M.D.                                          WAKERLIN, George E., M.D.                                      WELTON, David G@, M.D.                                          WILLIAMS, Robert G. W., Jr.
                        Project arid -%fedical f)irector                                Director o         Tanning                                     President-Elect                                                 Assistant for Personnel
                        NliSSOLiri R(-gi(,rial Nl(@clical I)r-ograiii                   Missouri    Regional     Medical     Program                   Medical  Society   of   the   State   of   North                Office  of   the   Deputy   Assistant   Secretary
                        T@@'f SS, Nlaitrine                                             University of Missouri                                            Carolina                                                        of Defense
                        C@)jiiititini(:ations SI)c(@ialist                              WALL, PaLtline                                                 WENNBERG, John E., M.D.                                         Health and Medical
                        Urii@-crsity of Mississippi NI(@di(@al Center                   Nitional Cancer Institute                                      Program Coordinator                                             WILLIAMSON, John, M.D.
                        UI,I,NfAN, Alice                                                National Institutes of Health                                  Northern New England Regional                                   Assistant     Professor
                        Assistant    Program    Coordinator                             WARD, Paul D.                                                     Medical Program                                              The Johns Hopkins University
                        Cornell  Nlcdical   College                                     Coordinator    and    Executive     Director                   WEST, Kelly M., M.D.                                            School of Hygiene and Public Health
                        ULNIER, Robert J., '.%4.D.                                      California    Regional    Medical     Program                  Director                                                        WITTEN, Carroll L., M.D.
                                                                                        WARLICK, William J.                                            Oklahoma Regional Medical Program                               Chairman     ,  Medical     Practices      Committee
                        .Nl(!jrtl)cr, Regional ,\d@,isory Groul)
                        North Dakota Regional Nledical Program                          Project Director                                               WESTLAKE, Robert B., M.D.                                       Ohio Valley Regional Medical Program
                        UTTERB.,kCK, Robert A., M.D,                                    South      Carolina      Regional      Medical      Program    Past         President                                          WOOD,  Courtney B., M.D., M.P.H.
                        Professor,    College     of     -Nfcdicinc                     WARNER,  Horner R.,  M.D.                                      American  Society  of  Internal                    Medicine     Coordinator,    Mt.    Sinai     School     of     Medicine
                        University      of       Tennessee                              Project  Leader                                                WHALEY,  Storm                                                  New York Metropolitan Regional
                        Si.it)(@orii@iiitt(@c  on   Stroke                              Intermountain        Regional        Medical        Program    Vice President of         Health Sciences                          Medical           Program
                        'Nfcifipliis Itegional                 I't-ograiii              Lzittcr Day  Saints Hospital                                   University      of      Arkansas       Medical       Center     WOOD, Owen J.
                        V,%LJN, William S., Ni.1).                                      WI-'Iili,  1)(-iiiiis   R.                                                                                                     Sales          Manager
                                                                                                             Consultant                                WHIIIPLE, Dr.  Gerald
                                                                                                                                                       Chairman,      'I'ri-St,,it(-       Regional       Advisory     Video I-' ngincering Company, Inc.
                                                                                                                          -(! Adiiiinis       '                                                                        Washington, D.C.
                                                                                        Division of Mccli(:@il Cai                          tration       Council
                        Greater Delaware Valley l@(@gif)nal                             llul)li(:  Health  Service                                     University Hospital, Boston                                     WOOLSEY, Frank M., Jr., M.D.
                           Nf(,dical Ilrograrri                                         WI-'Bli,     Hamilton,      Col.,      USAF      (MC)                                                                          Program Coordinator
                                                                                        Assistant    for-    lll@iiis,    Health    and     Medical    WHITE, Charles H.                                               Albany Regional  Medical  Program
                                                                                                  ,f    the    Deputy    Assist@itit     S(@crctary    Associate Director
                        f'til)li(  Inf(,r-iii;itiott Officer                                                                                           Ohio Itegiorial  Medical  Program                               WRIGHT, Jane C., M.D.
                        (:oloi-@i(l(.-Wy,@iiiinL, l@(-giori,-tl  M(!Cli(-;il               ,f 1)(.f(.rls(!
                           1'rogi-aiii                                                                           of 1)(-f(@ris(@                                                                                       Coordinator for NeNv York Medical
                                                                                                                                                       WHITMAN,  Sariiu(!I,  M.D.                                         College
                        VEVI@@11,KA,    ]",Llgcnc     NV.,     M@D.                     WEEKS,             William                                     Associate         Dean                                          New York Metropolitan Regional
                        .,@ssistant Director                                            Administrative     Assistant     to      the      Associate    S,ll,,),,l of Medicine                                             Medical           Program
                        Division of Medical Care Administration                            Director                                                    Case  Western Reserve  University
                        Ptil)li(: If(-alth Service                                      New Mexico Regional Medical Program                                                                                            IVU,   Dr.    S.    Y.
                        %71CKERSTAFI-',               Hugh                              WEIL,      Clifton      C.                                     WILBAR, Charles L., Jr., M.D.                                   Professor of Economics
                        Tennessee -.%lid-South Regional Medical                         Administrator                                                  Director                                                        University      of      Iowa
                           Program                                                      Flint     Goodrich     Hospital     of     New      Orleans    West Virginia Regional Medical                      Program     WURZEL, Edward M., M.D.
                        VREELAND,  EllwN-iine  NI.                                      WEINBERG,  Harr), B., M.D.                                     WILBUR,  Dwight,  M.D.                                          Executive           Director
                        Nurse Consultant           I                                    Chairman,       Regional        Advisory        Group          President-Elect                                                 American      Association      of      Medical      Clinics
                        Di%@isic-n of Nursiii@. Intramural Rescar(@ll                   Iowa  Regional  Medical  Program                               American Medical Association                                    XAVIER,            Mal
                           Brari(-fi                                                    WEIN'ERMAN,  E.  Richard,  M.D.                                WILKINS,  Robert J.                                             Administrative Assistant
                        But-(@au    of     II(-alt[i     Nianpo%ver                     Ili-ofessor    of    Medicine     and     Public     Health    Associate Director                                              Metropolitan       Washington,        D.C.,        Regional
                        llul)lic  Health Service                                        Yale  University  Medical  School                              Nortlitands Regional  Medical  Program                             Medical           Program

                                                                                                                                                                                                                                                                            157











                        YAKEL,    Ruth    M.                                                         APPENDIX         4      Samuel H. Proger, M.D.                           Helen  G.  Edmonds,  Ph.  D.
                        Executive   Director                                                                                 Physician-in-Chief                               Dean,    Graduate     School
                        The American Dietetic Association                                       DIRECTORY              OF    Tufts-New England Medical Center                 North    Carolina    College
                                                                                      REVIEW                    COMMITTEE    Boston, Mass. 021 1 1                            P.O. Box 432
                        YARNALL,   Stephen   R.,    M.D.
                                                                                                                                                                              Durham,   N.C.   27707
                        Director,  Project   Development                                       AND               NATIONAL    David E. Rogers, M.D.
                        Washington-Alaska   Regional   Medical                          ADVISORY                  COUNCIL    Professor and Chairman                           Bruce   W.   Everist,   M.D.
                           Program                                                               ON              REGIONAL    Department of Medicine                           Chief  of  Pediatrics
                        University of Washington Hospital                                                                    School   of   Medicine                           Green Clinic
                        YATES, William M.                                             MEDICAL                    PROGRAMS    Vanderbilt University                            709   South    Vienna    Street
                        Administrative Assistant                                                                             Nashville, Tenn. 37205                           Ruston,   La.   71270
                        Tennessee Mid-South Regional Medical               REGIONAL MEDICAL PROGRAMS                         C. H. William Ruhe, M.D.                         John    R.    Hogness,     M.D'
                          Program
                                                                                  REVIEW COMMITTEE                           Assistant    Secretary                           Dean,   School   of    Medicine
                        YOUNG,     James     R.                            Kevin P. Bunnell, Ed. D.                          Council on Medical Education                     University    of     Washington
                        Information     Officer                            Associate Director                                American Medical Association                     Seattle,   Wash.   98105
                        West Virginia Regional Medical Program             Western Interstate Commission for                 535 North Dearborn Street                        James    T.    Howell,     M.D.
                        YUNG, E. V., M.D,                                    Higher Education                                Chicago,  111.   60610                           Executive    Director
                        Director,   Survey   and   Planning                30th Street                                       Robert J. Slater, M.D,                           Henry   Ford    Hospital
                        Oregon Regional Medical Program                    Boulder, Colo. 80302                              President                                        Detroit,   Mich.   48202
                                                                           Geor e James, M.D.                                The Association for the Aid                      Clark   H.    Millikan,    M.D.
                        ZWICK,    Daniel     I.                                9
                                                                           Dean, Mount Sinai School of Medicine                of Crippled Children                           Consultant     in     Neurology
                        Associate Director of Program
                                                                           Fifth Avenue and East 100th Street                345 East  46th  Street                           Mayo Clinic
                          Management
                                                                           New York, N.Y. 10029                              Ne%v York, N.Y. 100 1 7                          Rochester,     Minn.      55902
                        Office  of   Economic   Opportunity                Howard W. Kenney, M.D.                            Mr. John D. Thompson                             George    E.    Moore,     M.D.
                                                                           Medical Director                                  Professor of Public Health and Director,         Director, Public Health Research
                                                                           John A. Andrew Hospital                             Program in Hospital Administration             New York State Department of Health
                                                                           Tuskegee Institute, Ala. 36088                    Yale University Medical School                   Roswell Park Memorial Institute
                                                                           Edward J. Kowalewski, M.D.                        New Haven, Conn. 06520                           666 Elm Street
                                                                           Chairman, Committee of Environmental              Executive    Secretary                              u
                                                                             Medicine of the Academy of                        Mrs. Martha L. Phillips                        Edmund D. Pellegrino, M.D.
                                                                             General Practice                                  Chief, Grants Review Branch                    Vice President for the Health Sciences
                                                                           Akron, Pa. 17501                                    Division of Regional Medical Programs          Director of the Medical Center
                                                                           George E. Miller, M.D.                              National Institutes of Health                  State University of New York
                                                                           Director, Office of Research in                     Bethesda, Md. 20014                            Stony  Brook,  N.Y.  I  1   790
                                                                             Medical Education                                                                                Alfred    M.    Popma,     M.D.
                                                                           College of Medicine                               NATIONAL ADVISORY COUNCIL                        Director,    Mountain    States
                                                                           University of Illinois                                 ON REGIONAL MEDICAL                         Regional    Medical     Program
                                                                           Chicago, 111. 60612                                             PROGRAMS                           525  West   je   erson   Street
                                                                           hilip M. Morse, Pli. D.                                                                            Boise,  Idaho   83702
                                                                           p
                                                                           Director                                          I-'Idwin L. Crosby, M.D.                         Mack   1.    Shanholtz,    M.D.
                                                                           Operations Research Center                        Director
                                                                                                                                                                              State    Health    Commissioner
                                                                                                                             American Hospital Association                    State  Department   of   Health
                                                                           Massachusetts Institute of Technology
                                                                           Cimbridge, Mass. 02139                            Chicago,  111.   60611                           Richmond,   Va.    23219
                                                                           Anne Pascasio, Ph. D.                             Michael E. DeBakey, M.D.                         Ex   Officio   Member
                                                                           Assistant to the Vice Ilresident                                Cliaii-iii@iii                        Willi@trii 11. St(-w@irt, M.1).
                                                                           Health Professions                                Department of Surgery                               Surgeon    General
                                                                           University of Pittsburgh                          College  of   Medicine                              Public    Health     Service
                                                                           443 Scaife Hall                                   Baylor University                                   9000  Rockville  Pike
                                                                           Pittsburgh, Pa. 15213                             Houston,  Tex.   77025                              Bethesda,     Md.      20014

                        158








                                                                                                    APPENDIX 5                          Evaluation                 Branch:
                                                                                                                                           Rlioda        Abrams....         .............  Program       Analyst.
                                                                                             DIRECTORY                  OF                 Arthur     B.     Hiatt,     Jr ..............  Program       Analyst.
                                                                             DIVISION             OF              REGIONAL                 Suzanne         G.         Paul ................ Program       Analyst.
                                                                                                                                           Laura         J.         Shouse ................. Program       Analyst.
                                                                                   MEDICAL  PROGRAMS                                       Mary         A.          Teller ........      ......... Program       Anaylst.
                                                                                                                                           Edward         S.         Walsh ................ Program       Analyst.
                                                                                                                                        Statistics and Analysis Branch:
                        OFFICE       OF       THE       DIRECTOR                                                                           Mary        V.         Geisbert ................ Public    Health     Analyst.
                        Immediate Office:                                                                                                  Loren       D.       Hellickson ..............  Public    Health     Analyst.
                        Robert    Q.    Marston,     M.D .....   ...  Director.                                                            Leah     Resnick.      .      @................ Public    Health     Analyst.
                        Karl    D.    Yordy .........          .....  Deputy        Director.                                              Jackie       M.       Rosenthal .............   Statistical    Assistant.
                        Margaret   H.   Sloan,   M.D..    .  . .      Associate Director for Organizational Liaison.
                        Maurice E. Odoroff. .         ........        Assistant to Director for Health Data.                            OFFICE OF ASSOCIATE DIRECTOR FOR OPERATIONS
                        Leroy G. Goldman            ............      Program Policy Specialist.                                           Richard B. Stephenson, M.D              ......  Associate Director for Operations.
                        Eva  M.  Handal.  .  ....  @  @.  @   ......  Committee Management Officer.
                        Elizabeth F. Fuller          ...............  Secretary to Director.                                            Operations Staff.
                        Oifice of Executive Officer:                                                                                       Ira    R.    Alpert ...................         Operations       Officer.
                        Charles Hilsenroth        ......  .......     Executive      Officer.                                              Robert       C.        Anderson .............   Operations       Officer.
                        Nicholas     G.      Cavarocchi.              Financial Management Officer.                                        Vincent J. Carollo, M.D             ..........  Operations       Officer.
                        Robert L. Quave.                              Administrative Officer.                                              John R. Hamilton, III, M.D              ......  Operations       Officer.
                        Norman E. Prince, Jr             .......      Personnel      Officer.                                              Robert M. O'Bryan, M.D                ........  Operations       Officer.
                        Anna V. Windsor      .....     ..........     Budget Analyst.                                                      Alphonse             Strachocki .............   Operations       Officer.
                        Lorraine H. Hughes          .... .........    Administrative Assistant.                                         Grants     Management      Branch:
                        Mary J. McCormack. .           .......        Office Services Supervisor.                                          James       Beattie ...................         Chief.
                                                                                                                                           Thomas                   McNiff ............... Grants Management Officer.
                        Ofice of Communications and Public InIformation:                                                                              i
                        Edward      M.       Friedlander ..........   Assistant to Director for         Communications                     Gerald         L.         Teets .... ........... Grants Management Officer.
                                                                         and Public Information.                                           George        F.         Hinkle ................ Grants Management Officer.
                        Frank   Karel   III         ................. Public Information Officer.                                          Arthur        Curry ...................         Grants Management Specialist.
                        Judith J. Fleisher   ...       .......   ...  Public Information Specialist.                                       Donald          M.          Fox ................. Grants Management Specialist.
                        Ellen   D@   Carter ......             ....   Public Information Specialist.                                    Grants       Review        Branch:
                        Simone D. Biren. .    ....        .......     Editor.                                                              Martha       L.        Phillips .......     ....... Chief.
                        OFFICE OF ASSOCIATE DIRECTOR FOR PLANNING AND                                        EVALUATION                 Grants       Review       Section:
                                                                                                                                           Peter        A.         Clepper ................ Public    Health     Advisor.
                        Stephen J. Ackerman            .........      Associate Director for Planning and Evaluation.                      Robert         E.         Jones ................. Public    Health     Advisor.
                        Planning Branch:                                                                                                   Patricia      K.       McDonald ............    Public    Health     Advisor.
                        Roland L. Peterson       ...........          Chief.                                                               Harold      F.       O'Flaherty ............    Scientific Grants Assistant.
                        Thomas Kinser.,. . @ . @ @  @  :...           Program        Analyst.                                              Jessie        F.        Salazar ................. Public    Health     Advisor.
                        Theodore    L.    Koontz,     Jr .... .....   Program        Analyst.                                           Grants     Operations     Section:
                        Lyman    G.     Van     Nostrand .........    Program        Analyst.                                              Lorraine       M.        Kyttle ............... Head.







                                                                                                                                                                                                                                                   159














                                              OFFICE  OF  ASSOCIATE  DIRECTOR  FOR
                                             PROGRAM DEVELOPMENT AND RESEARCH
                            Richard F. Manegold, M.D         .......  Associate Director for Program Dcvelol-ijiient
                                                                         -iiid ]Zescircli.
                         Continuing  Education  and  Y'raini@g  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   @V.    Golde,    M.D ...........  Training     Consultant.
                            Frank  L.  Husted,   Ph.   D..........    Head, Education Research Group.
                            Elsa J. Nelson.. @ ...........      ....  Health  Services   Officer.
                            Herbert 0. Mathewson, M.D         ......  Training     Consultant.
                            Marjorie L. Morrill      ... ......       Public   Health    Advisor.
                            Rebecca R. Sadin      ......    ........  Public   Health    Advisor.
                            Sarah J. Silsbee .....            ......  Public   Health    Advisor.
                            Jack   J.   Schneider,   M.D ...   ...... Training     Consultant.
                            ,John C. 'I'@ipp, M.I)  .....    ........ 'I'r;tiiiiiig Consultant.
                            Charlotte F. 'I'urner     ..............  Education @ind'l'raiiiiiig Spcciilist.
                        Regional I-lealth Services Branch.-
                            Philip   A.   Klieger,   M.D .........    Heid, 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.                                            Region                                                page
                                                                                                                                                                Awarded is of April 26, 1968.                                NEW    JERSEY    (see     also     Greater     Delaware
                                                                                                                                                                                                                                ,,ley,
                                                                                                                                                                                                                                            @6           ........................... 169
                                                                                                                                                                                                                             NEW                         ........................... 169
                                                                                                                                                                                           INDEX                             NEW     YORK,     see     Albany;      Central      New
                                                                                                                                                             Region                                                  page       York;     New      York      Meiropolitan      Area;
                                                                                                                                                             ALABAMA       (see       also       Tennessee        Mid-          Rochester; Western New York.
                                                                                                                                                               South)       ........            ........................ 162 NEW YORK METROPOLITAN AREA                        ..... 169
                                                                                                                                                             ALASKA,       see        Washington-Alaska.                     NORTH CAROLINA                   ...................... 169
                                                                                                                                                             ALBANY         ............       ...............       62      NORTH DAKOTA          ...............          ........ 170
                                                                                                                                                             ARIZONA        .......            ........................ 62   NORTHEASTERN OHIO                     ................. 170
                                                                                                                                                             ARKANSAS      (see      also       Memphis) ..........  16@     NORTHERN NEW ENGLAND                  .........       170
                                                                                                                                                             BI-STATE...                                             163     NORTHLANDS         ........          .................. 170
                                                                                                                                                             CALI        FORN                                        163     NORTHWESTERN OHIO               .............       ... 171
                                                                                                                                                             CENTRAL     NE@'Y6'@k','."                .  ...   ...... 163   OHIO      STATE      (see       also       Northeastern
                                                                                                                                                             COLORADO-WYOMING.                         .        ......          Ohio;    Northweitern    Ohio;    Ohio     Valley).. 171
                                                                                                                                                                                            .......   ......    .    .63
                                                                                                                                                             CONNECTICUT         .........                           164     OHIO VALLEY.
                                                                                                                                                                                                                                                 ................            ....... 171
                                                                                                                                                                                                       ......   ..   .       OLA    HOMA               ............................. 171
                                                                                                                                                             DELAWARE        VALLEY,         see       reater Del
                                                                                                                                                               ware Valley.                                                  OREGON      ............................            ... 172
                                                                                                                                                             FLORIDA        ......................              ...... 164   PENNSYLVANIA,        see        Greater        Delaware
                                                                                                                                                             GEORGIA        ..............     ................      164        Valley;      Susquehanna       Valley;       Western
                                                                                                                                                             GREATER           DELAWARE           VALLEY ..........  164        Penns
                                                                                                                                                                                                                                  RTCVvani
                                                                                                                                                             HAWAII         ........................                 165     PUE         RICO   .......          ..............    172
                                                                                                                                                             IDAHO,     see      Intermountain;      M      un      am       RHODE ISLAND, see                   ate.
                                                                                                                                                               States.                                                       ROCHESTER,        .......           ................... 172
                                                                                                                                                             ILLINOIS   (see    also    Bi-State)..    @..........   165     SOUTH CAROLINA           ..................           172
                                                                                                                                                             INDIANA    (see    also    Ohio     Valley) ..........  165     SOUTH        DAKOTA,         see         Nebraska-South
                                                                                                                                                             INTERMOUNTAIN                     ....................... 165      Dakota.
                                                                                                                                                             IOWA   ................    I .. @ ................      166     SUSQUEHANNA             VALLEY....              ....... 173
                                                                                                                                                             KANSAS         ................   ................      166     TENNESSEE      MID-SOUTH      (see      also       Mem-
                                                                                                                                                             KENTUCKY,      see      Memphis;       Ohio       Valley;          phis)            ................................... 173
                                                                                                                                                               Tennessee Mid-South.                                          TEXAS    ........   ..................                173
                                                                                                                                                             LOUISIANA      ..............................           166     TRI-STATE                 ............................. 173
                                                                                                                                                             MAINE          ............ ....................        166     UTAH, see Intermountain.
                                                                                                                                                             MARYLAND       .............................            167     VERMONT, see Northern New England.
                                                                                                                                                             MASSACHUSETTS,        see        Tri-State.                     VIRGINIA    ...............         ..............    174
                                                                                                                                                             MEMPHIS        .............................            167     WASHINGTON-ALA!SKA             ...........        ..... 174
                                                                                                                                                             METROPOLITAN         WASHINGTON,         D.C...          167    WASHINGTON,        D.C.,        see        Metropolitan
                                                                                                                                                             MICHIGAN       ............................             167        Washington, D.C.
                                                                                                                                                             M   I   N   N   ESOTA,   see    Northlands.                     WEST    VIRGINIA    (see    also     Ohio     Valley).. 174
                                                                                                                                                             MISSISSIPPI     (see     also      Memphis) ........    168     WESTERN              NTERSTATE               COMMISSION
                                                                                                                                                             MISSOURI     (see      ilso      Bi-State:      Memphis). 168      FOR        HIGHER         EDUCATION         (WICHE),
                                                                                                                                                             MONTANA,        see        Intermountain;        Mountain          see Mountain States.
                                                                                                                                                               States.                                                       WESTERN NEW YORK              ........  I     ......... 174
                                                                                                                                                             MOUNTAIN STATES                      .................... 168   WESTERN                  PENNSYLVANIA ...      ........ 175
                                                                                                                                                             NEBRASKA-SOUTH                       DAKOTA ............ 168    WISCONSIN                 ............................. 175
                                                                                                                                                             NEVADA, see Intermountain.                                      WYOMING,       see       Colorado-Wyoming;       Inter-
                                                                                                                                                             N  EW  HAM  PSH  I  R  E,  see   Tri-State.                     mountain;      Mountain       States.

                                                                                                                                                                                                                                                                                   161







                                  Name of Region                        81-State                                 California                               Central Now York                         Colorado-Wyoming
                                  Preliminary Planning Area             Eastern Missouri and Southern            California                               Syracuse, New York and 15                Colorado and Wyoming
                                                                        Illinois                                                                          surrounding counties


                                  Estimated Population                  4,775,000                                19,160,000                               1,760,000                                2,200,000
al                                Coordinating Headquarters             Washington University School of          California Committee on                  Upstate Medical Center, State            University of Colorado Medical
                                                                        Medicine                                 Regional Medical Programs                University of New York at Syracuse       Center

                                  Program Coordinator                   William H. Danforth, M.D.                Paul D. Ward                             Richard H. Lyons, M.D.                   Paul R. Hildebrand, M.D.
                                                                        Vice Chancellor for Medical Affairs      Executive Director                       Director, Regional Medical               University of Colorado Medical Center
                                                                        Washington University                    California Committee on                  Program of Central New York              4200 East Ninth Avenue
                                                                        660 South Euclid Avenue                    Regional Medical Programs              750 East Adams Street                    Denver,  Colo.   80220
                                                                        St. Louis, Mo. 63110                     Room 304                                 Room 1500
                                                                                                                 655 Sutter Street                        State University Hospital
                                                                        (tel: 314-361-6400,   ext. 3013)         San Francisco, Calif. 94102              Syracuse, N.Y. 13910
                                                                                                                 (tel: 415-771-5432)                      (tel: 315-473-5600)


                                  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           G. Duncan Bauman                         Roger 0. Egeberg, M.D.                   Wilfred W. Westerfeld, M.D.              John J. Conger, Ph. D.
                                  Group                                 Business Manager                         Dean, School of Medicine                 Acting President                         Vice President for Medical Affairs
                                                                        St. Louis Globe-Democrat                 University of Southern California        Upstate Medical Center                    and Dean, School of Medicine
                                                                        710 North 12th Street                    2025 Zonal Avenue                        766 Irving Avenue                        University of Colorado
                                                                        St. Louis, Mo. 63101                     Los Angeles, Calif. 90033                Syracuse, N.Y. 13210                     4200 East Ninth Avenue
                                                                                                                                                          (tel: 315-473-4513)                      Denver,  Colo.   80220

                                  Grantee                               Washington University School of          California Medical Education             Research Foundation of State          UniversityofColorado Medical Center
                                                                        Medicine                                 and Research Foundation                  University of New York
                                  Effective Starting Date of            April 1, 1967                            November 1, 1966                         January 1, 1967                          January 1, 1967
                                  Planning Grant

                                  Amount of Planning Grant              $603,965                                 $1,575 096 (1 st year)                   $289 522 (ls year)                       $361  984  (lst  year)
                                                                                                                 $2,974,'497 (2d year)                    $268,'634 (2dtyear)                      $339,'605 (2d year)

                                  Effective Starting Date of
                                  Operational Grant


                                  Amount of Operational Grant













                                                                                                                                                                                                                                     163








                                                                                                                                                                                                          Greater Delaware Valley
                                                                                                                                                                Georgia
                                                                                                            Florida
                                                                                                                                                                                                          Easte   Pennsylvania all(i portions Of
                                                                                                                                                                                                               rt'
                                                              Connecticut                                                                                                                                       ersey ard Delaware
                     Nan,e of Region                                                                                                                            Georgia                                   New  J
                                                                                                             Floricia
                                                                                                                                                                                                          8 TOO
                                                               Connecticut                                                                                          -
                                                                                                                                                                4 510 600                                        000
                     Preliminary Planning Area                                                                                                   ----                                     orgia           University City Science C(,
                                              --2,925,000                                                                                                       M@(3,c,@A,,-Iiatioll of G(,
                     i                    tion                                                               l@ori@l,, @dv,,,,@y C,,,,ncil, Inc.
                                                               Yale Univ(                         t                                                                                                       George C@ani[iier, M.D.
                     Coordinating Headqt                        an(] Ullive                                                                                                                               Wynnewood @iouse
                                                                Schoolof                                                                                                               ja Regional                           ter Aveiiiie
                                                                                                                                                                coo                                       300 East Laricas
                                                                                       M. D.                                                                    m                      f Georgia          Wynnewood, Pa. 19096
                     ,@o g      C..,dnat-r                                          ator                                                                        Me,                    N E.                                -4100)
                                                                                    onal Medical                                                                938                                       (tel: 215-649
                                                                  Program      Street                                                                           Atl
                                                                272 George             06510                  (tel: 904-376-3211, ext. 5377)
                                                                New Haven      Conn.                                                                            (tel:      404-876-7535)
                                                                 (tel: 2C)3-776-6872)
                                                                                                                                                                         Barr      M.
                                                                                                                                                                Dit                ia Regior'31
                                                                                                                                                                                 ram
                                                                                                                                                                                   on  0f Georgia
                      program Director                                                                                                                          M(                 reet N.E.
                                                                                                                                                                93                09
                                                                                                                                                                At
                                                                                                                                                                (tel:      404-875-0701)
                                                                                                                                                                                                                                      D
                                                                                                                                                                                                            Glen                         (-,Oil g
                                                                                                                                                                                                            Dea@
                                                                                                                               mp on, M.D.                                                                    of
                                                                                                                               evard                                                                        330(
                                                                                                                                 33606                                                                      Phil;
                                                                                       ring Company             (tel: 813-253-0991)
                                                                                        06720
                                                                                                                                                                                                                         @,ty@c ",C(,
                                                                                                                                                                                                             University
                                                                                                                                                                          ssociatioll of Georgia
                                                                                                                                  ry Council, Inc.              Medic
                                                                                                                                  -                                             1967                         April 1, 1967
                        Grantee                                                                                                                                 jankiary 1,
                                                                                                               @ve  ever 1, 1967
                                                                   july 1, 1966                                                                                                                                    31,494
                        Effective Starting Date                                                                                                                 $240  Ogg   (lst   year)
                        Of Planning Grant                                  -                                     $240,000                                       $51)5@079   (2d    year)
                                                                 4@(3) 6 6 2 2     t  -.r)
                                                                                 I' ye
                        Amount Of                                   $,     513   2,J Y
                         planning Grant
                         Effective Starting Date
                         of Operational Grant
                         A n'ou nt of
                         operational Grant














                            16i








                              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              Yale University School of Medicine         Florida Advisory Council, Inc.            Medical  Association   of   Georgia        University City Science Center
                                                                     and University of Connecticut
                                                                     School of Medicine
                              Program Coordinator                    Henry T. Clark, Jr., M.D.                  Samuel P. Martin, M.D.                    J. W. Chambers, M.D.                       George Clammer, M.D.
                                                                     Program Coordinator                                                                  Coordinator for Georgia Regional           VVonnewood House
                                                                                                                Provost, J. Hillis Miller                                                            3
                                                                     Connecticut Regional Medical                 Medical Center                            Medical       Program                         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                     (tel: 904-376-3211, ext. 5377)            Atlanta,   Ga.    30309                    (tel: 215-649-4100)
                                                                     (tel: 203-776-6872)                                                                  (tel: 404-876-7535)


                              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                     Arthur M. Rogers                           H. Phillip Hampton, M.D.                  Arthur P. Richardson, M.D.                 Glen R. Leymaster, M.D.
                              Advisory Group                         Director of Traffic                        I Davis Boulevard                         Dean      hool of Medicine                 Dean, Woman's Medical College
                                                                     Scovill Manufacturing Company              Tampa, Fla. 33606                         Emor@SUcniversity                            of Pennsylvania
                                                                     99 Mill Street                                                                       Atlanta,   Ga.    30322                    3300 Henry Avenue
                                                                     Waterbury, Conn. 06720                     (tel: 813-253-0991)                                                                  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                              $406 622 @lst year)                        $240,000                                  $240  098   Ist   year)                    $1,531,494
                              Planning Grant                         $338:513 2d year)                                                                    $555:079   @2d    year)

                              Effective Starting Date
                              of Operational Grant

                              Am ount of
                              Operational Grant


















                              164







                             Name of Re,iion                            Hawaii                                         Illinois                                       Indiana                                        Intermountain
                             ProlitTiinary Pl;jnnin,l Aro@i             linwmii                                        lllitioi!;                                                                                    Utah. and portions of Wyoming,
                                                                                                                                                                                                                     Mori@'in,l,  iLlatio,  and  Neva da
                             Estimated Population                       740,000                                        10,895,000                                     5,000,000                                      2,220,000
                                                                        University of Hawaii College of                Coordinating Committee of Medical              Indiana University School of                   University of Utah School of
                             Coordinating Headquarters                  Health Sciences                                Schools and Teaching Hospitals of              Medicine                                       Medicine
                                                                                                                       Illinois
                                                                                                                       Leon 0. Jacobson, M.D.                         Robert B. Stonehill, M.D.                      C.   Hilmon    Castle    M.D.
                             Program Coordinator                        Masato Hasegawa, M.D.                                                                                                                           sociate Dean and Chairman
                                                                        Suite 105                                      Dean of Biological Sciences                    Indiana University Medical Center              As
                                                                        Medical    Arts    Building                    Chairman, Coordinating Committee               1 1 00 West Michigan Street                    Department of Postgraduate
                                                                        1010 South King Street                           of Medical Schools and Teaching              Indianapolis, Ind. 46207                          Education
                                                                        Honolulu, Hawaii 96822                           Hospitals   of   Illinois                                                                   University of Utah College of
                                                                                                                       950   East   59th    Street                    (tel: 317-639-8492)                               Medicine
                                                                                                                                                                                                                     50   North   Medical    Drive
                                                                        (tel:         808-944-8499)                    Chicago,   111.    60637                                                                      Salt Lake City, Utah 841 12
                                                                                                                       (tel:         312-MU4-6100)                                                                   (tel: 801-322-7901)
                             Program Director                           William D. Graham, M.D.                        Wright R. Adams, M.D.
                                                                        Deputy Director                                Executive       Director
                                                                        Hawaii Regional Medical        Program         Illinois Regional Medical Program
                                                                        Lez!hi Hospital                                122 South Michigan Avenue
                                                                        Honolulu, Hawaii 96822                         Suite 939
                                                                                                                       Chicago,   Ill.    60603
                                                                                                                       (tel:         312-939-7307)
                              h.i,m.., Regional Advisory                Wilson   P.   Cannon,   Jr.                    Oglesby    Paul,    M.D.                       George T. Lukemeyer, M.D.                      Kenneth B. Castleton, M.D.
                             Group                                      Senior    Vice    President                    Professor    of    Medicine                    Associate Dean, Indiana University             Dean@ University of Utah
                                                                        Bank of Hawaii                                 Northwestern University                        School of Medicine                             college of Medicine
                                                                        P.O. Box 2900                                  School    of    Medicine                       Indiana University Medical Center              University of Utah Medical Center
                                                                        Honolulu, Hawaii 96802                         Passavant       Hospital                       1100 West Michigan Street                      Salt Lake City, Utah 84112
                                                                                                                       303 East Superior Street                       Indianapolis. Ind. 462C)7
                                                                                                                       Chicago,   Ill.    60611                       (tel: 317-639-8877)                            (tel: 801-322-7211, ext. 7201)
                                                                                                                       (tel:         312-WH4-4200)
                                                                        University of Hawaii College of                University    of    Chicago                    Indiana University Foundation                  unive sity of Utah College of
                                                                                                                                                                                                                     M
                             Grantee                                    Health Sciences                                                                                                                                 edicine
                             Effective Starting Date of                 July 1, 1966                                   July 1, 1967                                   January 1, 1967                                July 1, 1966
                             Planning Grant
                                                                                                                                                                      $384,750  Ist year)                            $456 415 @Ist year)
                             Amount of Planning Grant                   $108 00(, @Ist year)                           $336,366                                       $497,837 @2d year)                             $363:524 2d year)
                                                                        $194:771  2d year)
                             Effective Starting Date of                                                                                                                                                              April 1. 1967
                             Operationa  I Grant
                                                                                                                                                                                                                     $2,038,123 (lst year)
                             Amount of Operational Grant                                                                                                                                                             $2,215@234 (2d year)














                                                                                                                                                                                                                                                             165








                     Name of Region                        Iowa                                    Kansas                                   Louisiana                                Maine
                     Preliminary Planning Area             Iowa                                    Kansas                                   Louisiana                                Maine


                     Estimated    Population               2,755,000                               2,275,000                                3,660,000                                975,000
                     Coordinating Headquarters             University of Iowa College of           University  of  Kansas  Medical   Center Louisiana  State Department of           Medical Care Development, Inc.
                                                             Medicine                                                                         Hospitals
                     Program     Coordinator               Willard A. Krehl, M.D., Ph. D.          Charles E. Lewis, M.D.                   E. Lee Agerton                           Manu Chatterjee, M.D.
                                                           308 Melrose Avenue                      Chairman,   Department   of   Preventive Director                                 Program Coordinator
                                                           University of Iowa                        Medicine and Community Health          Louisiana State Department               Maine Regional Medical Program
                                                           Iowa City, Iowa 52240                   University  of  Kansas  Medical   Center  of Hospitals                            295 Water Street
                                                                                                   39th and Rainbow Boulevard               655 North Fifth Street                   Augusta, Maine 04322
                                                           (tel: 319-353-4843)                     Kansas City, Kans. 66103                 Baton Rouge, La. 70804                   (tel: 207-622-7566)
                                                                                                   (tel: 919-AD6-5252, ext. 271)

                     Program Director                                                                                                       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)
                     Chairman, Regional Advisory           Harry B. Weinberg, M.D.                 George A. Wolf, Jr., M.D.                Charles B. Odom, M.D.                    Merle S. Bacastow, M.D.
                     Group                                 Iowa Heart Association                  Provost and Dean, School of              Past President                           President
                                                           i333 West Lombard Street                  Medicine                               Louisiana State Medical Society          Medical Care Development, Inc
                                                           Davenport, Iowa 52804                   University  of  Kansas  Medical   Center 134 North 19th Street                    Director of Medical Education
                                                                                                   Rainbow Boulevard at 39th Street         Baton Rouge, La. 70002                   Maine Medical Center
                                                                                                   Kansas City, Kans. 66103                                                          Portland, Maine 04102

                     Grantee                               University of Iowa College of           University  of  Kansas  Medical   Center Louisiana State Department of            Medical Care Development, Inc.
                                                            Medicine                                                                          Hospitals
                     Effective Starting Date               December 1, 1966                        July 1, 1966                             January 1, 1967                          May 1, 1967
                     of Planning Grant
                     Amount of Planning                    $291,348 (Ist year)                     $197,945 (ist year)                      $490,448 (lst year)                      $193,909 (lst year)
                     Grant                                 $290,591 (2d year)                      $281,627 (2d year)                       $454,445 (2d year)                       $204,709 (2d year)

                     Effective Startin
                                     ,2 D  to                                                      June 1, 1967
                     of Operational    ranat
                     Amount of Operational                                                         $699,852
                     Grant






















                     166







                           Name of Region                         Maryland                                  Memphis Medical Region                     Metropolitan Washington, D.C.             Michigan
                           Preliminary Planning Area              Maryland                                  Western       Tennessee'Northern           District  of  Columbia  and   contiguous  Michigan
                                                                                                            Mississippi, and portions of               counties in Maryland (2) and
                                                                                                            Arkansas, Kentucky, and Missouri           Virginia (2)
                           Estimated Population                   3,685,000                                 2,425,000                                  2,160,000                                 8,585,000
                           Coordinating Headquarters              Steering Committee of the Regional        Mid-South Medical Council for Com-         District  of  Columbia  Medical  Society  Michigan Association for Regional
                                                                  Medical Program for Maryland              prehensive Health Planning, Inc.                                                     Medical  Programs,   Inc.
                           Program Coordinator                    William S. Spicer, Jr., M.D.              James W. Culbertson, M.D.                  Thomas W. Mattingly, M.D.                 Albert E.  Heustis,  M.D.
                                                                  Acting Coordinator                        Professor and Cardiologist                 Program Coordinator                       I 1 1 1  Michigan  Avenue
                                                                  Mar land Regional Medical     Program     Department of Internal Medicine            Metropolitan Washington. D.C.             Suite 200
                                                                      Y'@
                                                                  550 North Broadw.@5                       College   of   Medicine                    Regional Medical Program                  East Lansing, Mich. 48823
                                                                  Baltimore, Md. 2  @2                      University of Tennessee                    District  of  Columbia  Medical  Society
                                                                                                            858 Madison Avenue                         2007 Eve Street N.W.                      (tel: 517-351-0290)
                                                                  (tel: 301-955-7444)                       Memphis, Tenn. 38103                       Washi@ton, D.C. 20006
                                                                                                            (tel: 901-JA6-8892, ext. 437)              (tel: 202-223-2230)

                           Program Director




                           Chairman, Regional Advisory            William J. Peeples, M.D.                  Frank M. Norfleet                          Clayton Ethridge, M.D.                    William N. Hubbard, Jr.. M.D.
                           Group                                  Commissioner                              Vice President                             Associate  Dean,  School   of   Medicine  Dean, School of Medicine
                                                                  Maryland State Department of              Parts, Inc.                                901 23d Street N.W.                       University  of   Michigan
                                                                    Health                                  601 South Dudley                           Washington, D.C. 20037                    1335   Catherine   Street
                                                                  301 West Preston Street                   Memphis, Tenn. -38104                                                                Ann Arbor, Mich. 48104
                                                                  Baltimore, Md. 21201
                                                                                                                                                                                                 (tel: 313-764-8175)
                           Grantee                                The Johns Hopkins University              University of Tennessee College of         District  of  Columbia  Medical  Society  Michigan Association for Regional
                                                                                                            M edicine                                                                            Medical Programs, Inc.
                           Effective Starting Date                January 1, 1967                           April 1, 1967                              January 1, 1967                           Junel,1967
                           of Planning Grant
                           Amount of                              $518,443 @l st year)                      $173,119                                   $203,790 (lst year)                       $1,294,449
                           Planning Grant                         $412.227 2d year)                                                                    $216,322 (2d year)
                           Effective Starting Date                                                                                                     March 1, 1968
                           of  perational Grant
                           Amount of                                                                                                                   $418,318
                           Operational Grant





















                                                                                                                                                                                                                                     167













                 Name of Region                       Mississippi                              Missouri                                Mountain States                          Nebraska-South Dakota
                 Preliminary Planning Area            Mississippi                              Missouri, exclusive of St. Louis        Idaho, Montana,   Nevada,and             Nebraska and South Dakota
                                                                                                                                       Wyoming
                 Estimated Population                 2,350,000                                4,605,000                               2,160,000                                2,110,000
                 Coordinating Headquarters            University  of Mississippi Medical       University of Missouri School of        Western Interstate Commission for        Nebraska State Medical Association
                                                      Center                                   Medicine                                Higher    Education

                 Program Coordinator                  Guy D. Campbell, M.D.                    Vernon E. Wilson ' M.D.                 Kevin P. Bunnell, Ed.D.                  Harold  Morgan,   M.D.
                                                      Mississippi Regional Medical             Executive Director for Health Affairs   Associate Director                       Program    Coordinator
                                                        Program                                University of Missouri                  Western Interstate Commission for        Nebraska-South Dakota Regional
                                                      University of Mississippi Medical        Columbiii, Mo. 65201                      Higher Education                        Medical Program
                                                        Center                                                                         University East Campus                   1408  Sharp   Building
                                                      2500 North State Street                  (tel: 314-449-2711)                     30th Street                              Lincoln,  Nebr.  68503
                                                      Jackson, Miss. 39216                                                             Boulder, Colo. 80302                     (tel:    402-432-5427)
                                                      (tel: 601-362-4411)                                                              (tel: 303-443-21 1 1, ext. 6342)

                 Program Director                                                              George E. Wakerlin, M.D.                Alfred M. Popma, M.D.
                                                                                               Director, Missouri Regional             Program    Director
                                                                                                Medical Program                        Mountain States Regional Medical
                                                                                               Lewis Hall                                Program
                                                                                               406 Turner Avenue                       525 West Jefferson Street
                                                                                               Columbia, Mo. 65301                     Boise, Idaho 83702
                                                                                               (tel: 314-449-2711)                     (tel: 208-342-4666)
                 Chairman, Regional Advisory          Not identified                           Nathan J. Stark                         George D. Humphrey, M.D.                 Robert J. Morgan, M.D.
                 Group                                                                         Group Vice President                    President Emeritus                       President
                                                                                               Operations                              University of Wyoming                    Nebraska State Medical Association
                                                                                               Hallmark Cards, Inc.                    P.O. Box 3067, University   Station      916 West  10th  Street
                                                                                               25th and McGee Trafficway               Laramie, Wyo. 82070                      Alliance, Nebr.  69301
                                                                                               Kansas City, Mo. 64108
                 Grantee                              University of Mississippi Medical        University of Missouri School of        Western Interstate Commission for        Nebraska State Medical Association
                                                      Center                                   Medicine                                Higher    Education

                 Effective Starting Date of           July 1, 1967                             July 1, 1966                            November 1, 1966                         January 1, 1967
                 Planning Grant
                 Amount of Planning Grant             $454,206                                 $398 556 @Ist year)                     $876,855 (1 st year)                     $350,339 (1 st year)
                                                                                               $324:254 2d year)                       $1,082,107 (2d year)                     $349,367 (2d year)
                 Effective Starting Date of                                                    April 1, 1967                           March 1, 1968
                 Operational Grant
                 Amount of Operational Grant                                                   $2,887,903 (lst year)                   $206,913
                                                                                               $3,484,039 (2d year)




















                 168






                             Name of Region                       New Jersey                               New Mexico                               New York Metropolitan Area             North   Carolina
                             Preliminary Planning Area            New Jersey                               New Mexico                               New  York  Cit@and   Y@stchester,      North   Carolina
                                                                                                                                                    Nassau, and  uffolk Counties
                             Estimated Population                 7,000,000                                1,005,000                                11,480,000                             5.030.000
                             Coordinating Headquarters            New Jersey Joint Committee for           University of New Mexico School of       Associated Medical Schools of          AssociationfortheNorthCarolirta
                                                                  Implementation of Public Law             Medicine                                 Greater New York                       Regional Medical Program
                                                                  89-239
                             Program Coordinator                  Alvin A.  Florin,  M.D.                  Reginald H. Fitz, M.D.                   Vincent de Paul Larkin, M.D.           Marc  J.  Musser,  M.D.
                                                                  New   Jersey   Regional                  Dean, School of Medicine                 New  York  Academy  of   Medicine      Executive Director
                                                                  Medical Program                          University of New Mexico                 2 East 103d Street                     North Carolina Regional Medical
                                                                                                           goo Stanford Drive N.E.                  New York, N.Y. 10029                     Program
                                                                  88 Ross Street                                                                                                           Teer House
                                                                  East Orange, N.J.  07018                 Albuquerque, N. Mex. 87106               (tel: 212-427-4100)                    4019 North   Roxboro Road
                                                                                                                                                                                           Durham.   N.C.    27704
                                                                  (tel:     201-675-1100)                  (tel: 505-277-2321)                                                             (tel:    911)-477-8685)


                                                                                                           Irvin E. Hend  son, M.D.
                             Program Director                                                              University of r@ew Mexico
                                                                                                           900 Stanford Drive N.E.
                                                                                                           Albuquerque, N. Mex. 87106


                                                                  Joseph  R.  Jehl,  M.D.                  Not identified                           Vernon Stutzman                          George W. Paschal, Jr., M.D.
                             Chairman, Regional                                                                                                     Regional Medical Program                 President, Medical Society of State
                             Advisory Group                       President                                                                         New  York  Academy  of   Medicine         of  North   Carolina
                                                                  The Medical Society of New Jersey                                                 2 East 103d Street                       i 1 10 wake Forest Road
                                                                  315 West State Street                                                                                                      Raleigh,  N.C.  27604
                                                                  Trenton,   N.J.   08618                                                           New York, N.Y. 10029
                                                                  Foundation for the Advancement of        University of New Mexico                 Associated  Medical  Schools   of        Duke University
                             Grantee                              Medical Education and Research in                                                 Greater New York
                                                                  New Jersey
                             Effective Starting Date              July 1, 1967                             October 1, 1966                          June 1, 1967                             July  1,  1966
                             of Planning Grant
                                                                  $297,466                                 $449 736 @Ist year)                      $967,010                                 $435 851  @ist  year)
                             Amount of                                                                                                                                                       $773  674  2d   year)
                             Planning Grant                                                                $553:270 2d year)
                             Effective Starting Date                                                                                                                                         March 1, 1968
                             of Operational Grant                                                                                                                                            $1,5iO,796
                             Amount of
                             Operational Grant



















                                                                                                                                                                                                                                169

















                     Name of Region                       North Dakota                           Northeastern Ohio                       Northern New England                   Northiands
                     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.              Frederick C. Robbins, M.D.              John E. Wennberg, M.D.                 Winston R. Miller, M.D.
                                                          Dean, School of Medicine               Dean, School of Medicine                Program     Coordinator                375 Jackson Street
                                                          University of North Dakota             Case  Western  Reserve   University     Northern  New   England   Regional     Saint Paui,Minn. 55101
                                                          Grand Forks, N. Dak. 58201             2107   Adelbert   Road                    Medical Program
                                                                                                 Cleveland, Ohio 44106                   University of Vermont Co] lege  of     (tel: 612-224-4771)
                                                          (tel: 701-777-2514)                                                              Medicine
                                                                                                                                         25  Colchester   Avenue
                                                                                                                                         Burlington,  Vt.  05401
                                                                                                                                         (tel: 802-864-4511, ext. 244)
                     Program Director                     Willard Wright, M.D.
                                                          Program Director
                                                          North Dakota Regional Medical
                                                            Program
                                                          1600 University Avenue
                                                          Grand Forks, N-. Dak. 58201
                     Chairman, Regional Advisory          Lee A. Christoferson, M.D.             Irvine H.  Page,  M.D.                  Edward C. Andrews, M.D.                0. L. N e I so n, M. D.
                     Group                                The Neuro-Psychiatric Institute        Consultant    Emeritus                  Dean, College of Medicine              Chairman, Advisory Group
                                                          700 First Avenue South                 Cleveland Clinic                        University  of  Vermont                Northiands Regional Medical Program
                                                          Fargo, N. Dak. 58102                   Division  of  Research                  25  Colchester   Avenue                601 Medical Arts Building
                                                                                                 2050 East  93d  Street                  Burlington,  Vt.  05401                Minneapolis, Minn. 55402
                                                                                                 Cleveland, Ohio 44106

                     Grantee                              North Dakota Medical Research          Case  Western  Reserve   University     University of Vermont  College  of     Minnesota State Medical Association
                                                           Foundation                                                                     Medicine                                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 @Ist year)                    $370,904 (1 st vea r)
                                                                                                                                         $702,504 2d year)                      $529,250 @2d @ear)
                     Effective Starting Date of
                     Operational Grant

                     Amount of Operational Grant























                     170






                            Name of Region                         Northwestern Ohio                         Ohio State                               Ohio Valley                               Oklahoma
                                                                   20 counties in Northwestern Ohio          Central and southern two-thirds of       Greater Dart of Kentuc@y and              Oklahoma
                            Preliminary Planning Area                                                        Ohio (61 counties, excluding             contiguous pa!-t@ of Ohio, Indiana,
                                                                                                             Metropolitan Cincinnati area)            and West Virginia
                            Estimated Population                   1,360,000                                 4,680,000                                6,000,000                                 2,500,000
                            Coordinating Headquarters              Medical College of Ohio at Toledo         Ohio State University College of         Ohio Valley Regional Medical              University of Oklahoma Medical
                                                                                                             Medicine                                 Program                                   Center
                                                                   C. Robert Tittle, Jr., M.D.               Nell  C.  Andrews,  M.D.                 William H. McBeath, M.D.                  Kelly West. M.D.       Department of
                            Program Coordinator                    2313 Madison Avenue                       Assistant Dean, College of Medicine      Director, Ohio Valley Regional            Professor   and   Head,
                                                                   Toledo, Ohio 43624                        Ohio  State   University                   Medical Program                           Continuing Education
                                                                                                             410  West   10th   Avenue                1718 Alexandria Drive                     University of Oklahoma Medical
                                                                   (tel: 419-248-6201)                       Columbus,   Ohio    43210                Lexington, Ky. 40508                        Center
                                                                                                                                                                                                800 Northeast 13th Street
                                                                                                             (tel:      614-293-5344)                 (tel: 606-255-6684)                       Oklahoma City, Okla. 73104
                                                                                                                                                                                                (tel: 405-CE 2-8561)



                            Program Director


                            Chairman, Regional                     Edward L. Burns, M.D.                     Richard L. Meiling. M.D.                 Louis Wozar                               James L. Dennis, m.b.
                            Advisory Group                         Northwestern Ohio Regional                Dean College of Medicine                 Presidentand General Manager              Director and Dean
                                                                    Medical Program                          Oh i. @tate    University                Tait Manufacturing Company                University of Oklahoma Medical
                                                                   2313 Madison Avenue                       410  West   10th   Avenue                500 Webster Street                          Center
                                                                   Toledo, Ohio 43624                        Columbus,   Ohio    43210                Dayton, Ohio 45404                        800 Northeast 13th Street
                                                                                                                                                                                                Oklahoma City, Okla. 73104
                                                                                                             (tel:      614-293-5344)                 (tel: 513-224-9871)
                            Grantee                                Medical College of Ohio at Toledo         Ohio State University College of         The University of Kentucky                University of Oklahoma Medical
                                                                                                             Medicine                                 Research Foundation                         Center
                            Effective Starting Date                January 1, 1968                           April 1, 1967                            January 1, 1967                           September    1,    1966
                            of Planning Grant
                            Amount of                              $309.180                                  $126,182                                 $346 760 @lst year)                       $177  963  @Ist   year)
                            Planning Grant                                                                                                            $407:238 2d year)                         $282:100    2d    year)

                            Effective Starting Date
                            of Operational Grant

                            Amount of
                            Operational Grant




















                                                                                                                                                                                                                                    171









                           Name of Region                         Oregon                                    Puerto Rico                               Rochester                                 South Carolina
                           Preliminary Planning Area              Oregon                                    Puerto Rico                               Rochester, New York and 1 1               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         Medical College of South Carolina
                                                                                                                                                      Medicine and Dentistry


                           Program Coordinator                    M. Roberts Grover, M.D.                   A. Nigaglioni, M.D.                       Ralph C. Parker, Jr., M.D.                J. C. Chambers, M. D.
                                                                  Director, Continuing Medical              Chancellor, School  of Medicine           Cl, nical Associate Professor of          Medical College of South Carolina
                                                                    Education                               University of Puerto Rico                   Medicine                                55 Doughty Street
                                                                  University of Oregon Medical    School    San Juan, P.R. 00905                      School of Medicine and Dentistry          Charleston, S.C. 29403
                                                                  3181 Southwest Sam Jackson                                                          University of Rochester
                                                                    Park Road                               (tel: 174-723-5210)                       260 Crittenden Boulevard                  (tel: 803-723-9411)
                                                                  Portland, Oreg. 97201                                                               Rochester, N.Y. 14620
                                                                  (tel: 503-228-9181, ext. 519)                                                       (tel: 716-473-4400, ext. 3112)


                           Program Director





                           Chairman, Regional Advisory            Herman A. Dickel, M.D.                    Not identified                            Frank Hamlin                              William M. McCord, M.D., Ph. D.
                           Group                                  Member, Council of Medical                                                          Papec Machine Com@any                     President, Medical College
                                                                    Education                                                                         Shbrtsville, N.Y. 145  8                   of South Carolina
                                                                  Oregon Medical Association                                                                                                    80 Barre Street
                                                                  511 Southwest 10th Avenue                                                                                                     Charleston, S.C. 29401
                                                                  Portland, Oreg. 97205



                           Grantee                                U n iversity of Oregon M ad ical School                                             University of Rochester School of         Medical College of South Carolina
                                                                                                                                                      Medicine and Dentistry
                           Effective Starting Date of             April 1, 1967                             Application under review                  October 1, 1966                           January 1, 1967
                           Planning Grant
                           Amount of Planning Grant                                                                                                                                             $123 527 @lst year)
                                                                  $219,168 (lst year)                                                                 $306 985 @lst year)
                                                                  $231,125 (2d year)                                                                  $318:286 2d year)                         $379:246 2d year)
                           Effective Starting Date of             March 1, 1968                                                                       March 1, 1968
                           Operational Grant
                           Amount of Operational Grant            $221,191                                                                            $343,749




















                            172





                      Name Of Region                           Susquehanna       Valley                    Tennessee Mid-South                         Texas                                       Tri-State
                                                                                                          ia Eastern and  entral Tennessee and         Texas
                                                                                                           contiguous parts of Southern                                                            Massachusetts, New Hampshire,
                                                                                                           Kentucky and Northern Alabama                                                           and Rhode Island
                      Estimated      Population                2,140,000                                   2,700,000                                   10,875,000                                  7,010,000
                                                                                                           Vanderbilt University School of             U n iversity of Texas                       Medical Care and Educational
                                                                                                           Medicine and Meharry Medical                                                            Foundation, Inc.
                                                                                                           College
                       rogram       Coordinator                Richard   B.    McKenzie                    Stanley W. Olson, M.D.                      Charles A. Lemaistre, M.D.                  Leona Baumgartner, M.D.
                                                               3806 Market Street                          Professor of Medicine                       Vice-Chancellor for Health Affairs          Medical Care and
                                                               P.O. Box 541                                Vanderbilt University                       University of Texas                          Educational Foundation
                                                               Camp  Hill,  Pa.   17011                    Clinical Professor of Medicine              Main Building                               22 The Fenway
                                                                                 -3252)                    110 Baker Building                                                                      Boston, Mass. 02115
                                                               (tel: 717-761                               Meharry Medical College                     Austin, Tex. 78712
                                                                                                           110 21st Street South                       (tel: 512-GR 1-1434)                        (tel-. 617-262-3040)
                                                                                                           Nashville, Tenn. 37203
                                                                                                           (tel: 615-255-0692)

                                                                                                                                                       Spencer G. Thompson, M.D.
                                                                                                                                                       Regional Medical'Program of Texas
                                                                                                                                                       Suite 724
                                                                                                                                                       Sealy'Smith Professional Building
                                                                                                                                                       Galveston, Tex. 77550
                                                                                                                                                       (tel: 713-505-2425)
                     Chair'" an, Regional                      Raymond C. Grandon, M.D.                    Thomas P. Kennedy, Jr.                      John F. Thomas, M.D.                        Mac V. Edds, Jr., Ph. D.
                     Ad visory Group                           Secretary                                   President, Executi    Committee             Committee on Cancer                         Division of Medical Sciences
                                                               Dauphin County Medical Society              Health and HospitavlePlanning               Texas Medical Association                   Brown University
                                                               131 State Street                            Council                                     918 East 32d Street                         President, Medi&al Care and
                                                               Harrisburg,  Pa.   17101                    Vanderbilt University Medical   Center      Austin, Tex. 78705                          Educational Foundation, Inc.
                                                                                                           Hospital   Board
                                                                                                           St. Thmas H  ospital                                                                    22 The Fenway
                                                                                                           P.O. Box 449                                                                            8oston, Mass. 02115
                                                                                                           Nashville, Tenn. 37203
                                                                                                           Vanderbilt University                       University of Texas                         Medical Care and Educational
                       f                                                                                                                                                                           Foundation, Inc.
                     Ef  active  Starting  Date                June 1, 1967                                July 1, 1966                                July 1, 1966                                December 1, 1967
                     of Planning Grant
                     Amount
                     Planning                                         0                                    $265 841 @lst year)                         $1 271 013 @ist year)                       $439,037
                     Effective Starting    Date                                                            $524:738 2d year)                           $1:577:612  2d year)
                     of Operational Grant                                                                  February 1, 1968


                     Operational Grant                                                                     $1,630,304




















                                                                                                                                                                                                                                    173













                   Name of Region                        Virginia                                Washington-Alaska                        West Virginia                            Western Now York
                   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             Medical College of Virginia and         University of Washington School of       West  Virginia  University  Medical      School of  Medicine,  State  University
                                                         University of Virginia School of        Medicine                                 Center                                     of New York at Buffalo,  in  coopera-
                                                         Medicine                                                                                                                    tion with the Health Organization  of
                                                                                                                                                                                     Western New York
                   Program Coordinator                   Kinloch   Nelson,   M.D.                Donal  R.   Sparkman,   M.D.             Charles L. Wilbar, Jr., M.D.             John R. F. lngall, M.D.
                                                         Dean, Medical College of Virginia       Associate Professor of Medicine          West Virginia Regional Medical           Director, Regional Medical Program
                                                         1200 East Broad Street                  School   of   Medicine                     Program                                  for Western New York
                                                         Richmond,   Va.    23219                University   of   Washington             West  Virginia  University  Medical      School of Medicine. State University
                                                                                                 AA 312 University Hospital                Center                                    of New York at Buffalo
                                                         (tel:      703-Ml4-9851)                Seattle,  Wash.   98105                  Morgantown. W. Va. 26506                 Buffalo, N.Y. 14214
                                                                                                 (tel:     206-543-8540)                  (tel: 304-293-4511)                      (tel: 716-833-2726, ext. 32, 50)
                   Program Director                      Eugene  R.  Perez,  M.D.                                                                                                  William E. Chalecke, M.D.
                                                         Program Director                                                                                                          R.D. 2 Horton Road
                                                         Virginia Regional Medical Program                                                                                         Jamestown. New York 14701
                                                         700 Building, Suite 1025
                                                         700  East  Main   Street                                                                                                  (tel: 716-483-1840)
                                                         Richmond,   Va.    23219

                                                         (tel:      703-643-6631)
                   Chairman, Regional Advisory           Mack 1. Shanholtz, M.D.                 Donal  R.   Sparkman,   M.D.             Clark K. Sleeth, M.D.                    Douglas M. Surgenor, M.D.
                   Group                                 State Commissioner of Health            Associate Professor of Medicine          Dean, School of Medicine                 Dean, School of Medicine
                                                         State Department of Health              School   of   Medicine                   West  Virginia  University  Medical      State University of New York at
                                                         Bank and Governor Streets               University   of   Washington               Center                                   Buffalo
                                                         Richmond,   Va.    23219                AA 312 (University Hospital              Morgantown, W. Va. 26506                 101 Capen Hall
                                                                                                 Seattle,  Wash.   99105                                                           Buffalo, N.Y. 14214
                                                                                                 (tel:     206-543-8540)                                                           (tel: 716-831-2811)
                   Grantee                               University of Virginia School of        University of Washington School of       West  Virginia  University  Medical      Research Foundation of the State
                                                         Medicine                                Medicine                                 Center                                   University of New York
                   Effective Starting Date of            January 1, 1967                         September   1,    1966                   January 1, 1967                          December 1, 1966
                   Planning Grant
                   Amount of Planning Grant              $545,454                                $266  248  @Ist  year)                   $150798  lstyear)                        $149,241 (lst year)
                                                                                                 $655:148   2d    year)                   $208:910 @2d year)                       $383,717 (2d year)
                   Eff ctive Starting Date of                                                    February 1. 1968                                                                  March 1, 1968
                   Op:rational Grant
                   Amount of Operational Grant                                                   $1,032,003                                                                        $357,761

















                   174









                    Name of Region                       Western Pennsylvania                   Wisconsin
                    Preliminary Planning Area            Pittsburgh, Pennsylvania and 28        Wisconsin
                                                         surrounding counties
                    Estimated Population                 4,200,000                              4,190,000
                    Coordinating Headquarters            University Health Center of            Wisconsin   Regional   Medical
                                                         Pittsburgh                             Program, Inc.


                    Program Coordinator                  Francis S. Cheever, M.D.               John S. Hirschboeck, M.D.
                                                         Dean, School of Medicine               Wisconsin   Regional   Medical
                                                         University of Pittsburgh                 Program, Inc.
                                                         M-240 S6aife Hall                      1  10  East  Wisconsin  Avenue
                                                         3550 Terrace Street                    Milwaukee, Wis. 53202
                                                         Pittsburgh, Pa. 15213                  (let,. 414-272-3636)
                                                         (tel: 412-621-1006)
                    Program Director






                    Chairman, Regional                   Dan J. Macer                           T. A. Duckworth
                    Advisory Group                       President, Veterans Administration     Senior Vice President
                                                                                                Em
                                                         Hospital                                 o@loyers Insurance of Wausau
                                                         University Drive                       4    Grant street
                                                         Pittsburgh. Pa. 15240                  Wausau, Wis. 54402


                    Grantee                              Universit@ Health Center of            Wisconsin   Regional   Medical
                                                         Pittsburg                              Program, Inc.
                    Effective Starting Date              January 1, 1967                        September 1, 1966
                    of Planning Grant
                    Amount of                            $340,556  11 st year)                  $344,418
                    Planning Grant                       $326,765 (2d year)

                    Effective Startin
                                    C? Date                                                     September 1, 1967
                    of Operational   rant
                    Amount of                                                                   $630,149
                    Operational Grant




















                                                                                                                                                                                                                175














                                                                                APPENDIX  7                            the       td-inistration       of       hospitals,       and       in        co-       ing,        diagnosis,        and        tre@itment         reliting         to            "Grants  foi-  Pla?i?iitig
                                                                                                                       operation         ivitli          practicing          physicians,          medi-       heart     disease,      cancer,      or      stroke,      ind,      at      the
                                                                                                                       cal         center         officials,          hospital          administrators,       option      of      tl)e       applic@int,       related       disease       or            "SEC.      ')O'.      (a)      The       Surgeon       General,       upon
                                                                   PUBLIC                LAW                8@239      and        rel)resent-,iti%,es         from         @ippropriate         voliin-                         but  Only  if  ,;iieli  group-  -                                        the    recoillitio@ii@l,'Itioii     (@f     tli(,     N.,ttionfil     @(1-
                                                           89TH           CONGRESS,            S.            @).W      tilry health Wiseacres.                                                                                                         Nvitiliri      it      g@,ogr;lr)llil-
                                                                          OC'I'Oltl@lt        I;,         J!)(W'k      "A llillol-izflti,)), )f                                                                                                of                                           ,f
                                                                                                                                                                                                                         oli,! (,I- i,ior,@          f,-,.                                               ill,  lit]
                                                                                              AN            AC"I'          "SP,'C.   1)01.   (:I)   Tli4,r@!  !Ll'l-  lltli,I,OIIZ(,Id                                                                  III                            %%it],
                                                                                                                       be       itpl)ropri-@itf,(]       $50,000,000       for       tli(@       fiscal           ri@gtilittioil,;,   to  be                                 ['or   @t    rry-                                                   ..  ......
                                                                                                                       year       ending       June       20,       1966,        $90,000,000        for           ilig    out    the    1)url)o@(@,.,,     of     this     title;                                   institutions,,       all([       )tlier       public        oi-
                                                                                                                       the      fisetil      year      ending      June       30,       1967,       and              "(2)      Consists      of      out-,      or      iiior(@       medical            nonprofit                  @ig(,tici(,s         :,act         institutions
                                Heart         Disease,         Cancer,         and         Stroke          Amend-      $200,000,000,      for       the       fiscal       year       ending       June           (,eiit(,rs,  one or iiiort@ (-Ijllie@ll                              e(,Yi-            to  assist  tile,,,  ill  Pl@I]IT]jlll,  the
                                                           ments  of  1965                                             PO,     1968,     for     grants     to     assist     public      or      noii-           ti!rs,  ttrid  one  or  more  liosliitals;  and                                        of regional iii(@(lic@ti
                                                                                                                       profit         private          universities,          medicil          schools,              "(3)      has      ill      effect       cool)(@rati,,e       arriin,-e-            "(1))     GI',lilt,,;     under     this     (,etioll     lll;l@-     1)@@
                                                                                                                       research        institutions,        and         other         public         or           nients  @11110,19  its  component  I,                  air,,;      Nvl)icll                  olll.N-       upon       application       tli(,@r(,,for        at)-
                                To  amend  the  Public  Health                        Service       Act        to                                                                                                                                                                                        I)r
                                                                                                                       nonprofit  private  institutions  and  @,igenc'                                            the Surgeon (,'cner@il finds will be                                                   O"('(1     by     tll(,     Sijrge,)ii     General.      kii3-      sliel)
                                assist        in         combating         heart         disease,         cancer,                                                                                   ics
                                stroke,  and  related  diseases.                                                       in       planning,       ]it       conducting        feasibility        studies,           for     (@ffectiv(@ly     e@ii-rying     out     the     litirposes      of            ;Illf)li(-:ttion        be    :Lppl'Ol'e(I    only    if     it     (,oil-
                                                                                                                       @in(I    in    operating     pilot     Projects     for     ill(!     c     tab-           this   title.                                                                          :iiit,,  or  is  ,lil,l)ort(,(l  bN,-
                                                                                                                                                                                           m@s                                                                                                              "(1)   r(,@i.@oziab](@  ii."ilrilnee@   tilllt
                                    Be     it     enacted     'by     the     Senate     and      lioll8c      of      li,,Iinient       of       regional       medical       progra       s        of           "lb)     The     t(@riii      "Ile(lic,'tl      cent(,i"      means      :I
                                                                                                                                                         ,Ill(l  (leiiion'tr, ti(,n
                                Representatives         of         the         United          @tates          of      research,  training,                                                        tiv-       Tll('(Ii('Ill      School      or      other       medical       itIStittitiOTI                                [laid      I)tirsti@iiit      to       iny       ,ueli
                                Anterica  in  Congre88  assembled,  That                                                                                                                                                                                                                                 gl,;tll.c
                                                                                                         this          ities      for      cirrying      out      the      purposes      of       tills                             l@c)stgr:t(lu;it,@           medical]            training                      %%ill    11"    ''sell    0111@-    for     the     I)tirpos(@.,
                                Act       may       be       cited       as       the       "Heart       Disease,      title.       Stims        ,ipprol)riated        under        this        ;ectlon       :"'(I     011(@     or     more      hospitals      :Ifflliat(,d      tliei,(,-            for  ivliicii   1)@ii(i  Bell   ill                                  @itll
                                CANCER,                STROKE,                AND            RELATED                   for     any     fiscal      year      sliill      remain      available      for       with   for   te@ieliiiig,                               :[]Ill       (lettioll-            file   @it)l)lic:lblc   I)I.Oxi.,iolis    of    tili@,,    fit],,    @In't
                                    SEC.       2.       The        Public        Health        Service        Act      making     such     grants     until     the     end     of      the      fiscal       strittion  purposes.                                                                       the  r(@gtilittiolis  thereunder;
                                                                                                                       .v(,ar     following      the      fiscal      year      for      which      the           "(c)   The   terrTi   '(Critical                              center'                     "(2)                                                  that        tli,@
                                (42     U.S.C.,     ch.     6A)     Is      amended      by      t(l(ling      it                                                                                                                                                                                        :11)illi(-;trit  Nvill                 f@,i-  ,tich
                                the      end      thereof       the       following       new       title:                    OI)T,i:ltioli  is                                                               means itii  iri@,titiiti,)ii  (Or                     (if  art                             tr(,]   :Ll)ll   fill([
                                                                                                                           "lb)  A gi,:iiit  iiii(](@r  this title                         t)(,     for       tioll)    ill(!    primary    filll(-tl(,Ii    (.1,    iviliell     is     r(@-            ;it,,-
                                "TITLY,,          IX-EDUCATIO@-s,                                       RESEARCH,      part    or    Lll    Or    til(@    cost     of     the     1)]@Ltii)irig     or       ,search,      training       of       specialists,       @iii(I       (leiiion-                                                                of   @ill(i
                                TRAINING,                 AND                 DE@IONSTRATIONS                  IN      Other      ilcti%'Iti(@l,'      witli      respect      to       which       the       sti,:itioiis    ;tiid    i%,Illcli,    ill    coil['(-(-tioil     there%%,itti,            ('Ontario  l'ol'  site])                        funds;
                                THE          FIELDS             OF    HEART                  DISEASE,                  application       is       made,       except        thLt        any        fuel       1)roN,i(les        specialized,        Iiigli-(Iii,,ility        (li@i,-Ilostic               "(:I)      reasonable      fissurzinces      that      tlic,      @il)-
                                CANCER,               STROKE,                  AND                        RELATED      grant       with       respect       to        construction        of,        or
                                DISEASES                                                                                                                                                                      :Ind       treatment        services        for        inpatients        @iii(i            I)Iietlrlt     will     Intake(,     such     reports,      in      ,iieli
                                                                                                                       provision       of       built-in       (as       determined       in        ac-       outpatients.                                                                               form       and       containing        such        inrorniition        @is
                                "Ptirpo8e8                                                                             cordance          with           regulations)           equipment           for,           "((I)     The     term     'hospital'      iiit,,in.,      it      lioslii-            the       Surgeon       General       may       from        time        to
                                                                                                                       tiny     facility     may     not     exceed     90     per      centtim      of
                                    "SEC.      900.      The      purposes      of      this      title      are-      ,                                                                                      tzil      as      defined      in      section      (;25(c)      or       other            time       reasonably        require,        @inti        will        keep
                                                                                                                       the      cost      of      such      construction       or       (,(Iuipiiieiit.                                                                                                  ,ueli    recortis    in(]     ,ifford     s(Icli     ;iece:,s     theret(,
                                    "(a)         Through         grants,         to         encourage         and                                                                                             I)i!altli     f@icility     in     which      local      (,,capability      for
                                assist       in       the       establishment       of        regional        co-          "(C)       Trends       appropriated       l@ursti,,tnt       to       tills       (]!Ztgllo,.4is       @111(i       treatment       is       supported       :Ind            :is  the  Stir,-eoii   G(,iier@il                                 ziece.,-
                                operative           arrangements                         among            medical      title     sliall     not     be     itvallable     to     pay      the      cost                                                                                                  S;tl,y  to  :ts.@,iire  the                            iti,l
                                schools,          research          Institutions,          and          hospitals      of     hospital,     medical,     or     other      care      of      patient,,,       ;iti@iiiL@iited      by      the      I)t-o;,r@iiii      established       all-            (-@ition  of  such  reports ;  and
                                for         research         and         training         (including         con.      except     to     the     extent     it      is,      as      determined      in       (I(@r  this  title,                                                                           "(4)       ,i       satisfactory       911ONViDg        that        the
                                tinuing  education)                                                                    accordance           with           regulations.           incident           to           "(e)   The  term   'iionr)ro8t'  its                                     to            ,-applicant         has         designated         an          ii(l%,isory
                                                                   and       for       related       le        on-         ose          research,          training,          or          demonstration       tiny      Institution      or       agency       means       all       institu-            group,   to  advise  the           - ,tpplicant         (@tnd          the
                                                                                 in        the f        in             ill
                                strations   of  patient   care                                         lds     of      ativities         which         are         encompassed          by          the       tion      or      agency      which      is      owned       and       operated            institutions         and         agencies         participating         in
                                heart        disease,         cancer,         stroke,         and         related      purposes      of      this      title.      No      patient       shill       be       by       one       or       more        nonprofit        corporations        or            the  resulting  regional   medical  progra                              In)
                                diseases :                                                                             furnished        hospital,        medical,         or         other         C.IM       Dissociations      no      part      of      the      net      turnings      of            in     formulating     @ind     (,;trr,@-ing     )iit     the      I)I@iii
                                    "(b)       To       afford       to       the       medical        profession      at      any      facility      Incident      to      i,esetircli,      training,
                                ,and       the       medical       institutions       of       the        Nation,      or       d(@nioristratiori       iictl%,Itics       carried       out       with       Nviii(,Ii  iiiilr,@s,  ,r  may  l@iwftilly                        to      tll(@            for   tli(,   est@' bli,@firrierit      ;in(I      ol)f@r,,ttiori       of
                                through          such           cooperative           arrangements,           the      funds       :appropriated        I)ursii@int        to        this        title,       11(@riet'it  or      a iii,     iii-i@iti@                                   or            such        regional        iiie(lic@if         program,         @vlil(-Ii
                                opportunity      of       making       available       to       their       p,,L-      unless     lie      has      bc@tn      referred      to      such      facility       individuate.                                                                               @ttli,isory       group       recreates        practicing        I)Ily,@i-
                                tients       the       latest       advances       In        the        diagnosis      by it practicing  physician.                                                               (f)      Tli(,,          t.(-riii          'construction'          Includes            (71@Lns,  medical center                           liosf)itiii
                                ,lDd treatment of these diseases ; and                                                                                                                                        Reiteration,      major      repair      (to      the       (@xterit       per-            iiiinistr@itors,          representatives          from          @ipl)t-o-
                                    "(c)       By        these        means,        to        improve        gen-      "Definitions                                                                           initted    by    r(,gtil@ltiODS),              remodeling                  :Ind            I)t,iztte       medical       societies,       voliint-@ir3,        health
                                erally         the         health         manpower         and         facilities          "SEC.     902.      For      the      purposes      of      this      title-       renon,iition        of        4@xistiilg        buildings        (iiie@ltidirig                            and          representittii-ts          of           other
                                available       to       the       Nation,        and        to        accomplish          "(a)        The        term        'regicnil        wedic@il        program'       initi@il      (-(Iiiipnient      thereof),      ;iri(i       i'@-lil;tcerii(@nt            (,transitions,          institution.,,           ,Lzid           igenei,,s
                                these       ends       without       interfering       with       the        Pat-      ine@ins       a       cooperative       @irrfiiigenient        @imon.@        IL       of    ol)So]L't(-,    built-in    (;is     il(-ti,rtriiii(@(I     !it     :I(.-                            %%,itli    ,I(.ti%,ttieg    of     tll(@     kirif]     to
                                terns,      or      the      methods       of       financing,       of       Pa.      grotilk    of    ptil)ll(,     or     iioril@rollt     liriv:ttc     filstil@ll-                       N%Illl    regulations)                                                     I),-               oil      iiii(ii-r       the       program       ,iiiii
                                tient       care       or       Professional       practice,       or        with      tions      or      tigeiieles      engaged      in       research,       triiii-       (!xistirig  buildings.                                                                     itietribers     of     the      public      formulae      ivitli      thi,

                                176









                                         need     for      the      services      provided      tinder      the  accordance      ivitli       the       Davis-Bacon       Act,       as the    Council,    shall     be     entitled     to     receive     com- interested           national           professional            organiza-
                                         program.                                                                amended       (40       U.S.C.        276a-276a-5)        ;        and pensation      at      rates      fixed      by      the      Secretary, tions.
                                                                                                                 the      Secretary      of      Labor      shall      have,       with but      not      exceeding      $100      per      day,       including
                                      "Grants         for EBtabli8hn4ent        and        Operation         of  respect     to     the     l@ibor     standards      specified      in traveltime,      and      while      so      serving      away      from Report  to  President  and  Congress
                                      leegioizal Ile,lical Progi-ain.3                                           this      piirfigrapli,      the       authority       and       func- their    homes    or     regular     places     of     business     they   "SEC.  908.  On  or  before  June  :30,                1 a(3  7,
                                                  f@04.  (;i)  ']'II(! Stirg(@ori                                tion,,     set     fortli     lit      Iteorgitilziitiori      ri.@tri may      be      @ill(@wo(I      tr;tvel      ex[)eyis@',      including than     Surgeon     General      ;tfter      cozistil@,.itioii      with
                                                                                                                 Niiiiilj,-r(!(]   1,1   (,f   I!)50    (15    10.11.    :@17(;;    !-, lit@r  iliem  lit  licti   of   siil)sisteii(!e,   it@,   itijtliorize(i file  (Political,  ,4itill  iiil)rtiit  to  Ili(!
                                                                                                                            I:t:@z  15)  :,,,,I                   )r   (li@,    Act    [,.N           5 )f iii,,                                                                          to  tli@,                 ;All(]    trial!
                                                                                                                               ]:I,                                                    A,-l  @l'  II)-II;  (5           7:tl,  '-')  f,@i,             lit     (11  tili@                 it     report     of     file     activities
                                      schools,       r(-searcli       institutions,       ;irid        otlil.],  27(;(:).                                                              the  Govi-riiiii(@ii;t                (-@iiil)loy(xl    iiiteriiiit.-   tinder     this     title     together     with     (1)     a      state-
                                      public      or       nonprofit       private       @igencie,.s,       and "National         Advisory          Council          on          Regional teiitly.                                                             meet       of       the        relationship        between        Federal
                                      institution       to       assist       in       establishment        and Ifcdical Progrg,?ji,3                                                  Applications for                                                        financing       and       financing       front       other       sources
                                      operation         of         regional          medical          programs,                                                                        grants, recom-                                                          of     the     activities      undertaken      pursuant      to      this
                                      including         construction         and          eqUiPMCDt          Of kl)pointinent  of                                                      mendations.                                                             title,     (2)     an     appraisal     of     the     activities     as-
                                      facilities in  connection  therewith.                                   members.                                                                                                                                         sisted    under    this    title    in     the     light     of     their
                                         "lb)     Gr@,ints     tin(if@r      this      section      may      be            ,)O.-).  (;I)       Surgeon        (,encriil,        with      "(d)  The       Council      shall      advise      and       assist effectiveness     in     carrying      out      the      purposes      of
                                                                                                    :it)-                                                                              t.lic    Stirg(!oii    G(-iieral    lit    the    preparation    of     this       title,       ,in(i       (3)       recommendations        with
                                                       ill(-  Sijrgi,ort                 Any       sti(-])    lit(,   itlilir(,N@;tl   of   ill(!   S(@(!ret@iry,   m@iy    @IPI)Oillt, i,(,gtil;ttioiis for,     ;iiid     :is     to     policy     matters  respect     to     extension      or      modifictition      of      this
                                                       ii,@iy be                 only  if  it   is   r,-(@-   witliiiiit              to    the    civil     ;ervice     laws,     it  ;tri,,,,ing      with      respect      to,      the      administration title  lit  the light tliereof.
                                                       1)3,    the    @t([N,!,(,ry    groul)    described     N@iti(iii;tl   A(Ivisi)i-y    Council    oil    Regional    1\ledi-      of    this    title.    The    Council    sliill    consider    all
                                      lit   section   903(b)   (4)   and    contains    or    is    stip-     cal    Ilrogr@inis.    The     Council     shall     consist     of      applications       for    grants    under    this    title     ,ind     "'Reco?,ds  a?id Audit
                                      fiorted  1)3-  i,e@isonable a.,,siirane(@s  that-                       tried   Surgeon   (;enerzil,    who    shall    be    the    chair-      shall      make      recommendations      to      the       Surgeon         "SEC.    900.    (a)    Each    recipient     of     a     grant
                                            ,,(I)     l,'e(leral     funds     paid     pursu@int      to     ni@in,    @iii(I    twelve    members,     not     otherwise     in      General    with     respect     to     approval     of     applica-     tinder    this    title    shall    leep     such     records     as
                                         @iiiy   such   grant   (i@)    will    be    used    only    for     the    r(@gtilar     full-time     employ     of     the     United      tions   for   in(]    tlic,    amounts    of    gr@,iiits    tinder     the     Surgeon      General      may      prescribe,      incliltl-
                                         tlii@  I)iirpo.,(@s   for   which   1)@tid   :tied   II)   :I(,-     States,   who    ire    leaders    in    the    fields    of    the      this title.                                                             ing     records     which     fully     disclose     the      amount
                                                       %vitli tlif@                                    of     fiiiiiliini(@jit@il    sciences,    the     medical     scieric(@s,      "I?cqizlatiotis                                                         :itld     deposition     by     such     recipient     )f      tit(,
                                         this  till(, ;tit(]  flif!  rf,giil;it,i,)Til;                       .r  public  ;tlTair,;.  At@                two   of   tli(@   !II)-                                                                              proceeds    of    such     grant,     to     tot@,il     cost     of
                                                                                                                           iii(!ijil)(!rs sli@ill  1)(!  I)riictili-iiig  pliysi-         "Sic.  90(;.  The  Stirg(@oii                                        file     l@roject     or     undertaken;,,,     in      coiinectioil
                                                             iii,t,               faults tit;         rt,                     shall  1)(@  ('11tit;Lxl(lltig  ill   file   study,      ('oliSUlt@:lt!Oll   %%'itli   file    (@'OUDCil,    shall    I)r(@-
                                                        :tviiiliibl4,,  for   (!.@t.,tl@lislim(!nts   at'                                                                                                                                                      with   which    ,iucli    grant    is    made    or    used,    in(I
                                                                                             I)r(,gr:irli     tli;ignosi@,    or    treatment    of    heart     disease,     one      scrib()     general     regul@itions     covering     the     terms'    the    :iznount    of    that    portion    of    the    cost     of
                                                                                                                                                                                                                                                               his     project     or     undertaking     supplied     by     other
                                                                                                                      1)(@    outstanding    lit    tli(@    study,    diagnosis,      :tji(I  conditions  for  iipl)ro%@itig  @tl)plie;i           'io"'@
                                         with               to  NN,Iiicli  thi@  grtrit  is   ni@i(le   ;     or   treatment   of   ctincer,   an(]    one    shall    be    out-      for   grants    under    this    title    and    the    coordi.@,,-
                                            ,1(2)  the                   will    r@rovi(le    for    such     st@in(ling    in    the     study,     diagnosis,     or     treat-      tion     of     programs     assisted     tinder     this     title     sources,     and     such     records     as     will     facilitate
                                                                                                                                                                                                                                                               -in effective audit.
                                         fiscal     control     and     fund      accounting      I)roce-     inent of stroller                                                        with      programs      for      training,      research,      anci         "lb)     The      Secretary      of      Health,      Education,
                                         (lures     as     are     require(]     by      the      Surgeon                                                                              demonstrations     relating     to      the      same      diseases
                                                                                                                                                                                                                                                               and     Welfare     and     file     Comptroller     General      of
                                         General    to     assure     proper     (lisbtjrs(,@inent     Of     Term (,f office.                                                         -issisted    or    authorized    tinder     other     titles     of     the     United     States,     or     any     of     their      dulv
                                         an4l @teci)tinting for such                      funds                  "(t))    Each    ,tl)pointed    member     of     the     Cotin-      this  Act  or  other  Acts  of  Congrc%s.
                                                                                                                                                                                                                                                               ;authorized     representatives,     ,:Iiall      lian,o      access
                                         IZ(@cords,                                                           cil   sliill   hold   office   for   a   term   of   four    years,      ,rnformatioit      oil       Special       Treatiytc?tt       att(I     for    file    purpose    of    audit     and     examination     to
                                                                                                              except    filar    any    member    appointed    to     fill     @l      @raiiii?ig  Centers                                                     any      books,      documents,      papers,       and       records
                                            "(3)    the     tpl)licant     will     make     such     re-     vacancy    prior    to    the    expiration     of     the     term                                                                              of     the     recipient     of     any     grant     under     this
                                         parts,     in     such     form     and     containing      such     for      which      his      predecessor       was       @ippointed         "SEC.      907.      The       Surgeon       General       shall     title    which    ,ire    pertinent    to    any    such     grant."
                                         information      as      the      Surgeon      General       may     shall    be    appointed    for    the    remainder     of     such      establish,     and     maintain     on     a     current     basis.         SEC.   3.   (a)    Section    I    of    the    Public    Health
                                         from    time    to     time     reason@tbly     require,     and     term,    and    except     that     the     terms     of     office      a    list    or    lists    of    facilities    in    the    United
                                         will     keep     such     records     and      afford      such                                                                                                                                                      Service    Act     is     amended     to     read     as     follows
                                                                                                              of   the   members    first    taking    office    shall    expire,      States     equipped     and     staffed     to     provide     file         "SECTION    1.    Titles    I    to    IX,     inclusive,     of
                                         access      thereto      @is      the      Surgeon      (@eneral     @is    designated    b.@-    the    Surgeon    General    at    the      most      advanced      methods       and       techniques       in     this    Act    may    be    cited    as    the    'Public     Health
                                         may     fin(]     necessary     to     asstire     the      cor-     time   of    appointment,    four    at    the    en(]    of    the      the    diagnosis    .in(I    treatment    of     heart     disease,
                                         r(!ctnt@ss   and   verification   of   ,iicii   r(@ii(,rt.,    ;     first                                                                                                                                            Service Act'."
                                                                                                                              four ;it@ fli(, en(]  (if  tli(@  ,;e(@ori(I  year,      ciiic(,r,    or    stroke,    together    with     such     related
                                         and                                                                  ;iri(I   four   at   till!   end   of   the   third   year   @ifter      ixifoi,iii@itioii,     including     the      :availability      of         lb)    The    Act    of    Jul3-    1,    194-1    (58     Stat.
                                            "(4)  an3- laborer or meelianic                                   the   (]at(!    of    apl)ointiii(!nt.    Ali    ,ippointed    mem-      ,tdv;izicc(l   il)eciLlty   training   it)    such    facilities,;.     1;82),    as    amended,    is    further    @imended    b3,     re-
                                         by    @iny    contractor    or     subcontractor     lit     the     I)ei,   shall   riot   be   t-ligil)le   to   serve    continuously      @is  lie   cleeiiis   useful,   and   sll,,Lll   make   such   list     numbering   title    IX    (as    in    effect    prior    to    the
                                         performance      of      work      on      any      construction     for  more  than  two  terms.                                             or      lists      and      related       information       readily     ciitictment    of    this    Act)    as    title    X,    and     by
                                                                                                                                                                                                                                                               i-enumbering      sections      1)01      through      1)14      (as
                                         aided     by     payments     pursuant     to     ,Lny     grant                                                                              ;available     to     licensed     practitioners     and      other     in   effect   prior    to    the    enactment    of    this    Act).
                                         iin@](@r  till.,;  ,f!(!ti(@n  ivill  1)(!  late(]  wage,,,  lit     Compens@ition.                                                           lierson,,     requirin,     such      Information.      To      the     and      references      thereto,      its       sections       1001
                                         rates    not    ]@'s     Than     tlio@f!     prevailing     oil        "(c)     Appoiiit(@(I     members     (if     tells      Launch,      (Laid   of   iii;tkiii;,   such   list   or   lists    and    other     through  1014,  r(,sl)eetivel3-.
                                         siinil;tr                        fit   tire!    loc@ility    @is     i%-Iiilc     @itt(,ri(lirig      meetings      oi,      conferences      information     itiost      useful,      the      Surgeon      Gen-         APPROVED         OCTOBER         6,         1965,          10:15
                                         determined     by     file     Secretary     of     Labor     in     thereof     or     otherwise     serving     on     business     of      eral    shall    from    tiiii(@.    to    time    consult    ivith     A.,Nf.


                                                                                                                                                                                                                                                                                                                          1   77













                         Legiaative History:                                                           APPENDIX  8               (j)   "Advisory   group"   means   the   group      (d)  AdvisorV   group;   e8tabU8hment;   evi-
                                                                                                                               designated  pursuant  to  section   903(b)   (4)   dence. An application for  a  grant  under  sec-
                         House  Report   No.   963   accompanying   H.R.                                                       of the Act.                                        tion  903  of  the  Act  shall  contain  or   be
                         3140   (Comm.   on   Interstate   and   Foreign                                         REGULATIONS     (k)   "Geographic   area"   means   any   area   supported  by  documentary   evidence   of   the
                         Commerce).                                                           REGIONAL               MEDICAL   that  the  Surgeon  General   determines   forms   establishment of  an  advisory  group  to  prnog
                         Senate Report  No.  368  (Comm.  on  Labor  and                                    PROGRAMS            n  ,,,,mic   and   socially   related   region,   vide   advice   in   formulating   and    carryi
                         Public Welfare).                                                             MARCH    :L8,     1967   takig  into  consideration   such   factors   as   out the establishment and operation           ofa
                         Congressional Record, Vol. 111 (1965)                                                                 present  and  future   population   trends   and   program.
                           June 25: Considered in Senate.                                                                      patterns of growth  ;  location  and  extent  of      (e)  Advisory  group;  membership;   descrip-
                           June  28  :  Considered  and  passed  Senate.    SUBPART E-GRANTS FOR                               transportation  and   communication   facilities   tion. The  application  or  supporting  material
                           Sept. Z3:  H.R.  3140  considered  In  House.    REGIONAL MEDICAL PROGRAMS                          and  systems  ;  presence  and  distribution  of   shall  describe  the  selection  and  membership
                           Sept.  24  :  Considered  and  passed  House,                                                       educational,  medical  and   health   facilities   of  the  designated  advisory   group,   showing
                             amended, in lieu of H.R. 3140.                                                                    and programs,  and  other  activities  which  in   the  extent  of  inclusion  In  such  group   of
                           Sept. 29 :  Senate concurred  in        House    (Added  1/18/67,  S2   PR   571.)                  the opinion  of  the  Surgeon  General  are  ap-   practicing   physicians,   members   of    other
                             amendments.                                      AUTHORITY:    The    provisions of  this   Sub-  propriate  for  carrying  out  the  purposes  of   health professions,  medical  center  officials,
                                                                            part E  Issued  under  see,  215, 58  Stat.   690, Title IX.                                          hospital  administrators,  representatives  from
                                                                            see. 906, 79 Stat. 930 -, 42  U.S.C.  216,  299f                                                      appropriate    medical    @ieties,     voluntary
                                                                            Interpret or apply sees. 900, 901, 902   ,  903:   [] 54.403  ELIGIBILITY.                            agencies,  representatives  of  other  organiza-
                                                                            904, 905, 909, 79  Stat.  926,  927,  928,  929,     In order to be eligible   for  a  grant,   the   ttons,  institutions  and   agencies   concerned
                                                                            930, 42 U.S.C.  299,  299a,  29ab,  299c,  299d,   applicant shall:                                   with activities of the kind  to  be  carried  On
                                                                            299e, 2991.                                          (a)  Meet  the  requirements  of  section  903   under the  Program,  and  members  of  the  pub-
                                                                                                                               or 904 of the Act;                                 lie familiar with  the  need  for  the  services
                                                                              54.401           APPLICABILITY.
                                                                                                                                 (b) Be located in a State;                       provided tinder the progrnm.
                                                                              The  provisions  of  this  subpart  apply   to     (e) Be  situated  within  it  geographic  area     (f)  Construction;   purposeR,   pla",   ati,l
                                                                            grants   for   planning,   establishment,    and   appropriate under the provisions  of  this  sub-   specilicatie;ns;  narrative  description.   With
                                                                            operation  of  regional  medical   programs   as   part for carrying out the purposes of  the  Act.   respect  to  an  application  for  funds  to  be
                                                                            authorized by Title  IX  of  the  Public  Health                                                      used  In  whole  or  part  for  construction  as
                                                                            Service  Act,   as   amended   by   Public   Law   ED 54.404  APPLICATION.                            (leflned In Title IX, the applicant  shall  fur-
                                                                            89-239.                                              (a)  For7n8.  An  application  for   a   grant   nish In sufficient detail plans  and  speciflea-
                                                                            M 54.402  DEFINITIONS.                             shall be submitted on such  forms  and  in  such   tions as well as  a  narrative  description,  to
                                                                                                                                                                                  Indicate
                                                                                                                                                                             ay           -the needi nature, and  purpose  of  the
                                                                                                                               manner  as  the  Surgeon  General  m
                                                                              (a)  All  terms  not  defined   herein   shall                                                      proposed construction.
                                                                                                                               prescribe.
                                                                                                                                                                                    (g)   Advisory   group;   recommendation.   An
                                                                            have the meaning given them in the Act.              (b)  Execution.  The  application   shall   be
                                                                              (b)  "Act"  means  the  Public  Health   Serv-   executed by  an  individual  authorized  to  act   application for a grant  under  section  904  of
                                                                            ice Act, as amended.                               for  the  applicant  and  to  assume  on  behalf   the Act shall  contain  or  be  supported  by  a
                                                                              (c)  "Title  IX"  means  Title   IX   of   the   of the applicant all of the  obligations  speci-   copy  of  the  written  recommendation  of   the
                                                                            Public Health Service Act as amended.              fled In the terms and conditions  of  the  grant   advisory group.
                                                                              (d) "Related diseases" means those        dis-   including  those  contained  in  these   regula-   F-1 54.405  TERMS, CONDITIONS,
                                                                            eases which  can  reasonably  be  considered  to   tions.                                                        AND A-SSURANCES.
                                                                            bear a direct  relationship  to  heart  disease,     (c)  Description  of  program.   In   addition
                                                                            cancer, or stroke.                                 to any  other  pertinent  Information  that  the    In addition to  any  other  terms,  conditions,
                                                                              (e) "Title  IX  diseases"  means  heart   dis-   Surgeon  General  may  require,  the   applicant   and  assurances  required  by  law  or   imposed
                                                                            ease, cancer, stroke, and related diseases.-       shall  submit  a  description  of  the   program   by the Surgeon  General,  each  grant  shall  be
                                                                                                                                                                                  subject  to  the  following  terms,   condition,
                                                                              (f)  "Program"  means   the   regional   medi-   in sufficient detail  to  clearly  Identify  the   and  assurances   to   be   furnished   by   the
                                                                            cal program as defined in  section  902  (a)  of   nature, need,  purpose,  plan,  and  methods  of
                                                                            the Act.                                           the  program,  the  nature  and   functions   of   grantee.  The  Surgeon  General   may   at   any
                                                                              (g)   "Practicing   physician"    means    any   the participating institutions,  the  geographic   time approve  exceptions  where  he  finds  that
                                                                            physician  licensed  to  practice  medicine   in   area to  be  served,  the  cooperative  arrange-   such exceptions are not  inconsistent  with  the
                                                                                                                                                                                  Act and the purposes of the program.
                                                                            accordance  with  applicable  State   laws   and   ments In effect, or  intended  to  be  made  ef-
                                                                            currently engaged In  the  diagnosis  or  treat-   fective, within the  groul>,  the  justification    (a)  Use  of  funds.  The  grantee   will   use
                                                                                                                                                                                  grant funds solely for the  purposes  for  which
                                                                            meiLt of patients.                                 supported by a budget or  other  data,  for  the
                                                                              (h)  "Major   repair"   includes   restoration   amount of the  funds  requested,  and  financial   the grant was made, as  set  forth  in  the  ap-
                                                                            of an existing building to a sound state.          or   other   data   demonstrating   that   grant   proved  application  and  award  statement.   In
                                                                                                                                                                                  the  event  any  part  of  the  amount  paid   a
                                                                              (1)   "Built-in   equipment"   Is    equipment   funds  will   not   gupplant   funds   otherwise
                                                                            affixed to  the  facility  and  customarily  in-   available  for  establishment  or  operation  of   grantee is  found  by  the  Surgeon  General  to
                                                                            luded in the construction contract.                the regional medical programme                     have been  expended  for  purposes  or  by  RD3'
                                                                            c

                         178








                          methods  contrary  to  the  Act,  the   regulations    designated  in  the   application   as   responsible      (g)  The  geographic   distribution   of   grants    generally   accepted   and   established    account-
                          of this  subpart,  or  contrary  to  any  condition    for  the   coordination   of   the   program   shall   throughout the Nation.                                  ing  practices  or  as   otherwise   prescribed   by
                          to  the  award,  then  such  grantee,  upon   being    continue  to  be  responsible   for   the   duration                                                           the Surgeon General.
                                                                                                                                        C] 51.407  TERMINATION.                                                                                Funds
                          notified  of  such  finding,  and  In  addition  to    of  the  period  for  which  grant  funds  are  made                                                              (b) Direct     costs   in    general.
                          any  other  requirement,   shall   pay   an   equal    available.  The  grantee  shall  notlfy   the   Sur-      (a),  Termination  by   t)ie   Surgeon   General.    granted  for  direct  costs  may  be   expended   by
                          amount   to   the   United   States.   Changes   in    geon   General   immediately   if   such    official   Any  grant  award   may   be   revoked   or   termi-    the  grantee  for  personal  services,   rental   of
                          grant  purposes  may  be  made  only   in   accord-    becomes     unavailable     to   discharge      this   nated  by  the   Surgeon   General   in   whole   or    space,   materials,   and   supplies,   and    other
                          ance   with   procedures   established    by    the    responsibility.    The    'Surgeon    General    may   in  part  at  any  time  whenever  be   finds   that    items  of  necessary  cost  as   are   required   to
                          Surgeon General.                                       terminate   the   grant   whenever   such   official   in  his  judgment  the  grantee  has  failed  in   a    carry  out  the   purposes   of   the   grant.   The
                            (b)  Obligation  of  funds.  No  funds   may   be    shall   become   thus   unavailable    unless    the   material  respect  to   comply   with   requirements    Surgeon General may issue rules,              struc-
                          charged  against  the  grant  for   services   per-    grantee  replaces   such   official   with   another   of  Title  IX  and  the  regulations  of  this  sub-    tions,   Interpretations,   or   limitations    sup-
                          formed  or   material   or   equipment   delivered,    official  found  by  the  Surgeon  General   to   be   part.  The  grantee  shall  be   promptly   notified    plementing   the   regulations   of   this   subpart
                          pursuant  to  a  contract  or   agreement   entered    qualified.                                             of  such  finding   In   writing   and   given   the    and  prescribing  the  extent   to   which   partic-
                          Into  by  the  applicant  prior  to  the  effective                                                           r@ns therefore                                          ular  types   of   expenditures   may   be   charged
                          date of the grant.                                     0 54.40,6  AWARD.                                         (b)    Termination    by    the    grantee.     A    to grant funds-
                            ('a)  Inventions  or   discoveries.   Any   grant       Upon    recommendation    of     the     National   grantee  may  at  any  time  terminate   or   cancel       (c)  Direct   costs;   personal   services.   The
                          award  hereunder  In  whole  or  in  part  for  re-    Advisory   Council   on   Regional   Medical    Pro-   its  conduct  of  an  approved  project  by  notify-    costs  of  personal  services   are   payable   from
                          search  is  subject  to  the  regulations  of   the    grams,  and   within   the   limits   of   available   ing  the  Surgeon   General   In   writing   setting    grant   funds   substantially   in   proportion   to
                          Department   of   Health,   Education,   and   Wel-    funds,   the   Surgeon   General   shall   award   a   forth the reasons for such termination.                 the  time  or  effort  the  Individual  devotes   to
                          fare as set forth In Parts 6 and  8  of  Title  45,    grant   to   those   applicants    whose    approved      (c)    Accounting.    Upon    any    termination,    carrying  out  the  purpose   of   the   grant.   In
                          as  amended.  Such  regulations  shall   apply   to    programs  will  in   his   judgment   beat   promote   the  grantee  shall  account  for  &II  expenditures    such  proportion,  such  costs   may   Include   all
                          any  program  activity  for   which   grant   funds    the  purposes  of  Title  IX.  In  awarding  grants,   and   obligations   charged    to    grant    funds:    direct  costs  incident  to  such   services,   such
                          are  In  fact  used  whether   within   the   scope    the   Surgeon   General   shall   take   into   con-   Provided,  That  to  the  extent   the   termination    as   salary   during   vacations   and    retirement
                          of  the   program   as   approved   or   otherwise.    sideratiod,  among  other   relevant   factors   the   Is  due  in  the  judgment  of  the   Surgeon   Gen-    and   workmen's   compensation   charges,   in   ac-
                          Appropriate  measures  shall  be   taken   by   the    following:                                             eral to  no  fault  of  the  grantee,  credit  shall    cordance   with   the   policies   and    accounting
                          grantee  and  by  the  Surgeon  General  to  assure       (a)  Generally,   the   extent   to   which   the   be  allowed  for  the  amount  required  to   settle    practices  consistently  applied  by   the   grantee
                          that  no  contracts,  assignments,  or  other   ar-    proposed   program   will   carry    out,    through   at  costs  demonstrated   by   evidence   amt1stELc-    to all Its activities.
                          rangements  inconsistent  with  the   grant   obli-    regional  cooperation,   the   purposes   of   Title   tory to the Surgeon General to be minimu           m       (d)  Direct  costs;   care   of   patients.   The
                          gation  are   continued   or   entered   Into   and    IX, within a geographic area.                          settlement   costs,   any   noneancell&ble   obliga-    cost  of  hospital,  medical  or   other   care   of
                          that  all  personnel  involved  In  the   supported       (b)  The  capacity   of   the   institutions   or   tions  Incurred  prior  to  receipt  of  notice   of    patients  Is  payable  from  grant  funds  only   to
                          activity  are  aware  of  and  comply   with   such    agencies   within    the    program,    Individually   termination.                                            the  extent  that  such  care  is  incident  to  the
                          obligation.   Laboratory   notes,   related   tech-    and  collectively,  for  research,   training,   and                                                           research,   training,   or   demonstration   activi-
                          nical  data,  and  information  pertaining  to  In-    demonstration  activities  with  respect  to   Title   m K4.408  NONDISCRIMINATION.                            ties  supported   by   a   grant   hereunder.   Such
                          ventions  or  discoveries  made   through   activi-    ix.                                                       Section 601 of  Title  VI  of  the  Civil  Rights    care shall be  incident  to,  such  activities  only
                          ties   supported   by   grant   funds   shall    be       (e)  The  extent  to  which  the   applicant   or   Act  of  1964,  42  U.S.C.  2000d,   provides   that    if   reasonably   associated   with   and   required
                          maintained  for  such  periods,  and   filed   with    the   participants   in   the   program   plan    to   no  person  in  the  United  States  shall,  on  the    for  the  effective  conduct  of  such   activities,
                          or  otherwise  made  available   to   the   Surgeon    coordinate  or   have   coordinated   the   regional   ground  of  race,  color,  or  national  origin,  be    and  no  such  care  shall  be   charged   to   such
                          General  or  those  he  may   designate   at   such    medical   program   with   other   activities   sup-   excluded  from  participation  In,  be  denied   the    funds  unless  the  referral  of  the   patient   Is
                          times  and  in  such  manner  as  he   may   deter-    ported   pursuant   to   the   authority   contained   benefits  of,  or  be  subjected  to  discrimination    documented  with  respect  to  the   name   of   the
                          mine  necemry  to   carry   out   such   Department    in  the  Public  Health  Service   Act   and   other   under  any  program  or  activity   receiving   Ped-    practicing   physician    making    the    referral,
                          regulations.                                           Acts   of   Congress   including   those    relating   eral  financial   assistance.   Regulations   Imple-    the name of  the  patient,  the  date  of  referral,
                            (d)   Reports.   The   grantee   shall   maintain    to  planning  and  use  of  facilities,   personnel,   menting  the  statute  have  been  issued  as   Part    and   any   other   relevant    Information    which
                          and  file  with  the  Surgeon  General  such  prog-    and   equipment,   and   training    of    manpower.   80  of  the  Title  45,  Code  of  Federal   Regula-    may  be   prescribed   by   the   Surgeon   General.
                          ress,  fiscal,   and   other   reports,   including       (d)  The  population  to   be   served   by   the   tions.   The   regional   medical   programs    pro-    Grant  funds  shall  not   be   charged   with   the
                          reports  of  meetings   of   the   advisory   group    regional   medical   progrum    and    relationships   vide  Federal  financial   assistance   subject   to    cost of-
                          convened  before  and  after  award  of   a   grant    to    adjacent    or    other    regional    medical   the  Civil   Rights   Act   and   the   regulations.       (1)  Care  for   lntercurrent   conditions   (ex-
                          under section  904  of  the  Act,  as  the  Surgeon    programs.                                              Each grant Is subject to the condition                  cept  of  an  emergency  nature  where  the   inter-
                                                                                                                                                                                        that
                          General may prescribe.                                    (e)  The  extent  to   which   all   the   health   the  grantee  shall   comply   with   the   reqtlre-
                                                                                                                                                                                                current  condition  results  from   the   care   for
                            (a)   Records   retention.   All    construction,    resources  of  the  region  have  been  taken   into   ments of Executive Order 11246, 30
                                                                                                                                                                                          @:    which  the   patient   was   admitted   for   treat-
                          financial,  and  other  records  relating  to   the    consideration  In   the   planning   and/or   estab-   12319, and the applicable rules, regul. 0        to-    ment)   that   unduly   Interrupt,   postpone,    or
                          use  of  grant  funds  shall  be   retained   until    lishment of the program.                               and   procedures   prescribed   pursuant   there   .
                          the  grantee  has  received  written  notice   that       (f)  The  extent  to  which   the   participating                                                           terminate the conduct of such activities.
                          the records hav ' been  audited  unless  a  differ-    institutions   will   utilize   existing   resources   0     54.409     EXPENDITURES      BY      GRANTIDR.       (2)  Inpatient   care   if   other   care   which
                                          c
                          ent period is  permitted  or  required  in  writing    and  will   continue   to   seek   additional   non-      (a)   Allocation   of    costs.    The    grantee    would   equally   effectively   further   the   pur-
                          by the Surgeon General.                                federal  resourcw  for  carrying  out   the   objec-   shall   allocate   expenditures   as   between   di-    poses  of  the  grant,  could  be  provided   at   a
                            (f)@   Responsible   offloial.    The    official    tives of the regional medical pr(>@                    rect   and   indirect   @    lr6    a@rdance    with    smaller cost.

                                                                                                                                                                                                                                              179












                               (3) Bed and  board  for  inpatients  in  excess    continued  use  of  the   facility   or   equipment
                            of  the   cost   of   semiprivate   accommodations    for   the,   grant   purposes.    In    determining
                                                                                                                         geon    Gen-
                            unless  required  for  the  effective  conduct  of    i@-lietli(-r good cause exists, the Sur
                            such  Lctivities.  For   the   purpose   of   this    er,'Ll  Slltll  take  into   consideration,   among
                            paragraph,      "semiprivate       accommodations"    other factors, the extent to ivhich-
                            means   two-bed,    three-bed,    ,Lnd    four-bed       (1)  The  facility  or  equipment  will  be  de-
                            accommodations.                                       voted  to   research,   training,   demonstrations,
                                                                                  or   other   activities   related   to   title   IX
                            Fl 54.410  PAYMENTS.                                  diseases.
                               The Surgeon General      shall,  from  time  to                                     calling   for    a
                                                                                     (2) The  circumstances
                            time, make payments to      a grantee  of  all  or    change  in  the  use  of  the  facility  were   not
                            ,t portion of  any  grant  award,  either  in  ad-    I;nown,  or   with   reasonable   diligence   could
                            vance  or  by  way  of   reimbursement   for   ex-    not have been  known  to  the  ,Lpplicant,  at  the
                            penses  to  be  incurred  or   incurred   to   the    time  of   the   application,   ind   arc   circum-
                            extent  be   determines   such   payments   neces-    stances  reasonably  beyond  the  control  of   the
                            sary to carry  out  the  purposes  of  the  grant.    ipplicant or other owner.
                                                                                     (:t)        tire refi@'onal)le  assurances  that
                            n 54.,Ill   DIFFEITENT    USI@,     Olt     TRANS-           facilities  riot  previously  utilized   for
                                        rER :     GOOD       CAUSE         FOR    Title IX purposes  will  be  so  utilized  and  are
                                        OTHER USE.                                substantially  the   equivalent   In   nature   and
                               (a)  Compliance  by  grantees.   If,   at   any    extent for such purposes.
                            time,  the   Surgeon   General   determines   that    n 54.412  PUBLICATIONS.
                            the  eligibility  requirements   for   a   program
                            are  no  longer  met,  or  that  any  facility  or       Grantees   may   publish   materials    relating
                            equipment   the   construction   or    procurement    to   their   regional   medical   program   without
                            of which was  charged  to  grant  funds  is.  dur-    prior  review  provided  that   such   publications
                            ing its useful life,  no  longer  being  used  for    carry   a   footnote    acknowledging    assistance
                            the  purposes  for  which   it   was   constructed    from  the  Public   Health   Service,   and   Indi-
                            or  procured  either  by  the   grantee   or   any    cating that findings and conclusions      do    not
                            transferee,  the   Government   shall   have   the    represent the views of the Service.
                            right  to  recover  its  proportionate  share   of
                            the  value  of  the  facility  or  equipment  from    n 54,.41-  COPYRIGHTS.
                            either  the  grantee  or  the  transferee  or  any       Where the grlnt-supported ictivity       results
                            Institution  that  is  using   the   facility   or    in copyrightlble material, the author      is  free
                            equipment.    The    Government's    proportionate    to  copyright,  but  the  Public   Health   Service
                            share  shall  be  the  amount  bearing  the   same    reserves  i  royalty-free,  nonexclusive,   irrevo-
                            ratio  to  the  then  value  of  the  facility  or    cable license for use of such material.
                            equipment,   as   determined   by   the    Surgeon    El 54.,il4  INTEREST.
                            General,  as  the  amount  the  Federal   partici-       Interest  or  other  income   earned   on   pay-
                            pation  bore  to  the  cost  of  construction   or    riients I]TI(ler this  subpart  shall  be  paid  to
                            procurement.                                          the United States  as  such  interest  is  received
                               (b) Different use  or  transfer;  notification.    by the grantee.
                            The  grantee  shall  promptly  notify   the   Sur-
                            geon General In writing  if  at  any  time  during
                            its useful life  the  facility  or  equipment  for
                            construction  or  procurement   of   which   grant
                            funds  were  charged  is  no  longer  to  be  used
                            for  the  purposes   for   which   it   was   con-
                            striieted or procured  or  is  sold  or  otherwise
                            transferred.
                               (e)   Forgiveness.    The    Surgeon    General
                            may  for  good  cause  release  the   grantee   or
                            other  owner  from   the   requirement   of   con-
                            tinned  eligibility  or  from  the  obligation  of

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                                               Public Health Service Publication No. 1774




























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