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                                            DR. EDMUND D. PELLEGRINO                         see Contemporaries page 18

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                                        49


                 EdmundD.                                    campuses    in    less    than    twenty
                                                             @'ears.  He  has   been   bringing   his
                 Pellegrino, M.D.                            own    brand    of    "i@elevance"    to
                                                             medicine.
                 0  Plato   believed   that   to   be   a       Dr.    Pellegi@iiio     Nvent    from
                 good   physician   one   must    experi-    Oneonta      to      tlieii-little-known
                 ence  serious  illness.  In  1950,  sev-    Hunterdon     Medical     Center      in
                 en  years  out  of  New   York   Univer-    Flemington,   N.J.;    to    the    Uni-
                 sity  College  of  Medicine   and   with    versity   of   Kentuck@,   College    of
                 a  foot  on  the  first  rung   of   the    Medicine  (in   1959)   when   "it   was
                 research    ladder,    internist     Ed-    a  cornfield  in  search   of   a   cam-
                 mund   D.   Pellegrino   ",as   stricken    pus";  and  about  six  years   ago   to
                 with  tuberculosis.   A   vear   and   a    the  State  Univei@sity  of   New   York
                 half of bed rest,  followed  by  a  like    at   Stony   Brook   where   he    holds
                 amount  of  time   as   supervising   TB    down    three    jobs    simultaneously:
                 physician   at   Homer   Folks    Tuber-    director   of   the   Health    Sciences
                 culosis   Hospital   in   upstate    On-    Center,    univei'sity    vice-president
                 eonta,   N.Y.,    greatIN@    influenced    for  the  Health  Sciences,   and   dean
                 his (areer.                                 of  the  School   of   Medicine.
                    Recuperation    gave    Dr.    Pelle-       In  each  post,  he  has   left   his
                 grino   time   to   "cogitate   my   way    personal    brand     of     innovation.
                 back  to   health."   And   working   in    Unlike    some    who     often     pose
                 rural   Oneonta    rekindled    memories    problems,   then   leave    the    solu-
                 of   two   post-World   War   II   years    tions   to   others,    he    frequently
                 as  an  Air  Force  medical  officer  in    casts off  the  yoke  of  tradition  and
                 Montgomery, Ala.                            challenges     the      long-established
                    "I  was  educated  in   the   classi-    educational    assumptions    to    find
                 cal  tradition,  headed  for  a  classi-    new   ways   of   doing   an   old-fash-   leave   Stony   Brook   eventually,   but
                 cal  role  in  research  and   teaching.    ioned  job:  turning   out   good   phy-   I  hope  that  if  and   when   I   leave
                 But   my   experiences    changed    all    sicians.                                   Stony  Brook,  I   shall   have   brought
                 that.  In  Alabama,  I  came   face   to       Dr.  Pellegrino   is   impatient   to   the    right    people    together    and
                 face   with   some   of   the    medical    finish  one   job   so   he   can   move   have    created    an    atmosphere    so
                 problems    of     rural     America-the    on  to  the  next.  "It's  part  of   my   the  major   ideas   can   go   on   suc-
                 deficiencies  in  manpower,   the   lack    philosophy,"    he    explains.     "One   cessfully.   This   is   my    test    of
                 of  adequate  facilities.  In   Oneonta,    shouldn't  spend   the   bulk   of   his   whether the things I've done         have
                 many  of   the   same   needs   existed.    life   in   a   single   endeavor.   One   genuine validity."
                 I   became   convinced   that   one   of    ought  not  to  spend   his   time   too      The   trail   that   led   to    Stony
                 the  major  areas  of   concern   should    long   in   one   administrative   post.   Brook      began      at       Hunterdon,
                 be  health   care,   and   that   educa-    You  don't  grow  that   way.   If   you   where    Dr.    Pellegrino    began    as
                 @tion  should  be  more  closely  relat-    can't   make   a   major    impact    in   director   of   internal   medicine   and
                 ed  to  meeting   the   needs   of   the    seven   to   ten   years,    you @re   not later  moved   up   to   medical   direc-
                 Zommunity."                                 going  to  make   it.   For   the   good   tor.    Hunterdon    was     not     well
                    The     New      Jersey-born      boy    of   yourself   and   everybody    else,   known  then,  but   it   was   where   he
                 raised  in  Brooklyn  knew   that   this    you  ought   to   move   on   to   some-   wanted   to   be.   Hunterdon    had    a
                 was   what   he   wanted   to    do-work    thing else."                               goal:   to   develop   a    comprehensive
                 to   help   meet   these   needs.    And       When  you  move,  leave  a   bit   of   health  care   plan   for   this   rural-
                 he  has  been  doing   it   ever   since    yourself  behind.   "That's   the   real   agricultural    community     of     some
                 during  a  medical   career   that   has    test  of  an  idea,"  he   says.   "Does   42,000.
                 taken   him    to    three    pioneering    it  remain  after  you're   gone?   I'll      "It  was  the  most   exciting,   most

                 1 q


                                   evtror  acu                                                             a ac
                                                                                                               0
                                                                             Du vwi

                                                                                                  7 o7s
                                                                         Each  tablet  contai
                                                                     probenecid and 0.5 mg colchicine

                          Probenecid - helps reduce serum uric              acid   levels         Precautions:   Hypersensitivity   may   occur,   especially    with
                                                                                                  intermittent  use,  requiring  cessation  of  therapy   or   dosage
                          helps prevent or delay the  formation  of  crippling                    reduction.  Since  probenecid   raises   plasma   level   of   con-
                          tophi                                                                   jugated   sulfa   drugs,   plasma    concentrations    should    be
                          Colchicine o although  not  an  analgesic,  produces                    checked    occasionally    during    prolonged    Maladministration
                          dramatic relief of pain in acute attacks of  gout  *                    with  sulfa  drugs.  A   reducing   substance,   wnicn   disappears
                          helps lengthen intervals between acute attacks                          with  discontinuance  of  therapy,  may  appear   in   the   urine,
                                                                                                  giving a false-positive  Benedict's test'
                          NOTE:  CoIBENEMID'-is  indicated  in  the  treatment                    Adverse    Reactions:    Probenecid:    Occasionally,     headache,
                          of all stages of gout and gouty arthritis;  however,                    gastrointestinal   symptoms   (e.cf.,   anorexia,   nausea),    in-
                          it   should   not   be   started    during    an    acute    attack.    creased   urinary   frequency,   and   hypersensitivity    reaction.s
                                                                                                  including  dermatitis  have  appeare@.  Rarely,  flushing,   dizzi-
                          While     hypersensitivity     to     probenecid      may      occur    ness,  anemia,  and   anaphylactoid   reactions.   Hemolytic   one-
                          during    continuous    therapy,    it    is    more    likely    to    mia  which  in  some  instances  may  he  related  to   a   genetic
                          occur    with    intermittent     use.     The     appearance     of    deficiency of glucose-6-phosphate dehydrogenase          in     red
                          reactions     may     requ.ire   cessation   of   t@e'rapy   or   dos-  cells.   Extreme.ly   rare   instances   of   nephrotic   syndrome,
                                                                                                  hepatic necrosis, and aplastic anemia.
                          age     reduct@'on.                                                     Colchicine:  G.I.  disturbances  (e.g.,   nausea,   vomiting,   ab-
                          Indications:  Gout  and  gou,y   arthritis   except   a   presenting    dominal  pain,  diarrhea),  particularly   troublesome   in   pres-
                          acute  attack.  However,  if  an  acute   attack   is   precipitated    ence of peptic ulcer  or  spastic  colon.  Toxic  doses  may  cause
                          during   therapy   the   dru@   should    be    continued    without    severe   diarrhea,   generalized   vascular   damage,   and   renal
                          changing  the  dosage,  anct   additional   colchicine   should   be    damage   with   hematuria   and   oliquria.   Muscular    weakness,
                          given to control the acute attack.                                      hich  disappears  with  discontinuance   of   therapy,   urticaria,
                          Contraindications:    Hypersensitivity.    14ot    recommended    in    dermatitis,  and  purpura  may  occur  and   may   require   reduc-
                          persons  with  blood  dyscrasias  or  uric   acid   kidney   stones.    tion  of  dosage  or  discontinuation   of   drug;   rolonged   use
                                                                                                                                                   p
                                            -e instance  s,                                           cause a                     aidlastic anemia,
                          Warnings: In ra,                  henaturia,   renal   colic,    and    may           qranulocytosis,     '                      peripheral
                          costovert,--h,al  pain   have   been   reported.   May   precipitate    neuritis. Loss of hair  has  been  reported.  In  hepatic  dysfunc-
                          an acute attack  of  gout;  theoretically,  may  favor  urate  stone    tion,  consider  possibility  of  increased  colchicine   toxicity.
                          formation,  which  may  be  prevented  by  alkalization   of   urine    Supplied:  Tablets,  containing  0.5Gm  probenecid   and   0.5   mg
                          and  liberal  fluid  intake.  When  alkali   is   given,   acid-base    colchicine each, in bottles of 100.
                          balance   should   be   watched.   Salicylates   should    not    be    For  more  detcriled  information,   consult   your   Merck   Sharp
                          given  viith   probenecid,   since   coadministration   results   in    Dohrne representative or see the package circular.
                          inhibition oL the uricosuric activity  of  the  latter.  Cell  divi-
                          sion  in  animals  and  plants  can  be  arrested   by   colchicine.
                          In  certain  species  of  animal  under  certain   conditions   col-    0 MERCK SHARP & OCHME Di@isio@ of me,ck & Co,lNc,west Point,Pa 194M
                          chicine  has  produced  teratogenic  effects   and   has   adversely
                          affected  spermatogenesis.  Such  effects  have   not   been   dern-    WHERE      TODAYS      THEORY      IS      TOMORROW'S       THERAPY
                          onstrated in humans.
                          COIB-ENEMID for gout and the pain of  gout
                                                                                                                                                                       17


                                      LLIU

                rewarding  part  of  my  career,"  he    head  of  Columbia       University    long  espoused  by  the  medical  in-
                says.  "It  was  there  where  I  had    School of  Public  Health  and  Ad-    novator:   that   the   many   health
                my first insight  into  a  key  prob-    ministrative Medicine.                 disciplines   must   work    together
                lem  in  medicine's  relationship  to     For   Ed   Pellegrino,   Hunterdon    for the betterment  of  the  patient.
                society:  the  need  for   congruence    presented me with a    fresh  piece      Dr.  Pellegrino   believes,   also,
                between   what   a   physician   does    of  canvas  and  a  possibility  of    that  the  community  should  be   an
                and what  society  expects  of  him."    painting  something  personal,  new    integral part of  a  medical  center,
                  The   grass-roots    movement    to    and relevant."  There,  he  had  an    that  "those   who   participate   in
                establish the  center,  initiated  in    opportunity  to  practice  clinical    patient care  at  a  community  level
                1948,  had   just   begun   to   take    medicine,   but   much   more.   He    should be  brought  together  in  ac-
                shape  when  he   arrived.   Launched    was able to  help  fashion  a  com-    tion    and    purpose."    Hunterdon
                by  a  unique  group   of   citizens-    prehensive  health   care   program    provided  office  space  and  facili-
                poultry  and  dairy  farmers,   busi-    in a slice of rural America.           ties  for  such  agencies   as   the,
                nessmen,  industrialists,  and  corn-     At   Hunterdon,   Dr.   Pellegrino    visiting   nurse    and    homemaking
                munity     leaders-it     had     the    developed  what  was  probably  one    services,  the  mental  health  asso-
                support   of   the   county   medical    of the first  comprehensive  health    ciation,  and  the   community   ser-
                society and  had  gained  affiliation    centers at  a  community  hospital.    vices committee.
                with     NYU     Bellevue     Medical    Its   staff   practiced   community      Unlike   many    hospitals    where
                Center  some  70  miles   east.   And    medicine  in  a  day  before   that    general  practitioners   are   denied
                it had been guided  during  its  for-    now-commonplace    function    even    staff  rights  and  must  turn  their
                mative  stages  by  -none  less  than    had a name.  And  deeply  ingrained    patients  over  at   the   door,   at
                              d   E.   Trussel,   now    with this service was a  philosophy    Hunterdon   every    GP    in    good
                Dr. Raymon
                                                                                                   ModernMedicine/October4,1971  19


                  @t4

                                                                                                                                       tal, 'ii'tiat'
                  standing   with    his    medical    society1  tliev   @vere   not   as   responsive   to    the University hospi         1 1       in(y
                  I)eloii,s   to    the    attending    @taff.   the   health   needs   of   societN,    as    one of tire country's first         pliysi-
                  This   fits   into   the   Pellegrino   pat-   they might I)c,,."                            cians"assistants     proo-rams,      imple-
                  tei@n-.  the  GP,  or   family   pli@@sician    When   he   ari,l%!ect   in    l@entucky,    mentitig  @vays  to    inipron-e      rela-
                                  to call h'                                                        ritical    tioiislilps between    doctors.      social
                  as he prefers              im,        should   medicine  was  faced  by  c
                              I                   A       sys-   educational   issues:   how   to    relate    workers,  @ind  iiurses.  And  @@-liat  lie
                  be a coordinator of care.
                  tem    initiated    by    Dr.     Pellegrino   a   health   science   center    to    the    personally  feels  is  slc,,nificaiit,  his
                  placed   the   GP   in   just   that   role.   people  it  served:  the   need   to   in-    departi-iient    of     medicine     became
                  Patients    are    admitted    and     cared   trocluce     behavioral     and     social    one  of  the  first  in  the   country   to
                  for  1)3,  the   GP   who   has   privileges   sciences  into  the   hc@altli   sciences;    appoint    two    general     practitioners
                  on  the  i-nedical,   pediatric,   and   ob-i  a way  of  acliie@,iii(,,  a  balance  be-    to  its  full-time   faculty.   Under   the
                  stetric    staffs.    Major    surgery    is   t@@-een  science   and   a   more   human-    aegis    of     the     department,     the
                  performed    only    by    the     full_time   istic      patient-orientecl      outlook;    school     developed      pro-rams      for
                  staff.    But    the    GP    remains    the   seeking   answers   to    the    question,    the   teaching    of    physical    tliera-
                  responsible    agent.    He    admits    and   what   more   can   be   done    in    the    pists,   dietitians,   and   medical    as-
                  discharges,     writes      orders,      and   field of community medicine?                  sistants.  Out  of   this   embrvo   ure@N,
                  coordinates care.                                "'Here,"    he    says,     "I     could    the   School    of    Health    Professions
                    Another       Pellegrino       innovation:   grapple    with    these    problems    at    which    exists    at    Kentuckv    today.
                  at Hunterdon there are no        4 9    clinic their  earliest   stages.   As   professor      At     Kentucky,      Dr.      Pellegrino
                  days"   or     "service           patients."   and   chairman,   I   was   part   of    a    applied    much    of    what    he     had
                  Whether   they   pay   or    not,    they're   core    planning    roup     under     Dr.    preached    and    practiced    at     Hun-
                  all   seen    under    the    same    condi-   William  R.   Willard,   dean   of   medi-    terdon.   It   was   there,   too,    where
                  tions  and   their   care   is   the   same.   ciiie.   I   was   an   unofficial   'idea    he   laid   the   groundwork    for    con-
                  Each    has    an    attending     physician   n@an'-a    dean    Nvithout    portfolio."    cepts   he   was   later   to   apply    at
                  responsible for his care.                                                                                            as    also    while
                                                                   Working     "from     Ground      Zero,"    Stony Brook. It w
                    Hunterdon     ,   Dr.    Pellegrino    be-   he,  along  with  the   group   Dr.   Wil-    at    Kentucky    that    the    Pellegrino
                  lieves,     demonstrates      the      basic   lard   had   assembled,   was   able    to    philosophy    began    to     appear     in
                  principles     "worthy     of     considera-   build    a    faculty    that     combined    print  in  an  endless   flow   of   ideas.
                  tion  in  part,  if   not   in   toto,"   by   basic     and     fundamental     clinical    He    considers    himself    almost     as
                  all     communities     planning      health   research   with   a   concern   for    pa-    much   a   philosopher   as    a    plivsl-
                  centers.  And  he  took a        bit      of   tient   care    and    general    internal    cian.   He   is   as    deeply    concerned
                  Hunterdon   with    him    to    the    Ken-   medicine.                                     with  the  needs  of  society  as   he   is
                  tucky    cornfield     that     became     a     There    were    the    ii-iyriad    but    with   those   of   individuals   he   min-
                  medical school.                                more  routine   chores   in   building   a    istered   to   as   a   clinician.    These
                     The     50-year-old     physician     ad-   faculty   and   curriculum,   of   course.    views,    drawn    from    his     writings
                  mits,   in   retrospect,   that    he    was   But   these   were    not    enough    to'    and     commentaries,     give     insiglit
                  an unlikely choice for the       post     of   satisfy  a  restless  i-nan.  Dr.   Pelle-    into   the   philosophy   of    the    man:
                  chairman    of     the     department     of   grino   was   elected   to   the    Execu-       Medical    ethics:     "Societal     and
                  medicine.    "I    had     deviated     from   tive    Council    of    the    University    individual    values    are    increasingly
                  the   established   pattern,"    he    says.   Senate   and   then   to   its   chairman-    counterpoised     in      almost      every
                  "My    research     background,     as     a   ship.   And   it   was   in   that    post    medical    act.    Some    ratiotial    and
                  result  of  my  bout   of   TB,   had   suf-   that  he  became   involved   in   a   re-    just  order   must   be   established   be-
                  fered.    But    I    fitted    into    Ken-   vision   of   the   academic   plan    for    tween   these   values   to   ensure    the
                  tuckv's     notion     that      significant   the entire university.                        good   of    society    while    safeguard-
                  changes      in      medical       education      At   Kentucky,    lie    was    instru-    ing   the   traditional   rights   of   the
                  were    urgently     needed.     We     came   mental   in   developing   one   of    the    person."
                  into     a      sympathetic      congruence-   first    comprehensive    drug     infoi,-       Relevance:   "Medicine   is    an    in-
                  that    doctors     were     not     meeting   mation     centers,     expanding      the    strument    of    social    purpose.     it
                  all  the  needs   of   the   people,'   that   functions    of    the    pharmacist    at                         continued on  page  29


                    doesn't   exist   as    an    intellectual     In  1966,  Di-.   Pellecli-iiio   brought    earn    "parenthetical    degrees"     and
                    discipline,   but   only   because   soci-I   this    philosophy     with     him     to    on  the  diploma,  as  well  as  the   li-
                    ety   has   certain    problems.    Unless    Stoii@-   Brook.   4@'I'Iiis,"   he    en-    ceiise,   the   M.D.   would    be    fol-
                                                                                                                lowed by the specialty.
                    we  address   ourselves   to   the   reso-    tliuses,  N@@a%,lna  @iii   arm   to   the
                                                                                 n                       was     A  priniar3,  goal  will   be   to   pro-
                    lutiori   of   those   problems,   @@,e're    campus outside his \\-iiidow, "
                                                                               'ty   to   tal@e   my   ideas    duce  more   physicians   able   to   pro-
                    not   fulfillilig   our   responsibilities    an opportune                    I      new    vide     primary,     preventive,      and
                    as physicians."                               and apply them to a tota                                    care-N\,hat      he      be-
                    Humanity:     '@The     most      delicate    comprehensive       health        sciences    emergency            .   Liiiniet   health
                    of    the    phvsician's     responsibili-    centei,.                                      lieves  is  the  majol
                    ties,   protection   of   the    patient's     '@One    of    the    major    deterrents    care need in the country today.
                                                                                                                        airman   of    the    AMA    Coni-
                    welfare,  must  be  fulfilled  in  a   new    in  the   delivery   of   optimal   health     As ch i            in-     and     Allied
                                                                  care,"  he  believes,  "is   the   failure    mittees on  Nurs  ,
                    and  complicated  context.   It   is   the                                                            he    grapples     with     this
                    physician's   responsibility,   to    .;ee    of    communications    ind    lacl@    of    Health,
                    that    group    assessment    and    man-    precise    definition     of     functions    problem     daily. At   the   Lonal    Is-
                    agement    are    rational,    safe    and    among    health     professions.     Char-    land       campus,   plans         include
                    personalized.      He      must      guard    acteristically,  they   carry   out   edu-    courses    leading to   a   master's   de-
                    against     the     dehumanization      so    cational    functions    in     isolation.    gree  for   nurses and   at   least   bac-
                    easily    and     inadvertently     perpe-    It's   essential   that    they    develop    calaureates   for   others    in    allied
                                                                                                                health  fields.
                    trated  by  a  group  in   the   name   of    them    in    close    cooperation    from
                    efficiency."                                  the outset."                                   While  the   "final   profile"   of   the
                     Competence:        "Maintenance        of     This   is   what    is    happening    at    Stony   Brook    curriculum    is    still
                    competence   [is]    a    prime    ethical    Stony    Brook.    He    has     organized    to   be   determined,    basic    features
                    challenge.   Only   the   highest    stan-    the  center   so   that   the   deans   of    already are well developed.
                    dard  of  initial  and   continuing   pro-    the      colleges-Medicine,       Nursing,      Stony  Brook  will,   if   the   options
                    fessional   proficiency   is    acceptable    Dentistry,    Social    Welfare,    Allied    laid   down   by   Dr.   Pellegrino    are
                    in   a   technological    world.    'I'his    Health     Professions,     and      Basic    all  put  into  practice,  offer  a   mul-
                    imperative   is   now   so   essential   a    Health     Sciences-and     the     direc-    titrack    curriculum            providing
                    feature    of    the     patient-physician    tor    of    the    University    Hospital    briefer   initial   exposure   to    basic
                    transaction   that   the   ancient    man-    participate   as   equals    in    policy-    sciences     and     in-depth     coverage
                    date,  'Do  no   harm,'   must   be   sup-    making.                                       of  those  sciences  relevant   to   "spe-
                    plemented   by,   'Do   all   things   es-      He   hopes   to   reexamine   the   "as-    cial   roles   like   medical    research,
                    sential  to  optimal  solutions   of   the    sumption   that   the    basic    sciences    clinical   specialty,            community
                    patient's problem.' "                         as   now   taught    male    for    better    medicine,    family     medicine,     bio-
                      Philosophy:     "The     major      con-    medical practice."                            medical   engineering,    and    i-nedical
                    cerii    of    contemporary     philosophy      "We    must    concentrate    on     the    social   sciences.   Each    track    will
                    is  man's  existence,  and  it   is   here    introduction   of    the    language    of    require    a    different    concentration
                    a  dialogue   fruitful   to   the   physi-    basic   science,"   he   says,   "with   a    of    basic    sciences    and    clinical
                    cian   can   begin.   The   functions   of    later  concentration        on       those    experiences.     The      undifferentiated
                    the   physician   and   the    philosopher    basic  sciences  i-nost  relative  to  the    physician  of   the   past   will   be   a
                    are  not  to   be   confused.   The   doc-    field   or   practice   chosen   by    the    rarity."
                    tor proceeds by hypothesis                    student.    In    essence,    the    basic      Stony   Brook    brings    the    health
                    the   philosopher   clarifies   and   aug-    science   component   will    vary    with    professions    together     by     provid-
                    ments  the  concept,  puts  it  in   rela-    the   track   the   student   chooses   to    ing    common     classrooms,     clinical
                    tion   to   the   general    history    of    follow."                                      experiences,    and    models    of    pa-
                    ideas,   and   raises   the    fundamental       At    Stony     Brook,     he     hopes    tient    care    simultaneously    involv-
                    questions  of   ends   and   values.   The    eventually   to   turn   out    physicians    ing   students    from    all    of    the
                    relation  of  the   two   disciplines   is    exquisitely   competent    in    a    par-    schools  at  the  center.   In   addition,
                    not  one   of   subordination,   but   one    ticular  area  but  not   in   the   whole    a   physicians'   assistant   program   is
                    of interpenetration."                         scope    of    medicine.    They     would                         Continued on page 34

                                                                                                                    Moderii Ntediciiie October 4, 1971


            N4erck Sharp & Dohme
                 viral immunology
        leader in
                       announces:

           a sing e 'Inl'e ct'ion
            0 0
      .a ininistere at
        age 12 inont.. s
      .---or vaccination
       against t ree
      iseases
    \4-N4eas es
       1\4un-1
        u-:)e.


                                                                                                                            sed     for      Stony
                                                                 already  under  way  in   the   School     programs    propo ned   to    do    just
                                                                 of Allied Health Professions.              Brook  are  desi-
                                                                 Dr.   Pellegrino   believes   a    new     that."
                                                                 health  profession  Nvill   eventually     He   considers   affiliation    impor-
                                                                                   'ng  all   the   ex-     tant.  And  while  he  doesn't   infer
                                                                 emerge, enconipassi
                                                                                                one         that  patients  in  nonteaching   hos-
                                                                 istino., health professions in
                                                                 new body dedicated to the      im-         pitals  receive  lower  quality  care,
                                                                                          'ty   and         lie  feels  they  lose  the  advanta-e
                                                                 prevenient  of  coii-imuni
                                                                 individual  care.  It  will   engender     of  that  "critical  air  of   inquiry
                                                                 a  "'spirit  of  medical   ecumenism."     prevalent  in  a  university-affiliat-
                                                                 The   Pellegrino    blueprint    calls     ed institution."
                                                                 for   earlier   entry   into   medical     "Affiliation   is    a    univeysity's
                                                                 studies, a  briefer  stay  there,  and     pastoral  responsibility,"  he   adds.
                                                                 flexibility  in  program   selections.     "It  should  be  the  concern   of   a
                                                                 The   Stony   Brool@   student    will     medical  center   to   involve   every
                                                                 have   clinical    experiences'practi-     institution and  professional  in  its
                                                                 cally  from  the  day  he   steps   on     area."
                                                                 campus,  but  not  all   his   studies     Dr.  Pellegrino  realizes  he   "can't
                                                                 will be there.There   will   be   time     be  everywhere  at  once,"   nor   can
                                                                 on  the  wards  and  in  doctors'  of-     he be all things to  all  people.  But
                                                                 fices  and  provisions  for  "drop-out     he tries.  He  is  constantly  on  the
                                                                 periods for  work,  research  or  lib-     go-lecturing,     writing,     working
                                                                 eral studies."                             behind  the  scenes  rather  than   in
                                                                 Dr.  Pellegrino   is   mapping   plans     the limelight, to  further  his  medi-
                                                                 for widespread  affiliation,  stretch-     cal philosophies.
                                                                 ing  out  to  the  more   than   forty     Despite   a   heavy    schedule,    he
                                                                 hospitals   on   Long   Island.    Not     refuses  to  let  his  laboratory  and
                                                                                                  medi-     scholarly  activities  take   a   back
                                                                 only will this bring better
                                                                                                            seat  to  the   more   demanding   ad-
                                                                 cal  care  to  the  communities,   but
                                                                 be  believes  it  will   provide   the     ministrative   chores.   His   labora-
                                                                 kinds   of   experience   needed    by     tory  work   concentrates   on   corn-
                                                                 physicians  and  other   health   pro-     plex  studie  of  the   physical   and
                                                                                                                       s
                                                                 fessionals.                                organic chemistry  of  calcified  tis-
                                                                  "A  major  deterrent   to   the   ex-     sues. He  likes  to  work  with  small
                                                                 pansion  in  the  number   of   health     groups  with  an  ultimate  team  goal
                                                                 professionals,"   he   contends,   "is     of  establishing  a  biochemical  def-
                                                                 the  limitation  imposed  by   classic     inition  of  metabolic  bone  disease.
                                                                 curriculum'  structures  and  the  in-      Most   recently,    Dr.    Pellegrino
                                                                 sistence  on   providing   the   major     Iand his re  earchers  have  been  try-
                                                                                                                      s
                         Still serving...                        experiences for all  students  at  the     ing  to  determine   where   carbonate
                                                                 medical   centers    themselves.           fits into the  crystal  structure  and
                                                                   "By  a  judicious   combination   of     they  are  taking  a  closer  look  at
                                                                 curriculum  revision  and   the   con-     the   calcium   maturation   of   bone
                                                                 version  of  a  number   of   communi-     crystal   in   the    alien    embryo.
                           Miltowff                              ty  hospitals  into   major   clinical     "That,"  he   says,   "is   a   matter
                                                                 teaching   units,   it   can    become     which  has  vexed   chemists   for   a
                             (m@@robamate)
                                                                 realistic to think in  terms  of  sig-     hundred  years.  We  don't  have   the
                                                                 nificantly  larger  entering   classes     answer,  but  we  think   we've   sup-
                       WALLACE PHARMACEUTICALS         J!yi      in all  the  health  professions.  The                       Continued on  page  38
                       Cranb@iry, N.J, 08512
                                                                 34 Nlodern Nledicine  /  October  4,  1971


                  effectiveness of
                  the combination vaccine
                      M-M-R(MEASLES, MUMPS, AND RUBELLA VIRUS VACCINE, LIVE                                                          MSD)
                      M-M-R    has    shown     no     significant     reduction     in     ,(@i,oconversioii     rates.     The     serocon-
                      version    rates    remained    at    a    sufficient    level     to     demonstrate     :i     high     de-ree     of
                      effectiveness.
                              Year                 Vaccine                 Number             Number                  Seroconversion
                            Released                                  Vaccinated            Susceptiblie                   Rate

                                                                                                                      960/,6 Measles

                              1971                M-M-R                    1,@)51               756                   95% Mumps
                                                                                                                      940/i) Rubella

                                                                                                                                          seases
                      The    effectiveness    of    M-M-R     (reflected     in     sei,ocoiiversion     rates)     could     be     reliably
                      demonstrated    in     relatively     small     numbers     of     susceptible     children,     because     of     the
                      laroe numbers of children tested with the conil)oiient vaccines.

                          No  untoward  reactions  peculiar  to  the  combination    reactions have occurred, such reactions m y a so occur
                          vaccine (M-M-R) have been reported.                        ivithNt-,%I-R. A cause and effect relations p, however,
                                                                                     has not been established.
                          @Nloderate fever (101-102.9 F.) occurs occasionally. High
                          fever (over 103 F.) occurs less commonl@,. On rare occa-   Excretion of the live attenuated rubella virus from the
                          sions, children who develop fever may  exhibit  febrile    throat has occurred in the majority of susceptible in-
                          convulsions. Rash (usually  minimal  and  without  gen-    dividuals adrfiinistered the rubella vaccine. There is no
                          eralized distribution) may occur infrequently.             definitive evidence to indicate that such virus is con-
                                                                                     tagious to susceptible persons who are in contact with
                          Since clinical  experience  with  measles,  mumps,  and    the vaccinated individuals. ConseQuently, transnlission,
                          rubella virus  vaccines  given  individually  indicates    ivhile accepted as a theoretical possibility, has not been
                          that very rarely encephalitis and other nervous  system    regarded as a significant risk.

                      Adverse  Reactions:  Fever,  rash;  mild  local   reactions    duration.  The  incidence  in  prepubertal  children  would
                      such  as   erythema,   induration,   tenderness,   regional    appear to be  less  than  11/o  for  reactions  that  would
                      lymphadenopathy;     thrombocytopenia     and      purpura;    interfere  with  normal  activity  or  necessitate  medical
                      allergic reactions such as urticaria;  arthritis,  arthral-    attention.
                      gia, and polyneuritis.                                         How  Supplied:  Single-dose  vials  of   lyophilized   vac-
                      Occasionally, moderate  fever  (101-102.9  F.);  less  com-    cine,  containing  when   reconstituted   not   less   than
                      monly, high fever (above  103  F.);  rarely,  febrile  con-    1,000  TCID,.  (tissue   culture   infectious   doses)   of
                      vulsions,                                                      measles virus vaccine, live, attenuated,  5,000  TCID@.  of
                      Encephalitis  and  other  nervous  system  reactions   that    mumps virus vaccine, live,  and  1,000  TCID5.  of  rubella
                      have occurred very  rarely  with  the  individual  vaccines    virus vaccine, live, expressed in  terms  of  the  assigned
                      may also occur with the combined vaccine.                      titer  of  the  NIH  Reference  Measles,  Mumps,  and   Ru-
                      Transient  arthritis,  arthralgia.  and  polyneuritis   are    bella  Viruses,  and   approximately   50   mcg   neomycin,
                      features of natural  rubella  and  vary  in  frequency  and    with a disposable syringe  containing  diluent  and  fitted
                      severity with age and  sex,  eing  grea  es  in  adult  fe-    with a 25-gauge, %' needle. Also in  boxes  of  10  single-
                      males  and  least  in  prepubertal  children,  Such   reac-    dose  vials  nested  in  a  pop-out  tray
                      tions have  been  reported  with  live  attenuated  rubella    with  a  separate  box  of  10   diluent-
                      virus  vaccines.  Symptoms  relating   to   joints   (pain,    containing syringes.                                    mso
                      swelling, stiffness, etc.) and to peripheral nerves  (pain,    For  more  detailed   information,   con-
                      numbness,  tingling,  etc.)   occurring   within   approxi-    sult  your  MSD  representative  or   see    AERCK
                      mately  two  months  after  immunization  should  be   con-    the Direction Circular.  Mercli  Sha@p  &    3HARP&
                      sidered  as  possibly  vaccine   related,   Symptoms   have    Dohme, Division of  Merck  &  Co.,  Inc.,
                                                                                     IA7.,f P@i@f Pn lc)4RO                       )OHME


                                                       plied  a  lot   of   new   information      His  most  absorbing   and   reward-
                                                       which  will  give   direction   toward   ing  hours  are  spent  in  his  study,
                                                       developing  a   new   theory   as   to   adding  to  his  collection  of   4,000
                                                       just where  the  carbonate  fits  in."   nonmedical    books    and     dreaming
                                                         Dr.   Pellegrino    expresses    his   like Cicero of a library  in  a  garden
                                                       views   at   many   national   commit-   as  the  penultimate  setting   for   a
                                                       tees  and  task  forces  dealing  with   civilized life.
                                                       the most significant  issues  in  edu-      At  home  there  are  eight   Pelle-
                                                       cation  and  the  health  professions.   grinos   besides   himself.   He    and
                                                       And   while   many    are    "progres-   his  wife,   Clemintine,   have   seven
                                                       sive,"  he  prefers  to  confine  them   children, 9 to 26 years of age.
                                                       to this arena, to  worl-,  within  the      "We're   almost   evenly    divided"
             for
                                                       existing   framework   of    medicine.   he  says,  "between   those   who   are
             the                                         "I  eschew  crusades  and   spectac-   biologically   oriented    and    those
             pain                                      ular  statements,"  he   says.   "What   concerned  with   political   scienFp."
              in                                       lasting   value   would   they   have?      Two  of  his  sons  are  heade4  @0-
           ACUTE OTITIS MEDIA                          A  few  headlines,  a  day  of   glory   ward  medical   careers.   Thomas   en-
                                                       in  the  public  eye,  and   ostracism   ters   the   University   of   Kentucky
                                                       by my colleagues."                       Medical   School   this    fall.    And
                                                         Widely    published,    author    of   Michael,  still  in  high  school,  ap-
                                                       nearly   200   books    and    medical   pears   headed   toward    a    medical
                                                       papers,  member  of   four   editorial   career.
                                                       boards,  a  lover  of  words  and   an      Two  of   his   children   are   in-
                                                       addict  to  using   them   well,   Dr.   terested in law,  and  the  others  are
              AURALGAN relieves pain                   Pellegrino  believes  writing,  as  we   still  too   young   to   decide   what
                 fast ... reduces  aural               know  it,  may  be  on  the  way  out.   fields  they   wish   to   follow.   In
                                                       He's  convinced  that  medical   jour-   keeping   with   his   own   childhood,
                 Congestion. It is fully                                          I
              compatible with systemic                 nals, as  doctors  kiiow  them  today,   his  home,  he  feels,  is  the   major
                                                       will fall  prey  to  the  growing  so-   "humanizing     influence     in     my
                antimicrobial  therapy,                phisticatioii   of    the    computer.   life."
                                                0      Even  at  Stony   Brook,   plans   are      Even   as   he   dreams    of    new
                                                       being  made  to  train  future  physi-   worlds  to   conquer,   he   seeks   to
                                                       cians  in  the  use  of  the  computer   balance    his    multiple    interests
                                                       for  medical  care,   diagnosis,   and   through    deeper    family    involve-
                                                       continuing medical education.            meiit.  And   he   looks   forward   to
                Otic  Solution                           This  poses  a   philosophic   ques-   44 one  more  challenge  while  I   still
                                                                           I
                                                       tioii: will physicians be able to  re-   have   the    required    mental    and
                BRIEF      SU@,4MARY                   taiii their individuality  in  an  age   physical    agility    new     ventures
                AURALGAN Otic Solution
                Each  cc.  contains:                   of computerization?                      demand."   This   will    come,    per-
                Glycerin dehydrated ............ 1.0   cc. Dr.   Pellegrino   manages   to   do haps, in  the  "quiet  years,  an  e4ly
                 (Contains not more than
                 0.6%    moisture.)                    just  that  by   spending   his   time   retirement  fi@om  posts   of   leader-
                Antipyrine . . . , @............. 54.0   mg. away  from  medicine   indulging   his shil)   to   more   contemplative   en-
                Benzocaine .............. ......... 14.0   mg. lifelong  interests  in  medieval  and deavors-adding    to     my     library
                 (Also contains
                 8-Hydroxyquinoline sulfate.)          modern  philosophy,  in   the   trans-   and,   most   important,   writing    a
                Supplied:       r4o.       1000-AURALGAN lation  of  Latin  poetry,  by   play- cultural history of medicine."
                Otic  Solution,  in  package  containing
                15 cc.  bottle  with  separate  dropper. ing  tennis  or  the  piano,  and   by    And  in  doing  so,  Dr.  Pelleerino
                screw cap attachment.                  supervising  his  sons  who  keep  the   hopes   to   follow    another    Plato
                                                       lawn  of  his  Long  Island  home   in   prescription:  the   ultimate   bleiid-
                           AYERST LABORATORIES,        trim suburban condition.                 ing  of  medicine  and  philosophy.  D@
                            New  York,  N.Y.   10017


                                                                            JOHN W. GERDES, Ph.D., Coorditicitoi

                                        @EGIONAI,

                                        BOX 5796, BOISE, IDAHO 83705
                                        305 FEDERAL WAY, BOISE, IDAHO 83705
                                        TELEPHONE: (208) 342-4666

                                         September 20, 1972

                   Ms. Dorothy M. Bailey, Writer
                   Office of Communications and
                   Public Information
                   Department of  Health,
                   Education and  Welfare
                   Public Health  Service
                   Health Services and Mental
                   Health  Administration
                   Rockville, Maryland 20852

                   Dear Dorothy-.
                   Thanks for sending me the copy of the Nurse Practitioner vignette
                   which you prepared.  It is an excellent condensation, with only
                   three minor changes to be made:

                   In paragraph 4, third line should read:
                          ..."University Medical Center which was offering a
                          (instead of its first) pilot program..."
                   (Stanford no longer offers this specialized training - since the
                   pilot program for five nurses was conducted.)
                   The last sentence in paragraph 4 should read:

                          ..."Since February, 1972 they have been employed as
                          Family Nurse Practitioners under the sponsorship of
                          an Idaho physician..."
                   On the Back-up Sheet, the Core Staff Contact should be listed as
                   Mrs. Laura Larson, R.N., in our Regional office, rather than Mrs.
                   Merrell who is no longer with MSRMP.
                   A sequel to the story, for your information, is that Dr. Edwards, the
                   sponsoring physician, suffered a fatal heart attack July 2, 1972, and
                   the Cambridge clinic manned by one of the Nurse Practitioners was closed.
                   Just this month, the Clinic was reopened, when an Oregon physician
                   offered to sponsor the Nurse Practitioner "until a permanent physician
                   can be found... This is too good a program to let it die," he said.

                                                   Sipcerel/y,

                                                    (Mrs.@ Helen Thomson
                                                    Coordinator of Information
                   HT:kd
                                             l@: ( I ) @l @NI I @.@ 1 4 @ N


                                                           t  C, s C3, cl,
                                                                  c
                                                         Press-D(,r,@r-crat
                                                          D 49,222

                                                                        -,-Upes
                                            for coast's
                                            Deit-,Ltal Cl'l'i-iic

                                            By Staff Correspondent of fields, accordit-ig to Keene.
                                           SACRAME.NTO - A rural! it was established by  Dr.
                                                                  I
                                         dental  cl@,ilc  on  the  %Iendocino'Johii   Frankel,   a   d@,iiti'st   and   v@,-l
                                         Coas, could keep its d@)ors   ol,, z'O vea7-, k:ith ti2e U.S.i
                                                                                 -; C,2,
                                                                    .1  I:c
                                         islati(.n iri!roduced ih@s 'I)e crilv ctinic  for  nii'ies  ai@ounci'
                                         As_Qleml)!%7t-,ian B a r r y  Kee!ie,'%vhich offers dental services.
                                                                  I
                                         D-Santa Rosa.              "This    project    is    ackiiowledgedi
                                           The   Greenwood   Proicct,   u@ecilbv   everyone   as    a    iii(ist    success-I
                                         :bv  hundreds   ri,@' nio@-tl,,7 fi.,l riic(,el," Keene  jiisti
                                         children. 4n itii x.ear, is @!ear,  it has t,)rovide(i
                                         threatened by a loss of       to    hundreds     of     patients
                                         funds.                   mostly children.
                                           The     @@-as  the  su"t)jec.@t  of  a!  "It  enabled  dcl,@taT  St,,idci-its
                                         @l e nh  y  "ea@ure  articlc   last'and   instructors   a   chance   to   d,)n-l
                                         iveekl,nd in t Bav Area   ate  their  time  and   to
                                                                   serve   people   N%F@ia   not    otherwise
                                           Keetie's  bli! i%ouid   cljlliillueirece,,ve   dental   care,"    Keeie    ad-
                                         the  rural   dt?n',@A ei;
                                                       .nic D;",oi
                                              which       is now ni  The   as.,enibl%rinan   said   his   bill
                                         .S28.000  :!rant            i.,,Id   @,,pl)ropriaLc t 0
                                         go%-er.,,,m--nt@@ Re,,TioiiLil   the  clj,,iic  for  atii)titer
                                                                       "so that     care    @Nill
                                           @,',,ie cli,@c,  @n            !o be available to
                                         of Eik, is scheduled lo be      persons   on    the    Nlendoci-
                                         ished in June because of a lack no Coast."


                                                                                                         1,747)

                                                                                             k@
                                                                                                                           s
                                   Ambulance
                         The         Emergency         Ambulance Since    none    of    the    participating   continuing         program         through   serve      to      upgrade       emergency
                         Medical        Technician        Course hospitals      are       teaching       in-   Ukiah      Adult      Education.       The   care meets A,ith success.
                                                                 stitutions--- it               necessitated   students      represent      a       three    The   following   are   the   'xi,3t   of
                         originated   from              Regional                                                          area       and          include   the    physicians    serving    as     in-
                         Medical     Programs     99'@i     e@ct making      marty-      sacrifices      and   county
                         r  u  t  o  t  e  6T[6-efs  of  Everett adjustments to accomod          ate     the   imbulance,       firemcii,        forestry   structors:
                         Peterson,     owner     Of      Willits students    and    it     is     gratefully   and       law       enforcement        and
                                                                                        that           these   hospital personnel                             Robert        Sm alley,       ',%I.   D.
                         Ambulance service.                      acknowleged                                                                                William      Foster      ;@I.D.,       and
                         The   course   has   been   built    to hospitals    so    willingly    met     the     The   course   consists   of    lecture-   Joseph    Stetz   @I.D.    of    %V@llits;
                         State     Department     of      Public demand   in    order    to    assure    the
                         Health      spe@@tF6ns      in      ac- program of success.                           discussion-demonstration-,                   George    Fisher      '@I.D.;      Richard
                         cordance     .vith"the'-new      health                                               observation       and       participation.   Guthrie,     -NI.D.,     Robert     Werra,
                                                                   It   was   emphasized   that    it    was   'Me    classes    were    scheduled     to   NI.D.,    Jose    Vill@ir;ca,     '@l,.D.,
                         training    bill    AB    1730    which
                         became   effective    for    all    am- no   minor   task   to    assimilate    and   meet    at     Howard     Hospital     but   Robert  Kraft,  -%I      .D..        Frank
                                                                 put  on  a  course  of  this   nature   for   because     of     their     Si7e      the   Dziile@,,    -@I.D.,    Eugene    La-kass,
                         bulance   and   rescue   personnel   in                                                                                                                 Wilson.
                         ,March.                                                                     0    be   facilities     of      Baechtal      Grove   M,D.,  Leland
                                                                 our area; but it has proven t
                                                                 exceptionally         rewarding         and   School     were     graciously     offered   K.O.   llidi.ilev,  @I.D..        P, u,  i)
                         It     will     carry     certification
                         from   the   Ukiah   Adult    Education enthusiastically received.                    by Principal Paul tjbelhart.                 Curtis,               and          Richard
                         School        Principal        Marshall    There       are       presently       47     This   is   another   example   of   the   l,vrn2,n, . i'@I.D..   the   Pro,,f,@@arr,
                         lkve.                                   students      enrolled       and       many   wonderful         community         effort   Cc)orClinator     all     from     !:kiah.
                         Dr.   R.   Iyman   is   the   physician times    that     figure     anxious     to   and   cooperation   to    see    that    a   E)on  Thomas,                         Fort
                         coordinator      and             Martha enroll    in    the    next    class,     a   course   of   this   nature   which   will   Bragg.
                         Pet    son    R.N.,     co-oaner     of
                         er
                         Willits      Ambulance      is      the
                         clinical    instructor    and     nurse
                         coordinator.
                         The     instructors     include      15
                         Mendocino      County       physicians,
                         officer  Stone  of  the  Calif.   High-
                         way     Patrol,     Arnold      Ormsby,
                         Ormsby        Ambulance,         Joseph
                         Calamusa,       Administrator        of
                         Howard    Hospital,     Nlartha     and
                         Everett      Peterson      and      Ken
                         Donahue, Fire Cilief-Ukiah.
                         The    classes    started    in    Jan.
                         and   will   continue   through    June
                         12.  Classes  @vill  be  held  in   the
                         evening     with      clinical      ex-
                         perience  totalling   IF   hours.   The
                         clinical  experience  will   be   given
                         at     Howard      Hospital,      Ukiah
                         General                        Lakeside
                         @pital,    and    Red@)ud    Hosi)ital.
                         The    students    are    requir@    to
                         spend   actual   tii-ne   working    in
                         the,hospital      emergency      rooms.


           A report of activities from
           the Cancer Advisory Committee:
           Special Listing Project of  the
           Joint Commission on Accreditation of Hospitals

                     BENJAMIN F. BYRD, JR., MD, FACS, Nashville
                       Chairman, Commission on Cancer
                       American College of Surgeons

                     In the  spring  of  1972,  a  contract  to  identify    members  of  the  College  and  of  liaison   members
                     resources  available  in  hospitals  in  the  United    representing  various   national   professional   or-
                     States  with  special  capabilities  in   diagnosis,    gaiiizations with a special  interest  in  the  field
                     treatment,  and  education   programs   related   to    of  cancer.  (Ed.  note:  a  current   and   complete
                     heart disease,  cancer,  stroke,  or  advanced  kid-    i-ostei- of the Commission on  Cancer  can  be  found
                     ney disease  was  entered  into  between  the  Joint    in the ACS  Bulletin,  Vol.  58,  No.  5,  May  1973,
                     Commission    on    Accreditation    of    Hospitals    page  24).  Because  of  the   composition   of   the
                     (JCAH)   and   the   Regional    Medical    Programs    commission,  as  well  as  its   more   than   thirty
                     Service  (RMPS)  of  HEW.   At   about   this   same    years' experience  in  surveying  cancer  activities,
                     time  JCAH   entered   into   a   subcontract   with    the  decision  was  made  for   the   commission   to
                     the  American  College  of  Surgeons,  through   its    do the preparatory work as described herein.
                     Commission  on  Cancer,  to  prepare  that   portion    Cancer    Advisory    Committee    for    the    JCAH
                     related  to  cancer.  The  report  by  the   commis-    Special  Listing  Project  was  appointed,   contain-
                     sion  is  now  nearing  completion  of  its  initial    ing  representatives  from   the   American   Academy
                     phase, and it  is  the  feeling  of  the  commission    of  Pediatrics,  the  College   of   American   Path-
                     that  Fellows  of  the  College  should  be  advised    ologists,  the   American   College   of   Radiology,
                     of  the  fashion  in  which  this  report  was   put    the  American  College   of   Physicians,   and   the
                     together,  and  of   the   broad   objectives   that    American   College   of   Surgeons.   Many   of   the
                     guided  the  commission  to  its  preliminary   con-    individuals  from  these  organizations   belong   to
                     clusions.                                               other  societies  of  regional  and  national   scope
                       The  Commission  on  Cancer  of   ACS   is   named    with special interest in  cancer  and  related  prob-
                     by  the  Board  of  Regents  and  is  made   up   of    lems.
                                                                                A  Steering  Committee   of   the   JCAH   Special
           In brief . . .                                                    Listing Project studied at length  the  ways  of  ob-
                                                                             taining  information   that   could   lead   to   the
                     This report presents a brief history of the             categorization of facilities in the  four  fields  of
                     development @f  a  program  ad  inistered  by  the      interest.  It  was  agreed  that  a  mail  survey  of
                     Joint Co,(nmission on Accreditation of                  hospitals in  the  United  States,  other  than  psy-
                     Hospitals to determine which hospitals, other           chiatric  institutions,  should   be   conducted   to
                     than psychiatric, in the United States are              assay the  current  availability  of  facilities  and
                     equipped and staffed to provide the diagnosis           personnel  in  each  institution.  Responses  to  the
                     and treatment Qf four major diseases (heart,            questionnaire   were    received    from    hospitals
                     cancer, stroke, or advanced kidney),  and  of  the      representing 94 percent  of  all  acute  care  hospi-
                     role of  the  Commission  on  Cancer  in  carrying      tal  beds  in  the  United  States.  From   the   re-
                     out its responsibilities, under  subcontract  with      sponses  to  this  survey  of  7300   hospitals,   an
                     JCAH, for  the  cancer  segment  of  the  program.      inventory  has   been   prepared   which   identifies

                     18   American College of Surgeons


                                                                                              MEETING  OF  YOUNG   SURGEONS
                      creased involvement in the  areas  of  cost  con-
                      trol and quality care  delivery  in  response  to
                      rising national interests. Discussions for achiev-
                      ing these goals centered around  the  utilization
                      of data obtained by  continuing  surveys,  as  in
                      the Study on  Surgical  Service  for  the  United
                      States, or by  analysis  of  computer  data  gen-
                      erated   by   PSROS,   HMOs,   medical    founda-
                      tions, or  the  medical  insurance  industry.  It
                      was hoped that  there  would  be  increased  dis-      hernioplasty  by  family  practice   physicians   is
                      semination  of  this  information  through  mech-      declining   and   that   recently   trained   family
                      anisms  such  as  the  BULLETIN,  or  perhaps  by      physicians  are  not  eager  to  carry   out   major
                      trial sessions at Clinical Congresses  along  the      surgical  procedures.  The  need   to   define   the
                      lines of the open  forum  held  by  this  commit-      areas  where  family   physicians,   allied   health
                      tee last fall.                                         personnel  and  surgeons  might   best   use   their
                      The  discussants  were  strongly  interested   in      special  talents  and  expertise  in  providing  the
                      the  ACS  developmental  work   involving   norms      best  surgical  care  for  the   widest   group   of
                      and guidelines for standards  of  surgical  prac-      patients was stressed.
                      tice. It was felt that this activity at  the  Acs      The   problem    of    attracting    well    trained
                      level  could  provide   important   support   for      surgeons  to  rural  areas  and  smaller  towns  was
                      surgeons involved with these activities  at  com-      discussed.  It  was  concluded  that  it  would   be
                      munity or  chapter  levels.  It  was  anticipated      useful  to  encourage  availability  of  information
                      that these guidelines  would  improve  the  level      concerning open  surgical  positions  in  all  areas
                      of  effectiveness  and  competence  as  concerned      of  the  country  to  surgical  residents  and  sur-
                      Fellows  attempt  to  optimize  both   cost   and      geons   considering    changing    location.    Such
                      quality of surgical care in their own  hospitals.      information  would  include   surgeon   to   patient
                      The  workshop   discussants   wished   to   thank      population  ratios,  type  of  other  physicians  in
                      ACS  for  sponsoring  these  sessions  for  young      the  area,  and  other  data.  Further,  information
                      surgeons. Many  gained  additional  insight  into      that  would  indicate  that  certain   areas   might
                      the scope of activities  and  problems  addressed      be undesirable as a  potential  job  site,  such  as
                      by the ACS. All  felt  both  stimulated  and  en-      an   already   overcrowded    surgical    situation,
                      couraged  to  become  more  involved  in   health      would be included.
                      care delivery issues.                                  The   increasing   number   of    foreign    medical
                                                                             graduates  taking  the  board   exams   in   surgery
                      Workshop IV                                            and  assuming  surgical  positions  in  this   coun-
                      Surgical     manpower     distribution,                try  was  discussed.  It  was  concluded  that   the
                      job placement, and recertification                     foreign  medical  graduates  fulfill  an   essential
                      CONSULTANT:                                            role in  this  country  at  the  present  time,  and
                      Francis  D.  Moore,  MD,  FACS,  Boston                that  there  would  be  a  health  care  crisis   if
                      CHAIRMAN:                                              foreign   medical   graduates   were   not   allowed
                      William P.  Longmire,  Jr.,  MD,  FACS,                into  the  country.  However,  it  was   felt   that
                      Los Angeles                                            many of  the  foreign  trainees  are  exploited  and
                      RECORDF,R:                                             do not receive training  of  high  calibre.  It  was
                      Stephen  L.  Wangensteen,   MD,   FACS,                suggested that  it  might  be  useful  to  eliminate
                      CharlotWville, VA                                      surgical  training  programs  that  do   not   offer
                      Considerable discussion focused  on  the  role  of     high quality training.
                      the family  practitioner  in  performing  surgical      The  problem  of   recertification   was   reviewed
                      procedures. The College's position in this  sensi-     and  it  was  believed  that  the   College   should
                      tive and  important  area  was  pointed  out  (Ed.     require  attendance  and   participation   in   sur-
                      note: see Bull., ACS, Vol. 58, No. 6,  June  1973,     gical   programs   of   continuing   education    by
                      3, 29, 30 .                                            its  members.  As  an  example,  it  was   suggested
                      How to deal on the  local  level  with  such  pro-     that  a  Fellow  of  the   ACS   should   attend   a
                      cedures  as  endoseopy,  placement   of   dialysis     certain  number  of  ACS  meetings  over  a   speci-
                      catheters and closure  of  small  lacerations  was     fied  period  of  time.  In  addition,  recognition,
                      a  matter  for  extended  review.  It  was  empha-     in the form of a certificate,  for  attending  these
                      sized that a clear definition of what  constitutes     meetings  might  be  considered.  Physical  capacity
                      major  surgery  as  contrasted  to  minor  surgery     was also mentioned  as  a  possible  factor  in  re-
                      had never been delineated.                             certification.
                      The  overall  consensus  of  the  discussion   was
                      that  the  performance  of  operations   such   as                                   Continued on  page  29
                                                                                                          July 1973 Bulletin    17


                                                                                              CANCER  ADVISORY   COMMITTEE

                  the wide  range  of  personnel  and  facilities  that    by  the  Cancer  Advisory  Committee  and  will   be
                  have special bearing on one  of  the  four  areas  of    submitted,   upon   approval   of   the   Board   of
                  study.                                                   Commissioners  of  JCAH,   to   DHEW.   The   antic-
                    At  the  same  time  this   inventory   was   being    ipated publication date of  the  criteria  is  July,
                  accumulated,   the    Cancer    Advisory    Committee    1974.  Both  the  criteria,  when   published,   and
                  was asked to prepare  sets  of  criteria  that  would    the inventory  will  be  available  to  any  person,
                  permit  categorization  for  the  identification   of    lay or professional, requesting them.
                  those  institutions   having   special   capabilities     At  the  same  time  this  work  has   been   going
                  for the care of the cancer  patient.  These  criteria    on,  similar  preparations   have   been   completed
                  were  completed   by   the   Cancer   Advisory   Com-    and  submitted  in  the  fields  of  heart  disease,
                  mittee  in  January  1973,  and  then   reviewed   in    stroke,   and   advanced   kidney   disease.   Docu-
                  conjunction  with   the   inventory   of   facilities    ments  of  the  same  scope   and   furnishing   es-
                  which became available about the same time.              sentially  similar  points  of  reference  will   be
                    The   inventory   has   been   submitted   to   the    published  in  these  areas  at  the  same  time  as
                  Department   of   Health,   Education   and   Welfare    the cancer documents.
                  and  will  be  published  this  summer  by  the  Gov-     Following  are  the  Introduction  of  the   Cancer
                    nment Printing 0                                       Advisory   Committee   Report,   and   the   opening
                  er                   ffice. The  criteria,  following
                  exposure  to  interested  persons   via   publication    paragraphs  of  the  Guidelines  for  Categorization
                  in  professional  journals,  will  be  reviewed,  to-    of Hospitals for Cancer Patients.
                  gether  with  comments   and   criticism,   if   any,

                    The  most  important   requirement   would   be   a    result  from  the  criteria   recommended   by   the
                  special  interest  in  the  cancer  patient  on   the    committee.  The  governing  thought  has   been   to
                  part of the staffs  of  such  institutions.  The  en-    improve the care of  the  cancer  patient,  and,  to
                  tire  problem  is  made  exceedingly   difficult   by    this end, the following  guidelines  have  been  em-
                  the  great  number  of  different  disease  complexes    ployed in developing the criteria:
                  included  under  the  term  "cancer".   This   neces-      1.  Every  cancer  patient  should  be   able   to
                  sitates  consideration  of  the   many   capabilities    find  basic  diagnostic  services  within  his   own
                  required  in  evaluating  the  patient;  in  defining    community;
                  and  carrying  out  treatment   programs;   in   long      2.  Every  cancer  patient  should  be   able   to
                  term  follow-up  to  provide  rehabilitation,   early    find excellent  diagnostic  and  treatment  capabil-
                  treatment  of   possible   recurrent   disease,   and    ities within his region;
                  early detection  of  any  new  foci;  and,  most  im-      3. The eventual goal will  be  to  make  all  can-
                  portant, in critical  evaluation  of  the  effective-    cer services available  as  close  to  home  as  can
                  ness  of  the  treatment  program  in   patient   im-    be justified;
                  provement  and  Survival  as  well  as   cure.   Only      4. Considerations  of:  (a)  geography,  (b)  pop-
                  as  a  by-product  should  the  individual   hospital    ulation  density,  (c)  limitations  in  numbers  of
                  concern  itself  with  the  problem   of   epidemiol-    highly trained  specialists,  (d)  economic  limita-
                  ogy. This is  a  different  field  and  must  be  ap-    tions on  the  availability  of  highly  specialized
                  proached  in  a  different  fashion  from   the   re-    and  very  costly  equipment,  and  (e)   the   need
                  quirements  of  Section  907   of   PL   89-239   (as    for a certain volume of  cancer  practice  to  main-
                  amended by PL 91-515).                                   tain expertise of a highly  trained  team  for  cer-
                     The committee has  held  as  a  premise  that  the    tain services, all point in  the  direction  of  re-
                  cancer patient should be  treated  as  close  to  his    gionalization  of  services  and  the  necessity  of
                  or her home as  the  availability  of  trained  staff    making  available  a  stratified  system  of   care;
                  and specialized  facilities  will  permit.  The  cri-      5. Hospitals  vary  in  their  size,  number,  and
                  teria  for  various  categories  of  facilities  have    degree of specialization of  their  staffs,  and  in
                  been programmed to this end.                             the  availability  of  specialized   equipment   and
                     It is equally in  the  public  interest  that  un-    services;
                  necessary  reproduction  of  facilities  should   not                                               Continued
                                                                                                       July 1973 Bulletin     19


                     CANCER ADVISORY COMMITTEE

                       6.  Hospitals  should  also   be   differentiated    ment  of  cancer  patients   should   provide   the
                     as  to  their  missions  and  each  should  try  to    following:
                     identify  that  mission  and  range   of   services     1)  Multidisciplinary  approach:  for  all  cancer
                     most appropriate to its local situation;               patients, with consideration of and access  to  all
                       7.  Once  a  hospital  has  decided  on  its  ap-    modalities of therapy;
                     propriate  mission,  it  should  endeavor   to   do     2)  Education  and  training:  must   accept   re-
                     everything possible to fulfill its  mission  at  as    sponsibility  for  maintaining  a  structured  pro-
                     high a level of quality as possible;                   gram of continuing  education  in  cancer  for  its
                       8. Wherever  it  is  not  practical  or  economi-    own  professional  staff   and   community   physi-
                     cally feasible to have certain specialists  on  the    cians, and  for  the  development  of  a  practical
                     staff of  a  particular  hospital  where  diagnosis    level  of  cancer-oriented  health  education   for
                     and treatment for  cancer  patients  are  provided,    allied  health  professionals  and  the  lay   com-
                     arrangements     for     immediate     consultation    munity it serves;
                     should be  well  established  in  advance  so  that     3)  Assurance   of   quality   care:   must   have
                     no undue time  is  lost  in  obtaining  expert  ad-    utilization review, medical  audit,  and  discharge
                     vice  on  any  cancer  problem.  The  patient   can    planning;
                     then  either  be  treated  in  that  hospital  with     4)  Rehabilitation:  full  services  available  in
                     benefit of  expert  consultation  or  referred  for    house or by referral;
                     care to  a  hospital  where  the  necessary  exper-     5) Effective follow-up  through  a  cancer  regis-
                     tise is available; and                                 try and periodic re-evaluation; and
                       9. Where it  is  not  practical  or  economically     6) Continuity of care:  an  established  relation-
                     feasible to  have  highly  specialized  and  expen-    ship with at  least  one  extended  care  facility,
                     sive equipment for the  treatment  -of  cancer  pa-    nursing home, ambulant  or  limited  care  facility
                     tients located in a  given  hospital,  arrangements    and a home care service.
                     should  be  made  for  access  to  such  treatment.      On the basis of these  considerations,  the  Can-
                     It should be possible either to share  such  equip-    cer   Advisory   Committee    recommends    identi-
                     ment  with  another  hospital  or   community   re-    fication of three general categories  of  hospitals
                     source nearby, or to refer the patient  to  a  more    plus  a  special  category  including  centers  de-
                     distant hospital or regional  cancer  center  where    voted entirely to the treatment of  cancer,  or  to
                     such  equipment  is  available  dustified  by  bav-    the  treatment  of  special  types  of  cancer,  or
                     ing  a  large  enough  number  of  cancer  patients    limited to  the  treatment  of  special  categories
                     to maintain the  expertise  of  the  staff  and  to    of  patients  (such  as  women  or  children).  The
                     keep the cost of the treatment  per  patient  at  a    three  general   categories   selected   correspond
                     reasonable level.                                      essentially to  those  identified  by  the  Commis-
                       To be  more  specific,  all  hospitals  accepting    sion on Cancer of  the  American  College  of  Sur-
                     responsibility for definitive diagnosis and  treat-    geons.

                       In   summary,   the    Cancer    Advisory    Com-    Cancer,  ACS,  55  East   Erie   Street,   Chicago,
                     mittee for the  Special  Listing  Project  of  JCAH    Illinois  60611.  The   Cancer   Advisory   Commit-
                     has reached agreement on  sets  of  criteria  based    tee will  welcome  constructive  criticism  of  the
                     on the above guidelines  which  it  proposes  as  a    proposals  in  this  to-be-published   report   and
                     basis for categorization of hospitals.  A  detailed    hopes the project will  stimulate  the  health  and
                     report defining the categories  and  setting  forth    hospital  professions  to  consider  carefully  the
                     the  appropriate  criteria  will  be  published  in    most   appropriate   development    of    hospital-
                     selected professional journals in the near  future.    based resources for the  care  of  cancer  patients
                     Fellows of  the  College  interested  in  reviewing    in any given hospital.
                     this  report  may  write  to  the   Commission   on

                     20   American College of Surgeons


                                   NEW ENGLAND JOURNAL OF MEDICINE   -  8/19/71                                                                                -

            Vol. 285  No. 8                    MEDICAL EDUCATION IN THE SOVIET UNION-STOREY                                                                    437

                                                                    SPECIAL ARTICLE

                                  CONTINUING MEDICAL EDUCATION IN THE SOVIET UNION

                                                                        P. B. STOREY, M.D.
            Abstract   Physicians   in   the   USSR   practice   with-                    the   Ministry   has   evolved   an    educational    sys-
            in    a   system   organized    for    flow    of    health-                  tem   that   binds   all   phases   of   medical    educa-
            care  services  to   the   public,   and   for   flow   of                    tion   and   is   noteworthy   for   its   commitment   of
            patients   to   appropriate   back-up    diagnostic    and                    personnel,        financial       and       organizational          re-
            therapeutic   facilities.    The    present    medical-ed-                    sources  to   the   lifelong   improvement   of   a   phy-
            ucation  policy   of   the   USSR   Ministry   of   Health                    sician's   knowledge   and   skills.    The    most    im-
            is    oriented      toward        increasing       the      qualifica-        portant  role  is  that   of   the   13   Institutes   for
            tions  of   all   physicians.   This   poses   a   complex                    Advanced    Education    of    Physicians,    under    the
            problem        for    postgraduate          medical          education        leadership       of  the  Central           Institute     in      Mos-
            in   the   Soviet   Union.   To   meet    the    challenge                    cow.

                 ONTINUING      medical      education      in       the       Soviet     other   in    the    lifelong    developments    of    the    individual
            C     Union     ranks      with      undergraduate      and      graduate     physician.
            medical    education    as    a    critical    element     in     general
            quality    control    of    the    Soviet    health-care    system.    As     DIFFERENTIATION        IN         THE         SOVIET         EDUCATIONAL
            such,    it    is    organized    and    funded    on    an     All-Union                                   SYSTEM
            scale  in  such  a  way   as   to   assure   it   a   top-priority   role       The     process     of     differentiation     begins     with     the
            in  the  medical  educational  establishment.                    @t    is     child   in   the    10-year    general    school,    where    his    fu-
            closely    integrated    into     the     lifelong     medical     educa-     ture    is    determined    by    the    interplay    of     environmen-
            tional     process,     existing     in     dynamic     balance      with     tal    and    personal    determinants,    Many    of    the     10-year
            other    levels    of    medical    education    so    that    its    own     schools     are     specialized.     For     exai-nple,     about     30
            objectives     and     characteristics     change     and     grow     in     schools     in     Moscow     now      specialize      in      providing
            relation    to    changes    in    the    entire    health-care    system     some    of    the    curricular    instruction    in     the     English
            and   its    educational    underpinnings    Because    of    the    uni-     language,    and    two     use     the     Spanish     language.     If
            versal    organization    of    the    Soviet     health-care     system,     a  child  happens   to   live   in   the   area   served   by   such   a
            which    integrates     its     services,     research     and     educa-     school,   and   if   his   parents   are    agreeable,    his    primary
            tional       components,       continuing        medical        education     foreign-laiiguage    development     is     initiated.     if     during
            for   given   physicians    or    types    and    groups    of    medical     his    progress    through    the    10-year    school,    the     child
            workers    is    closely    oriented    to    the    needs    of    their     manifests    a    special    affinity    for    a    given    discipline
            daily work.                                                                   such    as    mathematics    he    may    be    transferred     to     a
               Soviet     "continuing     medical     education"      is      carried     school    with    stronger    resources    in    that    subject.     In
            out   under   the   auspices   of   the   Institutes    for    the    Ad-     any    case    most    students     will     receive     a     prolonged
            vanced    Education    of     Physicians.*     The     Central     Insti-     exposure      to      mathematics,      chemistry      and      physics,
            tute   for   such   education    is    in    Moscow.    Its    "centrali-     which   will    prepare    the    eligible    ones    to    take    com-
            ty"   is   reflected   in   the   fact   that   it   is   concerned   not     petitive   examinations    for    entry    into    the    medical    in-
            only    with    its     own     pedagogic     programs     for     pbysi-     stitute.   The   present   ratio   of    applications    to    available
            cians    from    the    entire    Soviet    Union    but    also     with     places in the medical institutes is seven to one.
            the    study    of    the    methodologic    problems     involved     in       Granting    successful    outcome    of     the     entry     process,
            lifelong learning         r p  ysicians.                                      a   critical   point   of   differentiation   occurs   in    that    the
               The    function    of    the    Institutes    for    Advanced     Edu-     prospective   student    now    must    enter    on    one    of    five
            cation    is    not    really    understandable    outside    the    con-          .1 le    routes:    the    medical    facult    (lechebniy);    the
                                                                                          I)OSSID                                        y
            text   of   the   entire    Soviet    educational    system    and    the     I-  .
            health-care    system,    both    of    which    contain    their     own     n@@iene    faculty;    the    stomatologic    faculty;     the     pedi-
            processes   of    differentiation    that    are    related    to    each     atric ficultv; or the medical-biologic faculty.
                                                                                            Entrv   into   one    of    these    routes    represents    a    com-
                                                                                          mitment   that   does   not    allow    for    crossover    at    subse-
               From  the  Department  of  Community   Medicine,   Hahnemann   Medical     quent   points   in   time,    except    by    re-entry.    Thus,    the
            College and Hospital, 235 N. 15th St.,  Philadelphia,  Pa.  19102,  where       tin the  Russian  language  the  word  "usovershenstvovaniye"  carries
            reprint requests should be addressed to Dr. Storey.                           the implication that one's  daily  experience  and  reflection  upon  it
               The work done in  development  of  this  report  was  supported  to  a     should contribute materially to the evolving maturity of the  individual
            great extent by the US-USSR Health Exchange Program.                          personality. This is the lifelong process of  usovershenstvovaniye  o  a
               "'Instituti  dlya  Usovershenstvovaniya  Vrachey,"  which  means  lit-     member of society, a process  subject  to  both  individual  and  social
            erally "Institutes for the Improvement of Physicians."                        control.


                     438                                          THE NEW ENGLAND JOURNAL OF MEDICINE                                                         Aug.    19,    1971

                     students    who    enter    any    but    the    medical    faculty    will     characterizing     quality     that     in     turn      determines      his
                     not    in    their    careers    be    concerned    with    problems     of     ultimate     eligibility     for     leadership     in      the      profes-
                     adult     medicine     or     surgery.     Similarly,      the      student     sion.
                     entering    the    medical    faculty    has    elected    not    to     be        It   is   important   to   have   an   idea   of    this    process    of
                     involved     in     the     care     of     children.     The      medical-     differentiation      to      understand      the      organization       and
                     biologic   faculty   is   a   new   one.   It   was   added   four    years     administration      of      the      continuing      education      process.
                     ago    to    provide    for    students    who     wished     to     become     The    narrative    used    above    to    illustrate    it     is     some-
                     involved   in   the    science    of    medicine    and    not    in    the     what    simplified    but    should    suffice     to     afford     insight
                     care of patients.                                                               into    the     educational     make-up     of     the     Soviet     physi-
                        Until   1968   the    curriculum    lasted    for    six    years,    at     cian.   If   further   details   are   desired,   the   reports    of    the
                     the    end    of    which    the    student    was    assigned    to    his     exchange    missions     in     health'     or     the     monographs     by
                     first    clinical    post@    Now    a    seventh     year     has     been     Field2,3   are helpful.
                     added,    the    beginning    of    which     represents     a     critical
                     point    of    differentiation    into    the     major     medical     and     Standardization in the Soviet Educational System
                     surgical     specialties.     The     seventh     year     is      approxi-        Another     general     and     very     influential      process      in
                     mately     equivalent     to     the     American     "straight     intern-     the    Soviet    system     must     be     considered     -     that     of
                     ship."    The    student    from    track    one,    for    example,    now     standardization.       The       separate        ministries        concerned
                     elects    medicine    or    surgery     or     obstetrics     and     gyne-     with    education    and    with    health     care     seek     to     make
                     cology,   and   commits   himself    to    that    field    of    interest.     uniform    on    a    national     @basis     their     respective     proc-
                     The   addition   of    this    year    to    the    curriculum    of    the     esses     and     their      respective      or      conjoint      products.
                     medical     institutes     represents     the     decision      of      the     They    achieve    this    end    either    directly,    by     establishing
                     Ministry    of    Health    to     move     toward     more     specialized     universally      applicable      educational       objectives,       curric-
                     training    of    young    physicians    before    they     start     their     ula    and    norms    of    student    response,    or    indirectly,    by
                     careers.                                                                        operating      through      the      corresponding       ministries       of
                        At   the    end    of    the    seventh    year    the    student    re-     the    various    republics    that     make     up     the     Union     of
                     ceivek."his    diploma    and    seeks    his    first     clinical     as-     Soviet      Socialist      Republics.      Standardization      is      also
                     signment,    which    will    last    for    three    years.    This    be-     sought    by    a     detailed     characterization     of     the     func-
                     comes   another   critical   point    in    the    process    of    differ-     tions   of   a   given   type   of   worker   and    by    a    close    de-
                     entiation    because    the    strengths     of     the     hospital     or     scription   of   the    responsibilities    and    duties    of    a    giv-
                     polyclinic    to    which     he     is     assigned     will     determine     en positions
                     his    ability    to    pursue    specialized    study    in    a     given        Knowledge    of    these    factors     allows     the     faculty     of
                     field    of    medicine    or    surgery,    and    will,@condition     his     the    Institutes    for    the     Advanced     Education     of     Physi-
                     future    selectability    when    he    has    completed     his     obli-     cians    to    meet    a    most    important     educational     constraint
                     gatory    first    three    years.     For     example,     the     depart-     -   that   of   knowing   where    a    student    is    in    his    educa-
                     ment    of    gastroenterology    at    his    new    hospital    may    be     tional    attainment    and,    critically,    where    he     should     be
                     on    the    accredited    list    for    training    in     gastroenterol-     in    terms    of    his    job    requirement.    Application    of    this
                     ogy.   If   it   is   not,   he   cannot   move   upward   in   the   "cat-     knowledge    guides    the     faculty     in     the     development     of
                     egories"    of    proficiency    of    this.     particular     area     of     curriculum    and    in    the    selection    for    a     given     course
                     medicine.*                                                                      of     students     with     like'backgrounds     and      similar      edu-
                       At    the    completion    of    these     first     obligatory     three     cational    needs.    The     further     requirement     for     a     more
                     years   the   next    critical    point    of    differentiation    occurs.     detailed     knowledge     of     the      actual      educational      need
                     This    one    is    conditioned    by    many    external    factors    as     of   the   individual   student   in    relation    to    his    own    per-
                     well   as   by   the   make-up    to    this    point    of    the    young     formance    is    attained    by    a    process    known    as    "precycle
                     physician.   As   in    any    country,    there    are    desirable    and     preparation."    The    prospective    student     receives     a     series
                     undesirable    posts,    with    a     strong     proclivity     on     the     of    assignments,    of    greatly     varied     nature,*     which     he
                     part   of   physicians   for    the    big    city    institutions.    Such     accomplishes   in   a   given    time,    perhaps    as    long    as    six
                     posts    are    available    only    on    a    competitive    basis,    so     months,  before  his  actual           11 presence"     at     the     insti-
                     that     one's      particular      experience      and      qualifications     tute.    These    assignments    are    turned    in    to     a     faculty
                     are    important    determinants    of    eligibility    for    a     given     advisor,     who     reviews     them     and     makes     judgments     on
                     post.     Position     availability,     whether     as     an     advanced     the    educational    status    of    the     learner.     The     learner's
                     trainee    in    the    ordinatura    (clinical     specialty     training)     subsequent      activity      during      his      presence      at      the
                     and     aspirantura     (academically      and      research      oriented)     course   is    shaped    to    some    extent    by    this    process    of
                     graduate    programs    or    as    a    staff     member,     thus     be-
                     comes    a    determinant    of    the    likelihood     of     and     the       tThe scientific organization of work is  a  highly  developed  methodology
                     rate    of     progression     of     a     physician     through     Cate-     in the Soviet Union. It is abbreviated as NOT - from the initial letters  of
                                                                                                     'Nauchnaya,  Organizatsiya  Truda  -   the   "Scientific   Organization   of
                     gories   III,   11   and   I   of   a   given    medical    specialty,    a     Work."
                                                                                                       fThis  may  range  from  submission  by  the  student  physician   o   the
                                                                                                     details of his own investigative study of a clinical problem,  to  his  com-
                      'The  degree  of  educational  accomplishment  and   expected   proficien-     pletion of a work-study project in a narrow field now  of  special  interest
                     cy in a given medical specialty  is  indicated  by  "categories,"  Category     to him -  e.g.,  clinical  electrocardiography  as  required  for  emergency
                     I being the highest, and Category III the lowest.                               purposes.


           Vol. 285  No. 8                 MEDICAL EDUCATION IN THE SOVIET UNION-STOREY                                                      439

           evaluation  of  his  need,   related   to   his   observed   per-    based for the most part on        the   departments    and    ac-
           formance and the requirements of his position.                       tive  clinical  and   research   units   of   the   many   hospi-
             Any   number   of   variations   on   this   theme   are   pos-    tal  sand   institutes   of   Moscow,   under   the    administra-
           sible,  ranging  from   rather   I)road-scale   coverage   of   a    tive direction of the Central Institute.
           subject   such   as   electrocardiograph,,,   for   a    hospital         AverN,  important  point  to  note   about   this   is   that
           ordinator  ("ward  physician"),   or   of   the   principles   of    the  top-level  personnel  at   these   locations   away   froi-n
           social   hygiene   for   a   regional   medical    administrator,    the  Central   Institute   are   not   staff   members   of   the
           to  acquisition   of   a   particular   surgical   skill   by   a    peripheral    institutions    who     "volunteer"     to     "run
           highly competent surgeon.                                            courses"   for   the   Institute   for   Advanced   Training   of
             The   important   point   to   be   noted   in    seeking    to    Physicians,  but  the   opposite:   they   are   full-time   fac-
           understand    the    Soviet    continuing    educational     sys-    ulty  meml-)ers  of  the  Central  Institute  who   are   located
           tem  -  its   objectives,   its   organization   and   its   pro-    out   where   they   can   do   their   clinical   and   research
           grams  to  meet   those   objectives   -   is   that   norms   do    work,  an  aspect  that  is   essential   for   their   continued
           exist   for   both   the   individual   student   at   a    given    competence  as  members  of   the   faculty   of   tl-ie   Insti-
           stage   of   differentiation    and    development,    and    for    ttite.   Ftirtheri-nore,   all   appointments   to   the   Insti-
           the position that he occupies or seeks to occupy.                    tute's   faculty   are   term    appointments    (seven-year    ,
                                                                                with   a   coi-nplex   administrative   and   professional    ar-
           Organization    of    the    Continuing     Medical     Education    rangement    for    reappointment     or     new     appointments
             System                                                             to   these   prestigious   positions.   Such   an   organization-
             In  the  Soviet   organizational   system   for   health   care    al arraiigei-nent guarantees the priority of duties o
           there  is  the  whole  issue   of   upward   mobility   of   phy-    the incumbents.
           sician   employees.   This   critical   concept,   in    general,
           is   missing   from   our   own   organizational   notions   con-    Educational Programs of the Central Institute in Moscow
           cerning continuing medical education.                                     Bec@itise of' its  "central"  role  the  Institute  in  M6s-
             In  ten-ns   of   objectives   the   stated   overall   purpose    cow   accepts   physicians   from   all    over    the    country
           of   the   Soviet   system   is   "the   improvement    of    the    and   maintains    a    deliberate    trend    toward    develop-
           professional   skill   and   qualifications   of    the    physi-    ment   of   its   l@rograms   for   the   more   highly   skilled
           cian"  -  a  goal  that  can  be  accepted   as   that   of   the    phvsiciatis,   leaving   less    highly    developed    resources
           American    understanding    of    continuing    medical     edu-    to  be  used  -,It  the  more  local  facilities  of  the   other
           cation.                                                              12   institutes.   Thus,   the   Central    Institute    attracts
             This  improvement   of   the   professional   skills   of   the    heads   of   local   ptiblic-health   and   medical-care   bodies
           physician   is   the   concern   of   the   USSR   Ministry    of    (of  republics,  territories,   regions,   and   large   cities);
           Health.   Soviet   doctors   can   improve   their   skills    at    teachers    from    the    higher    i-nedical     establishments
           city,  at  regional  and  at   inter-regional   (oblast)   bospi-    (the   medical   institutes   and   the   postgraduate    medical
           tals,  at  advanced  training   faculties   attached   to   medi-    educational    institutes);    top     specialists     (surgeons,
           cal  institutes,  and  at  the   special   institutes   for   the    internists,    pediatricians,    obstetricians,    psychiatrists,
           advanced   education   of   physicians.   There   are    13    of    etc.);  head   physicians   of   large   hospitals   or   depart-
           the   special   institutes,   located   in   Leningrad,    Kazan,    meiits  of  liosl)it@ils;  and  ]read  physicians   of   sanitary
           Kiev,   Kharkov,   Minsk,   Tbilisi   and   other   cities,   the    epideiiiiologic stations and their laboratories.
           largest   one   being   the   Central   Institute   in    Moscow,         In  1965  the  number   of   physicians   who   studied   at
           which is related to all others.                                      the   facilities    of    the    Central    Institute    exceeded
             The   Central   Institute   in   Moscow    has    61    depart-    10,000.  An  increase  in  number  of   physician   students   in
           ments  and  77  professors.  In  addition,   it   has   115   as-    recent   years   has   been   attributed   to   improvement    in
           sociate  professors   on   its   staff.   The   chairs   of   the    educational    methodology,    and    i-nost    importantly    to
           institute  are  grouped  into  five  faculties:   general   medi-    the   introduction   of   the   "pre-course   exti-ai-nural   and
           cine;  surgery;   pediatrics;   medical   liiology;   and   sani-    course iiitraiiitiral" approach.
           tation   and   hygiene.   The   Institute   is   headed   by    a         Before lie arrives at the Institute  the  physician
           rector  and   four   pro-rectors,   who   are   responsible   for    prepares  for  the   intramural   period   at   his   own   resi-
           training, research and administration. Its  administra-              dence  without   giving   up   his   regular   work.   By   read-
           tive  facilities  and  some   of   its   educational   facilities    ing   the    recommended    literature    and    doing    written
           are  located  at   the   large   hospitals   and   the   clinical    assignments,   including    reviews    of    pertinent    litera-
           research  institutes  of  the   city,   with   more   than   9000    ttire  and  reporting  on  his   own   clinical   or   laboratory
           beds  available  to  the  Central  Institute   for   its   educa-    investigations,  be  may  go   through   a   period   of   prepa-
           tional programs.                                                     ration  of  three  to  four  months.  All  this  work  is  guided
             Illustration  of  some   of   these   features   may   be   ob-    I)v   members   of   the   departmental   faculty    of    t    e
           tained   from    reference    to    the    Central    Institute's    Institute,   ,N,Iio   recommend   to    him    the    appropriate
           Annual  Listing  of  Courses  for   1970,4   which   is   a   47-    literature    and    send    him    specially    prepared     and
           page  description  of   the   courses,   their   characteristics,    printed   lectures,    methodical    materials    and    training
           their   duration    and    physician-student    eligibility    to    aids.
           participate  in  them.  The  educational   activity   itself   is         The  Institute  believes  that  this  period   of   prelimi-


                    440                                           THE NEW ENGLAND JOURNAI, OF MEDICINE                                                         Aug.  19,  1971

                    nar@, study  lets  him  develop  at  his  own  pace  a  much                      recent  physical  addition  to  the   resources   of   the
                    more  thorough  knowledge  of   the   subject   being   con-                      Central  Institute  is  a  high-rise  "Dom  Vracliey,"  or
                    sidered and  also  gives  the  facultv  the  opportunity  to                      house  for  doctors,  which  functions  as   hotel,   res-
                    evaluate  him  and  to  design   his   subsequent   institu-                      tatirant  and  library  for   the   participating   pbysi-
                    tional  period  of  study  more  appropriately.  This  is  a                      cians.   Seminar   rooms    and    electronic    equipment
                    convenience  for  the  physician,   his   family   and   his                      are available for use at the building.
                    place  of  work,  and  at  the  same  time  it  allows   the                        Fourthly,  the   course   in   electrocardiography   re-
                    Institute  to  increase  its   number   of   students.   The                      (Iiiires  a  five-month  period  of  home-study   prepara-
                    intramural  or  institutional   component   of   the   cycle                      tion,  with  a  subsequent  period  of   two   months   to
                    will last for one to two months at a minimum.                                     be  spent  at  the  Botkin  Hospital.  To  facilitate  the
                        Some  of  these  features   are   shown   in   Table   1,                     preliminary  process,  a  practical  manual  in   clinical
                    which  lists  the  particular   educational   offerings   of                      electrocardiography5  was   developed,   and   3000   cop-
                    one  of  the  61  departments  of  the   Central   Institute                      ies  ptil@lished   for   the   Central   Institute.   This
                    for  1970.   One   may   notice   several   special   points                      serves  as  the  reference  source  that   the   physician
                    from  this  table  and  from  the  remainder  of  the  cata-                      can  use  as  he  moves  through  his   home   study   as-
                    logue  that  illustrate  some  of  the  characteristics   of                      signi-nents.
                    the  Soviet  system  for   continuing   medical   education:                        Fifthly,  the  type  of  student   is   identified   for
                          To  begin  with,  there  are  no  short  one-day,  two-                     each  course.   Thus,   the   course   in   cardiovascular
                        day  or  one-week   "courses."   Of   the   406   courses                     and  renal  disease  indicated  in  the  third   item   in
                        listed for  1970  by  the  Central  Institute,  very  few                     Table I  is  designed  for  chiefs  of  service  at  back-
                        are of  only  one  month's  duration.  Thus,  a  colossal                     up level hospitals.
                        commitment of educational resources by                        e   Cen-          Sixthly,  of  the  five  courses  listed  at  the  First
                        tral Institute (and  the  other  Institutes  thi                              Department   of   Medicine   at   the   Botkin   Hospital,
                        the  USSR)  is  matched  by  a   substantial   r                              two  are  filled  with  physician  students  selected   by
                        investment of  time  and  effort  into  each  co                              the Ministry of Health  itself.  All  courses  are  listed
                          Secondly,   preparatory   home   study    and    clini-                     in  the   nationally   circulated   twice-weekly   newspa-
                        cal experience  are  hallmarks  of  most  of  the  listed                     per   for    medical    personnel,    the    Meditsinskaya
                        courses,  with   emphasis   on   melding   of   practical                     Gazeta.
                        and didactic work.                                                              Seventhly,  two  of  the   courses   (the   second   and
                          Thirdly,  the  actual  duration   of   the   intramural                     third  items  in  Table  1)  are  given  away  from   Mos-
                        part  of  the  course  in  Moscow  varies   considerably.                     cow,  in  the   smaller   cities   of   Petropavlosk   and
                        During  this  time  the  participating  physician   main-                     Kaluga.
                        tains his regular  salary,  and  receives  an  additional                       Eighthly,  the  emphasis  on   cardiovascular   subjects
                                                                                                      in  this  listing  represents  the  function  of  the  de-
                        stipend  to  cover  his  expenses  away  from   home.   A                     partnieiit  as  beaded  by  Professor   A.   Z.   Chernov.
                    Table 1. Courses in Continuing Education offered by  Depart-                      The  listing  of  the  courses  of  the   Second   Depart-
                    ment of Internal Medicine I of the S.  P.  Botkin  Hospital,                      ment  of  Medicine  is  oriented  to  chest  disease   and
                                               Moscow, in 1970.                                       clinical  pharmacology,  which  are   the   special   com-
                                                                                                      petence  of  this  department  under   Professor   B.   E.
                     ITFM No.                               COURSF                                    Votchal.
                          I     Functional methods of investigation of cardiovascular
                                  system: for general internists of hospital-polyclinic                 The  actual  content  for  two   courses   is   shown   in
                                  institutions of city of Moscow & Moscow region                      two  addenda,   which   can   be   obtained   on   request.*
                                  Thematic study from Jan I to June 30 (course con-
                                  ducted by means of telecasting, on intermittent basis)              The  first  of  these,  entitled  "A   Teaching   Plan   and
                                  Physician  assignment  by  Central  Health  Office of    Moscow     Program    for    the    Course    of    Specialization     of     Pediatri-
                          2     Current problems in cardiovascular pathology: for                     cians in  Pediatric Hematology'              I  (Table    2),    was     de-
                                  general internists of Kamchatsky oblast
                                  Thematic study from Sept 10 to Oct 10                               veloped    by    the    Institute    of    Pediatrics    of    the    Acade-
                                  Circuit  course  in  city   of   Petropavlosk-on-the-Kamchatka      lily    of    Medical    Sciences    of    the     USSR     and     reviewed
                          3     Diseases of cardiovascular system & kidneys: for general              I)N,   the    director    of    the    Department    of    Hospital    Pedi-
                                  internists of Kaluzhky oblast
                                  Thematic study from Oct I to 28                                     atrics     of     the     Leningrad     Pediatric     Medical      Institute
                                  Circuit course to city of Kaluga                                    on    October    28,    1968;     250     copies     of     the     teaching
                          4     Diseases of  cardiovascular  system  &  kidneys:  for  heads  of
                                  medical divisions of republic, krai, oblast, & city                 plan were issued.
                                  hospitals
                                  Thematic study from Oct 26 to Dec 26                                                             DisCUSSION
                                  Pbysician assignment by USSR Ministry of Health
                          5     Clinical electrocardiography: for directors  of  (electrocardio-        The     Soviet     system      of      continuing      medical      educa-
                                  graphic) diagnostic stations, kray, oblast, &  city  hospitals      tion   differs   in    a    number    of    major    respects    from    the
                                  & polyclinics                                                       American      concept      of      continuing      medical      education.
                                  Thematic study, precourse preparation from Aug I to
                                  Dec 31                                                                There    is    no    doubt    that    there    is    an    enormous    or-
                                  Studies at Institute will be in 1971
                                  Physician assignment by USSR Ministry of Healtb
                                                                                                        'From P. B. Stoi-ey, M.D., 235  N.  15th  St.,  Philadelphia,  Pa.  19102.


             Vol. 285 No.  8                      MEDICAL EDUCATION IN THE SOVIET UNION-STOREY                                                                          441

                  Table 2. Course Outline for Pediatric Hematology.*                           specialized service in a  given  institution  providing
                                                                                               care for a particular population of children.
             ITEM No.        SUBJECT MATTER                 No. OF TEACHiNci HR                   There is probably a  historical  determinant  operat-
                                                      LECTURE  PRACTICAL         TOTAL         ing here, in that the principal function of the  Insti-
                  I     Blood system in children            8         52           60          tutes  for  Advanced  Education  may  previously   have
                          (morphology & physiology)
                  2     Current methods of                  4         1 2          1 6         been to teach the essentials of a  given  specialty  to
                          investigation in pediatric                                           cadres  of  physicians  as  the   medical-care   system
                          hematology                                                           evolved   following   the    Revolution    and    World
                  3     Clinical picture  &  dif-           82        408          490
                          ferential diagnosis  of                                              War  11.  Now,  with  maturing  of  the   general   and
                          diseases of blood system                                             graduate  medical  educational  systems,  the  role  of
                  4     Immunobematology        &           10          2          12          the  Institutes  has  been  reoriented  to   continuing
                          blood  transfusion   in
                          pediatrics                                                           education of physicians  who  are  already  specialists
                  5     Organization of care for            2         -              2         in their own fields.
                          hematologic    patients
                  6     Clinical cytology &                 -         18           18             The  second  question  concerns  the   relation   be-
                          cytochemistry                                                        tween  the  Institutes  and  the  graduate  system  for
                  7     Marxist-Leninist                    24        -            24          production  of  medical  specialists   as   such.   The
                          philosophy & medicine
                          (in  special   program)                                              connection is an intimate  one  -  but  again  explica-
                          Totals                            130       492          622         ble only in the  context  of  the  Soviet  system.  The
                                                                                               Institutes no longer produce the  specialists  as  such
               Duration of course, 4 mo (622 teaching hr).                                     - i.e., as a primary  function.  However,  it  will  be
                                                                                               recalled that the Central Institute  in  Moscow  organ-
             ganizatiodal    and    financial    investment    in    it.    It    is     a     izationally  and  financially  supports   an   enormous
             principal     form     of     medical      education,      comparable      in     facultv     resource     at     the     leading     medical-care      institu-
             investment     of,     resources     to      the      undergraduate      sys-     tions    of    the    city.    These    faculty    members    of    the    In-
             tem     and     to     the     graduate     educational      system      that     stitute     for     Advanced      Education      are      full-time      heads
             produces     the     medical     specialists     (i.e.      the      "ordina-     Of    service    at     their     daily     working     institutions     where
             tura"         program'which      produces      the      clinical      special-    the     full-time     training      of      specialists      takes      place.
             ists,     and     the     "aspirantura"     program,      which      produces     These     trainees     thus     represent     one      aspect      of      the
             the research scientists and professors).                                          function     of     the     Central      Institute,      as      distinguished
               Perhaps     the     problem     can     be      looked      at      through     from      the      relatively       short-term       educational       courses
             two   questions,   the    first    of    which    is    whether    this    is     provided     for     physicians      already      in      practice,      which
             the     Soviet     method     for     producing     medical      specialists.     are listed in the Central Institute.s'annual schedule.4
             The   answer   to   this    question    has    to    be    both    yes    and        There    is    thus    an    organizational     integration     of     con-
             no.      There      are      the      graduate      programs,       mentioned     tinning     education      with      graduate      education      that      is
             above,    that    correspond     to     our     residency     and     fellow-     unique     in     its     orientation.     Continuing     e     ucation     is
             ship    training     programs     and     ultimately     lead     to     aca-     the    primary    reason    for    the    existence    of    the     Institute
             demic   and   staff    rank    in    the    Soviet    system.    These    are     and      determines      its      organizational       arrangement.       This
             the     principal     lines     of     development     of     the     medical     is    in    exactly    the    opposite    direction    from     the     Ameri-
             ,specialist    and    would    account    for    the     negative     answer.     can    svstem,    in    which    the    graduate    training     is     prima-
             But    in    terms     of     ordinary     practicing     physicians,     who     ry    and     continuing     education     is     usually     an     accessory
             are   not   part   of    this    academic    and    clinical    elite,    the     burden.
             affirmative     answer     is     appropriate.      It      is      obviously        Butrov      and      Alekseev,       indeed,       consider       postgrad-
             intended    in    the     course     on     pediatric     hematology,     for     uate      medical      education      to      represent      all       medical
             example,    that    the    trainees    are    going    to     be     involved     education     that      takes      place      beyond      the      undergradu-
             thereafter     in     pediatric      hematology      -      but      probably     ate    programs     of     the     medical     institutes.     They     divide
             not    exclusively    so.    So    that    what    one    sees    here     is     this     conceptually     into     two     consecutive      stages:      "spe-
             again    an    expression    of    the    organization    of    the    Soviet     cialist    training"    and    "further    training,"    the     former     to
             health-care    system    that    is    hot    directly    translatable     to     provide       the       necessary       theoretical       knowledge        and
             our     own     frame     of     reference.     The     working     pediatri-     practical    skills    in    the    specialty     field     concerned,     and
             clan    with    a    particular    interest,    for    some    reason,     in     the     latter     to     improve     qualifications     continuously      for
             pediatric    hematology,    or    from     a     polyclinic     or     hospi-     all    physicians     with     clinical     experience     of     not     less
             tal    that    has    a    need    for     improved     pediatric     hemato-     than    five    years.6    The    latter    stage    represents    the     ma-
             logic   service,   can    take    out    four    months    full    time    to     jor    investment    by    the    physician     in     his     lifetime     of
             develop     some     special     knowledge     and     skills     to      add     self-improvement     and      by      the      society      that      supports
             to   his    capability    as    a    pediatrician    and    to    the    man-     him in this effort.
             agement       resources       of       his       institution.       Depending        The    final    question     is     how     this     system     for     ad-
             upon    his     professional     background     and     the     nature     of     vanced training of physicians mi                                             e
             the     institutional     resources     subsequently      to      be      de-     to- th -e American educa-i-i6n"'a'l-sysf6ffi.'
             veloped,     the     ultimate     effect     of     the     four      months'        it  probably  does  n6i'               6---@6ry       much        practical
             educational    program    is,    in    fact,    the    appearance    of     a     relevance    at    present    for    three    reasons:    the    loose    sys-


                      442                                             THE NEW ENGLAND JOURNAI, OF MEDICINE                                                            Aug.    19,    1971

                      teiiiatizatioii     of     American      health      care      as      compared      care oi- in establishing the organization                  necessary        to
                      with     the     organized,      highly      structured      Soviet      system      @ippro@ich that synthesis of interests.
                      of      health-care      delivery      in      which      appropriate       ad-        Finally,     there     is     the      (luestion      of      how      these
                      vaiicement    and    reward     can     be     given     to     and     limited      three    programs    might    get    started,     or     how     all     three
                      to     those     with     better     training     and     performance;      the      might   function   in    rel@ition    to    each    other,    in    the    ab-
                      decentralized,          university-I)ased,          independent          nature      seiice    of     an     effective     coordinating     equivalent     of     a
                      of       our       general       medical       educational       establishment;      iiiiiiistrn@    of    health.    This     is     the     true     imponderable
                      and      the      predominantly      local      and      episodic      orienta-      that    plagiies    the     service     and     the     educational     compo-
                      tion    of     continuing     medical     education     in     our     country,      nents      of      the      American       health-care       system.       How
                      with      no      central      or      long-term      direction       available      does     any     system     operate     without     leadership     and     co-
                      to it.                                                                               ordination     -     a     lack     that     is     acknowledged      through-
                         There    are,     however,     some     potential     frames     of     ref-      out   the    system?    It    seems    at    least    reasonable    to    sug-
                      erence     to     which      the      Soviet      experience      might      be      gest   that    the    idea    of    a    national    plan    for    continuing
                      i:-el@'iiaht.    One    is    the    concept    of    a    National     Academy      medical      education,      as      proposed      by       the       original
                      for, Continuing  Medical  Education                  .7,11    The     organiza-      "Joint      Committee"      and      developed      by       the       Depart-
                      tional      and      programmatic      structure      of      the       Central      iiient      of      Postgraduate      Programs      @it      the      American
                      Institute    could    serve    as    a    useful    model    for    the     de-      Medical     Association,9     wedded      to      the      basic      concepts
                      velopment     of     such     a     system,     if     the     attempt     were      of     the     Regional     Medical     Program,     as     enunciated      in
                      ever      made      to      develop      continuing      medical      education      the     original     report     of     the     DeBakey      Commission      on
                      in    the    United    States    on    a    nationally     organized     basis.      Cancer,      Heart      Disease      and      Stroke,'O       would       have
                         Also     to     be     considered     is     the     developing     interest      @'ielcled    @t    comparable     nationwide     effort     if     the     two
                      of    the     Department     of     Medicine     and     Surgery     of     the      contemporary       movements       bad       been       pulled        together
                      United      States      Veterans       Administration       in       establish-      I)v       t       recognizable       and        recognized        coordinating
                      ing     a     nationwide     system     for     the      continuing      educa-      agency.    In    other    words,    there     is     a     primary     problem
                      tion    of     its     own     medical     personnel.     Such     an     orga-      in    org@iiiization    of    our    health-care     system     that     would
                      nized      system      for      advanced      medical      education      might      have    to    be    solved    before    a     rational     nationwide     pro-
                      find    relevant    models    in    the     Russian     system,     both     in      gt--,Lii)     of     continuing      medical      education      could      be
                      organizational       terms       and       in        pedagogic        approach.      developed.
                      Like       the       Institutes,       the       Veterans        Administration        (;iveil   a   set   of   decisions   that    would    lead    to    a    na-
                      Department       of       Medicine       and       Surgery       now       com-      tioiial     effi)it     in     continuing      medical      education,      it
                      mands    or    has    access    to    large    portions    of    the     Ameri-      would     become     most     important     to     study      closely      the
                      can        health-care        and        bealth-education        establishment.      Soviet      system      for      what      information      and       guidance
                      Its      own      organization      of       resources       and       manpower      the experience with it i-night provide.
                      could     allow     for     mobilization     and     movement      of      per-
                      sonnel      for      educational       purposes.       Educational       objec-                                  REFERENCES
                      tives     related     to     role      needs      could      be      determined      1.  ['],,inning for  Health  in  the  Soviet  Union:  A  Report  of  the  May,
                      with     relative     ease     for     'v'eterans      Administration      phy-          1970  Exchange  Group.  Bethesda,   Maryland,   National   Institutes   of
                      sicians   at   their   different   levels    of    activity.    If    such    a          He@tith,  Fogarty  International  Centet-  for  Advanced  Study   in   the
                      systeifl     were     developed      in      the      Veterans      Administra-          Health Sciences (in press)
                                                                                                               Field  MG:  Doctor  and  Patient  in  Soviet   Russia.   Cambridge,   Har-
                      tion    it     i-night     serve     as     an     extraordinary     continuing          vai-d University Press, 1957
                      educational      resource      for       all       practicing       physicians.      3.  l(ii,iii:  Soviet  Socialized  Medicine:  An   introduction.   New   York,
                                                                                                               The Free Press, 1967
                      The     handling     of     the     educational      needs      of      private      4.  Kilend@irniy   Plan   Usovershenstvovania   Vrachey   for    1970    (1970
                      physicians     in     relation     to     the     requirements     of     their          Schedule   for   the   Advanced   Training   of    Physicians).    Moscow,
                      practices    would     be     more     difficult,     but     probably     sus-          (Central Institute for the Advanced Training of Physicians, 1969
                                                                                                           5.  Chernov   AZ:   Prakticheskoe   Rukovodstvo   po    Klinischeskoy    Elek-
                      ceptil)le     to      whatever      analytical      systei-n      would      be          trokiii-diographii  (A  Practic@il   Manual   in   Clinical   Electi-ocar-
                      developed             for  Veterans         Administration               physi-          diogi-,,iphy).  Edited  by  AZ  Chernov.  Moscow,  Central  Institute  for
                                                                                                               the Advanced Training of Physicians, 1966
                      cians.                                                                               6.  Buti-ov VN,  Alekseev  VA:   Postgraduate   medical   education   in   the
                         The     third,     the     Regional     Medical     Program,     is      not          USSR. WHO Med Bull No 1-2, 1968, pp 1-2
                      yet      sufficiently      develo      ed      to       allow       speculation      7.  D@trley  W,  Cain  AS:  A  proposal  foi-  a  national  academy  of   con-
                                                          p                                                    tinLling medical education. J Med Edtic 36:33-37, 1961
                      about    its    future     organizational     form,     except     to     real-      8.  Storey  IIB,  Williamson  JW,   Cistle   CH:   Continuing   Medical   Edu-
                      ize  tliit  it   is   a nationwide      program      that      does       place          cition: A   new   emphasis.   Chicigo,   American   Medical   Association,
                                                                                                               1968
                      heavy     emphasis     on      continuii-ig      medical      education      to      9.  Dryer  BV:  Lifetime  learning  for  physicians:  principles,   practices,
                      attain    its     goals of    making    the    best     in     medical     care          proposals. .1 Med FdLic 37 (6): 1-134, 1962
                      ,available    to    all    the    American    people.     To     date,     how-      10, fliesident's  Commission  on  He@ii-t   Diseztse,   Cancer   and   Stroke.
                                                                                                               Report  to  the  President:  A   Nitionti   Program   to   Conquer   Heart
                      ever,   it   has    not been     particularly     successful     in      relat-          Dise@ise,  Cancer   and   Stroke.   Vol   1.   Washington,   DC,   Govern-
                      ing          continuing education     to     the     problems     of     health          ment Ili-inting Office, 1964


                                                                                        JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION
                          I-',(Iucatiiity for (-Iiai)(,e
                                                                                                                      July 1972

                          Allied health: @,i*.mensionsg
                          dilemmas, and decisions

                          J. WARRE-N PF,@'IRY, Ph.D.
                                and Protes@or, Health Science 4dministration,
                          a,-,d Dean, S@-@ril ol Ifeal,,h Related Professions,
                          State trniz;ersity of iN'ew York at Bugato
                                                                                                            In  1968,                       o     the     American      J.'Iivsical
                                       (I health professions are in a                                                 when    I    @poke    t
                          The allie                                                                                                               f my tilk Nvas '.Cli
                                                                                                            TlierLkpy Association. the title o                                 an,e
                          State of ferment; change is the order                                                                                                                   11
                                                                                                            Is the Nanic  of  the    Game:    The    Allied    flealtli    Pr(,fes-
                          of the day. Here is a current update of
                                                                                                            ,ions."   So   rnu(-h   has   happened    to    the    allied    heart]
                          recent det!elopments and problems.                                                professions  in  the  ii-iterim   that   only   the   inti@o   U(3tio!l
                                                                                                            is still pertinent. I quote:
                                                                                                            Nfany great tliinkers'liave responded to a  need  to  ex2j:t@.-i  ti.,e
                                                                                                            concept of attitudes required for  "cban,,e."
                                                                                                            NAPOLEON:  One  must  clian,e  otic's  tactics  every  ten   years   if
                                                                                                            one wiilies to -naintain ozie   4tiperiorit3,.
                                                                                                            G.B. SIIAW;  Progress  is  impossible  "  itliout  chance;  an@  tiloqc
                                                                                                            who cannot chance are tL;cless.
                                                                                                            WASITINGTON  ItiVl'.\G: There is a               rt,ii, f in
                                                                                                            even  though  it  be  from  bad  to  worse;  i,  I  have   fcu-i(I   in
                                                                                                            traveling in a ,tage coa(@ii, that i,, is ofter. a  comfort  to  sliift
                                                                                                            orii@'s position and be I)niis(-d in a iif',IV
                                                                                                            AlittAtIANI LIN(@OLN: The do,,Iiia,, (if the quiet  past  ,ire  iiiade-
                                                                                                            (juatf, to the stormy present;  @-i  our  case  is  new,  we.  Ti,ii-st
                                                                                                            think and act anciv.

                                                                                                            Dimensions
                                                                                                            What has happened to the allied              liciltb,.
                                                                                                            and occupations (Itiriii,, the past d(,,ca(Ic?
                                                                                                            of the expressed need      and demand        for qua,',fict',
                                                                                                            power   to   deliver   comprehensive   lic@ztitli   care   for   ti-ti-
                                                                                                            country,  oducatioti@'ll  instittitio)tis  at   a'ti   IeN-e!@   bearer
                                                                                                            to   respond   through   ttie   creation   of    new    cOiticati(.vna,
                                                                                                            structures.  Ne%v  divisions,  school,;,  'ITid   colle-,@s   for   tlc
                                                                                                                                   Si
                                                                                                            allied  health   profes   ctis   have   become   one   )f   the   rnost
                                                                                                            far-reaching  innovations   in   '@ical@tli   edi.ic-,tio@ii   -   q-v-
                                                                                                            crat decades
                                                                                                              Educational    pro,,rams    in    the    United     States     'liive
                                                                                                            been  identified  for  over  130  allied  hei'i',Ii   fields.   Toda)-,
                                                                                                            over   nine    hundred    colle-es    and    universities    are    in-
                                                                                                            volved in the education         of   allied   health    personnel    at
                                                                                                            the baccalaureate de@ree        or   higher.   At   the   same    time,
                                                                                                            hundreds of corn  unity         junior    colleges     have     already
                                                                                                            developed  allied  health  pro-,rtrus.   At   least   sevetitv   co   -
                                                                                                            leges  and  universities   have   foriied   or   are   foriiiiiig   ad-
                                                                                                            ministrative    structures    for    allied    lictltli    programming.
                                                                                                            In   addition,   practically   every    hospital    is    "into"    the
                                                                                                            training  of  allied   lieiltli   Nvoi-kers   in   one   way   or   an-
                                                                                                            other.  Front  all  of  these  sources.  ,iiere  is  the   t)oteiiiiiii
                                                                                                            for     development     of     health     iiiinpoiver at  ail   level,,
                                                                                                            scarcely    dreamed    of    several    vears    a,o.
                                                                                                               Every   health    profession    is    anal),ziii,, the   need    for


                     additional   supportive   personnel.   Thus   we   see   the              bilities and responsibilities  of  each  one  is  understood,
                     emergence  of  an  entirely  new  -roup   of   health   per-              appreciated,  and  utilized  by  the   medical   and   dental
                     sonnel.  Health  news  is   crowded   with   stories   about              coniiiiuiiit),,  we  Nvill  never  have  a  true  system   of
                     the  development  of  physicians'  assistants,   asQociates,              health care. It must  not  be  assumed  that  this  level  of
                     and  specialist assistants'  Professions    that    have    la-           utilization will just happen; it must  be  tati,@lit  as  all
                     bored long and  hard  to  require  @raduate  trairtin--  for              ititt.@,,ral part of medical  and  dental  school  curricula.
                         e  are  now  determinin-  that  assistants   can   enter                   I)ortaiice of this concept  of  utilization  is  spelled
                     practic                       n                                           The ini
                     their fields  with  less  formalized  education.  Unforttin.              out  in  President  Nixon's  Health   Message   to   Congress
                     ately, much  of  ibis  is  bein-  accomplished  iiiL  educa-              in 1971. Nvitli the folloivin,t@) terse words: "We will  also
                     tion with all too brief attention to  the  careful  analysis              encourage.  medical  schools  to  train  future  doctors   in
                     of just how ,,his ne%%- cadre of workers will fit  into  the              the proper use of other health personnel."
                     health iniazipo%ver  structure.  Present  clinical  programs              III  1969,  in  my  presidential  address  to  the   Associa-
                     will become the  proving  -,rounds  on  which  the  utiliza-              tion of Schools of Allied Health Professions, I said:
                     tion  of  three  new  health  personnel  will  be  confirmed              Barriers  Let%vcen  and  among  the  health  professions   must   be
                                                                                               broken down  if  we  are  to  succeed  ivitli  a  viable,  effective
                     or denied.
                     Enrollment  in  curricula   for   the   health   professions              health 1)roraiii. is it not now itbout tinif- to  consider  the  re-
                                                                                               lationiiip of each  li(-attli  profession  to  each  other-with  the
                     is at all all-time lii-ii. Coti(-erned students,  interested              starting point of discussion  riot  based  on  the  relationship  of
                                         tn
                     in identifyiti-   arid   enterin-   careers   in   which   they   call    the  professions  but  rather  the  relationship  of  each  to   the
                                 C)               n
                     be  of  service  to  society,  are   discovering   that   jobs   in       systems of health care  arid  the  function  of  each  in  relations
                     the  health  field  may  come  closest  to  meetili-   their   Per-       ship to the pati(@nt" As we  break  down  the  I)oazidaries  of  in-
                                                                                               difference, suspicion  of  intent,  and  concentrate  on  the  Simi-
                     sonal need for service.                                                   larities ivliieh  exist  in  educational  programs  and  in  patient
                     Thus   we   find    more    educational    institutiotl-,    geared       care  function,  we  will  discover  new  ways  to  learn  and  work
                     to  offer  more   health   pro-ranis   for   more   students   than       together.
                                                t'
                     ever   before.   The   combination   of   these    factors    seems
                     to  point  to   an   unparalleled   opportunity   to   move   ahead       INADEQtTA'rE      LEGISLATIVE      AUTIIORITY      AND      FUNDING.
                     in   health   manpower   education   that   will    ach7ieve    the       Another   ditenima   is   that    the    health    legislation    of
                     goals  for  both  quantity   and   quality   in   health   services       the  past  has  given  little  attention  to   the   allied   health
                     for everyone.                                                             fields.    The    only    important    federal    legislation    was
                                                                                                                                                t'
                                                                                               passed  only  six  years   ago   with   the   Allied   Health   Pro-
                     Dilemmas and decisions                                                    fe--,sions   Traiiiin-   Act   of   1966.   Tliou-Ii   grossly   and
                                                                                                                  0                          ZD
                     Wha@   then,   is   the   "lian,,'up?"   Why   doesn't   an   eval-       inadequately  funded  as  yet,  it  has  at  least   called   atten-
                     nation   indicate   that   we   are   acliievin-   pro@ram   objec-       ioii   to   all   entire   segment   of   the    health    community
                                                                C)     t)
                     tives  and  fliat  our  health  service   system   is   functioning       that   has    been    liniping    along    with    inadequate    re-
                     to   its   maximum   capacity?   Let   us   analyze   the   issues,       sources.   Because   of   the   number   of   new    prof@rams    at
                     for  herein  lie  the  reasons  we  still  have  a  lona   way   to       all educational levels developed in response           0to      man-
                     go.                                                                       power  needs,  the  net  effect  has   been   a   lower   level   of
                                                                                               fundin-    of    individual    programs.     Hundreds     of     new
                     UTILIZATION     OF     -ALLIED     HEALTH     PERSONNEF-.      Many       programs    have    been    established    by    universities    and
                     of  us  support  the  theory  that  health  care  in   this   coun.       colleges   to   respond   to   the   mandate   of   the    expressed
                     try  'will  never  be  a  workable  system   until   all   of   the       lic@iltli  n(@(,cls.  but  federal  ftinditi-  has   been   woefullv
                     fit:                                                                                                               0
                      altil  professions   are   re@o,,iiized   for   what   each   call                     to  assist   them.   The   staff   of   the   Division
                                                     C,
                     ;"@litrilitile. Priority ,ttici)ti4)!i must ;)(,- -i%,ert to educa-       of  Allit@(I  health   @Nlai)l)ower   of   the   Bureau   of   Healt
                                                                   n
                     ti@,lial arid clinical pro-rams at  all  If,-vels  for  the  allied       Pr@)feSSiOll:,  E(]L](!@itioti  and  Mail   ower   TrainiiiF-,   De-
                                               t@                                                                                      p                  -1
                     11"@tltlt  professions  arid  occupants,  but   until   the   capa-       parinictit    of    Health,    Fducation,    and     Welfare     has


                       waued an iiiten--c battle to     t  priority  for   fuiiditi-,       sharp criticism le eled at these expanditi-
                        tD                            ne                                                      v                                   proarams.
                       but   educational   pro@rams   counting   on   firm    support       f,ack'. of adequately  trained manpower to              provide
                       have been sorely disal)poii,,ted and discouraged.                    quality health care, rather than custodial         supervision.
                        Thiz-  year  we  will  carefully  2crutinize  die  effective-       has  been  a  major  hindrance  to   advances   in   the   care
                       ne-,s  of  the  new  special  improvement  and  special  proj-       of  our  older  population  and  of  the   severely   disa@led.
                       ect  grant  approach  to  allied  health  fundin@.   Addition-       -@llatiy  of  the  educational   pro-ranis   for   the   allied
                       al  funding  has  been  authorized,   and   educational   pro-       lie@titli  professions  have  an  obligation  to  expand  their
                       grams  xnust  move  witli  alacrity  to  place  the   projects       clinical  programs  to  react  and   respond   to   these   new
                       of their  institution  in  competition  for  these  resources.       facilities.  Assistants,  aides,   and   volunteers   must   be
                                                                                            trained  and  siipervi-@d  to  participate  in  a  comprelieii-
                       1,ACK OF QU@4L[Flfl)  FA(:ULTY  AND  INSTRUCTIONAT@                  sive  manpower   surge   to   asstire   quality   health   pro-
                       PFRSO-NNEL.  One  of  the  most  serious  irnpedimelit.-i   to       -rams in these new health facilities.
                       the  development  of  ativ   profession   or   occupation   is        Neighborhood    health    care    clinics    and    inner-city
                       the unavailability of a k%,ell-qiialified cadre of  iii-@truc-       health   1)rojects.   Current   experience   already   dictates
                       tional  personnel.  All  of  the  allied  health   professions       that  aspirations  for  delivery  of   quality   and   quantity
                       have   been   undergolti,-   major    technolo-ic    advances;       of licalt]L  care  in  these  new  kinds  of  outreach  facili-
                       took mtt dietetics to verify  this  statement.  ',Nlethods  of       ties  will  scletoni  be  a(,,Iiieved  without  delegating  re-
                       teaching  innovations  must  be  Cleared  to  the  newer   po-       spoiisible roles to allied  health  ))crsoniiel  for  planning,
                       tentials for self-iristrtiction.                                                                                     ams       which
                                                       pro-raninied    instru(,tiori,       de%-eloping, and implementing health pro-r
                       and the  latest  teacliiii,,  devices.  'Feaclier  preparation       ivill  respond  to  the  needs  and  objectives  of  the  corn-
                       for all educational levels has  been  placed  lii(,Ii  on  the       ititiiiity.  Allied  health  educators  must  make  every   ef-
                       priority lists of what we  need  to  accomf)lisli  our  goals.       fort to coordinate their clinical p   ro@ranis    with    coop.
                                                                                            crative  pro@rams  sponsored   by   Alodel   Cities,   Regional
                                                                                                       0
                       NEW SETTINGS FOR IIEAITll 4:ARE DELIVERY sys,rEsis.                  Medical   Programs,   and    Comprehensive    Ilealtli    Plan-
                       One of  the  most  si.-nificaiit  challenges  facin-  the  at-       riin- in local communities.
                       li.-d health professions  today  is  to  discover  and  imple-        Rural  health  care.   Statistics   prove   that   the   rural
                       nient  new  geo-rapliic  settiii,@s  for  clinical   proarams.       reas  of  the  country  are  in  as  severe  need   of   health
                                       0               0                    0               a
                       I feel  that  dietetics,  in  the  various  ways  in  which  the     manpower   as   many   urban   sectors.   Only   recently   has
                       internship   pro-rams   have   been   established   can    serve     the   I)Iiglit   of   the   rural    community    been    given
                       as  a  model.  NVe  must  break  the  mold   followed   by   too     priority   attention.   Another   challenge   that   will   tax
                       many  of  the  health   professions,   i.e.,   the   traditional     allied health  education  will  be  to'orietit  clinical  'edu-
                       idea that the location  for  all  clinical  traiiiin,,  of  stu-     cation for  many  of  the  allied  health  professions  to  the
                       dents  must  be  the  hospital.  Aittioti-ii  reco-niziiiff  the     needs  of  primary  care  physicians  in   their   efforts   to
                       special  contribution  of  hospital  setting   for   many   pro-     brain   quality   care   to   rural   communities,    including
                                                                 0                              ID
                       grarm,  we  must  create  new  clinical  facilities  for  allied     migrint workers' camps.
                       health in all  of  the  new  settings  for  health  care  deliv-       Health   maintenance.   I   will   not   add   to   the   con-
                       ery   systems   that   are   receiving    priority    attention.     troversy over the efficacy of    health     maintenance     and
                       These include:                                                       the   establishment    of    Health    Maintenance    Organiza-
                         Demonstration   projects   in    nursing    homes,    extended     tions   (HMOs)   as   one   of   the   new   approac   es    to
                       care  facilities,  and  rehabilitation  centers.   The   grow-       health    care    insurance    and     making     comprehensive
                       ing   geriatric   population   has   prompted    the    building     health  care  readily   available.   However,   with   emphasis
                       of  hundreds  of  new  extended  care  facilities,  b  -ut  only     on  prevention  of  illness  and  the   maintenance   of   good
                       now do we rec  iiize the crucial manpower            shorta-es       health,  more  attention   will   be   given   to   identifying
                                       'Ofy
                                         rD                              -         r
                       for (itialifie(i I)erF-oiiiiel to staff them. From tli(, Pi-(@,-;i-  early health problems iiid to  the  slitriti@  of  health  iii.
                       delil of 11(@ tTflite(I   lat@,  on  down.  there   has   be(-ii     formation   concerniti-   diet@tr)-   and   nutritional    rob-
                                                                                                                                                   p


                             lem-,,   drug   information,   alcoholism.   birth   control,    en-       Watts   community   in   their   efforts   to   establish   a   corn.
                                                                                                                              ilied  health  educational  pro
                             vironmental control, abortion. and similar problems.                       I)relictisiN@e  new  a                                          @ram.
                             This    will    be    shared    and    delivered    where     people       Not only must we      as  a  nation   be   in   a   better   position
                             learn   in   schools,   tvork   ii   factories,   and    live    iir       to'  provide  a  Iii,,Iier  quality   of   health   care   in   these
                             homes.  This   shift   in   emphasis   from   a   "sickness.   s)-s-       areas,   but   we   must   attract   and   hold    minority    repre-
                             tem"   of   acute   and   intensive   care   to   a   prevention-cn-       seiitation in the delivery of this care.
                             vironmental  and  extended        .care-reliabilitatiozi        eni-        Career     mobility      and      equivalency      testing.      The
                             phasis  will  require   important   cliaii@es   in   priorities   in       importance   of   these    two    concepts    and    the    decisions
                             educational    programs.    The    allied    health     professions,       needed   to    make    horizontal    and    vertical    mobility    a
                             alon-    with    medicine,    dentistry     and     nursin-     must       reality   and   not   just   a   dream   cannot   be    un    eresti.
                             conscientiously reasons wavs in         wlii(-Ii    curricula    can       niated.    The     national     attention     being     placed     on
                             aslltire   implementation   of   the   prioritv    of    prevention.       equivalency    tes@l@     is     now     be,,iiiriin-     to     reap
                             Recruitment    of     disatlt,,uttt5rged     @roups     into     the       (livid(@iids   as   each   profession   i@esses   the    way-.,    in
                             allied  health  professions.  Is  it  not  ji(3,.y  time  that   Nve       which   academic   credit   can    be    (lerin,ed    an(]    awarded
     y                       recognize  the  important   role   xve   must   play   in   recruit-       for other than pure classroom work.
                             me   minoritv   -roiip@   to   participate    in    allied    health
                             iD           .  C!)
     y                                  '?   laiiy   members   of   the   minoritv   and    other       Conclusiott
                             manpower. -@A
     i-                      ethnic   -roups   have   made    important    contribution.,.,    to       As   professional   educators,    clinicians,    and    adniiiiistra.
                             our  professions,  but   -,vc   mii   t   make   a   concerted   ef-       tors,  are   ,Vc   ready   to   make   decisions   that   Nvill   re.
                             fort  to  reinforce  this  position.   T%Iucli   of   the   delivery       sl)ond    to    the    changes    in    educational     pro,,rardming
     -,h                     of  health  services  in  the  n(nv  --cttiii-s  will  be  delivered       and  clinical      ractice    that    each    health    field    must
                                                                       C)                                                p
     n-                      by   representatives   of   itursitt--aiid   the   allied   Iieaitli       make?  With   financial   resources.   ti(,Iil(@r   than   ever,   we
                                                                n                                                                                  c
                             professions.   Openin,-   up   this   number   of   new    positions       ]ain't. pull in our belt,-; and  set  for  our,-elves  a  diflet-etit
                             in  the  health  field  brings  with  it  the  obligation   to   rc-       ..et  of  prioi-ities-tliose   that   reveal   a   deep   coi@iiiiit-
     .al                     cruit    many    new    professional    personnel    from    tlios(@       iiieiit to cli,,@iii C.
                                                                                                                        9
     n-                      groups   disadvantaged   in   various   ways    from    full    par-         "Yesterday    is    but     today's     memory     and     tomorrow
                             ticipation   in   these   advancements.   I   have   the    privil"c       is  today's   dream,"   so   the   Prophet   says.   May   sorie   of
                             of  being  one  of  two  white  persons   serving   on   the   iie%v       the   dreams   expressed   here   prove   to   be,   for   the   pro-
     [th                     national    committee,    Equal     Representation     in     Allied       fission   of   dietetics,   the   response   to   necessary   changes
     lw@                     Health,  and  some  of        my     finest     professional     ex-       that  will  bring  you  to   an   even   greater   role   in   health
     ,en                     periences have been in        working    with    groups    in    the       planning and health service in the future.
     .a
     iu-
     th                      New protein-rich dair   product
          e                                                       y
          to
                             A protein-rich dairy product that cotild double the milk supply for children of In ia
     uig
                             has been developed by the Central Food Technolo-ical Research Institute of Mysore,
                             India,   with   support   from   theinational   Institute   of   Arthritis   and   Metabolic    Diseases,
     ?,nd                    Bethesda, Maryland. The new product., called "Miltone," is a blend of pure peanut
                             protein,   hydrolyzed   starch    sirup,    and    ine  or  bitfi@lo  milk.   Previously,   the   residue
                             after   oil   was   extracted   from   peanutsi                    lizer and fced  ' Now    the    peanut
          to                 protein  I'Lsextracted   by   a   new   process                    ing   research)@   and   mixed    with
     sive                    milk.   After   pasteurization   and   bottliji                    ed  to   markets   and   urban   state
     iasis                   welfare  centers   for   children   of   low-im
     ,ood                      As part of a long-term, nutrition         Iresearch pro@ram, the goal of the Mysore project
     yin-.        2                                                                      c
                             is to devel(--Pp I)rotein-ricii  fo(Kl*  and  food  sul)l)lejiit@tit@  from  iiiexl)ejlsii,e  indigenous,
                             protein qotir(-es that will inilorovt@ the jiutritioiiil health of persons in
                             countries  Front   liSil@iliA   lit!altli   jetports,   86:   91-9.   191-1.


                CORONARY CARE NURSE
                TRA'INING PROGRAM

                AN EVALUATION

                Ruth Scheuer

                A  coronary  care   training   project   was   established   gram,  1970).  In  February  1970,  the            estern
                by   the   Western   Penns7/lvaitia    Reaional    Medical   P(,iiii@ylvania   Itegional    Program    (WP/RMP)    ini-
                Pro ram at t                                                 tiate(I  a  Coronary  Care   Training   Project   at   the
                the  knowled  e,  skills,   and   confidence   of   nurses   ITniversity  of  Pittsburgh  to   meet   community   needs
                ca?ing f or coy  c patients.  To  assess  the  effective-    for ti@ained nurses  to  staff  regional  intensive  CCU's
                ness  of  the  four-week  course  a   120-item   multiple-   (NN-P/RMP,   1970).   The   four-week   course    included
                choice  examination   was   developed,   u,hich   measured   117  hours  of  didactic  instruction,  laboratory   and
                the  nurse's  knowledge  as  well  as  her  confidence  in   clinical  experience,  independent   studyi   and   evalu-
                that  knowledge.  Nurses  were  required   to   give   the   ation.
                correct answer to  each  item  as  well  as  to  designate     The  following  criteria  were  designated   as   essen-
                whether  that  answer  was  certain,  a  partial  guess,     tial to tile success of tile program:  1)  participation
                or a guess.  Posttest  results.showed  that  nurses  who     in  the  four-week  course  would  result  in  extending
                completed  this  specialized  course  perfornzed  better     the  knowledge,  skills,  and   confidence   of   nurses
                and  with  greater  confidence  than  on  the   pretest.     cai,in(r for  patients  with  acute  myocardial  infare-
                Whereas  only  27.4  per  cent  of  the   answers   were     tions;  2)  graduates  of  the  program  would  be  able
                both correct and  given  with  a  high  degree  of  cer-     to titilize  the  knowledge  and  skills  acquired;  and
                tainty before the course, this figure rose to  66.3  per     31 patient care  would  be  improved  (Scheuer,  1970).,
                cenf  following  the  course.  A   six-month   follow-up       The  purpose  of  this  paper  is  to   describe   the
                exanzination  of  participants  showed  that   knowledge     methods utilized and  results  obtained  in  the  evalu-
                retention of  coronary  care  principles  remained  high     ation of these objectives.
                and that 77 per cent of the  nurses  tested  were  work-
                ing in  intensive  coronary  care  areas.  The  ultimate     Method
                goal of the project was  to  improve  the  care  of  pa-
                tients in. intensive coronary  care  areas.  An  ongoing       Upon  entering  the  program,  the   student   submit-
                method  to  assess  morbidity  and  mortality   in   re-     ted  a  questionnaire  providing  information   on   her
                gional  coronary  care  units  was  established   as   a     age,  previous  coronary  care  work  experience,   edu-
                result of this project.                                      cational  background,   and   expected   area   of   em-
                                                                             ployinent   at   completion   of   the   program.   This
                                                                             information,  in  conjunction  with  pretest  score  re-
                     DUCATORS   responsible   for    specialized    cor-     sults, enabled  the  faculty  to  ascertain  which  stu-
                      onary  care  courses  need  to  demonstrate   that     dents niigl)t need extra help during the-course.
                E    Inurses  have  the  requisite  knowledge,   skills,       Since the  nurse  in  the  CCU  is  required  to  take
                and  confidence  to  perform  effectively   within   the     decisive  action  in  critical   circumstances,   it4was
                coronary  care  unit  (CCU)   setting   (Department   of     deeiii(@(i iii-iportant that she not only  increase  her
                Health,  Education,  and   Welfare,   1968   and   1970;     knowledge  of  acute  coronary  care  during  the  four-
                Western   Interstate   Commission   on   Higher   Educa-     week program,  but  also  that  she  exhibit  confidence
                tion  and  Mountain   States   Regional   Medical   Pro-     in this knowledge.
                228                                                                                            NURSING       RESEARCH


                           multiple    choice    120-item    examination    was      determine, in  part,  whether  the  nurse  can  apply  her
                     Aven  befo're   (pretest)   and   after   (posttest)   the      knowledge  and  skills  of  acute  coronary   care,   each
                              This  test  included  a  Confidence   of   Knowl-      nurse  was  requested  to  submit  a  copy  of   the   CCU
                    i' edge Scale' which  measured  changes  in  the  student's      policies and standing orders  of  the  hospital  in  which
                     knowledge  a-s  well  as  the  degree  of  confidence   in      she  was   employed.   Examination   of   these   policies
                     that  knowledge.  For   each   test   item   the   student      showed  that,  in  some  units,  nurses  were   not   per-
                     indicated  the  correct  answer  as  well  as  her  confi-      niitted  to  institute  life-saving  treatment   such   as
                     dence in this choice  based  on  the  following  criteria:      defibrillation  and  administration  of  specific  cardiac
                     1)  CERTAIN-all  three  incorrect  items  could  be  iden-      drugs.   Consequently,   the   staff   of   the   Regional
                     tified; the  correct  item  has  been  isolated.  2)  PAR-      Medical  Program,   in   consultation   with   its   Heart
                     TIAL GuEs      ne  or  more  items  could  be   identified      Committee  and  the   faculty   of   the   Coronary   Care
                     as incorrect, but the correct  item  could  not  be  iden-      Project,   developed   and    distributed    comprehensive
                     tified.  3)  GUEss-no  item   could   be   identified   as      Coronary  Care  Unit   Standing   Order   GuidelineS3   to
                     incorrect.                                                      all hospitals  in  the  region.  A  follow-up  survey  was
                        The   120-item   test   was    divided    into    eight      planned  to  as-certain  if,  and  how,  these  guidelines
                     categories:  concepts  of   coronary   care,   physiology,      were adopted.
                     myocardial    infarction,    norm'al    electrophysiology,        Although  patient  care  statistics  were  collected  in
                     abnormal    electrophysiology,    pharmacology,    compli-      most   hospitals   with   a   designated   coronary   care
                     cations,   and   pyschological   aspects    of    coronary      area,  these  data  were   neither   systematically   com-
                     care.  An  analysis  of  the  knowledge   and   confidence      piled  nor  standardized.  Therefore,  a   Coronary   Care
                     scores  in  relation  to  these  specific  content  areas,      Morbidity   and   Mortality    Statistical    Form3    was
                     made  for  each  course,  enabled  the  faculty  to  exam-      developed  by  the   WP/RMP   and   introduced   to   hos-
                     ine  specific  course  content  and  determine  areas   of      pitals  whose  nurses   participated   iD   the   program.
                     weakness   and   strength   within   the   program.    The      Statistics are  compiled  monthly  by  The  nurse  in  the
                     faculty  could   then   set   standards   of   performance      unit  and   sent   to   the   Regional   Medical   Program
                     based on knowledge-confidence testing.                          office.  Every  six  months  reports   are   returned   to
                        A simulated coronary  care  area  was  built  to  serve      each hospital summarizing -statistics from its      '   own
                     as  a  learning  laboratory  for  students  in  the   pro-      unit  with  an  analvsis  of  cumulative  data  from   all
                     gram,  This  unit  contained   teaching   aids   as   well      participating hospitals.
                     as  equipment  available  in  most  CCU'S.  At  the   com-
                     pletion  of  the  program  an  Arrhythmia   Anne,2   capa-
                     ble  of  simulating  specific  cardiac  emergencies,   was      Results
                     utilized to  test  the  student's  arrhythmia  recognition        Comparative  analysis  of  prie-  and  posttest   scores
                     and  her  ability  to  institute   appropriate   treatment      of  200  students  relating   knowledge   to   degree   of
                     including:   defibrillation,   cardiopulmonary    resusci-      confidence  is  shown  in  Figure  1.  Whereas  only  27.4
                     tation,  and  definitive   drug   therapy.   To   complete      per cent of all responses  were  both  correct  and  given
                     the course  all  -students  were  required  to  pass  this      with a high degree  of  certainty  on  the  pretest,  66.3
                     examination.                                                    I)ei,  cent  of  the  responses  on  the   posttest   were
                        A  field  coordinator  attempted  to  visit  each  par-      answered  correctly  and  with  a  high  degree  of   con-
                     ticipant  within  six  months   following   her   training      fidence.
                     course in order  to:  1)  ascertain  whether  the  student        Pre-post   knowledge-confidence   scores   by    content
                     was  employed,  either  directly  or  indirectly,  in  the      area  are  shown  in  Table  1.  These   data   illustrate
                     care of  patients  with  acute  cardiac  disease;  2)  ob-      that  the  percentage  of   answers   in   each   category
                     tain a retrospective  evaluation  of  the  course  by  the      which  are  both   certain   and   correct   is   markedly
                     student in light of  her  experience  in  the  intervening      higher  on  the  posttest  than  on  the   pretest.   How-
                     six  months;  and  3)  administer  an   additional   post-      ever, there  is  no  difference  between  pre-  and  post-
                     course  examination  which  served  as  an  indicator   of      test  answers  which  were  incorrect  but  given  with  a
                     knowledge   retention.   This   examination    also    was      high degree of confidence.
                     used  to  pinpoint  specific  areas  of   learning   which        The   Kruskal-Wallis   One-Way   Analysis    of    Vari-
                     needed to be reinforced.                                        ance  by  Ranks  (H  Test)  (Siegel,  1956,  pp.  184-193)
                        Because  the  ultimate  goal  of  the   coronary   care      was  utilized  to  determine  whether  factors   such   as
                     project is the reduction   of  i-norbidity  and  mortality      age,  prior  work  or  educational  experiences  in  coro-
                     in patients with acute     myocardial   infarction,    the      nary  care,  and  expected  area   of   employment   post-
                     project criterion most difficult  to  evaluate,  but  per-      course   were   correlated   with   student    pre-    and
                     haps  most  important,  has  been  the   effect   of   the      posttest  performance  (Table  2).  The   H   Test   indi-
                     training  program  on  patient  care.   The   process   by      cated  that  pre-  and  posttest   performance   of   stu-
                     which this  goal  is  achieved  is  multidisciplinary  and      dents  35  years  and  under  differed  significantly  (at
                     multifocal.                                                     the .01 level)  from  those  36  years  and  older  (Table
                        As policies and  standing  orders  set  by  a  hospital      2A).   General   educational   background   was   not    a
                                                                                     significant  factor  in  pre-  or   posttest   performance
                        'The scale is adapted from the "Certainty scale"  developed  (Table   2B).   Tables   2C   and   D   illustrate    that
                     by the Office of Research in Medical Education, University  of
                     Washington, for the Washington-Alaska Medical Program.
                        2                                                              3Tht@se are available upon request from  the  Western  Penn-
                        Arrhythmia Re@usei Anne  t@  manufactured  by  the  Laerdal  sylvani:i Regional Medtcal Program, 3530 Forbes Avenue, Pitts-
                     Medical Corp., Tuckahoe, New York.                              bijrgh, Pennsylvania 15213.
                     MAY-JUNE, 1972 * VOL. 21, NO. 3                                                                                        229


                                                                                                                          rrect  and  Incorrect   Responses   to   120-
                        only     pretest     performance      was      affected      by      prior      Figure  I.   CO
                                                                                                        Item  Pre-  and  Postcourse  Tests  Relating  Knowledge  to
                        education     (formal     or     in-service)     in     coronary     care.                           Degree of Confidence'
                        When     students     were      grouped      into      categories      de-
                                                             .instruction        (Table        2E),
                        lineating       prior       arrhythmia                                                  65                       63.   3
                        experience     monitoring     patients     (Table     2F),     area     in
                        which     employed     (CCU     or     areas     other      than      CCU)              60
                               to  entering     the     course     (Table     2G),     and     ex-              55
                               0
                        Ppreictred    area    of    employment     I)ostcourse     (Table     2H),                                                              Pretest  N  @2   00
                        significant differences in pre_          and       posttest       perform-      z       50                                              Posttest   N   =198
                        ance among the groups were note4cl.                                             wu      45
                               Since    initiation    of    the     Coronary     Care     Training
                        Project,  the  field  coordinator  has            made            approxi-      0.      40
                        mately    184    visits    to    individual    students     within     six      z-      35
                        months     following     their     completion     of      the      course;      -
                        142   students   (77   per   cent)   were    found    to    be    viorking      w       30                        27.     4
                        in     an     intensive     coronary      care      environment.      This      oz      25        25.1
                                                                                                        0
                        figure    correlates    with    the     number     of     students     who
                                                                                                                20                                                  A19  .  0
                        expected    to    return     to     an     intensive     coronary     care                                  6.  7
                        environment     after     completing     the     course.      Six      per              15                                   13.
                        cent    of    the    students    were    no    longer     working,     and              1                                                                 o8. 2
                        17   per   cent   were   working    in    areas    other    than    inten-
                        sive      coronary       care.                                                                                                                            7. 2
                               Data    on    follow-up    testing    of    120    students    were
                        collected.     Eighty-five     students     were      given      identical
                        precourse,       postcourse,       and       follow-up       examinations.
                        Sixty-five    per    cent    of     their     total     responses     were
                        correct   on   the   pretest,   88   per   cent    on    the    posteourse                           CORRECT                                      INCORRECT
                        test,   and    85    par    cent    on    the    follow-up    examination,
                        indicating      that      knowledge      retention       of       coronary        -Pretest raw mean 72.9 (61 per cent correct)
                        care     practices     at     the     six-month     follow-up     remained              Ilo,,,ttest raw mean 98.1 (82 per cent correct)
                        high   .  In    September     1970,     the     follow-up     test     was

                                                 Table 1.   Knowledge-Confidence Scores by Content Area Expressed in Percent'

                                                                            PRE-  POSTTEST                                                 PRE- POSTTEST
                                                                   ANSWERS  IN  RELATION         TO  C(                   CORRECT ANSWMRS  IN  RELATION  TO  CONFIDENCE

                                                                                                                                               (2) PARTIAL
                                                                   IN                                                                             GuEss             (3)       GuEss
                                                          PRE       81,                      T       PRE        0                       T      PRE     POST         PRE        POST
                                                          o/.      o/o                               c/o        a/
                               Concepts          1                            16.0       :.o         1.5        1                              5.0      -           4.0           -
                               Physiology        33                           27.0       19.0        9.0                            8.0        18.0      8.0        12.0          1.0
                               Myocardial
                               tnfa-retion       21       2                   28.0       17.5        5.0        1.5       9.0       9.0        21.0     11.5        9.0           1.5

                               Normal electro-
                               physiology        21       35.0     76.0       21.0       10.0        9.0        1.0       6.0       6.0        15.0      6.0        14.0          1.0
                               Abnormal elee-
                               trophysiology     22       21.0     61.0       22.0       17.0        11.0       2.0       8.0       10.0       20.0     18.0        18,0          2.0
                               Pharmacology      14       23.0     55.0       23.0       18.0        10.0       2.0       7.0       10.0       23.0     13.0        14.0          2.0
                               Complications         6    23.0     64.0       30@O       21.0        7.5        1.0       4.0       6.0        21.5       7.0       14.0          1.0
                               Psychological
                               aspects               2    40.0     65.0       26.0       11.0        2.0        1.0       14.0      13.0       16.0      10.0       2.0
                               Total points      120      27.4     63.3                              8.2        2.0

                               -Pretest   N=200    students
                               Pre    est    mean=72,9
                                  t'
                               Percent  correct  =  ol
                               Posttest  N  =   198   students
                               Posttest  mean  =  98.1
                               Percent  correct  =  82
                               230                                                                                                                          NURSING RESEARCH


                                                                  Table    2.    Pre-    and    Posttest    Performance    Related    to     Student     Background'     (N     =     198)

                                                                                                                                        A.   AGE

                                                                                                                                        PRETEST                           PERFORMANCE**                 POSTTEST                         PERFORMANCX**
                                            AGE                                                    NUMBER                                               %                                                               %
                                            GROUP                                                  (0/0      )                   MEAN               CORRECT                           MEDIANI     MEAN             CORRECT                MEDIAN
                                        Up  to   35                                                161  (81)                     74.7               62.2%                             75          99.9               83.2%                           100.5
                                        36 and over                                                37   (19)                     65.0               54.0,7o                           62.5        90.1               75.1%                           89.1

                                                                                                            B.  GENERAL             EDUCATIONAL             BACKGROUND

                                                                                                                                        PRETEST                            PERFORMANCEI                 POSTTEST                          PERFORMANCEI

                                        EDUCATION                                                  NUMBER
                                            GROUP                                                  (  0/0   )                    MEAN               CORRECT                           MEDIAN      MEAN             CORRECT                MEDIAN
                                        Dlploma only                                               176 (88.9)                    72.6               6 0. 5 Olo                        72.5        97.8               81.5,7.                         99
                                        Collegiate                                                 22 (11.1)                     75.9               83.OVo                            78          99.9               83,00/o                         100

                                                                                                   NC@        PREVIOUS         COURSE         CORONARY         CAR]@                  NURSING

                                                                                                                                        PRETEST                           PERFORMANCE**                 POSTTRST                          PERFORMANCE'
                                        FORMAL  COURSE                                             NUMBER                                               0/0                                                             %
                                                GROUP                                              (%)                           MEAN               CORRECT                           MEDIAN      MEAN             CORRECT                MEDIAN
                                        None                                                       172  (87)                     71.7               59.7%                             73          97.7               81.4   clo                      99
                                        Up to I week                                               10    (5)                     76.2               63.5%                             75          96.9               80.7@o                          97
                                        2 weeks and over                                           16    (8)                     83.7               69.7%                             84          101.9              84.9%                           103
                                                                                                                                                                                                                            it

                                                                                      D.           PRIOR    IN-SERVICE           EDI'CATION                       CORONARY            CARE     NURSING

                                                                                                                                        PRETEST                           PERFORMANCE**                 POSTTEST                          PERFORMANCE'
                                        IN-SERVICE  CC                                             NUMBER                                               %                                                               0/0
                                            GROUP                                                  (%)                           MEAN               CORRECT                           MEDIAN      MEAN             CORRECT                MEDIAN
                                        0  to  5  hours                                            130   (66)                    70                 5   8.3   O/,                     69.5        97.2               81.0%                           99
                                        6  to  20 hours                                            58    (29)                    79                 65.SV@                            78          99.9               83.2%                           101
                                        Over  21  hours                                            10     (5)            1       7&5                63.7      olo                     79          98.8               82.3-/o                         99

                                                                                                            E.              PREVIOUS              ARRHYTIIMIA               INSTRUCTION

                                                                                                                                        PRETEST                           PERFORMANCE**                 POSTTEST                         PERFORMANCE**
                                            INSTRUCTION                                            NUMBER                                               0/0                                                             0/0
                                                GROUP                                              (0/0     )                    MEAN               CORRECT                           MEDIAN      MEAN             CORRECT                MEDIAN
                                        None                                                       50    (25)                    63.3               5   2.7   -lo                     61          93.5               77.9%                           94
                                        Up  to  10 hours                                           84  (42.4)                    73.7               61.4      clo                     65.5        98.5               8  2.0   clo                    101
                                        11  hours and  over                                        64 (32)                       79.3               6   6.1   0/0                     78.5        100.9              84.0     Olo                    102

                                                                                                   P.               PREVIOUS               EXPERIENCE MONITORING                             PATIENTS

                                                                                                                                        PRETEST                           PERFORMANCE**                 POSTTEST                          PERFORMANCE*
                                                EXPERIENCE                                         NUMBER                                               %                                                               %
                                                     GROUP                                                                       MEAN               CORRECT                           MEDIAN      MEAN             CORRECT                MEDIAN
                                        None                                                       45    (23)                    63.1               52.6%                             60.5        94.5               78.7%                           95.5
                                        Up  to  I  year CCU-ICU                                    86    (43)                    73.6               61.3      clo                     74          98.7               8  2.2   clo                    100
                                        Over  1  year CCU-ICU                                      67    (34)                    78.7               6   5.6    lo                     77.5        99.5               82.9%                           100

                                                                                                            G.        AREA         WORKING         IN PRIOR           TO           COURSE

                                                                                                                                        PRETEST                           PERFORMANCE**                 POSTTEST                         PERFORMANCE**
                                        AREA                                                       NUMBER                                               %                                                               %
                                        GROUP                                                                                    MEAN               CORRECT                           MEDIAN      MEAN             CORRECT                MEDIAN
                                        CCU-ICU                                                    127   (64)                    77.1               64.2      &lo                     77          99.8               83.20/c                         101
                                        Other                                                      71    (36)                    65.4               54.50/o                           64          94.9               79.1     'lo                    96

                                                                                                   H.            EXPECTED            AREA OF                  EMPLOYMENT                   POSTCOURSE

                                                                                                                                        PRETEST                           PERFORMANCE**                 POSTTEST                          PERFORMANCE*

                                        AREA                                                       NUMBER                                                                                                               0/0
                                        GROUP                                                                                    MEAN               CORRECT                           MEDIAN      MEAN             CORRECT                MEDIAN
                                        CCU-ICU                                                    159   (80)                    75                 62.5%                             75          99.1               82.6'Yo                         100
                                        Other                                                      39    (20)                    64.3               53.6%                             61.5        93.7               7  8.1   clo                    96

                                            Based    on       Kruskal-Wallis       One-Way       Analysis       of        Variance        (H-Te@t)        (fr(ini Siegel,             1956, pp.  184-193)
                                            Not  significant
                                            .05 level  of  significance
                                            .01  level  of significance

                                        MAY-JUNE,    1972     9     VOL.     21,     NO.     3                                                                                                                                                       231


                          Table 3.  Six-Month  Follow-up  Test  Scores  Related  to           RUTH  SCIIEUER  (Mount   Sinai   Hospital   School   of
                                          Area of Employment                                  Nursing,  New  York,  New  York;  B.S.,  University  of
                                                                                              Pittsburgh,  Pittsburgh,  Pennsylvania)   is   research
                                                                    MEAN       FOLWW-UP       associate and assistant to the director of  evaluation,
                                AREA OF                 NUMBER      SCORES      CORRECT       Western    Pennsylvania    Regional    Medical     Program,
                             EMPLOYMENT                 TESTED                                Pittsburgh.

                          Nurses working In
                          ICU-CCU                          30             85.5

                          Nurses working in
                          ;area.,; (,ttier Ttian ICU        5              68.4               have not  been  fully  determined,  a  system  for  evalu-
                                                                                              ating  morbidity  and  mortality  of  patients  cared  for
                          Total                            35              83                 in  the  CCU  has   been   introduced   in   the   Western
                                                                                              Pennsylvania  region.  Whereas   no   hospital   was   re-
                                                                                              porting  its  monthly  CCU  Statistics  prior   to   1970,
                                                                                              47 of  the  67  hospitals  with  intensive  coronary  care
                          shortened because  of  time  restrictions.  Test  results           areas   in   Western   Pennsylvania   were   participating
                          of 35  students  given  the  shorter  follow-up  examina-           in the study  at  the  end  of  1971  (Reed  and  Scheuer,
                          tion  are  shown  in  Table  3.  Xs  might  be  expected,           1972).  This  type  of   record   keeping   and   feedback
                          nurses  working  in   intensive   coronary   care   areas           hastens  the  recognition  and  correction   of   specific
                          scored  higher  than  nur-ses  not   working   in   these           problems  and  leads  to  improved  health   care   deliv-
                          areas.                                                              ery  to  patients  with   acute   myocardial   infarction.
                                                                                              The nurse's responsibility  in  this  evaluation  hell).-,
                          Discussion                                                          to reinforce her  role  as  a  key  member  of  the  staff
                                                                                              of her unit.
                           Comparison   of   pre-   and   posteourse   examinations             In  conclusion,  evaluation   of   the   %TP/RMP   Coro-
                          measuring   knowledge   and   confidence   showed    that           nary  Care  Training  Program   is   an   ongoing   multi-
                          participa6on  in  the  coronary  care  course   increased           purpose,  multidisciplinary  effort.  Not  only  does   it
                          the knowledge as well  as  the  confidence  of  the  par-           encompass  knowledge  of   how   many   nurses   are   be-
                          ticipants.  The  Confidence  Scale  is  a  valuable   in-           ing  trained  to  care  for  patients  with   acute   myo-
                          strument  for  measuring   changes   in   the   student's           cardial  infaretion,  but  it   also   provides   valuable
                          ability to  predict  the  correctness  of  her  response.           information  regarding  the  learning  process   and   how
                          The scale  has  been  used  in  student  counseling  when           this process is  translated  into  improved  patient  care
                          discrepancies    between    the    student's    predicted           for the region.
                          knowledge   and   actual   knowledge    are    displayed.
                          Students   who   demonstrated   more    knowledge    than
                          confidence or  the  reverse  could  be  assisted  by  the                                   References
                          faculty to  explore  ways  in  which  to  correct  knowl-
                          edge or confidence deficits.                                        REED,  DAVID,  AND  SCHEUER,   RUTH.   Reporting   statistics
                           Follow_up  student   interviews   indicated   that   the             in coronary care  units.  Penn  Med  75:53-55,  Jan.  1972.
                          majority  of  the  students  returned  to  care  for  pa-           SCIIEUEP,  RUTH.   An   Evaluation   Guideline.   Pittsburgh,
                          tients  with  acute  coronary  disease,  and,  therefore,             Coronary   Care    Nurse    Training    Program,    Western
                          utilized  knowledge  and  skills   learned   during   the             Pennsylvania   Regional   Medical   Program,   1970.   (Un-
                          four-week  program.  Test  scores   at   six-month   fol-             published)
                          low-up   suggested   that   although   knowledge   reten-           SIEGEL,  SIDNEY.  Non  Parametric  Statistics  for  the   Be-
                          tion  of  coronary   care   principles   remained   high,             havioral  Sciences.  New  York,   McGraw-Hill   Book   Co.,
                          those  nurses  who   did   not   return   to   an   intensive
                          coronary  care   area   required   frequent   follow-up   in-         1956.
                          struction   to   maintain   the    level    of    performance       U.  S.  HEALTH  SERVICES  AND   MENTAL   HEALTH   ADMINISTRA-
                          achieved at the end of the course.                                    TION.  An  Evaluation  Study   of   Coronary   Care   Nurse
                           Analy,sis  of  student  baseline  data   related   to   pre-         Training. (U. S.  Public  Health  Service  publication  no.
                          and   posttest   scores   helped   the   faculty    determine         2145)  Washington,  D.  C.,  U.  S.   Government   Printing
                          which   students   might   need   extra   help   during   the         Office, January 1970.
                          program.  Nurses  over  35  as   well   as   those   partici-
                                                                                                             Outlook  for   Coronary   Nursing.    Proceed-
                          pants   without   prior   experience   in   acute    coronary         ings of a conference  at Wheaton,  Md.,  May  23-24,  1968.
                          care  might  require   additional   assistance   during   the         (U.  S.  Public  Health  Service  publication   no.   1926)
                          four-week  program  in  order  to  perform   at   the   level         Washington,  D.  C.,  U.  S.  Government  Printing  Office,
                          of  tho.se  who  are  younger  or   have   had   some   experi-       1968.
                          ence   in   coronary   care.   The   data   suggested    that       WESTERN  INTERSTATE  CO
                          specific  courses  designed  for  students  based  on   their                                  UNCII@   ON    HIGHER    EDUCATION
                          prior  experience  in  acute  coronary   care   might   prove         AND   MOUNTAIN   STATES    REGIONAI,    MEDICAL    PROGRAM.
                          more efficient  than  a  single  course  in  which  all  stu-         Evaluation  of  Coronary  Care  Nurse  Training;   a   Col-
                          dents,  regardless  of  their   background,   are   included.         loquium  for  Teachers  of  Coronary  Care   Nursing   held
                           Although  the  effects  of  this  course  on  patient   care         at Missoula, Mont., June 18-20, 1970.
                                                                                              WESTERN    PENNSYLVANIA     REGIONAL     MEDICAL     PROGRAM.
                           The author acknowledges the  assistance  of  Enid  Goldberg,         Annual  Report.  Pittsburgh,   The   Program,   May   1970.
                          Ph. D., R. N.; Constance gettlemeyer, R. N.; David  E.  Reed,
                          M. D., and Douglas Vaughan                                            (Unpublished)
                          232                                                                                                       NURSING        RESEARCH


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                                                                --loll                                              t
                                                                                              C;
                                                                                                                                            ?eQuest  fo,-  I;Ie@-ature  @@o,-,,  G
                                                @ii(, i@tcl   Iiat ii,,                                                                     5tOt'ion    is  checked  of  a   resource,
                                                              oi
                                                                                                                 oil.          l@i4,("4_          -
                                                                                                                                            brcify      y  a,-i  Ar:zoria  Medi,:a@
                                                  4o                          cl;ii                                                         Nctwo.-k  technician.

                                                                                                                                                          i),  W.


                                                                         Ilie Ioitr)ial of -ilie
                                                                  SOUTH CAROLINA
                                                                       Medical Association
                                                                          JULY, 1972 -VOL. 68, NO. 7

                                                                                                    SOUTH  CAROLINA  REGIONAL
                                                                                                               MEDICAL  PROGRAM

                                                                                                             -VINCE ',%IOSELEY, NI.D., Coordinator

                                 THE  SOUTH  CAROLINA                                    REGIONAL  MED                                L
                                                                                                                              LC
                                                                                                                                   -A.4,,               Rk-M-,.             PLAN
                                FOR             MANPOIN'ER             EXTENSION,             AND             FOR              TI-IE              REGIONALIZATION
                                    OF           SERN'ICES           AND           RESOURCES           TO            liN'IPROVE            IIEALTH            CARE

                                             The Ilegioilal  Nledical Pro(Trani in  Soutli  Carolina  is  I)eincr
                                                                                                                                               greatly       expanded        in
                                      efforts    invol,.-iii(T    lic@iltli    manpower    de\-elopinciit,    primary    li@ilth    care    de'N-elopmeiit    pat-
                                      terns   and   re"ionalizzition   of   licaltli   facilities,   DiaiipoN\,cr    and    other    resources.    This    article
                                                       0
                                      outlines bow SCII-'\IP Proposes to Handle its I)i-oa(ler function.

                                   After   consideration   of   the    bealth    needs    and                vide  for  early  case  finding,   earlv   diagnosis,   ambu-
                               manpower     deficiencies     at      professional      teeli-                ],,ttorv  care,  and  preventive  medicine  in  its  broadest
                                                     ip                                       a                  e.   Efforts   to   improve   nutrition   and    emergency
                                                                       -els  in  Soutil   C   ro-            iiieclicii  services  are  additionally  reco@  ized  as  ob-
                               nical and occi  ational le\                                                   sells
                                                                                                                                                                n
                               lina,    the    Re,,ional    Advisorv     Group     at     its
                                                                      .   I
                               Annual'     Nicetiii,r     on      December      9,      19-10
                                                                                                               A   New   \Iissioi)   Statenient   for   Regional   \fedical
                               adopted the follo@\,iii(y statement:                                          Prot4riiiis   wis   adopted   I)y   the   Nationil   Advisory
                                                                                                             Council  in  jtine  1971.  According  to  this,  R.\IP  is  a
                               "The  South  Carolina  Regionil  \Iedical  1'rograiii  is   to                "flilictioziing  and  actioii-oriented  consortium  of   pro-
                               continue  pro,,raDIS   for   physicians   dentists,   ntirses,                %,iders  respoi)si\,e  to  health  needs  and  problems.   It
                               technical,  allied  health  professional  tiici   occupational                is a fi-,iiiic%\-ork within which all  providers  can  coiiie
                               grotips,  directed  towards  improving   patient   care   1)),                together  to  ii)eet  health  needs  that  cannot  he   iiiet
                               continuing   education   and   demonstration   programs    for                1)@- individual practitioners,  health  professionals,  lios-
                               the iiiipron-eiiietit  of  health  i)iinl)o%%,er,  the  (teiiioiistra-        I)itals  arid  otl)er  institutions   acting   alone.   It   also   is
                               tion  and  ciicouriigeiiient  of  new  techniques  for  (liag-                (lesi,,iie(i to take into  account  local  resources.  patterns
                               nosis  tnd  treatment,  p  ,raiiis  for  the  iiiiproveiiieiit                of practice and  referrals  all(]  needs.  As  such,  it  is  a
                                                            ro.,
                               of facilities, particiilti-I), coiiiiiittitity hospitals,  ind                potentially,  important  force  for   I)riiiging   ai)out   and
                               research  and  triiiiiiil-  in  iii(-tliods  to  improve   the                assisting   N%,itli   cliaiitTs   in   the   provision   of   personal
                               delivery  of  health  services  ind  care.  In   addition   to                health services and care@"
                               devoting ttti,iitioti to disease  areas  of  I)riiiiarv  Coll-                  NfcetiiiiZ in \I)-i-tle  Bt!@icli  @pril  29-30,  1972,  the
                               cei-ii - heart disease, cancer,  and  stroke,  ki(Itic),  dis-                SCII.Nll"s  Itegiotial  A(l@,isor),  Group   authorized   the
                               case iii(i otlit@r rcl,,itc(-l diseases - these  programs  are                orgiii)izittion to I)roa(leii its goals in the  following  in
                               to  utilize  the  specified]]%  id  ntifie(I  resources   in(i                order   to@   support   planning   iiicl   organization    of
                               lirik,,i,-Cs ill Nvt),s target will (.Ica] effccti%-ely  .%,itli  such        coilliiitillit), I)ased health e(Iticiltioil prt)gt-iiiiis; I)I.Orllotc
                               prol)leiiis  is  cost  control,       increased    accessil)ilit%"            a c
                                                                                                             ii I I)I@iii for  pli\-sici@iii  assistant  training  projects;
                               iiiil)ro%-(,(l ct)iiiiiitii-,ic.itioiis, iiid inil)ro%-c(l standards.         support  ,tti   cxl)ayi(lecl   role   of   the   iiiirse;   coordinate
                               'I'liroti,,Ii   the   Nlc(liciil   District   Coiniiiittecs   of   the        reerkiitiiieiit iiid placement for tic%v pi-of(@.ssi
                                                                                                                                                                   Olial      cate-
                               ltegioll@ll                            and     their     coiiiiiiittee        gorics;    evaluate     impact     arid     performance     of     new
                               relittiotisl)il)s  in  liaison  ,%-itli  agencies  concerned   \%,itli        types    of    personnel;     encourage     iiiijil)oN\@er     surveys
                               plai)iiitig  or  a(iiiiiiiistr4itioii   of   Health   care   programs,        arid   recruitment   programs;   develop    lic@iltli    1)rofessioiid
                               data tre to he developed                   %vill   lead   to   issist-        carcei-     opportunities     for     minority     groups;     develop
                               atice   in    proper    planning    and    pi,iorit),    setting    in        and   iii)plejiieiit    iii-scr%,ice    education    progi@aiiis    to
                               respect   to   specific    poptiLitioti    arid    geographic    needs                 career   l@i(Iders   tjid   to   tipgrt(le   the    perforin-
                               It)  order  to  assist  in  cost  coiitt-ol,   emphasis   is   to   he        @iti(,c of existing health personnel.
                               specifically  directed  to@vai-d  I)rograiiis  \%-Iiicii  N%-iU   pro-        Also,    that    a    mechanism    be     established     for     con-

                               JULY, 1972
                                                                                                                                                                                293


                                                                                             Nf(,(Iical Program has been  directed  to  assist
                                                                                             all project and  pro,,ram  directors  of  current
                                                                                             operational   SCRINIP   programs   in   extendinr
                                                                                                                            ist applicants for -ne
                                                                                             their service, and to ass                                  w
                                                                                             projects to  focus  their  activities  along  the
                                                                                             broader  lines  of  enhancing  the   availability
                                                                                             and quality of health care.
                                                                                                The  principal  objectives  of   the   @SCRI\IP
                                                                                             staff, in accordance ,N,ith        National    Advisory
                                                                                             Council iNlission  statements  and  the  Regional
                                                                                             Advisory Group, are to:
                                                                                             1. Promote demonstrations       among   providers   at   the
                             SCRillil  officials  confer  with         1) r.    Harold          loctl  level  of  both  new  techniques  and   innovative
                          ll,trl,,ulies,  Director  of  Itegional     Iledical   1'ro-          delivery  patterns  for  improving   the   accessibility,
                          grams Service, IN'ashiiigtoii, 1). ('.,     during    recent
                          Advisory   Group   meeting   in    Alvrtle    Ileach    that          efficiency, aiici effectiveness of health care.
                          resulted in an expanded health         .care    de%-elol)ment      2. Stimulate  and  support  those   activities   that   will
                          role  for  SCIt.,Nlll.  Shown  are  (left  to  right):   Dr.          both   help   existing   health   manpower   to   provide
                          Charles   1'.   Summerall,   111,   tssociate   coordinator;          more and better  ctre,  and  will  result  in  flie  more
                          Dr.  Vince   ilit)sele),,   coordinatoi-;   Dr.   31argulies
                          and   Dr.   James   W.   'Colbert,    Jr.,    chairman    of          effective  utilization  and  distribution  of  new  kinds
                          SCIZ31P's Advisory Group.                                             (or  conil)iiiations)  of   health   manpower.   Further,
                                                                                                to (lo this in  a  way  that  will  ensure  that  profes-
                          tiniiing cooperative regional   studies   and   modification          sioiial and technical  ,ictivities  of  all  kinds  (e.g.
                          of the obstacles  that  discourage  physicians  from  enter-          ii)foi-iiiational, training) lead to professional  growth
                          ing  and  remaining  active  in  primary  community,   prac-
                                                                                                -iii(I  development.   and   are   appropriately   placed
                          tice  of  medicine.   obstacles   and   opportunities   that
                                                                                                @N,itliiii  the  context  of  medical  practice  and  the
                          influence  primary  care  roles   for   nurses   and   other          coiiiiiiiinitn" by  assisting  with  the  development  of
                          paramedical   personnel   and   obstacles   to    ambulatory
                                                                                                Coiiiiiiiinitv  Based  Education   Progrims,   and   with
                          care  imposed  1)),   third   part),   pa),ment:   encourage
                                                                                                prot,,raiiis for  the  implementation  of  the   ',\atioDal
                          use  of  a  recently  developed  Problem  Oriented  '.\fedi-          Eiiiergei)cy Health Personnel Act.
                          cal   Record;   design   systems   of   public   information
                                                                                             3. Encourage   providers   to   accept   and   enable   them
                          regarding  available  health  services  and  personal   pre-
                          venti%,e  health  iiieasilres,  support  emergency   medical          to iiiitiate regionalization of health  facilities,  man-
                                                                                                power,  -,ind  other  resources  so  that   more   appro-
                          services  through  education   programs   and   deiiionstra-
                                                                                                priate  and  better   care   will   be   accessible   and
                          tion  projects;  reduce  infant  inortilit),   in   minority
                          populations,  especially  tl-Lrotigli  development  of  pre-          available  at  the  local   and   regional   levels.   In
                                                                                                fields where there  are marked        scarcities  of  re-
                          natal care  services  and  nurse  ii-iidwifery  programs.  .                                                                                  I
                             Additionally..  that   shared   bioengineering   services          sources, such  as  1-idiiey  diseases  particular  stress
                          programs  be   developed   to   provide   improved   safety,          will be placed on regionalization     so that  the  costs
                                                                                                of such care may be moderated.
                          reliability  and  efficiency  in  hospitals,   clinics   and
                          practitioners'  offices;  conduct   studies   on   the   de-       4. Identify, develop, and facilitate     the  iii-iplementa-
                          -,,elopj)ient  of  facilities  or  programs  for  economical          tion of new and  specific  iiiechanisii-is  that  provide
                          dojiiiciliary  care  for  the  incapacitated,   particularly          quality  control  and   improved   standards   of   care.
                                                                                                Such  (ItialitN  guidelines   and   perfomiaiice   review
                          the  elderl),;  determine  specialized  services  that   are
                          appropriate.  needed  and  available   and   through   link-          mechanisms    will.be required. especially in relation
                          ing  of   facilities   achieve   the   maximum   amount   of          to new and    i-nore  effective   comprehensive   systems
                          cooperation among hospitals and institutions.                         of  health  services,  and  by  recent  legislation   and
                             And  that  SCRI\IP  be  prepared  to  work  in   coopera-          draft  guidelines  will  be  necessary  if  R.\IP  is  to
                          tion   with   tppropriate   professional    societies    who          I)Iav  its  role  in  health  manpower  training,   emer-
                          express an  interest  in  ex  loring  alternative  care  de-          geiicy  medical  services,  areanvide  health  education,
                                                      p
                                                                                                ,iii(I the nIODitoring of (Itiality ' f
                          liverv   systems   and   that   SCRMP   assist   appropriate                                              o  care  in  lli\lo's
                          prof.essional   associations    in    developing    programs          and experimental health delivery systems.
                          assuring (Itiality health care.                                       In  considering   the   health   manpower   and
                             Broadening  of   SCR,\IP's   efforts   in   beilth   care       other service deficits in South Carolina,  it  is
                          delivery  represents  an  expansion  of  the  initial   con-       very   apparent    that    in    addition    to    numerical
                          cept  of  RMP  as  a  vehicle   to   speed   the   flow   of       deficiencies,   distribution   problems    are    of    con-
                          scientific  knowledge  to  health  providers  in  connection
                          with  heart  disease,  cancer,  stroke,  and  related   dis-       siderable magnitude.
                          eases.                                                                Despite   the   fact    that    the    Medical    Univer-
                             The   staff    of    the    South    Carolina    Regional       sity   of   South   Caro   na   is   rapidly    expan    ing

                          294                                                        THE JOURNAL OF THE SOUTH CAROLINA MEDICAL AssocIATION


                         its classes in the  several  Colleges,  -not  only
                         through  on-cainpus  programs  but  by   consortia
                         extending  its  undergraduate  academic   training
                         into  several  comniunity   hospitals   throughout
                         the State, it is evident that this will be  accom-
                         panied  by  a  considerable  time  lag,  and  that
                         other ways to  deal  with  the  professional  man-
                         power  shorta(,es  and   other   immediate   prob-
                         lems  must  be  developed.  Among  these  are   an
                         extension  of  existing  manpower   resources   at
                         all levels by:
                         1. Utilization of  assistants  and  new  types  of
                            personnel;
                         2. Better  coordination  of   transportation   and
                            c.ommunications   for   consultation,   instnic-            The   SCRMP   supported    state%-,-ide    Ciiildren's
                            tion and referral;                                        Heart  Screening  Ilrograni  is  carried  out   by   Dr.
                         3. Application  and   more   widespread   utiliza-           Arno  Hohn  (right),  Medical  Uni%@ersity  of   S.   C.
                            tion of new technology;                                   Hospital, assisted by Miss Julia Breeden.
                         4. Improved  resources  sharing   throughout   the           ordination  and  implementation  of   these   sev-
                            Region through program planning.                          eral and related activities  in  the  Region,  in-
                            It  was  pointed  out  by  the  RAG  in  Decem-           eluding  combinin-  funds  from   other   agencies
                         her, 1970,  however,  that  in  order  to  procure           or foundations, both public and  private,  NN,itli
                         better planning and  a  more  systematic  utiliza-           those of  RNIP  for  study  or  operational  grant
                         tion and application of a .,ariety of  data,  iii-           purposes.
                         eluding socioeconomic  data,  to  assure  priority
                                                                                      CONCEPT:
                         of effort, evaluation  of  efforts,  and  perspec-              It is evident that  for  an  effective  regional
                         tives  as  to  alternatives,,  would  require  the
                                                                                      or statewide  program  to  be  developed,  and  in
                         expansion   and   development    of    appropriate                               0
                                                                                      consideration  of  other   iiexN,   program   activities
                         and qualified staff. As  a  result  of  this,  the
                                                                                      now  being  developed   or   supported   by   Fed-
                         Regional   Advisory   Group   approved   the   use    of
                         Developmental Component Funds for an                 ad-     eral  appropriations,  that   an..overall   cooi-diiiat-
                                                                                      ill(,  body  for  the  entire  State   should   be   de-
                         vanced planning studv. Out of this study            has
                                                                                      -,eloped  to  which  the  Ile(rioiial   '\Iedical   Pro-
                         developed the following concept for the              co-     grain  can  effectively   rel@ita   at   the   Recioilal
                                                                                                                                      0
                                                                                              In   addition   to    its    established    sub-
                                                                                      level.
                                                                                                              'ty   relationships   with   re-
                                                                                      region   or conimuni
                                                                                      gioiial  councils,    CHP-(b)     a(lencies,     Appala-
                                                                                      cbia,  '-\Ioclel  Cities,  Coastal  Plains,  and   other
                                                                                      health    planning    bodies    or     councils,     the
                                                                                      SCRNIP   noxN,   has   effective   sub-re-ional   opera-
                                                                                                                             -er,   and   par-
                                                                                      tioiis. At the State le%-ell bonve%
                                                                                      ticiilarly  in  view   of   the   compactness   of   the
                                                                                      entire   State.in    geography,    transportation    and
                                                                                      comnluiiicatiODs,   a   regional   systems   and    pro-
                                                                                      gram planning resource is urgently needed.
                                                                                        This  is  needed  for   full   community   of   effort
                                                                                      in  order  to  provide  for  true   regionalization   of
                            Nurses receive updated    coronary   care    training
                         through ctitirse,, supported by the S. C.      Itegional     resources   and   regional    plaiiniii-.    Cu)-rcntly,
                         Medical  1'rogriiii.  Slto%%-ti  are  (left  to  right):     there  is  no  overall  coordination   or   single   re-
                         Sandra  Harrington,  IZ.N.,  Kingstree;  Linda   lieaty,
                         It.N., Myrtle  Ileicii;  Lillian  White,  lt.N.,  Jantes     source  for  service  to  assist   community   or   sub-
                         Island; iNI.'try   Weaver,    It.N.,    Walterboro;    Dr.   regional  area  planning   activities   or   to   assist
                         1'eter ('. (,,xzes  and  Jan  Ileroil,  of  the  Medical
                         University of S. C. Division of Cardiology.                  or   develop   regionalization    linkages    for    im-

                         JULY,1972                                                                                                         295


                                                                              by   the   Regional   Medical    Programs    Service
                                                                              and   the   NIH   for   Areawide   or    Comi-nunity
                                                                              Health Education Centers.
                                                                                 'I'o approve, establish  local  guidelines,  mon-
                        L                                                     itor  and  evaluate  such  activities   a   Regional
                                                                              Planning   Committee   of   the   RAG   is   to   be
                                                                              organized in  order  to  involve  in  its  delibera-
                                                                              tions   a   number   of   health-related   agencies,
                                                                              professional   association   representatives,   gov-
                                                                              erniiieiital representatives,  educational  institu-
                                                                              tioii representatives
                                                                                                     members   of   the    public,
                                                                              representatives  of  CHP  bodies,   and   the   mem-
                                                                              bers  of  the  Medical   Districts   Committee,   of
                                                                              whom   the   majority   are    now    representative
                      Introducing new technology is      an     important     RAG members.
                     part of the  expanded  SCIZ'.,%IP  mission.  An  ex-        This  resource   will   also   provide   guidance
                     ample  is  linking  community  hospitals   by   te       for  Program  staff  to  be   recruited   by   SCRMP
                     phone  to  major  medical  centers   for   coronai
                     care consultations. Above,  Nlary  Harrelson,  R.P       in  order  to  be  capable  of  providing  the  con-
                     sends  heart  patient's   -electrocardiogram   (EKG)     sultative staff s   port   needed    by    community
                     from  Dorchester  County   Hospital,   Sumnierville,                      UP
                     to the 'tledical University of S. C. Hospital's  CCU     health study groups.
                     by telephone.                                               'I'he   expanded   activities   of   SCRMP   pro-
                                                                              grain staff,  will  be  directed  towards  coordina-
                     provement  of health      care   by   systems    ap-     tioii  of   manpower   training,   coordination   of
                     proaches,   or   to   regionalize    commi-inication     continuing   education,   program    planning    and
                     and consultative  activities  for  health  services.
                                                                              development,   systems   analysis,   provision    of
                       The  staff  of   the   South   Carolina   Regional
                                                                              appropriate consultation  in  a  variety  of  socio-
                     Medical   Program   is   currently   providing    to
                                                                   C,         economic   areas   needed   in   health    planning,
                     some degree such coordination of effort,         as
                                                                              and  for  the  development   of   demonstration   or
                     was  demonstrated  in   the   package   presentation
                     of the  several  grant.  applications  submitted  as     experimental  programs   and   the   evaluation   of
                                                                              these,  and  especially  to  serve  as   an   agency
                     a   program   for   the   improvement   of    health
                                                                              for  assistance  in  program   planning   with   in-
                     manpower   through   Physician   Assistants   Train-     (lividual  community  efforts  to  provide  for   an
                     i-ng  Programs  and  consolidated  as   a   combined
                     grant  application  to  the  National   Center   for     overall regional strategy.
                     Health    Services    Research    and    Development     .  One  may  ask  if   the   present   SCRMP   staff
                     and  tci  the  Health   Manpower   Bureiu   of   the     is not in  some  sense  providing  for  these  sorts
                     NIH  and   more   recently   for   a   similar   co-     of activities now.  The  answer  is  Yes,  but  only
                     ordination  in  respect   to   developing   a   com-     ii-i a limited degree.
                     munity  based  health   education   center   linkage        The  projects   of   the   South   Carolina   Re-
                     for  several  related  projects  involving   several     gional  NIedical  Pro-ram,   though   initially   in
                     community hospitals.                                     1968  and   until   1970   almost   entirely   cate-
                       It  is  also  evident  that  such  statewide   co-     gorically    oriented,    have    broadened.    This
                     ordination  of  effort  is  immediately  needed   in     occurred  rapidly  for  most  as  soon  as   project
                     view   of   the   statements   and   recommendations     directors  knew  that   their   efforts   could   be
                     made  in  the  Public  Laws  for  the  adiiiinistra-     expanded  beyond  the   strictly   categorical   and
                     tion   of   the   Emergency    Employment    Assist-     narrower  areas  of  care.  The  Program  Staff  has
                     ance  Act  of   1971   (PL   92-54),   the   Compre-     also  sought  to  guide  applicants  for  new  proj-
                     hensine   Health   Manpower    Training    Act    of     ects  especially  to  design  and  expand  the  ser-
                     1971  (PL  92-54),  and  the  Nurse   Training   Act     vices  of  currently  exsiting   personnel   through
                     of  1971  (PL  92-577),  the  National  Center   for     ncxv  technology,  have   promoted   the   re@train-
                     Health    Services    Research    and    Development     ing  of   personnel,   and   have   consulted   with
                     application   guidelines   and    those    developed     others  interested  in  new  arrangements  for   the
                     290                                                THE JOUR,-,'Al, OF THE SOUTII CAYTOLINA MEDICAL ASSOCIATION


                             delivery   of    services.    Ambulant    care    and    ser-       materi@ils   can   be   skillfully   focused    to    promote
                             ,.-ices  to  isolated   or   deprived   areas   liaN-e   been       chaii(res   or   new   ways   for    communities    iii    an
                             encouraged,,aiictfiiiaiicially     aided      to      improve       overall     sense,     or     to     prevent      duplication
                             comniunications.       Educational        supports        for       through   the   promotion    of    sharina    of    resources
                                                                                                                                           In
                             professional    and    technical    ,rotips     have     been       and   ci ities.
                             extensively     and     assi(luousl-\-     organized      and         Past    attempts    to    provide    certain    of    these
                             supported,     particularly     atteinptincr     via      our       coiistilt@ition   services   by   or    through    out    Re-
                             Educatioii       Service       ET\'-Teleplioiie        System       (,ioiial    Office    Pro(,ram     Staff,     lia\-e     been
                             and    other    communications    s%-steins    to     support       limited    by    force    of     various     c@ctinistaiices,
                             the    '@\IUSC    to    provide    education    to    improve       such   as   funding    and    the    time    available    be-
                             services  and   care   at   the   comiiiuiii@,   level,   and       @-oiid    that     required     by     ongoing     operations
                             provide  this  iii  ways  xcqtiirii),,  as  iittle  loss   of       itiid development.
                             time   as   possible   for   those   receiving    this    in-         Other     tgencies,     with     certain      of      these
                             structioii   to    be    away    from    their    evei-NldaN-       cal),.tl)ilities,  are   likewise   limited   to   iiistitli-
                             professional practice.                                              tioiial    needs,    and    thus    at     many     community
                               We   are   iioNN@   attempting   to   assist   others    to       levels,   decisions   Lre   too   ofteii   taken   x@@itliout
                             utilize   funds   other   than   R'\IP   funds   fliat    are       the  benefit  of  exact  data  or   the   sort   of   gi-iid-
                             now    beconiin(,    available    tlirou-ii    the    Eiiier-       ance    needed     for     sound     planning     and     for
                             gency    Emplovii-lent    Assistance     Act     of     191-1       alteriiati%7e   approaches,   and    often    with    dul)li-
                             (PL   94-54),   and   the   Health    Niaiipo@N,er    Triiii-       catix,c efforts.
                             incr    Act    of    19'il,    both     the     Comprehensive         We    believe,    therefore,    that     South     Carolina
                             Act   (92-5'iS)    and    the    -Nurses    Trainiii,,    Act       can   profit    from    a    strona    committee    of    the
                             (92-571-',,   to   further   these   sorts   of   activities,       RAG    made    til)    of    individual    members     NN-lio
                             and  esl)eeiall\r  to   focus   these   iii   selected   bos-       liaN-e    of    themselves    each    appropriate    stature,
                             pitals   -,N-bere    expanded    regional    sei-\-ices',tiid       reitsoiial)lc    authority,    sufficient    autonomy,    and
                             stipportin-,   services   for   ,icljac-ciit   smaller   bos-       political    impact,    tnd    who    can    establish     bv
                             pitals   can   be   established    tbroti(rh    the    Coi)i-       presti(,e   and   leadersliij)    recognition    plans    for
                             mi,inity-Based     Healtl-i     Education     Center     type       better   coordination    and     use     of     funds     and
                             concept and expanded hospital service                               (,rants' to  ,x,ork   at   the   State   level   with   corn-
                             a(les                                                               m-Liiiitv   interests   iii   developing    pro-raiiis    and
                               As   we  look  at   NNbat   is   needed,   let   us   coii-       systematic approaches to deal          Nvitli local     prob-
                             sider  what    the     Col-iimuiitiv-Based     Health     Ed-       leiiis, but yet present tli@se         from     beina     too
                             tication    facility    for    expanded    manpoN@,ei-    can       isolated; but rather to be ible to                eiicotira,e
                             do  Nvitli  funds  xn,hicli  are  I)eiii-  i-nade   available       Iiiika(,es    and    resource    sharing     xn@itli     some
                             I)v    the    Coii,,ressioiial    Acts    previously     men-       @itithoritati%,e  backup.  This  will          not       only
                             tioned.                                                             better    utilize    SCII'I\IP    funds     available     for
                               We   are   leariiiii,,   from   our   Nieclical    District       iinprON-iiia  community health  care,  but                  I
                             Committees    what     the     community     xx,isbes     and       assist   program    development    ,N,ith    fi-ilids    from
                             health  needs  are.  TI-icre  is,  lio%%,e,.,er,   no   truly       other sources.
                             coordiliatiiic,   I)odNy   statewide   iioNN@    to    assist         Such     a     comi-nittee     will     need     supporting
                             and   able   to    serve    iii    expanding    or    coordi-       staff   capil)lc   of    providiii(,    studies    and    re-
                             nating    efforts    except    as    our     Regional     Ad-       search   to    improve    community    health,    and,    ill
                             x,isory   Groul)    and    its    comniittees    do    iionv;       addition,   by   an    appropriate    staff    section    act
                             these   can    and    should    assist    i-nore    Nx-idclv.       to   guide   educational   activities   needed    in    ctir-
                             Likewise,   sources   for   sn-stenis   laniiiiig,   ca,alti-       ricultuii   iiid   program   pl,,tiiiiinc,,   for    comiiiu-
                                                                    p
                             ation,  pro(fl-aiii  plaiii)iii(,,  analysis   of   N@ai-ious       iiity-I)ased   health   education    activities    to    pro-
                             data,   essential   for   aii@,   plaii   \vith    long-range       iiiote      expansion      of      nonprofessional       man-
                             prospects, do not exist        in    a    coordinated     way       power,    more    i-iiiiformity     of     curriculum     and
                             through               pi-ioi,it),  settiiig4l'-@evaluatioiis,       ti-,iiiiiii(y,  and  transferability   of   traiiiiiicf   ex-
                             and   the   de-%@elopiiient   of   alternatives   and   fli(,       pericii(@cs,l)y   recognition   of   or   certification    of
                             promotion     of     educational     and     infori-nation@il       itcadei-nic    equivalency    for    technical    and     oc-

                             JuLY,1972                                                                                                                     297


                                                                                             ants to expand the efforts  of  the  iio@v  limited
                                                                                             number  of  lieiltli  professionals,  which  latter
                                                                                             groups,  despite  all   efforts   by   professional
                                                                                             schools  Nvill  continue  in   short   supply   for
                                                                                             many years.
                                                                                                N@7e  have  advised  the  GoN,,ei-iior's   Office
                                                                                             and  the  Commission  on  Iliglier   Education   of
                                                                                             our  current  plans  to  develop  this  concept  of
                                                                                             regioiializ@itioii  of  effort  by  expanding   the
                                                                                                                of  the  Nle(lical  Districts   Corn-
                                                                                             iiiittee.  Through  this  Same  mechanism,   better
                                                                                             coordination of all State  a,,eiicies  relating  to
                                                                                             tli(@ health field \@,e believe  can  be  achieved,
                                                                                             as NN,ell as better utilization of all  our  educa-
                                                                                             tioii@il resources in the various  coheres  in  our
                                                                                             State, coiniiiiiiiit), and pi-i\-ate  institutions,
                                                                                             incluciiii(, those of the  infedical  UiiiN,ersity,
                                                                                             and    our    technical    as    N\-ell    as    general    educa-
                                                                                             tioii.,il facilities.
                                                                                                TI)is iicN\,Iy e       nded  committee  -,N,ill  exert
                                                                                                                   xpa
                                                                                             its   efforts   to.   ii-nprove    health    iiianpoNN-er    needs
                                                                                             I)v activities ,x,bicb:
                                                                                                  I-.jicotirage   the   establishment   or    maintenance    of
                                                                                             pi-oLraiiis  to   ille@,iate   shortages   of   health   personnel
                                                                                             in  areas.   designated,   tlirotilah   training   or   retraining
                                                                                'Niedi
                       A Poison-Drug Information Center at the @                     -       siicli  personnel  in  facilities  located  in  such   ireis,   or
                   Cal  University  is supported           by   SCIt.111'.    @kl)ove,       to  otliei-N@-ise  improve  the  distribution   of   health   per-
                   Sidney Smith, a pharmacist              in   the    NIUS('    flos-
                   pital's     Department     of      Ilbirmaccutical      Sci-N-ices,       soriiiel I)v area or I)y specialty group;
                   checks    information    received    from     a     computer     in       "B.  l'o   pi-on@icle   trammel   programs   leading   to   i-nore
                   responding    to    t    telephone    query    concerning    poison       efficient titilizttion of health personnel;
                   or drug information.                                                      "C.  'I'o  iiiitiate   new   types   and   patterns   or   improve
                   cup@itional    level    personnel     NN,itbin     the     Rc(yion,       existing   patterns   of   trainiii,@.   retraining,    continuing
                   and  thus  simultaneously  expand  trainiii                      to       education, and  ,i(l@,,ince(I  training  of  lie@iltli  personnel,
                                                                              9
                   increase    the    availability    of    services    and     health       including    teachers,    administrators.     specialists,     and
                                                                                             para-profession@ils  (p@irticiil,,ti-IN@
                                                                                                                                 ,   p]insiciaiis   assistants,
                   care,      along      NNitb      improved      employment       and
                                                                                             (rental  tl)er,,ipists,  and  pediatric   nurse   practitioners)-,
                   advancement opportunities.                                                "D.   'fo   encourage   iie%v   or   more   effective   approaches
                       It    is    only    by    such    coordination    of     effort       to  the  organization  ID(]  clelivern,  of   lie@iltli   services
                   that     deadheading     in     the     health     service     pro-       through  training  iiidiN7idtials  in  the   use   of   the   team
                                                                                             at)i)roacli  to  cleli%,ei-y of health  services            other-
                   fessional    or     occupational     fields     can     be     pre-
                                                                                             wise;
                   vented,      that      career      opportunities       can       be       "E.  To  assist  Sttte,  locil,   or   other   regional   arrange-
                   opened,    and    that    able    people    can    be     ii-iaiii-       iiieiits  among   schools   and   related   org,,ij)izations   and
                   tailied    in    employment    as    a    result    of     improved       institutions; and
                                                                                             "F.   'ro   promote   i-egiojialization   of   services    through
                   career    opportunity    in    the    health    service     fields.       iiiipro%@c(l   coii)iiiiiiiicatioiis   iiin,olviiig   the    SCRMP
                       It   ",III   be   only   tlirouh   such   efforts   that    the
                                                   0                                         \IUSC   11-Ilospital   Networl-,   in   cooperation    with    the
                   turnover    rate    of     some     skilled     and     semiskilled       Stite   ETN7   in(I   telephone    system    and    other    NIUSC
                   employees    in    healt.h    facilities    can    be     al)at(@d,       coiiiiiitii)icatioii resources."
                   and    that    job    barriers     cai     be     penetrated     so         We     hope     members     of     an     expanded      Nledical
                   that     occupational     and     educational      ladders      can       District       Committee       to       iiiiproN7c       Community
                   be   achieved.   -Only   in   this    N,.,ay    can    the    staff       11@tltli     Services     will     achieve     coordination     of
                   Nvorkers    of    smaller    bospital.@    be    assured     oppor-       effort  in   trial   of   iienv   systei-ns,   tiid   in   extend-
                   tunities     for     staff     advadceiiieiits     and      receive       iiig   miiipoxx,er,   ictivities   which    IINIP    is    vitally
                   the     sorts     of     continuing     education     needed     to       iiit(-i-csted  in  and   charged   ,N,itli,   but   NN?Iiieli   it
                   become    and     remain     effective     aides     or     assist-       cqiii    only    acliicv(,@    noNN,    piecemeal    because    it

                   298                                                               THE JOURNAL OF TITF SOUTH CA11OLINA ,%Irr)iCAL  AsSOC1.4,TION


                      exists  as  only   one   of   the   several   sep@ii-ate by    demonstration    and     training     techniques,
                      health-related or(ranizatioiis.                      aettiiliv  assistiii(,   existing   manpower   expiiii-
                        It is by this route that we believe      or-anized sioii,   and   is   health   care   more    accessible,
                      .\Icdiciiie and medical   edtication@il    institutions effective,  and   efficiently   delivered@'   If   not,
                      can  likc\\,ise best  exert  tlieii-  strcii(Ttlis   and should   the   objectives    of    the    program    be
                      kno,.\rled,,c in t,,uidiiiiee iii)d c\@aluatioil.    cliaii,,ed  or   projects   discontidued?   There   are
                        In order to better  cai-r\-  out  its  mission   in decisions  vital  to  the   SCIINIP   and   other   Re-
                      South    Carolina    staff    functions    and     coni- gioiial   i\lcdical   Pro-rzims.   Simply    expanclina
                                                                                             ZD                        C)
                      mittees  of   the   Ile(lioiial   Advisor   Group   will programs  and   expeiidiii,,   funds   -will   not   be
                                       n              y                     11                      0
                      be   reorganized   aiid   be    functionally    oriented helpful  to   health   care,   nor   merely   expanding
                      rather   thin   cate(yoriciillv   oriented.    Committee iiiaiiponver.
                      menil)ersl)il) \\-ill  also  reflect  this  to  (ireater It   will   require   leadership,   effort,   and   co-
                      degree   thin   previously.   The   SCRNIP    will    be operation   by    the    physicians    and    community
                      able  to  respond  more  qLiickIN,  to  iien@,   oppoj-- leiclei-s   to  accomplish the       ii-npro\@ements
                      tuniti(,s for the physicians of South    Carolina,   needed and sought.
                      and  other   members   of   the   health   profcssioils, SCBNIP can and sliould   provide   the    fraiiie-
                      to assist in seekiii,, and   secul-iiic,   the   support for the actions needed.
                      needed that                                          The    proposed     membership     of     the     newly
                       A.   Promote   iiiion(,,   providers   at   the   local cxl)iiiic](@d committee will consist of the  follo,,N,-
                      level  new  techniques  and   iiino\,ati\-e   deli\-ei-v iii(y i-epreseiitatiN,es,  most  of  wlioi-ii  are  now
                      patterns  to  iiiiproN,6   accessil)ilit),,   efficiency members of the RAG:
                      and effectiveness of health care.                    The State Board of Health
                       B.   Support   activities   that    would    help    to T)ie  S.   C.   -\Iedical   Association   Council   and
                      improve  utilization  of  existiii(r  maiipo\@,ei-   and Foundation
                      new  kinds  of  niatipo\-,,er,  especially  in  nuclei-- Ilealth Insurance Providers
                      served areas.                                        TI)c   S.   C.    Department    of    Vocational    Re-
                       C.   Encotira-e   re-ionalizatioii    of    '    health habilitation
                      facilities.                                          The S. C. Departi-neiit of Education
                       1).   Assist   in   developing   specific    mechanisms The S. C. Department of Public NVelfare
                      for  quality   control   and   approved   standards   of 'Technical education schools
                      care.                                                The Commission oii I-li(,her Education
                       E. Like\x,ise,    the    promotion    and     develop- Office   of   Coli-ipreliciisive    Health    Planning,
                      iiiciit of systei-ns  for  (  1)  nionitoriiia  the  qiial- State Board of Health
                      ity of health   care;   (2)   improi-einent   in   einer- -Nleinl)crs  from  the   public
                      gency me ica services.                               The  S.  C.   Hospital   Associ,ition
                       F. By such supports  to   health   services    de-  Tli(,   Goveriior's   Plaiinilicr   &   Grants   Office
                                                                                                    In
                      livery sN @stenis, I)ette-.- utilization and improved foi-  Community   Affairs
                      distribution of health manpower  for  services       The S. C. Department of Meiital Health
                      and patient care should result.                      Tlic! S. C. @Niciital Retardation Commission
                       G. Lastly, but of  priinar),  importance,  is       The S. C. Nurses'Association
                      the function of  yearly  evaluation  tiid  re-       Ilepi-eseiitati%,es of allied health  science
                      evaluation of the SCIliNIP pro-raiii  and  its        schools
                      component projects. Are the  programs  really,       The Nledical University of South Carolina

                      JuLY,1972                                                                                       299


                      Vol, 286  No. 4                              RAI)I.;k'I'ION                   I"[,()O%l E'I'

                                                                           SPECIAL ARTICLE

                      RADIATION THERAPY IN NEW @HAMPSHIRE, NIASSACHUSETTS AND RHODE ISLAND
                                                                                 Output and Cost
                           BERNAIZI) S. 111,00%1,                 OSLEI@ I,. I'E'I'I'-I@SON,      Ni.1).,            ANI) S.kNIUI:I, 1).
                      Abstract  There are large          variations   in    input,    out-        far higher proportion of patients with cancer, an
                      put and cost of radiation          therapy      among      different        the  therapy     provided     is     more     expensive.      The
                      categories of hospitals.  Hospitals with simi              'lar     pa-     greater   cost   is   due    mainly    to    the    larger    and
                      tient   loads   exhibit   similar   investment,   staffing   pat-           more     diversified      staff     administering             radiation
                      terns and disease mix. The use of facilities,                   equip-      therapy.
                      ment  and   staff   in   low-patient-lbad   hospitals   is   less             Five   major    centers    could    provide    the    necessary
                      intensive and includes a high proportion of                      benign     radiation   therapy   in   the    area    studied.    The    cost
                      conditions.     The      high-patient-load      centers      make           would   probably   be   higher,    but    the    results    could
                      more intensive use of their resources and                   treat     a     well be superior.
                         ISING    medical-care    costs    throughout     the     world           1)), iiii@, t@-pe of irradiation diiriii(,  196f).  Since  dzit@t
                                                                                                                                             I
                      Rhave   induced   a   search   f'or   greater    efficiency    of           collection I)etran in June, l@)70, the fiiiaiici@il
                      resource   allocation   and   more   effective    delin,erv    of           iiiatioii  Nvas  gathered  for  the  previous   hospital   fiscal
                      health  and  medical  care.  \ILicli  of  the  rise  is  due   to           @,eai,   of   October   1,   1968,   through    September    ')O,
                      the  increase  in  utilization  of  medical   services   and   to           1.9C)(). 'Flie patient tre@ttmeiit (lat@i %vei-c  g@ttliered  for
                      the   changing   nature   of   the    practice    of    medicine,           the year ending December 31, 1969.
                      which   involves   the   greater    use    of    expensive    and             The cl@it,,t recorded for  e@iell  patient  iiiclll(l(@(i  tile
                      complex   techtiolo,.,),   ai-id   procedures,   Tile    product,           c@itegoi-v  of  disease,  number  of  treatments,  iiii)@iti(@tit
                      as  Feld,,iteiii  has   ei-npliasized,   has   changed.'   i\lost           or otitl-)i,itient, first or recurrent ('()LIl@s(. of,
                      c(!oiloniie  research  is  coiceiiti-iited  on  the  large   are-           ai)d  tN@I)e  of  treati)ieiit   (stipcr\,olt@i@,c-,   ortlio\@oltiIL4e,
                      as  -  on  hospital  and  insurance   costs,   and   on   prinia-           superficial],   radioactive   iiiipl-,iiit   oi-    applications.
                      ry   physician   changes   -   and   not   with    the    smaller           These dita ,N,ere oi)taii)ed from eitliei- tli(,,
                      components   that   make   tip   each   of   the   areas.    This           iiielital lo(., book or  the  individual  patient  ii-c@itiiieiit
                      study   concentrates    on    one    such    component,    radia-           records.
                      tioi-i therapy.                                                               The  information   on   hospital   income   i,liid   exl)eiidi-
                                                                                                  ttires N@!,ts available oill@7 in aggregate  0
                                                                                                                                                      f' i-ii)  and  Nvits-
                                                 OBJECTIN@E                                       o]3t@iiiied  from   tl)e   hosl)itzil's   fiscal   records.   Of   tli(-
                       The    purpose    of    this    investigation    is    to    deteriiii-    sampled    hospitals,    one    provided    no    tbei-@il)@-     during
                      nii-te   the   various    t@,pes    of    diseases    currently    being    1969;   -,mother   that   treated   oi)ly   -'-)5   patients    declined
                      treated   I)v    irr-,Idiatioii,    total    patients    treated,    the    to   ftiriiisli   information   on    the    disease    categories    of
                      number   o'f   treatments   given   to    each    patient,    the    to-    patients    treated.    The    definitions    of    the    fiii@tilciiii
                      tal    number    of    treatments    given    iii    each     radiation-    terms   used    conform    to    standard    iccotiiitiiig    or    eco-
                      therapy unit ai-id the hospital costs of therapy.                           iioiiiic usage.*
                                              STUDY DESIGN                                                                     RESULTS
                        A  sample  of all  hosl)it@ils  iii          New         llitrnpsbire,      All    tile    information     gathered     was     separated     into
                      Massachusetts ;iiid Rhode Isl@ind             from    the     uiiin,erse    three   categories   -   input,    output    and    cost.    The    data
                      providing rAdiittioTi  tlierap@@ was          selected    rLtiidoiiil-,7    on   input   are   concerned    with    the    f@icilities,    c(Itiii)-
                      after    stratification     I)v     reaching     function     (universal    iiici)t   iiid   personnel.   The   data   on   Output   deal    Nk-itli
                                                                                             y
                      affiliated,   ot@ier   teacl)iiig   and   iioiiteacliiiig)   .iiid   I)v    the   patients,   their    disease    and    treatment.    Fiii@iiiciiii
                      number   of   treittiyieiits    given    during    1968    (less    than    diiti    i-elite    to    the    income    and    expenditure     under-
                      1500    treatments,    or    low    patient    load,     1500     treat-    tikeii 1)@, the hospital. 7'/ie hospital Lost i.@ oitlil
                      ments  or  more,  or   high   patient   load).   One   fourth   of   the    cet-tt(,tl with the (Iii.(!e@t 1))-ovivit)ii of i-(tdicitio@t
                                       itcli  cell  %k,ere  studied,  Nvith  it   minimum   of    I)il.  It  does   not   include   inpatietit   costs.   It   does   iii-
                      hospitals in e
                      one hospit@il sttidied per cell.                                            cIti(le   costs   of    continuing    or    student    education    iii-
                        The     patient     population     included     everyone     ti-e@ited    ctirr(@ci  by   the   department.   Ti-iivel   expenses   or   -,viiires
                                                                                              I   forgone by patients are @ilso excluded.
                        From the Dcp,,trtniefit of PreN,enti%,e and Social Niedicine,  Harvard    Input
                                      -,True the Derirlrer,@i -f C'ornmi-nitv NI(-(Iicine- I Jniver-
                      sity of Pennsylvania School of Nledicine (address  reprint  rcqucsts  to
                      Mr. Bloom at the Department  of  Preventive  \Iedicine,  Harvard  Nledi-
                                                           \@12gs- 02115).


                                                                                              NE\V                                      01:   \IE1)1(:INE

                                                                             Table 1. Facilities and Equipnient, by  Hospital  Group,  1969.

                                      I rE"l                                                                                             liosi@il;\l (iKOk.1'
                                                                                         t@ll%'IRSITY   KI.I.AIEJI                             offiER   IEACIfIN(i
                                                                                                   A             B                                                                            -4
                                   No. of lio@pit@ils                                              4             2                                  2           3                              2             3
                                   Ficilities (ft")                                           12.865             475                            2,200       1,060                          5.113        l@870
                                   I'(Itiipnient:
                                   SLIVei-voltage:
                                      1-inear accelerator                                          2             -                                  -           -                              I
                                                                                                   I             -                                              -
                                      Betatron
                                      Cob@kit                                                      3             -                                              -                              I             I
                                   Orthovc)ltage                                                   4             2                                  2           3                              1
                                   Superficial                                                     4             2                                  2           .-                             2             1
                                   Total  capital investment                             S 1,504,346  $72.3 35                               $223.500           $99,350                  S4;42@603         S)73.,;6.@

                                   'A indicates high, & 11 low p@itient load.

                                   able for the provision  of  radiation  therapy  and  tlieii-                               number  of  patients  treated,  total  Treatments   (zil.'ell
                                   1969  cost.  Table   2   shows   the   personnel   and   the                               and  average  i-itiml)er  of  treatments  for  each   Patient
                                   cost  for  fiscal  1968-69.  The  larger  treatment  centers                               are presented. The range is from a 101%11" Of  4.3  tre,-,',-
                                   have        more   extensive        facilities        and         equipment,         a     ments      per      patient      in      a       iioiiteaching,       low-patieiit-loid
                                   greater number  and  di-,,ersitv  of  skilled  manpower,  @i                               hospital to a high of 19.()  treatments  in  a  iiiiiversit,.
                                   larger         capitil         investment         and         higher         personnel     affiliated,   high-patient-loid   major   medical    cei-,tey
                                   costs.     In     the     hospitals     with     high     patient     loads,      per-     These    differences    -,ire    due    i-nainl\,    to    the    iiiix     of     dic-
                                   soniiel costs are a far higher  proportion  of  total  costs                               eases       treated.       The       in,@ior        medical        centers        tre-@
                                                              I                                                               more      patients,      iiielil(lill,-      maiiN7       rnalixiiaiit       le,;io!Il-
                                   than    in     those     \k,itl     low     patient     loads.     The     lCw-treat-'                                                                      I
                                   ment-load        hospitals        provided        their         few         treatments     more     difficult     to     treat,     and     give     more      treatments      t(,
                                   by       borrowing       personnel       from       the       radiology        depart-     each      patient.      The       low-pitient-load       hospitals,       in       con-
                                   meiit. There are few, if -tny, nonpli\                                       personnel     trast,    treat    more    benign    --rowtlis     -,Ii-id     fewer     pi-ol-,Ie-@i-@
                                   (physicists,        dosinietrists         tnd         radiation         technologists)     cancers.      The       ver\l       large range     in     patients     and      treat-
                                   to     provide     the     complete     range     of     services     for      patient     ment@ is striking.
                                   treatment.      In      all      low-patient-load      hospitals,       the       bulk        Table  4  slio\@,s  the  patients'   Treatment   status   -
                                   of     the     personnel     cost     is     for     the      part-time      physician     whether      treated      on      an      outpatient      or      inpatient      his;-.
                                   and          technician.          The          higb-patieilt-load           hospitals,     and    \,,7hetlier     a     first     or     recurrent     course     of     treatment
                                   with     their     greater     diversity     of     staff,      show      a      wider     The       iioiiteacliiiig       hospitals,       usuall\-       located        outzi@t-
                                   distribution       of       cost       among       the        various        personnel     the      metropolitan      areas,      provide      more       priiiiar\.       tre@il-
                                   categories.                                                                                ineiit,   \vbereas   the   te@icliiiig  hospitals   include
                                   Output                                                                                     greater        proportion         of         treatments         for         recurrence-
                                                                                                                              The      low-pittiont-load      hospitals      treat      a       larger       propo3,-
                                      In  Table  3,  the          aggregate      statistics      on       the       total     tioii     of     their     patients     as     outpatients,     owing     in      Itrzr

                                                Table 2. Number, Type and Cost of Personnel, by Hospital Group, October 1, 1968, to September 30, 1969.
                                             ITEM                                                                                               HOSPITAL      CIP.OTJP'
                                                                                                   UNIVI:RSIIY REI-AFEF)                               OTKER TEACHI!'G                               NONL  EkC  141"
                                                                                                   A             B                                       A            8                                 A
                                   No. of hospitals                                                4             2                                     2              2
                                   No.   of    F7Et
                                      radiotherapists                                              7.5           0.15                                  0.75           0.1                            1.8
                                   No.   of    F'FE
                                      physics personnel                                            5.6           0                                     0.8            0                              0
                                   No.   of    F-FE
                                      teclinol                                                     11.0          0.25                                   2.0           0.@                            4.06           0
                                                ogists
                                   No.   of    f7fF
                                      all other personnel                                          11.5          0.45                                   0.55          U.;"
                                   Annual personnel cost                                    $563,903             $7,660                                   $88,499     $6.9@@)
                                   % of total cost                                                 67.7          35.8                                 56.7            20.9                           66.4


         72                                   \-(,I. 28C)   No- -1                                                  RADI.,%']'ION                                                    E'l-

                                              Table 3.       Total     Patient     and     Treatment     Loads,     by      Hospital                             Cost
                                                                                         Group,      1969                                                          Of   tli(,,   expenses    iiictii-i-ed    b@,    the    hospitals    ft)r    t'@
                                                                                                                                                                       -O\,Islo
                                                14(APITAL               PATIENT     No. oi@          TOTAL          I-OTAI,           AN        l@l@A(;I.                        it of rit(li@itioii therapy, the cost of
                                                 GRokip              LOAI)        HOSI@ITALS        PAT]f.NTs        TIEAT.@IENTS        II([-Af\[[.,,TS/        I)eii-s    most    he@i,,,il\,    oil    the    liigii-I)iitieiit-load
                                                                                                                                       PA I I
                                              UiiiN,crsity           High                4           2,232          34,798              15.6                     t@ils.   'file   exteiit   of    stziffiiig    and    costs    in    tile
                                                related                                                                             (13.2-19.0)-                 1),,ttieiit-lo@id    liosl)it@tis    is,    by    contrast.     lo\%-.     Expense
                                                                     Lo%\,               2              151               1,450           9.6                    supplies    is    relatively     minor-     in     all     lio,;I)itlt'IS,     t,-
                                              other                  High                2              545              5,766           10.6                    though    in    all    Iiigli-pati(,iit-load    I)osl)it@ils    tile\-
                                                teaching                                                                            (       9.4-15.4)            ttite   it    higher    percentage    of    tile    total.    O\-eylie@t(I    @ill
                                                                     Low                 3              56                  810         14.5                     del)i-e(@iatioii      expenses      are       iiiversel\-       I)i-o,,lortii)titl
                                                                                                                                    (I 1. 7-1  S.  1)            patient    load.    The    largest    portion    of'    e.\I)(-ii@es     in
                                              Noiiteachiiig          High                2              640         10,875               17.0                    low-I)atieiit-load      hospitals,      which      is       fixu(,       is
                                                                                                                                    (13.8-18.7)
                                                                     Low                 3              254              1,843            7.3                    overhead tiid depreciation.
                                                                                                                                            4.3-11.1)              N@,'Iieii    total    costs    are    viewed     in     rel@itioti     to
                                                                                                                                                                 ntin)l)ei-      of      patients      treated      and       Treatments       -,i\
                                               *Figures in parentheses are ranges.
                                                                                                                                                                 average    costs    are    greatest    in    t    e    iig    -I)iltiei-it-
                                              measure     to      the      treatment      of      nearly      more      I)eiiigii                                hospitals    (Table    7).    The    onl@,    exception    is     the     ()tli..-
                                              conditions.                                                                                                        teacliil'ig-bospital      group      providing       less       thrift       l@5i@
                                                 Table     5     shows     that     patients     -%\,itil     malignant     I)roc-                               treatments.    This    is    due,    in    part,     to     the     iiicltisiti-,i
         it                                   esses    account    for    the    btilk     of     all     patients     (83     per                                the    sui-vey    of    one    hospital    tli@it    did    not     provide
         t-                                   cent)    and    for    an    even    larger    proportion    of     all     ti-eat-                                treatments     during     the     year     tender      sued-\-,      thus
         d                                    ments     (96     per     cent).     The     range,     by     hospital      group,                                iiig     the     average     costs.     The     reason     for     the
         y                                    however,   is   great   -    from    30    per    cent    to    98    pci-    eclat                                I)er-patieiit     loid     fotind     in     the      Iiigli-treatiiient-l(i,,.,'.
                                              for   patients   and   fi-oiii   68   per   ceiit    to    99    per    cent    for                                hospitals     is      the      larger      and      more      cost]\.      staff..
                                              treatments.      Patients       \vith       cancer       were       cliaracteristi-                                slio\vn   iii    Table    2.
         it                                                                                 radiation      over      two      week,,      or                        Ili     eN,erN,     hospital     studied     the     cost     of      ,)ro,.-4c
                                              call),    givei-i    r-,xtc-iisi\?e
                                              more,     whereas     those      with      benign      conditions      tisti-,IIIN'                                radiation           therapy      far      exceeded       the       income       deep".
                                              received     one     to      four      treatments.                                                                 with         only   three     exceptions.     One     made      oiilx.      a
         0

         n
                                                     Table    4.    Percentage    of    Primary    Treatment,    Treatment    of    Recurrence,    Inpatient    and    Outpatient,    by    Hospital     Group.     19-@.

                                                                     HOSPITAL                     PATIENT                No.       OF                   TOTAI-           % PRIMKRY                  %'I'REATNIENT                      %
                                                                 CROUP                               LOAD              HOSPITAI     S                   PATIU@N IS      TREAT NIENT                 OF RECURRENCE               OUTPATIENT                 I%PkT-.Fl      I
                                                         University related                          High                       4                       2,232                    73.2                     26.8                         66.8
                                                                                                     Low                        2                       151                      70.9                     29.1                         69.6
                                                        Other          teaching                      High                       2                       545                      80.2                     19.8                         67.7                    -,2.
         e
                                                                                                     Low                        3                       56                       73.2                     26.8                         98.2                    1,8
                                                                  Nonteaching                        H     igh                  2                       640                      89.1                     10.9                         77.7
                                                                                                     Low                        2                       229                      93.9                         6.1                      97.4                    :!.6
         a                                                  All       hospitals                                                 15                      3@853                    77.9                     21.1                         71.1                    29.9

                                                  In        all         the         hospitals         studied,         with         the         exception of     mal          profit,          and          two          covered          expenses.           In
                                              the     noiiteicliiiig,      low-patient-lo@id      ones,      there      is      t                                hospitals       income        covered        less        than        50        per        ceit        c%.'
                                              great       deal       of       siiiiiiarit@-        in        the        distribution        of        the        costs.           Five           aclditionil           hospitals           generated           en,-,)i!,,--,
                                              malignant        diseases        treated         (Table         6).         In         most         liospi-        income      to      cover      only      between      V2      and      '/3      of       their       cc@-'
                                              tals       about       50       per       cent       of       all       patients        were        treated        One      other      hospital      met      80      per      cent      of      its      costs      fr.,)I,@
                                              for    three       types       of       cancer       -       those       of       the       lungs       and        incoi-ne.
                                              breast and the  l@,i-nphoma group.                                                                                     In       1969       there        were        67        hospitals        in        '\ew        liailil-

                                                       Table       5.       Total       Patients       and       Treatments,        Percentage        of        Malignant        and        Benign        Conditions,        by        Hospital        Group,        19C--O

                                                     HOSPITAL          CIROUP       PAIIE@%T         LOAD                           T(ITAI-                                      % N%'IIH CANCER                               % wiT ti BL NICN
                                                                                                                         PAIII@NIS          IREA1.11L."[S                  PATIENTS          TREAT SI LNTS                           PATIE@NIS                   i-
                                                   University           related             High                                2,232              34,798                        94.8               98.6                               5.2                 1,4
                                                                                                                                                                                 55.6               Fl".Il
                                                   Other teaching                           H   igh                             545                 5,766                        65@3               87.7                               34.7                12.3
         @O                                                                                 Low                                 56                      810                      98.2               99.5                               1.8                 0.5
                                                                                                                                            l@        QIK                        RA  A              96.0                               15.6                4.0


                                 192                                       'FIIE NE"'                                         Ol,'        NIEI)I(@INF@                               Iitn.   27,    l@)72
                                          Table 6, Diagnosis, According to Site, and Percentage of Total Patients, by Hospital Group, 1969.
                                     SilL          1-01 Al P@%l [i-N I F,        U.Ni%,i Rsii), Rr..I.AIED  I'@)          01   li@,it   I'LACilIN(i                     NoN I F.ACIIIN(;
                                                                                  lii6ii               1,0,A              tfl(;Ii              low                141(@ll

                                 Ntalignant:
                                 Oral                     3.1                    3.9                   0                  0.2                  1.8                4.7                     0
                                 Pharynx                  1.4                    1.4                   0                  1.1                  1.8                2.5                     0
                                 Gastrointestinal         6.7                    8.  I                 2.6                5.5                  10.7               5.1                     1.7
                                 Nose, car. larynx        2@6                    3.2                   0                  0.6                  1.8                3.4                     1.7
                                 Lung                     15.3                   18.6                  4.6                13.4                 12.5               12.5                    311
                                 Breast                   16.5                   17.3                  13.2               i 5.6                28.6               16.6                    9.6
                                 Female reproductive      8.5                    9.9                   2.0                6.8                  5.3                9.4                     1.7
                                 Male genital             2.5                    3@2                   1.3                2.2                  0                  1.6                     0
                                 Kidney, ureter,          3.9                    4.1                   0                  4.0                  7.1                4.5                     1.7
                                 bladder
                                 Skin                     4.3                    3.4                   2.0                3.5                  3.6                7.2                     7.9
                                 Lymphatic s%@stem        9.8                    12.4                  3.3                7.3                  3.6                8.3                     0.9
                                 (1@@tiiphonia)
                                 Other                    8.9                    9.2                   26.5               5.1                  21.4               8.6                     1.3
                                 Nonnialignant:
                                 All                      16.4                   5.2                   44.4               34.7                 1.8                15.6                    70.3
                                 All hospitals            100.0   (3.853)*       100.0 (2,232)         100.0 (151)        100.0 (545)          100.0 (56)         100.0 (640)         100.0    (254)

                                 'Figures in p;irenthees indicate tot@@l patielit5.
                                 sliire,    Niassachtisetts    and     Rhode     island     that     had     fit-     st@iffilig     levels,     larger     and      more      complex      f@ici      ities
                                 cilities    for    radiation    tlieral)v.    \lore    than    65    per    cent     Fire(]     e(Iiiipnieiit     an(]     deal     with     i-nore     I)rol)lem      dis-
                                 gave    less    t)iati    150()    treatments    per    Nlear.,2    NIost     of     eases.
                                 the  e(iiiil)zne)it  was  for  either  stipei-fi       cial      (40      units)         The     cost     of     building     and     e(Iiiil)piiig     the     facilities,
                                 or    ortlio-,,oltage    (65    units)    tre@itnients,    There     were     13     altliott,,,Il     large,     is     overshadowed      I)y      the      total      ex-
                                 col)alt   units,   two    of    \N,hicli    were    in    lo,,N,-p-,ttieiit-load     peiidittii.es     that     will     I)e     incurred     over     the      operatiii(r
                                 hospitals.    For    %@erv     hi,@b-eriei-gy     irradiation     there     \vas     life     of     the     unit.     On     the     average,     @iiintiil      operating
                                 available     one     Betatron,     three     van     de      Graaf      genera-     costs    \vere    e(Itial    to    64    per     cent     of     total     investment.
                                 tors    and    four    linear    accelerators,    all    at     higli-I)atieiit-     with    a    range    of    14    per    cent     to     151     per     cent.     The
                                 load  centers.                                                                       low-p,,Itieiit-load         hospitals         incur         average          operating
                                 The    total    investment     and     cost     of     operations     of     all     costs     eqtial     to      17      per      cent      of      gross      investment,
                                 radiation    facilities    in    the     tliree-state     area     has     I)een     \vliere@is     in      the      Iiigli-patieiit-load      centers,      average      -
                                 estimated    from    the    study    sample    data     (Til)le     8).                           operating      expenses      equal       75       per       cent       of
                                 The    bigii-pi,ttieiit-load    hospitals,     20     of     the     67     hos-     gross              investment..
                                 pitals   with   radiotlieral)),   f@icilities,    ac(-otiiit    for    60    per                                      DISCUSSION
                                 cent  of the     total     iii\-estiileilt     outlays     provide     93      per
                                 cent  of all    treatments    and    inctir     90     per     cent     of     the       This       investigation       has       dei-noiistrated       large        varia-
                                 annual Costs    in    the    three    states.     It     is     evident     that     tioiis    ill    input,    otitpilt    and    cost     of     radiation     ther@ip\-.
                                 average      annual      operating      costs      and      investment       are     Ilosl)itals     \\,itli      sii-niiiir      patient      loads      and      teaching
                                 similar    for    all    hospitals    with    low    patient     loads.     This     functions       showed       little       variation       in       investment       in
                                 is  dtie to     similar     facilities,     e(Iiiil)i-iieiit     and      staffing   facilities    and     e(Iiiipilleiit     and     in     personnel,     ])tit     high-
                                 patterns.      The      higl)-I)atietit-lo@id      centers      show      higher     1)iitieiit-load      centers      had      capital      investments      three      to
                                 ol)er,,ttii-ig    costs     and     iiivesti-neiit.     They     have     higher     five    times    greater     tl)@iii     those     of     tile     lo\v-l)atieiit-load
                                        Table 7, Total Expenditures and Average Costs, by Hospital Group October 1, 1968, to September 30, 1969.
                                 fiOSPITAI (;ROt,P                  PAII@'T                No. or                     TolAl   COS]                        AN'L.R (;E                      A\  F-RA(,E
                                                                   I,OAD                       Hosi,IIALS                                            COST/PA I ]EN  r  (s)          COSIft   RF.ATkiFNT    (S)
                                 University related                High                       4                           832,706                         374.93                             23@94
                                                                                                                                                     (321.91-406.3    I)*                 (16.9i-30.20)
                                                                   Low                                                    21,404                          141.75                             14,76
                                                                                                                                                     (13'-).97.156.63)                    (11.97-22.1-1)
                                 Other teaching                    High                        2                          155,966                         28   1.53                          26.98
                                                                                                                                                     (260.08-396.79)                      (25.79-1-7.531
                                                                   I-OW                        3                          33,380                          596.07                             4  i.21
                                                                                                                                                     (449.82-5     13.73)                 (29.72-43.81)
                                 Nonteaching                       High                        2                          1784628                         288.58                             16.41
                                                                                                                                                     (182.8'-)-330.95)                    (13.21-17.70)
                                                                                                                                                          ')n4   65                          28.20


                         %,()I, 286  No. @l                           RAT)IA'I'ION 'I                               I-"[' Al,.                                                    I
                         Table 8. Estimated Gross  Investment  and  Annual  Operating  Costs  of  All  Radiation-Therapy  Units  in  New  Hampshire,  N?iassa-
                                                                 chusetts and Rhode Island, by Hospit@il Group, 1969.
                         liost-ii Al- (jRot@p    ['A I  If-Nl    No. OF                 IIIAI [A)            A\ I IZA(;@.       F-Sl III @l  I  11  IANNLIAI, AVFT(A(IE .'kN't It
                                                  LoAr)        I l(JSPI rA] S      ]'OIAI           (;R,)Ss                     01-i  i@  %I  INC;  COST   S0111@RAII.I(i(l)lt
                                                                                   I          I      S                                                       fiosi@il,@l,   S
                         University, related      11   igh            8                       2,557.000       3     19.625                 1.974.142                246.768
                                                  l@o\k,              1 2               806.000                 67.1    67             116.560                   9@7    13
                         Other teaching           H   igli            I 0                    1,137.000         1    13.700                1.72'-,475               172.248
                                                  Low                 1 4               597,000                     42,643             136,158*                   9.7   26
                         Nonteaching              liigh               2                 49       1.000         24    5.500             178.628                      89@314
                                                  Low                 2 1                    1,205@Ooo          57.38    1             19     1.140                  9.102
                         All htispitals                               67                     $6,793@000      S    i(it.388         S4.3      19,103t               $64.464
                         Includes total cost of hospital unit that perfL,inied no therapy.                              tintcrest iricotiie  foregone  not  includei  in  ittiN@  estiniziled  cot@.
                         hospitals.  N\'Iieii  the  investment   per   case   is   coiii-                is  stril@iiig.  The  radiotherapists,   wl)o   \,,,ere   -,I,,,,-are   of
                         pared,    the    differences    disappear.     These     two     f@ictors,      this fact, repeatedly st@tted tli@it the appropriate
                         low investi-nedt and  fe\,,,  personnel,  allow  IoN\7ei-  titi-                I)ital   i-oles   ,A,ere   reversed:   the   niijoi,    treatment    ceii-
                         lization   without   any   Increase   in   cost   per   patient.                ters \\,ere often treating  patients  palli,,iti\,elN-  \N-lieii
                         This,  however,  limits   tl)e   versatility,   and   range   of                tli(*,   should   have   I)eeii   providing    the    priiiiar\,    treat-
                         treatment     capabilities     as     compared      to      the      high-      iiieiit,   and   tl-ie    smaller    hospitals    were    giviii@l,    the
                         patient-lo,id   centers   and   ma\,   limit   the   raii(,,e   of    I)a-               course    of    treatment    when     they     should     Iiiix-e
                         tieiits   who   can   OI)tain   optimum   care   in    the    lo\x,-Io,,id      I)eeii
                         hospitals.                                                                      The   final   criteria   for   ziiiv   treatment    (!enter    is    prod-
                         In    addition    to    the    problems    of    financing    kind    cost      ticti\,it\,,  which  not  oiil%-  iiivol\,es  \-olliiiie   I)tit   has   a
                         is    the    shortage    of    the    personnel    needed    to     direct      dimension of qtialitv.        riie   final    case    outcome    is    the
                         and    give    radiation    tliertp@,.    There    are     simpIN,     not      I)est   iii(@@istire   of   qtizilit\-.   ]:)o   the   more    expeii@in-e
                         c-,i-iougli pli)@sicians,  pl,-,@sicists,  d(,siiiietrists  all(]  tc!cli-      hi@,l)-I)@itieiit-lo@ici (centers      produce       iiiore        ciires.
                         iiologists  ill  this   stil)sl) ecialtv   to   treat    the    number    of    loiigei-   stirn,ival   or   fewer   coml)licatioiis'@@   This    stiicl\.
                         patients   who   coiild    be    expected    to    benefit    from    this      his   no   data   oil   this   (Itiestion.   Ilowe\@(-,r,   Grahaiii   and
                         therapy.'-'                                                                     PLlotic,eL-   presented    e-,@i(leiice    that    the    survival    rate
                         In     the     lo\?.,-patient-load     hospitals,     tl)e      diagnostic      \N,@is   better   in    Iiigli-patieiit-load    centers    for    patients
                         radiologists    and    oti-ier     staff     provide     the     radiation      ti-(!@.ited  1)),  irradiation   for   cancer   of   the   cervix.-3   The
                         therapy on a part-time basis. The diagiios                               -      superior    result    was     ttril)tite
                                                                                  tic       radiolo                               a             d   to   the    special    physical
                         gist   must   perform   the   functions   of    the    pli),si(@ist    and      f@icilities    and    equipment,    a    concentration     of     clinical
                         dosimetrist    and    even    of    the    technician.     This     repre-      material   and   the   gre@iter    experience    and    skill    of    the
                         sents   borrowing   of   people   -,,%,Iio    have    other    priiil-.trv      staff.   Thus,   the   crux    of    the    question    rests    on    the
                         functi(iiis   and   is   a   poor   utilization   of   a    r@idiologist's      (iiiilit@7   of   the   product   and   higlili(l,lits   the   need    for
                                                                                                         data   oil   the   results    of    treatment    reflecting    surx-6-,-al
                         time   -   not   only   because   lie   is    performing    too    iiiaiiv
                         functions   but   also   I)ecitise   it   detracts   froi-n   his    pi-i-      tiii-ie   and   the   qtialit)-   of   life   during   survival.   N@'itli
                         mary     function     of     diagnostic     radiology.     This     lowers      rise   of'   the   criteria   established   bNl    the    Committee    for
                         his    productivity    in     both     functions     and     also     runs      Radiation Therapy Studies' and              the    findings    of     Gra-
                         counter    to    ,he    increasing    trend    to    separate    diagiios-      liai-o  iiid  Paloticek,3   it   appears   that   the   future   coi,.r,;e
                         tic     and     therapeutic     radiology     in     training__and      in      should be to strengthen the m@ior centers and
                         practice.                                                                       don the units with lo,.N- patient loads.
                          The    diseases    and    conditions    treated    in     the     bosl)i-       The    r@iiige    of    operating    costs    experienced     bx-     the
                         tals    with    high    "Ind    low    patient    loads     were     quite      individual    hospitals    was    great.    It    costs    three     times
                         different.    The     high-I)atieiit-load     units     treated     larger      as   much   to   treat   a   1)@itient   in    the    most    expeii-;i\-e
                         numbers      and      percentages      of      cancer.      The       low-      liigii-I),Ittient-load   center   as    in    the    least    costl@-    ION\--
                         patient-load    iiiilts    treated     niann,     I)enigii     conditions,      1)@itieiit-load   hospital.   The   high   costs   are   due,   @t.,   our
                         such   as   bursitis,   pl@iiitir   \vart,   keloid,    ten(loi)itis    and     data   have   slio-,N,ii,   to   the   larger   and    more    diversified
                         el)icondyliti.s.   E(juitlly   striking,    ,Nas    the    small    amount      st@iff  gi\,illg  i-@idiatioii   therapy.   The   tre@itnieiit   of   more
                         of   radiation    therapy    given    foi-    I)eiiign    conditions    in      1))-ol)lciii   cases   and   the   use   of   a    great    varietN,    of
                         the    liigli-I)aticilt-loid    centers.    One     call     only     as@-      equipment coiiti@ii)ittes to big ier cost.
                         whether   this   w@is   due   to   ,I   lack   of   time    oil    tlleil-        \Nitliiii     the     homogeneous      liigli-I).iticiit-load,
                         seliedtiles  for   ll)illor   dise@,ises   or   wlietl-ier   tliev   ill)-                        i-otil)  there  was  also  it
                                                                                                                          9
                         posed    different    criteri@t    for    the     use     of     radiation      costs    ol'    therapy.    There    was     a     per-I)atieiit     ct)@t
                         therapy.                                                                        diff'ei-(-iice  of  3()  per  c7ciit  t)et\\eeil  kill
                                                                                                                                                                                  it
                           At      file   Iiigli-I)atieiit-lo,,id     centers,           especially      iiiost    expensive    hospitals.    \N'itliiii    other     liosp,     i,
                                                                                                                   .1                       . ... ... -,I      -)O  i)pr  celit  to


                                                                               NE\%' 1'.N(;I,ANI).)Ot'RN,.@l, Ol-' Nil.@Dl(',INE                                                    2-,.        l@172
                          194
                          be   dii(.@   to    diff(@riiig    (@iiiiical    tecliiiies,    st@iffilig    I)at-        per   c(@lit   of  the  patients  ti,e-         l,ted       foi,       engineer.
                          teriis,    i-nix    of    diseases    tre@ited     oi-     t(-ttiitl     management     A  iiiiiioi-  expansion  of' the  lo@id  of the             iii@@joi-        treat-
                          of the     r-lidiittioti-tliei,@11)@7    units.       If    these       cost            iii(,@iit  cei)tei-s  could  -,tl.)sort)  this  small        load.             Such
                                                                                                                                 iit    \N,otild    cori-(,(-t    tli(@    inefficient     use     of
                          differences     are     due     to     the     management     of     the     units,
                          sa\@iiigs     to     the     pretreat     and     the     hospital      can      be     personnel    in    the    lo\N,-p@itieiit-lo@id     liospit@ils.
                          chie\,ed      I)N,      al)l)lic@itioii      of      modern       iii@iiiageiiieiit     fit    jti(Igi)i,,    the    location    of    iii-lkior     treatment     centers,
                          a                                                                                                     I
                          teciiiiics     and     business     practices     to     the      operation      of     one    must     consider     not     on]\,     the     cost     of     construction
                          the units.                                                                              and    operation    but     also     the     travel     cost,     triL\-el     time
                          It     itl)pears     ti-iat     service     industries     in     general,      and     -,Iiid    loss     of     income     I)v     the     patient.     This     ;ii-gues
                          the    medical    indtistrn,    in    1)@ti-ticiilztr,     -,Ire     (Characterized     against     total     centralization     of     radiation     tlieriij)-,-,     but
                          by    low     prodticti\,itv     and     few     economics     of     scale.     As     ol)N@iotislv     does     not     support     the     current      practice      of
                          hospitals     increase     the     scope      and      magnitude      of      their           hospitals    operating     at     -a     low     capacitn-     \%-itli     an
                          patient    @ind    tre@,itineiit    load,    new    and    varied    st@iff     are     inefficient vise of personnel.
                          added,      the      use      of      technology      is      intensified,      and     \lore    than     @)5     per     cent     of     the     population     in     the
                          costs rise faster than output.                                                          Massachusetts,        New        Hampshire         and         Rhode         Island
                          The    use     of     radiation     in     the     trez-ttiiieiit     of     cancer     arei   live   %vitliiii   80   km   (50    miles)    of    a    mi@ior    f@icilit\
                          has     been     expanding     steadilN,     for     the     past     75     years.     Five     centers,     lockited     at     existin(i     institutions.      \\,otild
                          i%lajor     advances      during      the      past      two      decades      have     be     a     more     appropriate     number     than     the     67      currently
                          given    rise    to    a    greater    demand     for     i-adi@itioti     therapy,     in     operation,     with     still     more     planned     to     coii)e     on-
                          further       specialization       of        radiotherapists        and        more     line     in     the     immediate     fi-ittire.     Four     Iiigl)-piitieiit-loid
                          iiiteiisi%-e use of f@icilities and equipment.                                          centers     loc@ited      at      Hanover      Cited      \@ialicliestei-,      New
                          An     iiiil)ort@int     question     is     the     number     and     type     of     Hampshire,        Springfield,        \la.@s-,Icbusetts,        and         Pro\@i-
                          centers     needed     to      treat      the      expected      patient      load.     deiiee,    Rhode     Island,     along     with     the     centers     in     Bos-
                          Six     hundred     and     tliii-tv-ei(rlit      patients      Nvere      tre@tted     tf.)ii,    could    eiisil),    handle    the    entire    patient     load     and
                          in   the   i-rost    proclii(-tiN,e    (.-enter    in    the    saiiil)le.    flow-     i-neet the test of patient convenience.
                          ever,     in     oliserving     the     utilization     of      facilities      and
                          equipnici-it     the     opinion     was     reached     that      a      sul)stan-     We    are    indebted    to    the    1'ri-St@tte    Regional     Niedicii     Pro-
                          tial     increase     in     productivity     could      be      accomp'l.islie(I       grain foi- financial aid, advice and rich).
                          with little addition        to      personnel      and       cost,;.       Although
                          capital   otitla-,.s   ire   a   si-iiall   part    of    the    totl]    expeiidi-                                  REFEIIENCES
                          ttire    incurred    over    the     operittiiig     life     of     the     units,     1. Feldstein  NIS:  The     Rising    Cost    of    Hospital    Care.    Cambridge,
                          they  can  scarcely         be     justified     for     the      treatment      of        Ni@isszichLisetts, Harvard Institute ot'Econo  ic Research. 19 i
                                                                                                                  'I. Peterson  Ot..  Duffy  BJ:  A   Report   on   Ra   iotheritpv   Faziiities   and
                          few     patients      when      other      well      equipped      and      staffed        Personnel  in  the  Tri-State   Region.   Boston,   Medic,-il.Care    and    Edii-
                          units lia\re iijiused       capacity.                                                      cation I-oiindatioii. lncoi-poi-@ited. September, 1970
                           Ctirreiitl),, there        are     13     m@ijor     treatment     centers      in        Graham   JB,   Paloucek   F:   Where   should    cancer    of
                                                                                                                  3                                                                the   cervix    be
                          Massachusetts,        New        Hampshire        and         Rhode         Island.        treated'?   a   preliminary   report.   Am   J   Obstet   Gynec@ll   9-:405-409.
                                                                                                                     1963
                          Nine     are     in     the     Nletrol)olitan     Boston     area.     Two      Of     4. Comniittee   for   Radiation   Therap@,   Studies.   A   PrcKiect   for   Radia-
                          these      ire      undergoing      exp@,Liision      programs      that       will        tion 'I liet-itpy in  the  UniteLl  States:  A  final  report  prepared   by   the
                                                                                                                     Subcommittee   on   Regional   Nledical   Programs   of   the   Ctmniittee   for
                                             .,ic    their     ctl)acitv.     The     eight     low-patieiit-        Rittliation    Therapy    Studies.    Bethesda,    National    Institutes     of
                          greatly iiiereit
                          load      hospit@ils      in      the      sample      accounted      for      onlv        Health, October 24, 1968

                                                                                      MEDICAL  PROGRESS

                                                         THE BIOSYNTHESIS  OF COLLAGEN (First of Three Parts)
                                                      Nii(:IIAEI- 1. (;IZAN-l',                             ANI) I)AR@%']N .1. I'Ro(:i@op,                   I-Iii.D.
                          TNTEIII,--ST     in     the     I)io(-Iietiiisti-@,     of     coll@i,,@en      de-     titice     in     diseases     of     connective      tissues      Collagen      is
                          JL  i-i%ics  ill  pitrt  from  its  iil)tii-idittice,  in  1)@tri   fi@t)ii-i   its     pi-ol),Il)]-,7  the  i-@iost                   rroteii-i   in    the    I)tijti@iii
                          unusual   properties    tiid    in    1)@ti-t    from    its    likely    iiiil)or-     body,     ,tiid     it     is     the     iiitkior     constituent     of      most
                                                                                                                  collitecli@;e  'kissitc,                  -).                               f')!Il-
                            I-roni the departments of Medicine and         Biochemistry.    University     of     1)oiieiits   of   these   tisstic@,s   are    el;tstiii,    t    related    fibrous
                                          @,@ii the Ilhilkicielplii@i  (iencral  Hospital  (@@ddress  reprint
                                                                                                                                ,,irl  tlle    lIss    of    siti,,zir     polymers     known     @is


                                                                                       JOURNAL OF
                                                                            ri It) or,, @., I It @ (11
                                                                            Pilrw YO[@K, N. Y.
                                                                            h'iO%']-HLY 230,000

                                                                          DEC         1971           4@
                                UR@IP,L OF
                   AMERICAN JO
                   INURSING
                                                                             N. to R.N. in One Year
                   tiEW YORK, ti.Y.                                       L.P.
                   MONTHLY 230,000                                        in New Alabama Program
                              197 i                                       Philcarnpbell,   Ala.-Licensed   practi-.
                  DEC                                                     cal nurses are  now  able  to  obtain  an
                                                                               iate  in  applied   science   degree
                                                                          assoc
                                                                                                              one
                                                                          and become registered nurses in
                  Louisiana Nurses Have Grant                             year instead of two at the new      Ex-
                  for Continuing Education
                  New    Orleans,     La.-The     Louisiana                     ntal Mobility P               rth-
                                                                          perime                rogram  at   No
                  -State  Nurses   Association   here   has
                                                                          west  Alabama   State   Junior   College.
                  received  a  grant  from  the   Louisiana                 Average  age   of   the   30   students
                  Regional.  Medical  Program  to  set   up               enrolled   this   year   is   about   40@
                  a   statewide   system   of    continuing               according  to  Norma   Ferguson,   direc-
                  education  programs     for   nurses.                   tor  of  nursing.  They  are   taking   a
                  Amount of  the  grant  is  $100,000.                    heavy  course  load-18   hours   a   quar
                  The program is administered            by               ter,  she  said,  and  were  required  to
                  LSNA  under   the   direction   of   Mal-
                  colm  Martin,  a  specialist  in   commu-
                  nity  development,  and   seven   region-               I challenge the first  level  by  examina
                  al   coordinators,    who    must    have                 tion. They take  their  clinical  experi-
                  degrees  in  nursing.  The  coordinators,                 ence at one of five local hospitals.
                  located  in  Baton   Rouge,   Shreveport,                  The  first  year  is   funded   by   the
                  Lafayette,  Lake   Charles,   Alexandria,                 State  Board  of     Education,      with
                  Monroe,  and  here,  will  assess   local                 matching  grants  of  $25,000  from   the
                  needs  for   continuing   education   and                 Alabama Regional     Medical      Program
                  then  will  plan  seminars   and   short-                 and the Manpower     Training   Act.   An
                  term   courses   to   be   conducted   by                 additional   $10,000   came   from    the
                               nd   schools   of   nursing.                 North   Alabama    Hospital    Council.
                  universities a
                  Regional  coordinators  will  work   with
                  statewide   and    regional   advisory
                  councils
                   The   grant   expires    in    February,
                  when   the   nurses   association   hopes
                  to be  re-funded  or  to  obtain  funding
                  from the  state  legislature  to  connect
                  the program  with  the  state  university
                  svstem.


                   IMAGF= COMMUNICATION  BY TELEPHONE

                                                                                              Milo  M.  Webber  and  Howard  F.   Corbus
                                                                                           Saint  Agnes  Hospital,  Fresno,   California
                                                             and  the  Univervity  of  California  Hospital,  Los  Angeles,   California

                    A simple, inexpensive, reliable systei
                                                              n  for  trans-                     STUDY PROTOCOL
                   mitting  organ  imaging  examinations  to  remote   loca-    Ninety  scintillation  scan  examinations  were   trans-
                   tions  would  have  manyuseful  applications  in  nuclear
                   medicine. In this pa   I                                   mitted.  The  type  of   examination   and   the   display
                                        per  we  will  review  our   experi-  material  used  are  shown  in  Table   1.   Before   each
                   ence  with  a   method   of   transmitting   radionuclide
                                                                              transmission, a brief  clinical  history  was  given.  The
                   images to  a  distant  location  using  slow  scan  tele-  image  was  interpreted   by   the   receiving   physician
                   vision and ordinary telephone lines.                                  I
                                                                              with  the  interpretation  being  recorded.  At  a   later
                                       EQUIPMENT                              time,  the  films  were  viewed  directly  with  the  same
                                                                              clinical  information  and  another   interpretation   was
                    Ordinary (real-time)  television  is  suited  to  motion  recorded.  The  results  of  the  telephone   and   direct
                   picture-type  visualization  of  the  happenings   at   a  interpretations  were  then  compared  and  tabulated   as
                   distant location.  Nuclear  images,  including  radioiso-  positive for  pathology,  negative,  or  equivocal.  Organ
                   tope  scans  and  gamma  scintigram  pictures,  generally  imaging   examinations   were   recorded   as   "positive"
                   are static; therefore it is not necessary that the  capa-  when an  abnormal  cold  or  hot  area  could  be  identi-
                   bility of real-time television be present. It is possible  fied on at  least  two  views  with  anatomic  correlation
                   to send images one  frame  at  a  time  by  a  facsimile.  and  the  official  interpretation  recorded  an  abnormal
                   However, facsimile does not lend  itself  easily  to  the  finding.   Renograms   were   interpreted   as    abnormal
                   format of  the  radioisotope  scan.  Generally  facsimile  when  one  or  both  analog  curves  depicted  a   delayed
                   -is used with opaque material and is limited to  a  fixed  peak  (over  5   min)'Or   a   delayed   excretory   phase
                   size.  Certain  television   techniques,   however,   are  (over half the peak value  at  15  min)  and  when  serial
                   adaptable to transparencies  such  as  are  used  in  nu-  scintiphotographs  confirmed  the   sequence   of   events
                   clear  medicine  and  can  also  be  used  with   various
                                                                              shown  in  the  curves.  "Equivocal"  interpretations  in-
                   sizes and shapes of  original  material,  whether  trans-  cluded  organ  imaging  examinations   in   which   varia-
                   parent or opaque.                                          tions  in  size  and  shape   might   be   attributed   to
                   The  method  used  in  this  study   involved   a   slow-  anatomical  variation   (usually   liver   and   perfusion
                   scan  video  system   adapted   for   transmission   over
                   existing telephone lines. At the  transmitting  terminal,
                   the equipment consisted of  a  television  camera,  tele-  Received Oct. 2), 1971; revision  accepted  Jan.  25,  1972.
                   vision  monitor,   video   converter   (Colorado   Video.  For  reprints  contact:  Howard  F.  Corbus,  Dept.  of  Nu-
                                                                           '  clear Medicine,  Saint  Agnes  Hospital,  530  W.  Floradora
                   Inc.),  standard  x-ray  view  box,-and  telephone   data  Ave., Fresno, Calif. 93728.
                   set  (Bell  602C  Data  Set).  The   receiving   terminal
                   was,equipped  with  a  video   converter   and   magnetic
                   rotating disc  storage  device  (Colorado  Video,  Inc.),
                   television monitor, an(.' -,n  identical  data  set.  The
                   receiving  video  converter  contained   a   video   disc
                   .memory  feature  which  allowed  the  transmitted  image
                   to be  retained  on  the  television  monitor  until  the
                   next  transmission.  The  equipment   was   compact   and
                   could  be  housed  in  a  small  cabinet  or   desk   top                -,.j
                   ,(Fig. 1). No special wiring  except  for  the  telephone
                   was  required.  Simple  telephone  pickups   and   ampli-
                   fiers were  helpful  for  conference  use.  A  zoom  lens
                   accessory  for  the  television  camera  was   used   and
                   was felt to aid  in  rapid  adjustment  for  the  various  FIG. 1. Receiying terminal for nuclear medicine image commu-
                   film sizes, reducing times  of  setup  for  transmission. nicotion system.
                   Reprinted  from  the   JOURNAL   OF   NUCLEAR   MEDICINE,
                   June, 1972, Volume 13, Number 6, pages 379 - 381.


                         WEBBER AND CORTIUS

                                                                                                         no instances in which a positive direct interpretation
                                   TABLE   1. TYPE OF EXAMINATION AND                                    had been preceded by a negative telephonic  inter-
                                        DISPLAY          MATERIAL          TRANSMITTED                   pretation.     In     four     cases     a      telephonic      interpretation
                                Type   of       No, of                Type of                            of     "equivocal"     was     followed     by     a     positive     reading.
                             examination        loses          material   transmitted          No.       Since,       however,       an       interpretation       of       "equivocal"
                             groin   icon          57          X-ray  film,  10  X  141       251        would    be    an    indication    for    either     direct     viewing     of
                             Liver   scan          15          X-ray  film,  14  X  17         70        the     films     or     further     examination,     it     was     concluded
                             Lung    scan          8           Polaroid format                  9        that     no     significant     abnormalities     were      missed      during
                             Renogrom              6           Renogrom graphs                  5
                             Thyroid scan          2           Radiographs                      2        the interpretation of the transmitted images.
                             gone    scan          2           Data sheet                       I             Seven    examinations    might     be     considered     as     "fa     e
                             Totals                90                                         338        positive"     transmissions.      One      was      read      as      abnormal
                                                                                                         by     telephone     and     normal     directly.     Four      were      read
                                                                                                         as    positive    by    phone    and    equivocal     by     direct     inter-
                         lung     scans)     and     probable     artifacts      or      abnormalities   pretation.     Seven      were      interpreted      as      equivocal      by
                         seen    in     only     one     view.     The     official     interpretation   phone     and     negative     when     viewed      directly.
                         recorded     the     type     of     abnormality     and     usually     sug-
                         gested    additional     or     repeat     studies.     "Negative"     inter-                                EVALUATION
                         pretations     consisted     of     those     examinations      in      which        Comparison        of     the     two     methods     of      interpreting
                         no    abnormality    was     noted     and     the     official     interpre-   organ       image       examinations       reinforced       the       authors'
                         iation    was     recorded     as     normal.     The     two     interpreta-   overall      impression       of       the       transmission       technique,
                         tions    of    each     scan     were     then     compared.     Observations   namely,     that     examinations     transmitted     in      this      manner
                         were    also    made    regarding    the    reliability    of    the     sys-   can    be    interpreted     promptly     and     with     a     degree     of
                         tem,     resolution,     photographic     factors      in      the      gamma   accuracy     sufficient     for     clinical     use.      The      resolution
                         images    which     made     for     best     transmission,     and     cost.   of     the     imaging     instruments     displayed     on     the     actual
                             The    general    routine     was     as     follows:     The     initial   films    did    not    appear    to    be     degraded     in     transmission
                         telephone    contact    was    made.    A    single    view    was     trans-   since     the     abnormalities     on     all      positive      examinations
                         mitted    (equipment    takes    I    00    see),    after    which    verbal   were      identical      and       no       significant       "false-negative"
                         discussion    took    place    using     the     talk     mode     of     the   transmitted        interpretations        were        rendered.        Further
                         data   set   while    the    image    was    retained    on    the    receiv-   experience      in       transmission       technique       and       improved
                         ing    monitor.    In    practice,    four    or    five    patient    exami-   equipment     should     decrease      the      incidence      of      "false-
                         nations    were     transmitted     and     discussed     in     a     period   positive"     interpretations.      The      system      was      sufficiently
                         of    approximately    1    hr.    Much     of     the     discussion     in-   flexible    to    permit    transmission     of     material     of     varied
                         volved     the     technique     of     scan     performance     and      the   composition       and        size.
                         diagnostic     -question     posed     by     the      particular      exami-        Except    for    films    of    low    contrast,    all    organ    image
                         nation.                                                                         examinations         recorded         on         radiographic.film        were
                             The     transmitted     material      included      primarily      radio-
                         graphic    films    upon    which    scan    images     bad     been     made
                         (Table    1).    It    also     included     Polaroid     displays,     reno-              TABLE 2. COMPARISON OF TELEPHONIC
                         gram      graphs,      some      radiographs,      and      printed       ma-                    AND          DIRECT          INTERPRETATIONS
                         terial.    The     use     of     a     zoom     lens     permitted     quick        Interpretation                                    Phone      Direct
                         changes    of    film    size     between     transmission.     The     tele-           identical                68      Positive         32         32
                         vision    camera    was    used     with     a     standard     view     box.        Phone positive,                     Negative         36         48
                         No special masking was required.                                                        direct negative          I       Equivocal        19         10
                                                                                                              Phone negative,                     Technically
                             In   the   course   of   this   study,   four   10   X    14    or    two           direct positive          0         inadequate       3          0
                         14     X     17     transparency     scans     were     generally     grouped        Phone positive,                                      -          -
                         and    transmitted    at    one    time,    which    made     it     possible           direct equivocal         4       Total            90         90
                                                                                                              -Phone negative,
                         to transmit four views of a brain scan at once.                                         direct equivocal         0
                                                                                                              Phone equivocal,
                                                                                                                 direct positive          5
                                                         RESULTS                                              Phone equivocal,
                             The      comparison      between      the       telephone       interpre-           direct negative          9
                                                                                                              Phone technically
                         tation    and    direct    interpretation    is    shown    in    Table    2.           inadequate:
                         In    68    of    the    90    examinations,    the    two    interpretations              Direct positive       I
                         were    the    same.     When     both     interpretations     were     posi-              Direct negative       2
                         tive,    the    abnormal    features    were     identical;     i.e.,     the        Total                       90
                         positive interpretations were consistent.-                        re     were
                         380                                                                                                              JOURNAL       OF       NUCLEAR       MEDICINE


                                                                                        IMAGE  COMMUNICATION  BY   TELEPHONE

                transmitted  without  difficulty.   With   proper   mag-  displaced  downward  from  the  main  image.   The   ap-
                nification,  35-mm  negatives  could   be   transmitted.  pearance  was  not  unlike  "ghost"  images  which   are
                Scintiphotographs  displayed  on  Polaroid   film   were  occasionally@seen in  real-time  television  where  more
                successfully  transmitted  as  were  analog  curves  re-  than one path  for  the  radiofrequcncy  picture  signal
                corded during  renograms.  Gross  features  of  selected  exists.  The  artifacts  could  be  eliminated  on  many
                radiographs  could  be  transmitted,  such  as   cardiac  occasions by breaking  the  circuit  and  reestablishing
                size on chest x-ray and isolated  findings  in  contrast  the connection.
                studies. The  system  was  simple  to  operate  at  both
                the sending and  receiving  terminal.  Nuclear  medicine                  FUTURE APPLICATIONS
                technologists were  able  to  operate  the  transmitting      The participants in this  study  have  been  encour-
                terminal  after  approximately  I  hr  of   instruction.                                  I
                                                                          . aged by the technical capability  of  the system    and
                Setup  time  was  minimal   and   the   combination   Of  intrigued by the teaching  potential  of  asimilar  sys-
                zoom lens and television  monitor  eliminated  the  need  tem. It is our  hope  that  future  studies of this  sort
                for  special  masking.  No  transmission  was  cancelled  will facilitate further the application  of t  e   univer
                because  of  equipment  failure  except  for  a   period  sity teaching  center's  special  knowledge and   experi-
                when telephone service  At  the  receiving  station  was  ence  in  a  community  hospital   setting.   Additional
                interrupted  due  to  an  earthquake.   No   maintenance  formally structured teaching  projects  will  be  under-
                was  required  during  4  months  of  regular  use.  Al-  taken to explore this  potential  more  fully.  Improve-
                though cost figures were  kept  during  the  study,  the  ments  in  equipment  can  be  expected  to  result   in
                special design of  the  experiment  and  recent  changes  im  roved  resolution,  faster  transmission,  and   re-
                                                                              p
                in  equipment  rendered  this  information  meaningless.  duced  costs.  Improvement  in  the   quality   of   the
                Replacement of  the  data  set  with  a  standard  voice  images  should  make  it  possible  to  transmit  radio-
                coupler will reduce the fixed  cost  substantially,  and  graphs, photographs, and written  or  printed  material.
                toll call time  undoubtedly  would  be  shortened  in  a  Improved  storage  devices  may  make  it  possible   to
                working situation.  Even  with  the  system  as  it  was  store a series of  examinations  at  the  receiving  end
                used, it was concluded  that  the  cost  was  reasonable  of the terminal to  be  interpreted  at  a  later  time.
                and  within  the  budget  of  a  moderately  active  de-  Smaller hospitals,  especially  those  in  remote  loca-
                partment.'                                                tions, might  wish  to  perform  routine  organ  imaging
                                                                          examinations  and  arrange  for  immediate   interpreta-
                                    LIMITATIONS                           tion at a distant center.  Several  hospitals  might  be
                  Slow-scan television is  suitable  for  static  images  linked to a single center  with  the  necessary  trained
                Ionly.  However,  serial  images  from  d  namic  studies physicians to provide expert interpretation,  thus  pro-
                                                       y
                can be transmitted in groups of  six  or  eight  frames.  viding  an  important  category  of  diagnostic  service
                Cerebral  flow  studies  and  serial   scintiphotographs  to a population of  patients  who  otherwise  might  not
                taken  during  renograms  were   transmitted   in   this  receive this service, or who might  have  to  be  trans-
                manner. The system  was  unable  to  detect  and  trans-  ferred to  a  point  where  the  service  is  physically
                mit small changes in image  density  at  the  white  end  available.
                of the gray scale, in spite of the contrast  enhancement
                effect of minification. As a  result  some  underexposed                        SUMMARY
                films or films of  low  contrast  could  be  interpreted      The  investigators  evaluated  a   slow-scan   video
                directly but  could  not  be  transmitted  successfully,  system capable  of  transmitting  static  nuclear  medi-
                even  though  the  minified  image  on   the   receiving  cine scan images over the  telephone  line.  The  system
                monitor could be  adjusted  to  a  degree  for  contrast  was found to  have  potential  for  future  applications
                and  brightness.  Resolution  was   grossly   inadequate  in bringing nuclear medicine services to  small,  remote
                for routine  radiograph  transmission.  Accurate  inter-  hospitals. The results of this study  indicate  that  no
                pretation of  printed  material  was  limited  to  block  positive  examinations  were  misread.  However,   there
                lettering of I in. or larger. Further refinement in  the  was a  tendency  for  television  interpretation  to  be
                equipment  will  probably  enhance  the  capability   to  equi-vo(-al or positive when direct  interpretation  was
                transmit  printed  material   since   the   manufacturer  P--gative. It was felt that the difficulties which w ere
                proposes its use mainly for this purpose.                 encountered in this initial  use  of  the  system  could
                  Distortion of the  image  and  noise  artifarts  wf're  be overcome
                occasionally bothersome but rarely pre,,,-,P.Ied  inter-
                pretation of !he image. The type of arti@fact  that  was                   ACKNOWLEDGMENT
                most distressing was an imaot, if  lesser  intensity  or     T,his study was made possible by a feasibility grant from
                of reversed etav  scale  w@l'o@h,was  occasionally  seen  t Calif@rnia Regional Medical Programs, Area  IV,  UCLA.

                Volume 13, N,- .,,jer 6


                                 lw

                                                                                                                          6,            -@II)INDAY, OCTO"r'(?  15,1972

                                                                                                                                      .77'
                                                                                                                                                                           @77

                                                                                                                    41 4 -11
                                                                                                                                                                     NcTi)v VII W(,
                            @-.1 N       I O'U-. .9
                                                                                                                                to ille                     roi3,,               wf)n,@ail
                                                                                                                                   ks
                                                                                                                                W,
                                                     fit                                                                  it                                                   in     bj?r
                                                           ri i?,
                                                                                               ri
                          wo!",                                                                                                                                    iNiveft    I-%).    Sle
                      c      w   i
                                                                          @@oti never        z!, e t        t@)            9      af   a  (@oixir)iltiiid  fn@el,   ire  of  'lie   le-i't
                                                                                                                                                                              L
                                                                   si       ;,you, just (,o t@,e bEst yt),v                                                        as
                                                                      V-                                                                   -ler sto -ilacii
                                                                                                                                                                w
            T@a@- cle-;sion px-obably           s"@-;ed    ti-@e
                                                                         it Nv@as     a             41 o del@i@vei!   t         -aii(i 1.)r.
                                                                                                      ed    aitd     (',,ove                   A    riccO,'e    broiiglii    up    fr@,;Ii
                                                                                ali.Ve. Ile     lirit
                                                                       C         IC  Sli.1w.                                    blf@ocl.  ]'tit                         i@@      coiritic,
                                   l@;, "r-ie                      ba k h(ti-,-
                                                                                                                                from.? Th
                                                     s(i                                   *   *   *                                            e    aorta'?    O,,-     some     organ,."
      @he                  v-,.,olllttj live 'Lh,@,cjz,yh  Ili@,
                                  ,ty
                                                     a'
      LL-ip tO                                                                                        s a;, (It    yi

            A @few
                                      tb@ caiiii of
                                  as ilie vvo)-ian
                                          'aive     begtri     a
                          toward           ri@cove,-y.

                   @IAI)ISO.N.  Di-                           A.

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                                   ri,aki-   a
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                                      to sht-,o me
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                                   to             a...d' n


                       'i@ rj

                                                                     a r@

                       "yo-O

                                     Dr.

                       4-Frcciu,,,ntj,yl  even
                                                      ti-@ e
                 At @i
                     Yi,. il I                                                          Dr. Moyl                                  -ra 5 before deciding his next move.
                                                                                                       can  exami,,its  X           y

                                                                                                                     C I'@ -i f CA@es--    c-@dar'iy                          ccn-
                                 bf@             b-oL    it    tiki@-s    a
                                                                                                                                                 c,
                                                                                                                                                   tre of           trauma      p4,-

                                                                                   i         .,  ,                           i               rflic pri@iiz)%v aiid th(,-
                                                                                                                                           -dar,,,,   ficisritils   usiially   don't
                                                                                                           or@ P..tqe                      'live  ttie   manpo%ver   or@   deck   24
                                                                                                                                           lio,,trs  a  day,  no,-  can   the@v   a@
                                                f) @@i i' I -ri ij t@. c   'Lo                                               I.,Iicil      for,4  thc.,   sop@,,'sti,,,ated   equip.
                                                                                            Tile l@atii),,ial S a    y      (o
                                                                                                        tr"es.
                                                                                                                                                                                         O.C
                                                 i.itiulrc. Ca,,,                                            a riioth--           h
                                                                                                                                                     they Ct!l (@T@'), if t'iclre  1.5  @l
                                                                                                 Zll;l"clreti at             Says
                                                                                                                                                                  i.,i      or    so
                                       Fie            to
                                                                                           "Yoi Say        hospital  bill  of   the        .1@vay,  is  to  stal)ili.@ted  the   pa.
                       Of'k-ei-i  it           Lot  be                                     NVCI"Iillil ivLtt) lived was  ibout             tieiit                             the
                                                                                                                             ri,,,ht                                    *.he  a,  r-
                               y@        vilyiell@@,  if        1)atij?,ii-                                                                ivlys, and star,' , ili,@c iiil-
                            lve,                                                                                                           fluids   -   for   the   tril)   to   tic
                                                                                             It
                                                                                                                                           larger
                                                                                                        to   th(,   cty    fatliers
                       4,1     I-IAD     A     LO-]'     of     trc)u,')Ie@                      evil                                        4;r
                                                                                           -,iid  It,'@d   thein   'We   gotta   do            @@i  Etircipe,    t@e.    trend    is
                                                                                                                             ari-                    rel,,ioial    trauma    liospi-
                                           Air,   Ciri-,ey,   r@l'    A-@)-                biiiir,'C.  It             got       ary
                                        wits all'
                                        ,'I                                                                "     says        ollief                             I)eco,.qiiog  @-tp.
                                          ,         '@l.              raise                                                                                            11
                                                                                                                                                    in 'Ct)is
                                                                                                                                           p@
                                                                                                     Here leisili,ll,
                                                                                                                                                                             to t@
                                                                                           i).Titil -@-e can get sonic                       a% I A 1) IO.N' I SCIOS@,           lie,
                                                                                                                                  y
                                                                of tile"                                                                                 Los Angeles       fiLis   a
                                                               Avis     oi,
                                                                      witl,                            Nll'-,RSE,"  s.-3?s   i\ir,.                   So does
                                                                                                                                                   Dr.
                                                                                                                Gcd,         bad
                                                                                           I   NNi@6 to

                                                                                           it if risky

                                                                                              y                              T II @v
                                                                                                                                           4(10 CIE

                                                                                                                 'k, IV'

                                                                                           ra,@ed for
                                                                                                       i@,c: S',),  XI  care.)


              Army  personnel  and' thei,-          says ;@Irs. Carney,         to      talk she is, and especially ii-lien  she
              families arc iloNim by DC-9 eaclr     Avitli   the   man   next   door.   Ilis sees the teciia,,cd diii,,Iiter  of
              year from all over the United,        w@ifc   was   one    of    the    womerf the men next door. She  looks  iti'
              States.                               killed."                               the niirror,  and  the  ravi-es  of
                                                      She     lools     at     her     three the accident arc  barely  visil)lo.
                 "THE    HARDEST    thing,"    children,    and.think-s    how    lucky    ."It's   a   fantastic   hospital,"
                                                                                           she   says.    "Tremendous    care,
                                                                                           and   so   personalized,   when   r
                                                                                           wrote  my  thank-you   letters,   I'
                                                                                           almost  wrote  to  the  small  city
                                                                                           doctor. I think I still

                                                                                           i)IPS.   C@kr.NEY   isn't    alone.
                                                                                           Dr.',Nloylaii -cts the tough  ones.
                                                                                           There  was   a   girl   from   Por-
                                                                                           tal-c,  ivitli  28   stab   wounds-
                                                                                           inflicted   by   an   unknown   as-
                                                                                           sailant.
                                                                                           There    was    t    farm    I)ov,.
                                                                                           pitched  from  a  tractor  and  run
                                                                                           over  by  a  plow.  The'anal   irea
                                                                                           ivas  enucleated,         literally
                                                                                           scooped  out   to   the   abdominal
                                                                                           cavity.   There   was   an'cldcrly,
                                                                                           man,  victim  of  a  guti  %vouird,
                                                                                           and two  little  Eait  Side  girls,
                                                                                           badly  burned   when   a   pan   of
                                                                                           grease caught  fire  and  the  fire
                                                                                           spread to their clotliin,-.
                                                                                           And,  with  a   proaram   to   bet-
                                                                                           ter  utilize  the  services  -   of
                                                                                           regional   trauma   centers   under
                                                                                           way,   more   ind   more   of   the
                                                                                           most   grievously   injured    per-
                                                                                           sons is-ill come to  lkladison  ind
                                                                                           other   centers,   and   more   and
                                                                                           more lives will be saved.
                                                                                           Maybe ygqrs.


                                                                                                                                 1) Ive to W,:ijt Llt)
                                                                                                                                                            I i' @-(iii
                                                           oi'
                                                                                                                                                                           cliaiif.,P.  to
                                                                     Ali                     .1
                                                                                                                                       It               yiiii a b
                                                                                                                                        b@_i say  ,ii@,           And     it will
                                                         'la]        si)ecia"ltj    traiieil    lo                                                                                      clit
                                                                                                      I

               Mad,'@on f;renic,-t',Iohn Kommer,'Yight, iti<,>,"s an                        their training., Bernie Schmeizer, the instructor, Lend
                                                                                     of     Corol Krebs, R.N.,.watch his -.-og,-ess.
            ir(lyen,bu@ 'tube t'IVII @'-n     Charles Dirienzo as port                                                                PI
                                                                                                                            .,State            Photn Ity Ed-tvin Stein

                                                                                                                                 Nvil' have a half dozen                                tged
       do@v-n  on                 'a-                                     '[le inay tie         ,tirway,                 Df!r
                                                                     Solis ethic for -@vill'it car               al,@lie i       C   Is alon'.@ @vitti h
                                                                                                                                  it-II,                        iiit tvbjcb,        tinder.,
                                          Vi.,e  a,-roti@it   (if                      if yf,,tir Ie,-trt   is                   ttit! doctor's      orders,   lie'll    be    able    to-'.
                                                        r    pill    or just
                                                                                                             JL

                                                  ucf
                                          ANC-1@'                    r@ietticaltiort 'that h@-  ca@i  Yiv(!@  N@f  'I,  it'@(                  net,,.  'Flic-    fejeral     I)el)t.     I)f
              AS   ",,;IkiE    Al@t.,c@UTA@
                                                       @-i,-t i,,i   the          tit' si@loi,s.                                                                         Wt.!If.-,re      is
                                                                                                                                                             i-tivitig          emergei,,cy@
                                y                   a
                 f.,Y                       NV   3
                                                              As                                                                 rt)f,-@,ro.   operation,   wit,i    a    view    ot    cut-
                                      ti"oli                  De     Leie"llc@'I.1,y zi". )',,is           i)i'lc44!,@  the      tilig dtf@vii on                   ileal,b-.,.
              41 i @Lg
                                                                                    iiiat he can see you,- el
                                                                                                                           ec          f(itteral  sLil)V)Orti  foi-   cifiertz"ey
                    w                                                          so
                                                                     -:Lr c) c a- i - d- r a m.                                  care service.        Five   Nvere   granted.    One
                 le dt,@ei     S  llve,3,a,l     Cy(          II
              TI,                                     -s"   W;,l          'I'ile cloctfj,, can t,?Il I
                                                    'liit  1-        el eel
                                                              lip                                  azid thin  fileriiaii


                                                                                                                                                                   11 (I %V
                                                                                        ly
                                                                                                                                                             ovfl

                       is ,,,c

                         kilt.! (.'re!
          le
                                   ki   by

    Lie                            %art.
                  s  :ire
    -Neil

       "IT       A   -N
                     JOUN'TS

                     y

             44.@) start Wi?i    c,   Car

                         (it-'  ti  at  wpy..
                     yv-.ii -,,art  lqicy.,rc

               Daillx,   ZL                           r,,-emon  Ga.-Y                       irserts cirwa-Y i@-ito dum, my while jchnt
                                               Ts-inkle and Bob Gessie,- look ori. Dr. %'-Iaude, Toylor is a.l@ right.
           I&,, sp@nt a lot of                                                                                    ournoi Pholos b, E-:dwi,@i stain
       'f le f i r@.rrc,@n a re a 'A CT.-cr til,e .,lot  friin   booLs,   but   by t-a@,i 'c@@ u  says                            based    O,(jdor.
                                                                                              d-ia:L-,-@ c, s is d i @' iL:@
        p                                                          do 4cli, .    -                                                        I
          ial.   iev're  ir@                                                                                        t.,   Or he @,,iy sk@r, ove-        C
                                 r,. i                        III     let wil.@  by                some
          ri,,orA.,ih@-y@re   let-    rcp    Soii-@el t:iie her%)-  -add,                                   of     the  a D @osriital to take @i     h,-di
                -f  fee@i,iqiici   @n,,qd  Zlies before ii,-, g,@ to the
               r,                                                                                                       b,.,riieil. person to a B  or  all  Al
                burbles be riei;vc.-(,,d.  p'-Ita-,, died I)eeatise ',Iie,v %.were Vi'@hen tire first *@,roup  of  Big  liospittil @.-ho.@c tic.,       care@
           re  Carl,,,         li,  g",vc             at the rate of once
                                                                                 iiren,,exi  has   been   trained,   a  is
                                                              no',               ]left,                                                                 I
            @irti    @.ow     to i-i  @,-t   all ,.xv'jee a In                              @)      start,   IV-ith    )O
            ':'                               -- o@ '                                      by 'Ctic     of the  v-ear,                       t.,         s  t;
            L h   I.          -g.lio1v   to sul,p t
              'C Ve          A         an                                   @l,,                        i
               a  roLs   del;!tv,4;,    d    And      @tiremer, are                @,And tile iri.,Ii)rtiat-oti @vill be grai.ifyi@if, 'Lhili@;         .he@
                                                                                                   ('file          our @,wliole  p,,oiet."  says        Dr.'
          a  person   iook;s     r-@t!*    low to cope t;vith iiis.,                                                                    c
    @vhj-,@!         urico@i:sl_lioas        T@lie         of a  @icart  attack             will be                     -V@lor,   141.s   tile   SPrif    of,,
        I   rorLI;e4 -1 nf! @v;"It,s ricit, ;s not restricted 4LO ile                             [1@ie f-i@Ist  year.  CG;)t,)Cratt,)n on all 'Loveis
         li CIYc      C
                 dedi  ,tted,   say   the  Avile is str,Cl-.en ill his -'lo-no,           tbare the -@r@         IV.',h
    i@t  vollnzc,;-        amid now ilif!  -  "A  good   many   one-!La.,   ae-  '@O  cmerge,,7.cl,        the    rext   tacWlt-,?,   t@,L,   nu@,ics,     ,h&
                             ;,-n(i says?  cidliits -are C,-iuse-ul  either  b@         o!id ')O ;" l@l",e tb;rd                   il-ic
                                                                                                                                      'cs,       te
        -;-2@V     about     ill        I  Heart attaclil;, wih                  T4,,-,L,"i sli-iare L, C@o7cn  or  -o  -s,@ a't p a g e,, i,@,
                                                                        a  'or.  video '@rL3irAl,,,g falls. -
                           Lo dt). -l, '@d or I)y             ys !)r T yL                                               @he      @ls %'no       to
                                                                                                                                          @,iii all
                                                                                                  HI@ ifibs  r)f  t@:e
                                             AND, IF        E car-                 O'%E   Oli'    T
                                                                          b                    be to             f  lie 4CI,     V                      r.,3 (.,f
                                                   is a'@ Is o h,- @,i nor h ai                                            @_.               Pi  corlrle.
               'kil:lr r-rii;zhv.  b@,-,.i    !7,c;-,rL af@tixk,      use   @,f                      troy!'  11   tile   thc, ;tal@, far  '%he          or all
                                                          is
                                                                                                                        P,!Cjplc of

                                                       he         etcr@n-      a-,! bi,,@@

           ei--- ca-@i ;-ef 4  4i,(!  er,@e, -en,-y ri%,,.)rri, on a portable      c, F-. h, @t 'r@ !,-i i,@ i@-
                       i.Ili(!             a,-ifl on @tlo                                   tills -is

                                                                                                         into

                                   start
                                           ni,
                             says     Dr.                                                     v                 heart
                                           1 5 i,, i i i                                                   A)itals ,@ts


             ARKANSAS REGIONAIL, MEDICAIL PROGRAM

                          500 UNII'EI?SITY TONVEI@ IILDG.       12TH tT ITNIVERSITY       Ll'rrl,E PO('K     722       6 4 5
                                                                                                                (AREA COI)F, 501)

               It'. SILN'ERBLArr,.NI.D.,.COOltl)l',ATOIC

                      September 5, 1973

                                                        M E M 0 R A N D U M

                      TO:      Mike Posta, Acting Chief
                               Mid-Continent operations Branch
                               Regional Medical Program Service
                          @enneth Endicott, M.D., Director
                               Health Resources Administration
                               Department of Health Education &            Welfare

                      FROM: Arkansas Regional Medical Program

                      Even though the present administration is desirous of stigma-
                      tizing RMPS we in Arkansas are reminded daily of how our citizens
                      have been helped. Enclosed is a recent article regarding Medical
                      Technology training.

                      JW:lw

                      Enclosure


                                a                           lab h@ -
                                         Lz3
                By ODARE MURPHREE, MT(ASCP)
                Little Rock, Ark.

                Techs in Arkansas, small labs are not only unable
                to participate in continuing education, but frequently
                are undertrained to begin with. A Little Rock hospital                        lab
                is beginning to do something about that, though,
                with the help of a three-year Federal grant.

                WHILE    MAKING     their     consulta-    with  an  up-to-date   lab   employing    to equip our  classroom,  pay  instruc-
                tion   rounds   among   nine   Arkansas    60  registered  techs  and  performing    tors and clerical personnel,  and  pick
                rural hospitals, three of  our  pathol-    500,000  procedures  a  year.  So   in    up the  travel  expenses  for  instruc-
                ogists   reached   a   common   conclu-    1969,  we  applied   for   a   Federal    tors who hold seminars  in  small  hos-
                sion: Laboratory techs  in  those  hos-    grant   through   the   Arkansas   Re-    pitals.  And  we  now  provide  contin-
                pitals  simply  needed  more  training.    gional Medical  Program,  and  at  the    uing    education    in     hematology,
                They saw,  for  example,  one  lab  'in    same time  spent  $20,000  to  prepare    blood  banking,  general  and,  special
                which  Coombs  serum   was   added   at    a classroom in which  to  uporade  the    chemistry, urinalysis,  serology,  bac-
                the start of a  crossmatch  before  the    training of  rural  techs.  Our  grant    teriology, and microbiology.
                protein  was   removed,   thus   making    application received letters  of  sup-      We've    recruited    our    trainees
                it  impossible  to  obtain  an   incom-    port from  the  state  health  depart-    through   various   professional   pub-
                patible   crossmatch.   Another    tech    ment's  Bureau  of  Laboratories,  the    lications  and   plain   word-of-mouth.
                boiled   Diazo   reagent   because   he    Arkansas Society of  Clinical  Pathol-    Most of the  m,  despite  the   variety
                thought  it  should  be  yellow  before    ogists, and the  Arkansas  Society  of    of  courses  we  offer,   have   wanted
                being used  in  manual  bilirubin  pro-    Medical   Technology.   Three    years    to  learn  more   about   bacteriology;
                cedures.  Another   lab   staffer   did    and three revisions of  the.  applica-    four of our present  class  of  10  are
                prothrombin   times   by   the    sweep    tion later, the grant was approved; it    involved in this training,. and  10  of
                hand on the wall  clock.  Not  all  lab    covered three  years,  effective  July    the 12 on our  waiting  list  have  ex-
                work  in  rural  Arkansas  is  of  this    1,  1972.  We  requested  a  total  of    pressed interest in it. It's  not  sur-
                nature,  but  the  fact  remains   that    $79,538,  which   the   Federal   Gov-    prising,  because  bacteriology-a   de-
                some labs have  techs  with  little  or    ernment   approved   initially.   How-    manding  discipline  with  which   most
                no training.                               ever, with  recent  cutbacks  in  Fed-    rural  techs   have   only   occasional
                   In  1968,   Baptist   Medical'Center    eral spending, our  grant  period  has    contact-tends    to     be     Arkansas
                made slight  progress  toward  a  solu-    been reduced to  two  years,  and  the    techs' weakest area.
                tion by training three of  these  techs    total amount we'll get  is  closer  to      In bringing rural techs  to  our  lab
                for  one  week  each  at  hospital  ex-    $39,000. This has  forced  us  to  re-    for  training,  we've  worked   out   a
                pense. We felt, though,- that  we  were    duce   the   numbe'r   of   techs   we    rather   unusual   trade-off.   Usually
                equipped   to   do   much   more   than    planned to train  each  year  from  40    we're able to  send  a  replacement  to
                that.  Ours  is  a   440-bed   hospital    to 20.                                    the trainee's  lab  to  work  there  as
                                                             Nevertheless,  the   Federal   money    long as the trainee  is  with  us  (one
                The author is chief technologist  at  Baptist
                Medical Center.                            we've received so far has  enabled  us    to  eight  weeks).   Our   replacements

                36    MEDICAL LABORATORY OBSERVER


                Du ng a two-week stint in bacteriology, trainee Don Dixon
                gets _eriencestudyinggrainstains,coachedbytechBarbaraMonroe.

                                                                                                                       MLO )!ULY-AUGUST 1973    37


                                         How a big cit,,, lab helps rural techs

                                                                                             A

                                       Spending time in several lab departments traitlee,51ieila
                                       Htirt performs a crossinatch (top) Under the scrutiny of
                                       fecii Julie Etidsley, then tries her hand at a niicrogasometer.

                     40    MEDICAL LABORATORY OBSERVER


                                                                                                  are  recentl   graduated   techs,   who
                                                                                                             y
                                                                                                  generally   have   difficulty   finding
                                                                                                  work   in   technologist-rich    Little
                                                                                                  Rock.  The  small  hospitals  do  their
                                                ON
                                                                                                  part  by   paying   the   replacement's
                                                                                                  salary and  providing  him  with  lodg-
                                                                                                  ings, as  well  as  continuing  to  pay
                                                                                                  the trainee's salary.
                                                                                                    It's  well  worth  mentioning,  inci-
                                                                                                  dentally, that  the  replacements  have
                                                                                                  typically   been   enthusiastic   about
                                                                                                  their   experience   in   rural    labs
                                                                                                  (though none as  yet  have  elected  to

                                                                                                  remain wo
                                                                                                             rking  in  one).  They  find
                                                                                                  that, in contrast  to  their  large-lab
                                                                                                  orientation  with   its   emphasis   on
                                                                                                  specialization, small  labs  want  them
                                                                                                  to be generalists; they also find  they
                                                                                                  have  more  direct  contact  with  phy-
                                                                                                  sicians and patients and  are  able  to
                                                                                                  correlate  lab  results   and   patient
                                                                                                  care more closely.
                                                                                                    Our  trainees  are  housed  in  rooms
                                                                                                  at the  nurses'  residence   and   take
                                                                                                  meals  at  the  student-personnel  caf-
                                                                                                  eteria (the costs  are  borne  directly
                                                                                                  by the  hospital).  They  work  at  our
                                                                                            @i    lab  in  an  apprenticeship   situation
                                                                                          lo,@    from  8  A.M.  to  4:30   P.m.   daily,
                                                                                                  under the close supervision of  a  sec-
                                                                                                  tion chief or an  experienced  tech  he
                                                                                                  appoints. Lectures  and  slide  presen-
                                                                                                  tations  are   offered   when   needed,
                                                                                                  and the trainee  has  a  reference  li-
              Trainee Dixon watches as Mrs. Monroe reads culture plates.                          brary (financed by the  grant)  at  his
                                                                                                  disposal.
             Bacteriology is the inost-sough t-af ter training.
                                                                                                     Specifically,   the   trainees   are
                                                                                                  taught  to  perform   up-to-date   pro-
                                                                                                  cedures  and  operate   modern   equip-
                                                                                                  ment.  For  example,  in  bacteriology,
                                                                                                  trainees   are   given   unknowns    of
                                                                                                  stock cultures  we  keep  on  hand  and
                                                                                                  are taught  to  identify  bacteria  and
                                                                                                  perform  sensitivity  tests.  In  hema-
                                                                                                  tology, the trainee  studies  a  number
                                                                                                  of unusual slides under  the  dual  mi-
                                                                                                  croscope,  with  the  assistance  of  a
                                                                                                  veteran  tech,  and  is   expected   to
                                                                                                  identify the atypical cells on a  blood

                                                                                                               MLO JULY-AUGUST 1973    41


                            'B'     it  lab  helps   rural   techs
                               19C y

                                                                                                           f) i fill t,

                                                                              As section  head  Laura  Pierk6wski                              Hur'
                                                                              brushes up on urinalysis. Soon. she 11 return to h4         b

                                                  %.J
                                                                              smear.  Blood  bank   trainees   are     0g)
                                                                              taught to perfomi blood.          in-    cell
                                                                              eluding  back  typi
                                                                                              ng)   ana     cross-     on
                                                                              atches: serums contain
                                                                              dies are given the tr  ee      o  is     a
                                                                              ected to identil                  m      fari
                                                                              the 'incompatible c
                                                                                                                       prov
                                                  typing, back                Our trainees  cc                  e      man
                                                                              bckgrounds.    Oi                 5      the tr
                                                                              years' experience in a         but       eral call  A
                                                                              no formal training, sp         eek       hospital adi
                                                                              learning to identify a                   cians c
                                                                              blood cefls. A forme                     ment in thei
                                                                              teacher, who became
                                                                                                                       our coi
                                                                              fo   at training, spent                  more  c
                                                                              our bacteriology 1,                      our tr@
                                                                              aar's formal  tr                         results,
                                                                              ol, spent a  wi                          qnd  facu
                                                                              ba  And  a  CLA                          the traini
                                                                              ician's office le                        annual re
                                                                              ology-e
                                                                              0      m                                 it's
                                                                              f btahe
                                                                              at cultw                          e      ter
                                                                              analysis of uri cultures
                                                                                                                       @om
                                                                              in some cases. small@                    sh
                                                                              aren't able to send a tec                ita
                                                                              to them. Thanks t                        an
                                                                              90
                                                                              e're@ able to send fac                   aft
                                                                              tors   Present seminars a'               Based o
                                                                              pitws upon request. The,                 the needs
                                                                              so far-on red cel                        think it'

         @@@ fi             . mEbir-,AL,  Bo    6RY ossERvER                                                                                                         I
             i@ :                                                                                            I
                            5 @                                                                                                                                      I


                   A System of Continuing Medical Education
                                                     Based on Medical Audit

                                                         WILLIAM R. FIFER, M.D.
              THERE   ARE    5,000    physicians    in    Minnesota     methods such as  medical  television,  tape  cassettes
              who are in clinical  practice.  As  individuals  they     and videotapes are available.
              are  solely  responsible  for  maintenance  of  their        Although there is no organization  of  this  series
              Clinical competence.  As  student,  intern  or  resi-     of  random  experiences,  there  is   certainly   more
              dent, the physician devoted all of his  attention  to     continuing  medical  education  offered  than  any  of
              learning.  Now  his  principal  activity  is  patient     us can use.
              care. To do this job well,  he  must  constantly  up-                      Learning Theory
              date  his  medical  knowledge.  Due  to  rapid  infu-        Educators  tell  us  that  retention  of  knowledge
              sion of new  information  from  biomedical  research,     depends on its utility and its relevance.
              a physician's knowledge store  has  a  half  life  of        Educators also tell us  that  there  is  a  "teach-
              less than ten years.  A  physician  who  fell  asleep     able  moment"  at  which   time   we   are   maximally
              like  Rip  Van  Winkle  ten  years  ago   would   not     receptive  to  new  knowledge.  In  clinical  medicine
              know   about   Rhogam,   about   ethambutol,    about     we  reach   the   teachable   moment   when   we   are
              staging  procedures  for  Hodgkin's  Disease,   about     confronted  with   a   clinical   problem.   We   then
              coronary bypass surgery,  about  amniocentesis,  etc.     call a consultant, go to  the  library,  or  in  other
              @onal  Medical  Programs  were   created   to   close     ways  acquire  a  needed  piece  of   information   to
              the, gap b&twee       I     tower  and  the  practic-     solve the  problem  of  John  Smith.  We  will  remem-
              ing  physician.  Northland  Regional   Medical   Pro-     ber  the  problem  and  our  solution  long  after  we
              gram, like all Regional Medical  Projzrams,  has  em-     have forgotten the source of our information.
              phasized  continuing  medical  education   (CME)   as            Identification of Continuing Medical
              the  principal  means  to  upgrade  the  quality   of
              medical care. The  basic  question  in  CME  is  "Who                      Education Needs
              needs to  know  what?"  and  we  have  begun  to  im-        Given  an  almost  unlimited   number   of   oppor-
              plement a  statewide  system  of  continuing  medical     tunities to learn, how does a  physician  decide  what
              education  based  on  the  determination  of   knowl-     to  chooses  When  we  divide  medical  practice  into
              edge needs by review of actual  patient  care,  medi-     what   we   know   (knowledge)   and   what   we    do
              cal audit.                                                (medical  care),  the  question   becomes:   What   is
                  Modes of Continuing Medical Education                 it we need to know in  the  context  of  what  we  do?
                How  do  physicians  continue  their  medical  edu-     There are three  currently  popular  means  of  deter-
                                                                        mining  needs:   self-assessment   tests,   individual
              cation? First, patient care experiences are  a  vital     practice profiles, and medical audit.
              learning resource. Second,  consultations  and  daily        Self-assessment  examinations   are   now   offered
              contact with  other  physicians  contribute  greatly.
              Third, hospital staff meetings, medical and  special-     by specialty societies in many  fields.  The  internal
              ty  society   meetings   provide   new   information.     medicine  examination  is  called  MKSAP-11,  and   is
              Fourth, continuation courses are  provided  in  abun-     sponsored  by  the  American  College  of  Physicians.
              dance. Fifth,  reading  medical  books  and  journals     It is divided into  nine  subject  areas  and  may  be
              continues to  educate.  Finally,  innovative  leamino     taken either as  a  closed  or  open  book  test.  The
                                                                        examinee, after taking this test, learns  two  things:
                                                                        (1)  what  he  knows  of  internal  medicine   divided
               Feasibility Study by the University of Nfirmesota Component  of
              the Program Staff of  NRMP,  Inc.,  supported  by  HEW  grant  #5 into  nine  categories,  and  (2)  how   he   compares
              G03  RM@l.  The  opinions  presented  do   not   constitute   en- with his peers.
              dorsement by HEW or NRMP, Inc.
                Dr. Fifer is a Professor, Department  of  Medicine,  University Individual practice profiles  measure  not  what  a
              of Minnesota Medical School, and Associate  Director,  Northlands
              Regional Medical Program.                                 physician  knows  but  what  he  does.  Developed   by
              DECEM13ER, 1972                                                                                               17


                                                            MINNESOTA MEDICINE

                  the  University  of  Wisconsin  Medical  School,  this      patient  care.  Thus,  we  hoped  to  "set  tops  spin-
                  technique is as follows: A physician  carries  a  tape      ning" at a rate  of  five  per  year,  and  hoped  they
                  recorder  with  him  for   several   days,   recording      would keep  on  spinning  after  our  seed  money  sup-
                  information for each hospital visit, office visit, and      port was  withdrawn.  At  present,  four  of  the  five
                  telephone call.  The  tape  is  then  analyzed  and  a      will  continue  the  program  on  their  own,  and   we
                  report describing his practice profile is sent to  the      have  begun  working  with  four  new  hospitals.  [Al-
                  physician.  Along  with  the  profile,  the  physician      bert   Lea,   Fairview   (downtown),   Methodist   (St.
                  receives  an  educational  prescription   which   says      Louis Park) and  St.  Cloud]  in  the  second  year  of
                  "inasmuch  as  you  do  these  things,  you  need   to      the program which began April 1, 1972.
                  know  these  things."  The   University   then   lists
                  those courses, meetings, lectures, etc.,  most  perti-                           Methods
                  nent  to  the  knowledge   requirements   defined   by         To   implement   our   program,   we   have   worked
                  his practice analysis.                                      directly with the affiliated hospitals to assist  their
                    Medical Audit is defined  as  a  system  of  contin-
                                                                              DCME's  and  medical  staffs  to  establish  a   system
                  uing  medical  education  based  on   the   evaluation      of  medical  audit.  In  addition,  we  have  conducted
                  of the quality of patient care as reflected  in  medi-      monthly  medical  audit  workshops,  an  annual  state-
                  cal records. We feel that medical  audit  is  superior      wide  hospital  staff   conference,   and   an   annual
                  to either self-assessment exams or  practice  profiles      continuation  course  on  medical  audit  at  the  Uni-
                  in that it demonstrates  the  application  of  medical      versity  of  Minnesota.  To  establish  an  audit  pro-
                  knowledge to patient care situations.                       gram in a hospital, we  found  it  necessary  to  teach
                    The  Minnesota  Medical  Audit  Program   is   fund-      the process to the medical staff.
                  ed  by  Northlands  Regional  Medical   Program,   and         The process of medical  audit  involves  six  steps:
                  promoted  by  the  University  of  Minnesota   program         1.  Criteria  must  be  defi@4  for   optimum   care
                  staff. Described as a "Feasibility  Study  of  Medical      of the disease  or  condition  to  be  studied.  If  we
                  Audit," the  program  began  April  1,  1971  in  five      study patients  discharged  with  a  primary  diagnosis
                  Minnesota   community   hospitals   (Austin,    Fergus      of diabetes mellitus, we  set  the  recording  of  fun-
                  Falls,  Hibbing,  Virginia  and  Worthington).   These      duscopic  examination  for  95  percent  of   the   pa-
                  hospitals  were  selected  because  of  their  diverse      tients examined as a criterion.
                  geographic  distribution   and   because   they   were         2.  Actual  care  must  be   reviewed   to   display
                  relatively  "closed  systems'  in  which  the  medical      existing  practice   patterns.   We   may   study   100
                  staff-hospital  relationship  was  well   established.      consecutive  admissions  for  diabetes   mellitus   and
                  Their sizes range from  64  to  185  beds,  and  their      find  that  36  percent  of  the  charts  have   fundu-
                  medical staffs  contain  from  17  to  40  physicians.      scopic examinations recorded.
                  Altogether,  they  comprise  142  physicians  and  663         3. Ideal vs.  actual  must  be  compared  to  deter-
                  acute beds.                                                 mine if a gap  exists.  In  our  example,  the  gap  is
                    To  qualify  for  participation  in  the  study,  we      between  36   percent   actual   performance   and   95
                  asked each  hospital  to  meet  four  conditions:  (1)      percent optimal performance.
                  approval  of  the  program  by  the  governing  board,         4' Gaps  must   be   translated   into   educational
                  administration  and   medical   staff,   (2)   medical      objectives to form the  basis  for  a  continuing  edu-
                  records  information  retrieval  capability  (four  of      cation  program.  In   our   example   we   state   the
                  our first five hospitals  have  PAS/MA.P),  (3)  will-      objective  in  this  way:   "Following   an   education
                  ingness to  create  an  education  budget  to  respond      program  on  diabetic  retinopathy,   95   percent   of
                  to  identified  educational  needs,  and  (4)  apoint-      the  charts  of  patients  discharged  with  a  primary
                  ment by the medical staff of one  of  its  leaders  to      diagnosis of  diabetes  mellitus  will  contain  a  re-
                  work  20  percent  time  as  director  of   continuing      corded funduseopic examination.
                  medical   education   (DCME).   Northlands    Regional         5.  The  education  program   must   be   implement-
                  Medical   Program   provided   the   funds   for   the      ed. We may  decide  on  a  series  of  three  presenta-
                  DCME position. It  was  understood  by  the  hospitals      tions, one on classification of  diabetic  retinopathy;
                  that  NRMP  financial  support  would   be   withdrawn      one  a  presentation  of  fundus   photographs   and/or
                  at the end of  the  one-year  study  period.  We  felt      clinical  experience  sessions;  and  one  on  photoco-
                  that one year was  adequate  to  determine  the  value      agulation techniques with laser beam.
                  of the medical audit  program  in  terms  of  improved         6. Finally, we  must  evaluate  the  program  at  an
                  18                                                                                           MINNESOTA   MEDIC .I,NE


                                        SYSTEM OF CONTINUING MEDICAL EDUCATION

            appropriate  interval.  In  our   example,   we   study     actual  care.  The  medical  staff  then  performs  the
            the  next   100   consecutive   records   of   patients     evaluative step  by  comparing  the  optimal  with  the
            discharged  with  a  primary  diagnosis   of   diabetes     actual level of  care  to  detect  gaps  which  may  be
            and  determine  the  number  of  recorded   funduscopic     closed by continuing educations
            examinations.  If   actual   performance   remains   at        In addition to  working  with  individual  hospitals
            36  percent,  our  program  failed;  while  if   fundu-     to  assist  them  to  institute  audit,  we  have  con-
            scopic  exams  jumped  to  82  percent,  we  caused   a     ducted  monthly  medical  audit   workshops   using   a
            change in leamer behavior.                                  44 show and  tell"  format  in  which  various  hospitals
               What are the requisites  for  a  hospital  staff  to     present  audits.  Nurses   were   included   initially,
            perform   medical   audit?   First,   they   must    be     but now  have  split  off  into  a  separate  group  to
            efficiently   organized.   The   common   practice   we     develop nursing audits.  We  accept  this  split  as  a
            encounter is horizontal  review  of  care  rather  than     temporary expedient,  and  plan  to  bring  the  health
            vertical  (holistic  or  patient-centered).   We   have     team   together   by   focusing   on   patient-centered
            often   recommended   a   reorganization   of   medical     (vs.   professional-centered)   and    outcome-oriented
            committees  with  the  anchor  committee  (called   the     (vs. process-oriented) audits.
            audit  or  professional  activities  comniittee)   sys-        In  addition  to  the  workshops  we  sponsored  two
            tematically reviewing profiles of patient care.             more  formal  conferences:  The  first  of  these   was
               Second  a  medical  staff  must   have   a   medical     the  First  Annual  Minnesota   Hospital   Staff   Con-
            records   department   capable   of   information   re-     ference  in   September,   1971.   This   two-day   in-
            trieval  on  demand.  If  an  audit  committee  of  six     vitational   conference   was   attended   by   manage-
            men  decides  to  study  the  management  of   diabetes     ment  teams  made  up   of   trustees,   administrators
            mellitus by reviewing all  the  charts  for  one  year,     and key medical staff leaders  from  each  of  27  hos-
            they  might  first  decide   what   basic   information     pitals.  The  theme   of   the   conference   was   the
            should  be  recorded  on  all  diabetes  charts.   This     quality  of  medical  care  in   community   hospitals.
            information   can   be   quickly   provided   by    the     Its  objective  was  to  convince  trustees  that   the
            medical  record  librarian  from  the  computer  print-     responsibility for  quality  was  legally  theirs,  and
            outs   (PAS/M").   Then   they   might    select    for     that  they  discharged  this   responsibility   through
            deeper  study  a  certain  group  of  diabetics   which     the  organized  medical  staff.  We  followed  this  UP
            are  disi)laved  in  groups  on  the  computer   print-     with a  two-day  continuation  course  at  the  Univer-
            outs.  Having  decided  to  look  at  diabetes   either     sity  of  Minnesota  on  the  "how   to"   of   medical
            broadly or at  a  specific  problem  in  diabetes,  the     audit in  October,  1971,  attended  by  63  physicians
            committee  first  sets  pattern  criteria  for  optimal     from hospitals  all  over  the  state.  We  feel  these
            performance, then  goes  to  the  records  to  see  how     companion  efforts  have  helped  to  create  a   broad
            actual  care  measures   up   to   optimal   standards.     climate  of  acceptance  of  medical   audit   in   @e-
            The  information  they  need  to  review  care  may  be     sota,  and  have  developed  a  cadre   of   physicians
            divided  into:  (1)  that  which  the  medical   record     capable of leadership.
            librarian   can   get   from   the   PAS/MAP   computer                            Results
            printouts    (example:    percent    of     funduscopic        It is premature  to  evaluate  the  success  of  the
            exams),  (2)  that  which  the   medical   record   li-     first year's effort. We  intentionally  structured  the
            brarian  can  find  by  studying  the  chart  (example:     program loosely to permit  great  diversity  of  activ-
            percent  of  diabetics  taught  foot  care),  and   (3)     ity among the  participating  hospitals.  We  felt  the
            that  which  requires  medical   judgment   and   hence     program  would  be  more  likely  to  succeed   if   it
            review  of  the  record  by   a   physician   (example:     was their  very  own  rather  than  a  University  pro-
            app     riateness of the surgical therapy  of  diabetic     gram  in  their  community.   Because   each   hospital
                rop
            peripheral  vascular  insufficiency).  In   this   way,     is so different politically and  organizationally,  the
            the  comniittee  can  systematically  review  the  care     program took different.forms at different sites.
            of  diabetics  in  their  hospital  to  determine  what        Despite  operational  obstacles,   and   thanks   to
            continuing education in diabetes     is   most   appro-     dedicated  work  by   the   DCMEs   and   small   staff
            priate for their medical staff.                             committees,  the  first  year's   hospitals   developed
              Iin   organt.zing  medical  audit,  only  the   medical   skills in  medical  audit,  learned  to  develop  their
            staff  can  establish  optimal  standards.   The   med-     own  pattern  criteria,  and   learned   to   formulate
            ical  records  department  prepares  the  displays   of     education  programs  for  the  medical  staff  in   re-

            Drict,,m[IE-R, 1972                                                                                              19


                                                             MINNESOTA MEDICINE

                   sponse to specific  gaps  identified  by  audit.  They     as a group, for  every  single  patient  cared  for  in
                   accomplished  dozens  of  audits  despite  heavy   pa-     the institution.
                   tient   care   demands.   Education   programs    were        2.  Medical  staff  organization   is   a   problem.
                   produced  and  when  an  outside   speaker   was   em-     The  medical  care   appraisal   function   is   spread
                   ployed,  he  was  informed  of  the  educational   ob-     about   in   many   committees   and   each    hospital
                   jective  before  he  spoke  to  the  staff.  Time  has     must  solve  this  problem  in  its   own   way.   Some
                   not  yet  permitted  completion  of  the  audit  cycle     redesigned  their  committee  structure,  others   left
                   to  see  if  the  education  resulted  in  change   of     the committee structure  essentially  intact,  and  re-
                   physician behavior  by  re-audit  of  the  disease  or     assigned  functions.  Common  to   all,   owever,   was
                   condition.  We  await  these  re-audits   with   great     the perception of a need  to  be  organized  to  accom-
                   interest.                                                  plish the job of medical care appraisal.
                      Subjects dealt with by the first  year's  hospitals        3. The  state  of  medical  records  is  a  problem.
                   included the  use  of  antibiotics,  anemia,  diabetes     Since  medical  audit  requires  "the   evaluation   of
                   mellitus,   myocardial    infarction,    appendectomy,     medical  care  as  reflected   in   medical   records,"
                   hypertension,   duodenal    ulcer,    cholangiography,     the  record  becomes   the   key   document.   If   the
                   cholecystectomy,  the  use  of   tranquillizers,   and     record is complete,  legible  and  contains  a  concise
                   urinary  tract  infection.  In  some  instances   data     discharge summary, the  record  librarian  is  able  to
                   were pooled and shared by the hospitals.                   abstract  it  for  PAS/MAP.  The  latter  step  permits
                      Two  hospitals,  in  auditing  myocardial   infarc-     another chance for error, however, and we  ame
                   tion,  concluded   that   pacemaker   capability   was     that the record abstract was  often  the  weakest  link
                   necessary for  optimal  care.  As  a  result,  members     in the information retrieval chain.
                   of  each  medical  staff  returned  to   the   medical        4. Definition  of  optimum  criteria  by  the  medi-
                   centers for training in the use of  transvenous  pace-     cal staff is a problem. They are  much  more  inc  ined
                   makers.  Another  hospital,  after  auditing   myocar-     to simply "take  a  look  at  a  subject  and  see  how
                   dial infarction, decided  they  needed  to  know  more     we're  doing,"  without  having  first  defined  stand-
                   about serum lipids, and instituted a series  of  medi-     ards.  The  criteria   committees   often   asked   for
                   cal  staff  education  sessions  designed  to  improve     "cookbook"  standards  developed  by   "the   experts,"
                   their diagnosis and therapy of hyperlipidemia.             and  had  to  learn  that  the  educational  value   of
                      Audits of diabetes mellitus  led  one  hospital  to     standard  setting  probably   equals   that   of   care
                   institute a series  of  educational  programs  on  re-     evaluation.
                   cent  advances  in  the  therapy  of  diabetic  retin-        In  addition  to  continuation  and   expansion   of
                   opathy. They selected  this  topic  after  discovering     hospital-based  medical  audit,  we  plan   to   extend
                   that  only  34  percent  of  the  patients  discharged     our  program  activities  this  year.  Beginning  April
                   with a primary  diagnosis  of  diabetes  mellitus  had     1,   1972,   Northlands   Regional   Medical    Program
                   their  fundi  examined.  Another  hospital  concluded,     has  funded  demonstration  projects  to  extend  audit
                   after studying their diabetic care, that  they  needed
                   to increase the  use  of  other  health  professionals     to: (1) the  outpatient  setting,  and  (2)  the  prob-
                                                                              lem-oriented  record.   These   new   directions   rec-
                   (nurse and dietitian) in the  education  of  the  dia-
                   betic patient.                                             ognize  and  attempt  to  correct  two  limitations  of
                      Almost every  audit  disclosed  room  for  improve-     hospital-based  medical  audit.  The  first   is   that
                   ment  and  indicated  a  specific  behavioral   change     hospital-based audit does  not  apply  to  the  medical
                   that was desired.  The  medical  staff  felt  that  an     care,  which  takes  place  in   ambulatory   settings.
                   educational  program   would   produce   the   desired     Three  group  clinics  (East  Range  Clinic,  Virginia;
                   result  in  some  cases;  in  others,  they  chose   a     Nicollet  Clinic,  Minneapolis;  and  the   St.   Louis
                   procedural or operational solution.                        Park  Medical  Center,  St.  Louis  Park)   have   been
                                                                              funded to  carry  out  computer-based  audits  of  out-
                                        Discussion                            patient  care  this  year,  and  we  look  forward   to
                      We can generalize  about       a  few   things   we     their results with great interest.
                   learned in the first year:                                    Audit  of  the  problem-oriented   record   attempts
                      1.  Before  action  occurs,  an   attitude   change     to correct a  second  deficiency  of  the  conventional
                   must  occur.  We  have  seen  a   general   acceptance     hospital  medical  audit-namely  that  it  accepts  the
                   of  the  peer  review  process,  and  of  the  concept     diagnosis as given, and is unable to  critically  study
                   that  the  organized  medical  staff  is  responsible,     diagnostic  process  or  outcome.  By  auditing   prob-

                   20                                                                                          MINNESOTA MEDICINE


                                        SYSTEM OF CONTINUING MEDICAL EDUCATION

              lems rather than diagnoses, we can set criteria  for                         Swmary
              and evaluate the  care  of  100  consecutive  admis-       Northlands  Regional  Medical  Program   has   be-
              sions for chest pain or headache, or jaundice,  etc.     gun  to  develop  a  system  of  continuing  medical
              This strategy moves us closer to the real  world  of     education  based  on  needs  demonstrated   by   the
              patient care and offers exciting  opportunities  for     process of medical audit.  This  system  offers  the
              doctors to apply the educational  process  to  their     potential to: (1) increase the relevance of  contin-
              own  logic  sequence  in  patient  management.   Two     uing medical education by  relating  it  to  patient
              hospitals  (Bethesda  Lutheran  and  Miller  in  St.     care, (2) provide  on-site  leaming  experiences  in
              Paul) began these demonstration  projects  on  April     community  hospitals,  (3)  merge  continuing  medi-
              1, 1972,  and  we  will  be  greatly  interested  in     cal education and patient care by  making  the  com-
              their results.                                           munity hospital a teaching hospital, and (4)  Ei)ove
                                                                       all, improve patient care  through  continuing  med-
                                                                       ical education.

              I)FCEMBER, 1972                                                                                            21


                               A Dialogue with Sir William Osler on
                                                    PostgTaduate Education
                                            Critique of a Northlands Regional Medical Program
                                                                   RUSSELL V. LUCAS, JR., M.D.

                        T  WAS  A  TYPICAL  August  night  in  Minnesota,                   ical  performance.  We  hear,   for   example,   that
                   sultry, wind gusting, sheets of  rain  assaulting  my                    1/3 of recent medical school graduates fail  to  con-
                   window and distorting  the  lights  occasionally  ap-                    tinue postgraduate training  once  they  start  prac-
                   pearing  in  the  inky  black.  I  had  labored  some                    tice.'  Estimates  suggest   that   20-70%   of   all
                   time, in vain, to prepare an evaluation of  "A  pilot                    M@D.'s fail to  participate  significantly  in  post-
                   project  in  postgraduate  education   in   pediatric                    graduate educational endeavors.112
                   cardiology   and   neonatology."   My   friend    Win                    Sir William:
                   Miller was acting like an editor. All creativity  had                        "Things  haven't  changed  much  then!   Let   me
                   escaped. I gazed vacantly out the window.                                recall what I thought  about  that  at  the  turn  of
                       A rich warm  voice  projected  from  the  shadows.                   the century. Bear with me if I  falter  occasionally;
                   "I had an interest in  postgraduate  education,  per-                    you're  aware  that  we  don't  remember  w   at   we
                   haps I can help." I turned  to  see  a  tafl  slender                    write.*
                   man  of  impressive  bearing.  His  black  hair   was                          If  the  License  to  practice  meant   the   completion
                   beginning to recede,  a  full  moustache  adomed  his                        of  his  education  how  sad   it   would   be   for   the
                   upper lip, and his black piercing eyes were  set  off                        practitioner, how distressing to his patient.3
                   by full brows and  an  acquiline  nose.  Despite  his                        I was moved to  sadness  by  a  physician  of  my
                                                                                            acquaintance who
                   appearance,  he  seemed  a  warm  and   understanding                        crawled  up  on  the  bank  and  the   stream   left   him
                   man.                                                                         there, but he did not know it.3
                       Sir William Osler.                                                       On  the  other  hand,  the  country  doctor   who
                       During the  discussion  that  ensued,  I  had  the                   maintained his skills and utilized his  opportunities
                   wits to  take  some  notes  which  I  used  later  in                    for postgraduate education filled  me  with  joy."
                   recording our conversation.                                              Author:
                                           Introduction                                         "You're  implying  that  the  physician,  now  as
                   Sir William:                                                             then,  lacks  appropriate  motivation  for  continued
                       "Before  we  get  down  to  your   problem,   what                   learning."
                   is the state of medicine these days?"                                    Sir William:
                   Author:                                                                      "Some perhaps, but that's not  the  whole  story-
                       "Not too well if we take at  face  value  what  is                   What about the professor,  the  medical  school,  who
                   described by the press, the 'lay  medical  journals',                    are bypassed by  the  stream  of  medical  knowledge.
                   and politicians  of  all,callings.  They  lament  the                    I used to call that condition 'old fogeyism'.
                   widening gap  between  medical  capability  and  med-                          Would  you  know  the  signs  by  which,   in   man   or
                                                                                                institution,   you    may    recognize    old    fogeyism?
                       This report is based on a demonstration project entitled "Pilot          There are three;  First  a  state  of  blissful  happiness
                   Study in Postgraduate Education in  Pediatric  Cardiology,"  spon-
                   sored by the University  of  Minnesota.  it  was  a  romponent  of           and  contentment  with  things  as  they   are;   secondly
                   Northiands  Regional  Medical  Program,  Inc.  supported  by   HEW           a  supreme  conviction  that  the   condition   of   other
                       ran,*' G ' Rm-M2l. The opinions  presented  do  not  Institute
                   .g.d..,.e.toby  NRMP,  Inc.,  or  by  the  Department  of  Health,           people  and  other  institutions  is   one   of   pitiable
                   Education and Welfare.                                                       inferiority;  and  thirdly,  a  fear  of   change,   which
                       Dr. Lucas is Professor of Pediatrics, Dwan Professor of  Pedi-
                   atric Cardiology, University of Minnesota School of Medicine.                not alone perplexes, but appals.3
                       *Direct quotes from Sir William's writings are in  references.
                   Other conunents are  poetic  license,  but  reflect  the  author's
                   understanding of Osier's philosophy.                                         Are these signs of old fogeyism in  today's  pro-
                   22                                                                                                               MINNESOTA         MEDICINE


                                                                          SIR WILLIAM OSLER

                    fessors and medical schools?"                                            liked   the   idea,   modestly   funded   us,   and    helped    us
                    Author:                                                                  define the following goals:
                       "Yes,   in   some   the   condition   is    quite    advanced."       1 .   Provide     immediate     postgraduate      education      in
                    Sir William:                                                                   pediatric cardiology throughout Minnesota,
                       "Then     perhaps     faulty      postgraduate      educational       2.    Established    more    effective     methods     of     post-
                    methods   play   an   important   role   in   the    failure    of             graduate education; and
                    physicians    to    participate     in     postgraduate     educa-       3.    Encourage     local     physicians      to      assume      a
                    tional opportunitiesi"                                                         larger role in their postgraduate education."
                    Author:                                                                  Sir William:
                       "We  thought   so!   In   our   design   of   a   pilot   study         "You   call   $30,000   a   year   modest!    I    recall    when
                    in    postgraduate    education    in    pediatric     cardiology,       little   more   than   twice   that,   $70,000,   was   the   total
                    we   started   with   the   assumption    that    faulty    educa-       budget   for   all   1   1   Canadian    medical    schoolS.4    My
                    tional   methods   were    a    major    factor.    We    believed       apologies!    Let's     hear     how     you     attacked     those
                    that  our   own   past   efforts   and   others   failed   because       worthy goals."
                    they:                                                                                     Methods and Results
                       a.     did not identify  the  needs  of  the  learner-physi-          A .   Utilization    of    the    Crippled    Children's    Service
                              cian;
                       b.     allowed little active  participating  by  the  learn-          Cardiac   Clinic    as    a    focus    for    Postgraduate    Edu-
                              er-physician;                                                  cation
                       c.     too   often   provided   a   mass   of   unintegrated          Author:
                              facts;                                                           "Through      the       encouragement       and       cooperation
                       d.     did  little  to  develop  analytical   abilities   or          of    Dr.    Mildred     Norval,     arrangements     were     made
                              judgment;                                                      to utilize   the   crip   led   children's   cardiac   clinics   as
                       e.     did not allow the  acquisition  of  new  skills;  and                                p
                       f.     were  seldom  conducted  in  the   physician's   nat-          foci   for   postgraduate   seminars.    In    our    three    year
                              uraI environment."*                                            experience,   thirty   crippled    children's    cardiac    clinics
                    Sir William:                                                             in    nine    Minnesota    communities    were     utilized.     In
                       "Well,    Well.    What's    necessary    for    good     post-       each   of   these   clinics,   15-75    children    with    cardiac
                    graduate education then?"                                                disease   are   seen.   The   clinics   are    staffed    by    pe-
                    Author:                                                                  diatric    cardiologists    from    the    Mayo     Clinic,     St.
                       "We thought the following:                                            Louis   Park    Medical    Clinic    and    the    University    of
                    l@   The   specific   needs   of    the    practicing    physician       Minnesota.     A     number      of      different      educational
                         must    be    identified    and    the     curriculum     de-       programs    were    utilized    in     conjunction     with     the
                                                                                             crippled children     's   cardiac   clinics   over   the    period
                         signed to meet them.                                                of the pilot study as follows:
                    2.   The    practicing    physician     must     actively     par-       1 .   Informal lectures.
                         ticipate in the learning process.
                                                                                                   An   eight    session    curriculum    designed    to    meet
                    3.   The    postgraduate    program    must    be     person     -             the   needs   of   the    racticing    physician    in    the
                         ized    so    that    differing    needs    of     individual                                    p
                         physicians may be met.                                                    area    of    pediatric     cardiology     was     formulated
                    4.   A    significant    portion    of    the     program     must             and   utilized.    This    gave    the    visiting     pedia-
                         occur    in    the    physician's    local    environment.                tric  cardiologist     guidance     for     his     discourse
                    5.   The program should be patient oriented.                                   and     eliminated     the     possibility      he      would
                    6.   The    program    must    be     conceived     as     contin-             talk   about   his    favorite    defect    or    his    cur-
                                                                                                   rent   research  efforts.        The      lectures       were
                         utng    over    the    professional    lifetime    of     the             given    during    noon    lunch    breaks    at     hospital
                         physician."                                                               staff   meetings,   in   the   early   afternoon    at    the
                    Sir  William-                                                                  cardiac   clinics,   in   the   late   afternoon    at    the
                       "I   see.   You're   trying   to   switch   from   a    teacher
                    oriented   curriculum    to    one    that's    oriented    toward             cardiac   clinics,   and   at   night   after   dinner    and
                    the   physician   learner,   How   did   you   go    about    it?"             in    conjunction     with     county     medical     society
                    @thor:                                                                         meetings.    The    noon    and    early    afternoon    ses-
                                                                                                   sions were least well attended."
                       "The     Northlands     Regional     Medical     Program,     a       Sir William:
                    federally     funded,     regionally     directed     organization          "Perhaps   practicing   physicians    are    still    busy    in
                       *Editor's Note: These several points apply  to  all  phases  of
                    medical equation                                                         their clinics and miss lunch."
                    DEcEmBER, 1972                                                                                                                            23


                                                                 MINNESOTA MEDICINE

                  Author-.                                                         Sir William:
                     "That's  right.  On  the  other  hand,  the  late  after-           "Perhaps,  but  do  all   your   teachers   teach?   I
                  noon  and  evening   sessions,   though   better   attended,     doubt   it.   Some   won't.   Others,   who   will,   aren't
                  had  a  rather  high  percentage   of   inattentive   physi-     asked.  This   looks   like   a   problem   money   is   not
                  cians."                                                          required   to   solve,   but   rather   harmony   and   good
                  Sir William:                                                     will in our profession.
                     "Hypoglycemic    and    sobriety     factors,     respec-            Medical men, particularly in smaller places@  live
                  tively."                                                               too much apart  and  do  not  see  enough  of  each
                                                                                         other. In large cities we rub  each  others  angles
                  Author:                                                                down and carom off each other without  feeling  the
                     "Our   next method was:                                             shock very much ... as a  preventative  of  such  a
                  2.   Patient  oriented  case   discussions   after   cardiac           malady, attendance  upon  our  annual  meetings  is
                       clinics.   These   sessions   allowed   the   physician           absolute, as a cure it is specific."4
                       to  participate  in  the   examination   of   a   child     Author:
                       with   congenital   cardiac   disease    and    discuss           "Perhaps  then,  even  if  some  of  our   pedagogical
                       the  details   of   management.   In   one   variation,     methods   were   suboptimal,   the   fact    they    encour-
                       patients   with   'interesting   and    common    prob-     aged   physician   dialogue    was    most    important."
                       lems   were   held   over   and   presented   to    the     Sir William:  "Quite so.
                       physicians   for   their   examination   and    discus-     Author:
                       sion.  This   was   a   most   valuable   exercise   if           "Sir  William,  your   words   about   the   isolation
                       there   were   a   small    number    of    physicians.     of  physicians  brings  to   mind   a   totally   unexpected
                       However,  if  more  than  3   or   4   physicians   at-     result  of  our  educational   efforts   in   the   crippled
                       tended,   a   great   deal   of   time    was    wasted     children's clinics. It has to do with:
                       while   each   patient    was    examined    and    the     4.    Education  of   allied   health   personnel   in   the
                       sessions  lost  clarity  and  direction.  For  a  small           Cardiac   Clinics.   Early   in   our   program,   the
                       number,  this  type  session  was  a   most   effective           public   health   nurses   and   social   workers   in
                       educational   device.   A   second   variation,    use-           the  cardiac  clinics  asked  for   educational   ses-
                       ful  for  a  larger  number  of   physicians   was   to           sions  tailored  to  their  needs.  They  were   aware
                       present  the  history  and   physical   findings,   re-           of the many problems faced by t                 commu-
                       view   Xrays   and   electrocardiograms   of   a   num-           nity  in  providing  the   optimal   environment   for
                       ber  of  patients.  Each  case   was   the   basis   of           children   with   heart   disease.   Therefore,   com-
                       discussion,   often   spirited,   of    the    problems           munity   school,   hospital   and    @public    health
                       posed to the -practitioner."                                      nurses,  social  workers,   and   school   administra-
                  Sir William:                                                           tors,  teachers,  and  athletic  directors  were   in-
                     "That  sounds  better.  The   focus   is   now   on   the           vited  to  special  sessions  at  the  close  of   the
                  patient."                                                              cardiac   clinics.   Brief   explanations   of    con-
                                                                                         genital   heart   disease    and    rheumatic    fever
                  Author:    "Our next approach was:                                     were   given   followed   by   a   lengthy    question
                  3.   Physician  attendance  at   the   crippled   children's           and   answer   period.   The   discussions    centered
                       clinic.
                       The  practicing  physician  often  visited   the   car-           on the child  with  heart  disease;  his  habilitation
                       diac  clinic  to  review  the  findings   and   manage-           and  rehabilitation,  special  school   and   activity
                       ment   of   a   patient   he   had    referred.    This           programs   required,   his   medical,    dental    and
                                                                                         nursing  needs,   as   well   as   the   psychologi
                       provided   an   opportunity   to   review    thoroughly           stress   imposed   on   the   children    and    their
                       the  physical  findings   and   the   natural   history           families."
                       of the cardiac disease and its management."
                  Sir  William:                                                    Sir   William:
                     "NovV you   ire    getting    somewhere!    You've    re-           "Those  are  the  things  we  doctors  used  to   take
                  discovered   the   perfect   medical   learning   situation,     care   of.19
                  the triangle of student-patient-teacher."                        Author:
                  Author:                                                                "That's  true,  but   most   physicians   today   wel-
                     "This  was   unquestionably   the   best   learning   ex-     come  this  help.  The  major  problem,  as  it  is  in  all
                  perience, but  it  takes  one  teacher  for  every  student.     human   affairs,    is    meaningful    communication.    We
                  T'hat's an expensive method."                                    saw   evidence   that   avenues   of    communication    be-

                  24                                                                                                   MINNESOTA  MEDICINE


                                                                SIR WILLIAM OSLER

                tween   the   allied   health   personnel,   parents,   com-       I . impart   the   knowledge   and   skills   necessary   to
                munity   physicians   and    medical    center    physicians           the recognition of the sick infant.
                were   unclogged   by   these   shared    educational    ex-       2.  Provide   the    knowledge    and    skills    necessary
                periences."                                                            for  appropriate  therapy   in   the   areas   of   oxy-
                Sir William:                                                           genation,  heat  control,   feeding,   acid   base   and
                   "So  you   had   30   of   these   educational   programs           electrolyte   balance,    treatment    of    infections,
                in   nine   Minnesota    communities.    How    many    stu-           and treatment of congestive cardiac failure.
                dents?"                                                            3.  Provide   the   means   to   determine   when   a   sick
                Author.                                                                infant  requires  transfer  to   a   specialized   diag-
                   " 1 80  physicians,  and  290  nurses  and  other  allied           nostic   and   treatment   center   and   the    methods
                health people."                                                        of optimal transfer of the infant.
                Sir William:                                                           An  in-service  training   program,   lasting   one-half
                   "May  I  ask  two  critical  questions.   First   regard-       to  one  day  was  given  in   21   hospitals.   Each   pro-
                ing  the  scope  of  the  program.  I  recall  that  I  once       gram  was  conducted  by   a   physician   and   an   infant
                said   pediatrics   was   the   best   specialty,    because       intensive  care  nurse   from   the   University   of   Min-
                children's  ailments   were   too   diversified   to   allow       nesota    Hospitals.    Preliminary    discussion    between
                                                                                   t     I
                Much    specializations    But     pediatric     cardiology;       he  visting   team   and   the   community   hospital   per-
                isn't that splitting the hair pretty fine?"                        sonnel  established  the  specific   local   situation   and
                A                                                                  problems  with@in  the   context   of   the   above   goals.
                   uthor:
                   "That   we   learned.    The    NRMP    people    thought       In  the  21  hospitals,  380  nurses,   LPN'S,   and   tech-
                so, too."                                                          nologists and 45 physicians were served."
                                                                                   Sir Wifflam:
                Sir Winiam-                                                            t'i suppose  it  is  still  true  that  many  of  the   new
                   "Secondly,  while  the  cardiac  clinics  were   in   the       and  specific  medical  facts  and  skills  are   soon   ob-
                physician's  community,   they   weren't   really   in   his       solete."
                practice environment.
                     About the hospital centers all  that  is  best  and           Author:
                   highest in the profession of medicine. In it, not  in               "True   enough@   Important   as   these    new    facts
                   the medical school proper, not in  the  laboratories,           and  skills  were,   a   more   important   consequence   of
                   not in the museums, we doctors I  ive  and  move  and           the   in-service   programs   was   the   establishment   of
                   have our being."6                                               improved     communication     among     nurses,     techni-
                Author.                                                            cians  and   physicians.   We   also   observed   that   the
                   "We   recognized    the  validity   of   both   of   your       University   nurse-doctor   team    improved    their    un-
                critiques.   Therefore,   in   1970   we    embarked    upon       derstandine, of infant care."
                a  program  to  provide  postgraduate   education   in   the
                care  of  the   sick   infant   in   community   hospitals."       Sir William:
                B.   In-service   Training   for   Nurses   and   Physicians           "The  teacher  usually  accrues  the   greater   benefit
                in Neonatal Intensive Care                                         in his encounter with a student."
                Author:                                                            Author:
                   "Several   factors   favored   utilization   of    infant       I   "Evidence   that   improved   patient   care    resulted
                care  as  a  focus  for  an  in-service   educational   pro-       trom  these  programs  can  be  found  in   several   areas.
                gram  for   physicians   and   hospital   personnel.   These       Changes   in   nursing   and   hospital   procedures    were
                                                                                   often  instituted   during   and   immediately   after   the
                included  the  recent   improvement   in   definitive   care       in-service  session.  Several  institutions  sent   one   or
                for  infants  born  with   serious   cardiac   defects   and       more   nurses   to   infant   intensive   care   units   for
                other   congenital   problems,   the   almost    revolution-       long-term  trainino,.  Finally,  there  was  a   significant
                ary   improvements   in   supportive   care   for   infants,                          C,
                the   need   for   the   acquisition   of   new    technical       increase  in  the  number  of  sick  infants   referred   to
                skills,  and  new  treatment  philosophies   in   the   care       neonatal   centers   in    Minnesota    and    an    equally
                of  infants.  Further,  since  the  infant  has  a   limited       dramatic   improvement   in   their   initial   recognition,
                response  to  illness,  the  techniques  of   medical   care       local care, and transport.
                necessary  for  the  infant  with   serious   cardiac   dis-       Sir William:
                ease  applied  equally  well  to  all  who  are  sick.   The           "These   programs   represent    considerable    effort.
                goals of our in-service program were to,.                          I'd be interested in knowing the participants.,'
                DECEMBER, 197Z                                                                                                                25


                                                                               MINNESOTA MEDICINE

                        Author:                                                                      wish  to  shoulder  the  responsibility  for  their   own
                            "The  NRMP  through  funding   and   by   helping   us                   continuing  education.   Many   it   seems,   hand   over
                        to  continuously  refine  our  goals,  and  evaluate   our                   this  most  important  responsibility  to  others,  their
                        progress.   The   Division    of    Crippled    Cbildren's                   societies, their journals, their medical schools."
                        Services,  director,  and  clinic  personnel,   made   the                   Sir    William:
                        cardiac   clinics   possible.   The   Minnesota    Chapter                       "A little  harsh,  don't  you  think,  on  both  stu-
                        of  the  AMA,  the  Minnesota   Chapter   of   the   Acad-                   dent  and  teacher?  As  I   once   predicted,   medicine
                        emy  of  General  Practice  and   the   State   Board   of                   in  the  U.S.  provides  the  world's  keenest   inspira-
                        Health provided approval and support.                                        tion.113
                            The  County  Medical  Societies   and   the   hospital                   Author:
                        staffs,  provided  their  meeting  times  and   facilities                       "Sir William, your life and writings  reflect  a  re-
                        for  our  programs.  The  St.  Louis  Park   Clinic,   the                   markable  sensitivity  to  the  medical  needs  of   your
                        Mayo   Clinic,   and   the   University   of    Minnesota,                   time.  This  sensitivity  to  your  own   era,   accounts
                        provided  the   teachers   pediatric   cardiologists   and                   no  doubt  for  your  unusually  accurate  prescience  of
                        nurses for all the programs."                                                our  present  time.  Would  you  care  to  predict   what
                                       Discussion and Conclusions                                    lies in store for medicine in the U.S. today?"
                                                                                                     Sir    William:
                        Sir William:                                                                     "Recall  that  I've  said  few  men  over  40  retain
                            "It  would  appear  you  and  your   colleagues   have                   their creativity. It's  been  ;i  while  since  I  passed
                        achieved   modest   success   in   reaching   your   first                   that  milestone.  Moreover,   the   mark   of   an   old,
                        two  goals.   You   have   carried   postgraduate   educa-                   perhaps  wise,  man  is  to  know  when  to  quit.   How-
                        tion   into   Minnesota.   You   also   seem    to    have                   ever, an old  fool  seldom  can  resist  the  chance  for
                        instituted   some   improved    methods    of    postgrad-                   a  final  word.
                        uate study.                                                                      First,  postgraduate   medical   education   is   too
                            But  what  have  you  done  to  encourage  the  physi-                   important to  be  left  to  the  professors,  or  to  the
                        cian  to  assume  greater  responsibility  for  his   edu-                   societies, or to  the  journals  or  to  the  government.
                        cation?  A  physician  should  return  to   formal   study                   It must be nurtured, like life  itself,  by  each  physi-
                        for  several  months   every   few   years.   During   all                   cian.  He  must  accept  all  the  help   he   can   get,
                        my  tenure  at  John   Hopkins,   I   held   courses   for                   searching  always  for  the  defects  in  his  knowledge,
                        practicing physicians.                                                       the faults in his reasoning.
                               To meet these  good  earnest  students  from  all                            I would encourage  him  in  a  keenly  skeptical
                            parts of the country, some of  whom  have  been  in                          attitude ... ever remembering Benjamin  FrankIin's
                            practice fifteen or twenty years,  stimulates  ones                          shrewd remark that 'he  is  the  best  doctor  who
                            optimism as to the outlook of the profession."3                              knows the worthlessness of the  most  medicines.'7
                        Author:                                                                          Second,  all  augers  well  for   American   medicine
                            "We must admit to failure in this regard,                    Sir         as  long as it  retains  the  excitement  of  discontent,
                        William.   In   three   years,    only    one    physician                   the tumultuousness  of  conflict,  the  ecstasy  of  dis-
                        availed  himself  of  this  opportunity   to   return   to                   covery, and the humility of commitment.
                        the  University  for  one  or  two   months,   even   with                       Finally,  each   physician   marches   to   his   own
                        a  modest  stipend  provided  for   study.   Perhaps   our                   drum.  Learn  the  beats  of  your  colleagues,   so   as
                        offering  was  too  specialized.  Perhaps   we   did   not                   to  understand  them  better,  and  to  more  fully   ap-
                        "sell"  hard  enough.   It   may   be   physicians   don't                   preciate your own beat."

                                                                                             References

                        1.  Vollan  DD@  Postgraduate  Medical  Education   of   the   United        3.  Osler William: The importance  of  post-graduate  study.  Lancet,
                            States' Report of the Survey of  postgraduate  medical  education            2:73, 1900,
                            carried out by the Council  on  Medical  Education  in  Hospitals        4.  Osler William: The  growth  of  a  profession.  Canada  Med  Surg
                            of  the  American  Medical   Association,   1952-1955,   Chicago,            i 14:129, 1885,
                            American Medical Association, 1955.                                      5.  Osler  William:  Remarks  on  specialism.  Boston  Med   Surg   J
                        2.  The Physician's Continuing Education. Report of  the  status  and            126:457, 1892.
                            objwdves  of  postgraduate  education  by   the   Comniittee   cn        6.  Osier William: On the influence of a hospital  upon  the  medical
                            Profe@ional  Education  of  the   American   Heart   Association,            profession of a community. Albany Med Ann, 22:1, 1901.
                            New York, 1961.                                                          7.  Osler William: The  treatment  of  disease.  Canada  Lancet,  42:
                                                                                                         899, 1909.

                        26                                                                                                                     MINNESOTA      m


                                                        REPRINTED    FROM    THE
                                                  journal
                                      OF  THE  TENNESSEE  MEDICAL   ASSOCIATION

                                  OWNED  AND  PUBLISHED  BY  THE   ASSOCIATION

                                                                 FEBRUARY,   1972
                                                                VOLUME 65,  NO.  2

                                                                        Self-l?eview  Conferences.,
                                                                                         A Contribution to Problems  of
                                                                        Continuing Education and  Peer  -Review
                                                                                                                 E.  WILLIAM  ROSENBERG,  M.D.*

                           Amid   the   increasing    demands    upon    physicians      1.  The   local   group   of   physicians   choose   some
                       both    for    more    continuing    education    and    for   aspect of practice to consider.
                       more   control   of   quality   of   practice,   there   ap-      2.  The  same  group  agree   upon   criteria   of   per-
                       pears  to  be  at   least   one   bright   spot.   That   is   formance   and    outcome    that    would    represent    a
                       the  increasing  evidence   that   there   are   some   rel-   desired level of practice.
                       atively   simple   and   painless   maneuvers    that    may      3.  The  group  review   their   recent   work   to   see
                       provide  the  profession   with   a   solution   that   will   if these criteria are being met.
                       satisfy both demands simultaneously.                              4.  If  they  are,  that  subject   is   passed   and   a
                           Slee,l  Eisele,2   Brown,3   and   Uhl4   among   others   new one considered.
                       have  pointed  out  the  feasibility   of   a   process   of      5.  If  they  are  not,   discrepancies   between   ideal
                       self-correction    based    upon    an     improved     per-   and  actual   practices   are   aired.   A   suitable   pro-
                       ception   of    actual    practice    shortcomings.    While   gram    of    self-improvement    is    begun    and    con-
                       described  in   varying   terms,   the   essential   process   tinued  until  actual  practice   is   found   to   coincide
                       is as follows:                                                 with desired standards.
                                                                                         It  can  be  seen   that,   in   addition   to   a   com-
                                                                                      mitment  to  quality,  such   systems   require   as   their
                                     CREDIT AVAILABLE                                 two  key   elements:   1)   a   staff   large   enough   and
                           1. The  American  Academy  of  General   Practice          sufficiently   informed   to   draw    up    adequate    cn-
                             awards  physicians   who   participate   in   these      teria  of  performance  for   each   of   the   many   areas
                             informal conferences two hours  of  prescribed           of   practice,   and   2)   a   method   sensitive    enough
                             continuing  education  credit,  provided  they  are      to   detect   actual   levels   of   practice   performance.
                             scheduled  30  days  in  advance.  If   not,   each
                             physician who participates receives two           s         Information   about   a   stairs    own    patterns    of
                             of elective credit.                                      practice   is   now   available    through    the    Profes-
                           2. The   American   Medical   Association   has    ac-     sional     Activity     Study/Medical     Audit      Program
                             cepted  these  conferences  as   eligible   on   an      (PAS/MAP)    provided     to     client     hospitals     by
                             hour-per-hour  basis  for  credit  under   category      the    Commission    on    Professional     and     Hospital
                             four of the Physician's Recognition Award.               Activities    (CPHA)     in     Ann     Arbor,     Michigan.
                           3. The   Joint   Commission   on   Accreditation    of     The    PAS/MAP     service,     although     widely     used
                             Hospitals  has   acknowledged   that   these   con-
                             ferences  fulfill  their  revised  requirement   in      in  some  parts  of   the   country,   is   used   by   only
                             continuing  education,  i.e.   that   the   medical      a  few  hospitals   in   Tennessee   and   by   even   fewer
                             staff  of  a   hospital   "provide   a   continuing      in   the   75   county    region    encompassed    by    the
                             program  of   professional   education,   or   giv!      Memphis    Regional    Medical     Program.     The     PAS/
                             evidence of  participation  in  such  a  program.--      MAP    reports    can    be    obtained    by    even    the
                                                                                  I   smallest   hospitals   and   we   expect   that    Tennessee
                           *From   Memphis   Regional    Medical    Program,    969   Physicians  will  find  this   sort   of   information   in-
                       Madison   Avenue,   Memphis,   Tennessee   38104   and   The   creasingly   available   as   more   and   more    hospitals
                       University  of  Tennessee  College  of  Medicine,   Memphis.   install the system.


                        102                                    SELF-REVIEW CONFERENCES-Rosenberg                                    February,    1972
                           Without    difficulty    to    all    but    the    large,      4)  The   consultants,   usually   two,   drive   to   the
                        specialist-staffed   hospital   is    the    capability    of   conference  site  and   review   with   the   local   doctors
                        deriving   suitable   internal   standards   for   which   to   how   the    patients    were    and    might    have    been
                        aim.  The  local   definition   of   desired   standards   is   managed.
                        not  only  a   major   part   of   the   educational   aspect      The   conferences   were    begun    (under    the    name
                        of  the  program,  it  also  seems  to  be  vital   in   gen-   "Advanced    Clinical    Conferences")     as     what     we
                        erating   acceptance   of   the   plan   by   most   doctors.   hoped would be a realistic way of dealing wi
                        After    working    with    such    systems    for     almost   two   of   the   most   common    objections    to    conven-
                        twenty   years,   Slee   has   stated   that   doctors   will   tional    continuing    education    programs    ("I    can't
                        rarely   alter   their   previous   patterns   of    practice   get    away,"    and    "The    programs     aren't     about
                        to   conform   to   any   standards   that   they   did   not   what my patients need").
                        have a voice in setting.                                           Discussing    the    management    of     actual     cases
                           A   recent    report5    of    the    AMA    Council    on   instead   of   delivering   prepared   talks    appears    to
                        Health    Manpower    identified     this     problem     and   meet   both   of    these    objections    at    once.    The
                        indicated   a   special    concern    for    the    physician   conferences   are    patient-related    and    thus    clear-
                        who  either  has   little   or   no   hospital   contact   or   ly  relevant.  Also,   by   removing   the   need   to   pre-
                        who   practices   in   a   small   or    unaccredited    hos-   pare   and   deliver   a   lecture   we   have   been    able
                        pital.                                                          to  broaden   our   potential   faculty   to   include   most
                                                                                        of  the  practicing  specialists   in   our   region.   Since
                               SELF-REVIEW CONFERENCES                                  these   practicing   specialists   constitute   about    50@o
                           Very  small  hospitals   are   a   feature   of   the   75   of   our   physician   population,   it   is   possible    to
                        county      Memphis      Regional       Medical       Program   utilize   this   very   large   but   underused   group'   to
                        region   and    also    of    Tennessee.    Just    over    a   provide   a   widely-dispersed   faculty    with    a    con-
                        year  ago  a   program   of   what   we   are   now   calling   sultant/participant   ratio   averaging    one    to    four.
                        "Self-Review   Conferences"    was    begun    as    a    co-   Table    one    shows    the    topics     of     conferences
                        operative   effort   of   the    Memphis    Regional    Medi-   during   the   first   twelve   months   of   the    program.
                        cal   Program,    the    Division    of    Continuing    Edu-
                        cation   of   the    University    of    Tennessee    Medical        TABLE     ONE:      Topics      of      Conferences
                        Units,   and   the   Tennessee   Chapter   of   the    Ameri-   Acute Chronic Hepatitis        Hypertension
                        can   College   of   Physicians.   In   the   first    twelve   Acute Myocardial Infarc-       Kidney    Disease
                        months   of   the    program    we    have    sponsored    61      tions and Arrhythmias       Leukemia or Lymphomas
                        of   these   conferences,   and    as    we    have    gained   Anemia                         Liver   Disorders
                                                                                        Arrhythmias                    Management of Cardiac
                        more   experience   with   them,   have    come    to    look   Athletic Injuries                 Arrhythmias
                        on   them    as    perhaps    providing    a    measure    Of   Breast Disease                 Neurosurgical   Injuries
                        both    standard-setting    and    internal    review     for   Cardiology                     Obstructive Pulmonary
                        the very small hospital staff.                                  Cholesterol                       Disease
                           Briefly,    the    mechanism    of    these    conferences   Dermatology                    Organic Phosphate
                                                                                        Diabetes                          Poisoning
                        is:                                                             Emphysema                      Oncology
                           1)   A   small   group    of    physicians    (who    need   Cigarette Smoking              Pancreatic Disorders
                        not  constitute  a   hospital   staff)   select   some   area   Endometriosis                  Pediatric Neurology
                        of patient care to review.                                      ENT                            Pediatric   Problems   in
                           2)  They   prepare   three   or   four   case   abstracts,   Exercise and Rehabilita-          Dermatology
                                                                                           tion for the Cardiac        Renal Failure
                        including    details    of    how    they    managed    their      Patient                     Ruptured Uterus
                        cases.   Hopefully,    no    physician    works    up    more   Gastroenteritis                Sexual Problems
                        than one case.                                                  Gastroenterology               Sickle Cell Disease
                                                                                           . 1. Bleeding               Sore Feet
                           3)    The     Memphis     Regional     Medical     Program      1. Disorders                Summer         Complaint-
                        is   contacted.   We   find   two    qualified    consultants   Heart                             Diarrhea and Colitis
                        who   agree    to    study    the    case    abstracts    and   Heart and Circulatory          Toxemia
                        critically   review   management   in   light   of    current      System                      Urology
                        medical   thinking.   The   visiting   faculty    has    been
                        composed   of   both   practicing   specialists   and   full-      Among    the    features    of    the     program     that
                        time  University   of   Tennessee   faculty   (in   a   ratio   pleased    us    were    its    low    out-of-pocket     cost
                        of  three  to  one)  who  have   been   glad   to   do   this   (consultants    travel    and    talk     without     compen-
                        without compensation.                                           sation,   except   for   their    travel    expenses),    and


                    February, 1972                      SELF-REVIEW CONFERENCES-Rosenberg                                           103
                    the   increased   personal   contacts    between    rural  dividually    by    participating    physicians.    These
                    practitioners   and   metropolitan    consultants,    and  conferences  thus  do  not  raise   any   of   the   emo-
                    between  practicing  specialists   and   full-time   fac-  tionally-induced   hackles    conjured    up    by    the
                    ulty   members.   By   and   large,    the    conferences  term "peer review."
                    have   been   very   weh-received.   Also,   while    the    Yet  if  the  participants   will   start   to   think
                    bulk   of   our   program   has   consisted   of   inter-  of  the  conferences  as   a   place   where   they   can
                    changes   between   practicing   generalists   and   spe-  effectively   "seff   review"   their   practice   habits
                    cialist  consultants,  we   have   had   meetings   where  rather  than   a   place   to   "keep   up,"   we   shall
                    a  group  of  internists  discussed   appropriate   cases  have    achieved    a    major    advance.     Williamson7
                    with visiting consultants.                                 has  clearly   shown   that   keeping   up   and   knowl-
                                                                               edge   alone   do   not   insure   proper    performance.
                                     FLTTURE      PLANS                        By  shifting  the  emphasis   of   the   program   toward
                       We   hope   that   our   decision   to   change    the  an  increased   perception   of   patterns   of   patient
                    name   of   the   conferences   from   "Advanced    Clin-  care,  we   believe   we   can   move   from   peripheral
                    ical    Conference"    to    "Self-Review     Conference"  concerns    about    "how    well-informed    are     the
                    was   not   just   an   exercise   comparable   to    the  doctors?"   to   the   crucial   concerns   about    "how
                    widespread   attempts   to   alter   various    corporate  well are we taking care of our patients?"
                    images   by   similar   techniques.   We    believe    we
                    have   enough   experience   with    the    program    to                       References
                    have   confidence   in   the   mechanics   of   an    in-    1. Slee,  Vergil  N.:  Measuring  Hospital  Effective-
                    formal,    across-the-table    conference    between    a  ness: Patterns of Medical Practice,  The  University  of
                    local   group   and   visiting   consultants   where   it  Michigan Medical Center Journal, 35:112, 1969.
                    is   the   participants'   own   chart   abstracts   that    2. Eisele, C. W.: The Medical  Audit  In  Postgraduate
                    are  being  discussed  in  front  of   the   local   col-  Education, Eisele, C. W.  (ed.)  The  Medical  Staff  in
                    league and visiting consultant alike.                      the  Modern  Hospital  (New   York:   McGraw-Hill   Book
                       There  have   been   instances   in   which   one   or  Co., Inc., 1967), p 213.
                                                                                 3.  Brown,  C.  R.,  Jr.,   Uhl,   H.S.M.:   Mandatory
                    the   other   participant   group   were    disappointed,  Continuing   Education:   Sense   or   Nonsense?   JAMA,
                    usually   either   because   a   local   group   expected  213:1660, 1970.
                    a  lecture  and  was  not   prepared   to   really   par-    4. Uhl,  H.S.M.:  Continuing  Medical  Education,  New
                    ticipate   or   when   a   consultant   came   and   gave  Eng J Med, 284:50, 1971.
                    a  lecture  that  a  prepared   group   did   not   want.    5.  AMA  Council  on   Health   Manpower:   Continuing
                    For   the   most   part,   however,    the    conferences  Competence of Physicians, JAMA, 217:1537, 1971.
                    have  been  conducted   in   an   atmosphere   that   re-    6.  Freymann,  John   G.:   Leadership   in   American
                    stores  one's   faith   in   old-fashioned   words   like  @edicine:  A  Matter  of  Personal  Responsibility,  New
                     professional" and "colleague."                            r-ng J Med, 270:710, 1964.
                                                                                 7.  Williamson,  John  W.:   Evaluating   Quality   of
                       It  must  be  emphasized  that  the   initiative   for  patient Care, JAMA, 218:564, 1971.
                    the   conferences   comes   from   the    local    group,    (EDITOleS NOTE: Reference No. I is  reprinted  in  its
                    the  choice  of  a  topic  is   theirs,   and   the   se-  entirety as a special item in this issue of the  JOURNAL
                    lection  of  what  cases   to   present   is   made   in-  p. 140.)


                                                                                                          ning on a    regional     and      community
            Special   Communication                                                                       hasIis   of   an   order   never   heretofore
                                                                                                          adopted  in  this  country.  With  the  nee-
                                                                                                                      .  al   or    community    plan-
                                                                                                          @essary region
                                        nodap                                                             ning,  the   medical   facilities   ill   be
            The Co                                     t   of                                                                               w
                                                                                                          .recognized   as   possessing   at    least.
                                                                                                          three  major  levels   of   capability   for
                                                                                                          serious   illness,   emergency   i    e-sup-
            Stratified Medical Care                                                                       port   units,   special-care   uni    (coro-
                                                                                                          nary,    pulmonary,     intensive),     with
            Irving S. Wright, MD                                                                          continuation@care   facilities,   and    re-
                                                                                                          gional   reference   centers.   The    plan-
                                                                                                          ning  will  require  (a)   careful   differ-
                  here   appears    to    be    emerging   terial   and   manpower    resources    in-    entiation   of   function   based   on   the
                   a    remarkable    unanimity     from   volved  when  several   hospitals   located    categorical  needs  and  the   capacity   of
            Thoth      professional      and      public   in   close   proximity    develop    highly    the  facility  and  (b)   a   close   inter-
            sources  that  medical   service   must   be   complicated   services   such   as    open-    relationship   between    the    participat-
            reorganized   in   the   immediate   future.   heart   surgery,    coronary-care    units,    in   personnel   and   facilities   at   all
                                                                                                             9
              The  simple  approach  which   first   oc-   advanced   radiation    and    angiographic    levels.
            curs  to  some  is  to  provide  more  funds   sections  when  the  case  load   indicates      Type  I  Facilities.-Using   as   an   ex-
            in   the   hopes   of   quickly.   producing   that  a  single  unit  could   handle   all    ample    the     middle-aged     man     who
            medical   facilities   and   personnel   and   cases  more   efficiently.   The   approach    develops    an    acute    myocardial    in-
            greatly    improved     medical     service.   has been  to  review  all  pertinent  medi-    farction,    stratified     medical     care
            Those   who   are   experienced   in    this   cal literature and  to  draw  on  the  life    should  operate  as   follows:   No   longer
            problem  recognize  that  funding   is   in-   experiences  of   the   approximately   150    does he  lie@  at  home  awaiting  the  turn
            deed  essential  but  that  instant  results   members   of   the   commission   to   pro-    of fate.  His  introduction  into  the  sys-
            are not  to  be  expected.  It  takes  years   vide  a  set  of  authoritative  guidelines    tem, which may be terme   type
            and  not  months   to   traifi   physicians,   regarding   the   resources   and    mecha-    facilities,  may  come  through   his   pri-
            nurses,   and   technical   personnel.    It   nisms  which  will  be  essential   as   we    mary   physician   who,   once   the   diag-
            also   takes   many   months,   often   sev-   face  the  future.   These   reports   have    nosis  seems  probable,   directs   him   to
            eral  years,  to  plan,  fund,  and  develop   appeared    serially     in     Circulation    the   emergency   room   of   the    nearest
            new  or  renovated  facilities  and  to  as-   (May-July,   'Dee   1970;   Jan-Aug   1971)    well-equipped   hospital.   If   a    modern
            semble   and   pretest   the   rather   com-   and  periodically  in  some   other   jour-    ambulance    with    life-support     equip-
            plex  equipment  and   units   now   consid-   nals  and,  judged  from  the  great@  num-    ment  or  a  more  elaborate  mobile   coro-
            ered   essential    for    modern    medical   ber  of  requests  for  reprints  and  fur-    nary-care  unit  is   available,   so   much
            care. In  order  to  provide.  quality  care   ther  information,  they  have  proven   to    the better.  But  time  is  of  the  essence
            for  large  numbers   of   our   population,   be of value. Their  content  will  riot  be    and   delay   may   forfeit   the   opportu-
            considerable  restructuring   of   the   use   reviewed in detail here.                       nity  of  life  preservation.   The   physi-
            of our resources will be essential.              Of  particular  interest  has  been   the    cian, if  he  is  well  equipped,  may  pro-
              For  the  past  three  years  the   Inter-   spontaneous    and    independent    devel-    vide    life-support     emergency     care,
            Society   Commission    for    Heart    Dis-   opment  of  a  concept   which   has   been    including     monitoring,     administration
            ease   Resources,   under   contract    with   designated  as  the  system  of  stratified    of   lidocaine   and   other   drugs,    and
            the Regi,                                  -   care.  Stratified  care  requires  that   a    chest  massage,   or   even   direct-current
                      %@             lir2grAms       Ser
              ce @@                   Public   Law   89-   community's   total   medical    resources,    conversion.   Many   times,   however,   the
            @239,  section  907),  has  been  developing   including  in  particular  its   hospitals,    patient  is  not  near  his  physician,  but
            guidelines   for   optimal    medical    re-   are  organized  in  a   system   in   which    today  there  should  be  a   life   support
            sources  for  the  prevention   and   treat-   each  plays  a   separate   but   essential    heart     station     activated     whenever
            ment  of  the  major   cardiovascular   dis-   role.  Such  divergent  categorical   study    large  numbers   of   people   are   congre-
            eases.   Emphasis.has    been    on    iden-   groups  of  the  commission  as  those  de-    gated  and   where   heart   attacks   occur
            tifying  and   defining   those   character-   voted   to   congenital   heart    disease,    frequently,   and   often   sudden   deaths.
            isties  of  the  medical  environment,   eg,   coronary   heart   disease,   and    pulmo-    Examples  should   include   all   hospitals
            physical   plant,   equipment,    personnel,   nary  heart   disease   working   independ-    whether   or   not   they   have   coronary-
            training,   staffing   patterns,    adminis-   ently  came  to   the   same   conclusions-    care  units,  industrial  plants  and  large
            trative   structure   and   other   signifi-   that  within  the  present   framework   of    offices,   airports,   stadia,   and    race
            eant   @   components   required   for   the   medical practice  with  all  of  its  vari-    tracks.    In    such:stations,    emergency
            practice  of  cardiovascular   medicine   of   ations,  or  with   any   conceivable   new    lifesaving   measures    @may    be    taken
            high  quality.  Attention  has   also   been   system for  the  future,  present  and  fu-    prior  to  moving   the   patient   to   the
            drawn  to  the  prohibitive  waste  of   ma-   ture resources must  be  used  more  @  ef-    hospital     emergency     rooms.     Modern
                                                           ficiently and  that  this  will  require  a    emergency    rooms     must     be     fully
              From the Inter@ety  Commission  for  Heart   stratified  system  to  be  effective.  The    equipped   and   st@ffed   with    personnel
            Disease Resources.
              Reprintr requests to Suite 204, 44 E 23rd St, patient  load  demands   this,   and   mod-   trained  to   deal   with   myocardial   in-
            New@York 10010.                                ern  technical   advances   require   plan-    faretion-the    number    one    cause    of

            ,892   JAMA, @Feb 14, 1972  Vol 219, @No 7                                                               Stratified  Medical   Care-Wright


                                                                                                   0
                                                         brei  it
                                                                    with
                                                                                         ac                                       nO @SPIRONOIACTONE@
                                                   the onY- s                                                                               ----ne
                                                   antagoni,                                                                      ed diuresis with
                                                   mini@al r                                                                      m loss...
                                                   especially in                                                  the digitalized patient

                                                                                                                                                                                          or oscites  of  congestive  heartfailure@cir-
                                        Produces  a  gradual,  -sustained   diu'resi@                                                    rhosis of the I iver  and  the  nephrotic  syndrome;  idiopoihic  edema.  Some  patients  with
                                                                                                                                         malignant effusions  may  benefit  from  Aldoctone,  particularly  when  given  with  a  thia-
                                   which,   over   a,period   of   weeks   may   be
                                                                                                            I                            zidediuretic@
                                   greater  than  that  produced'   with   f.urose-                                                         Contraindicaflons-Acute  renal"Lnsufficiency,  rapidly  progressing  impciirment   of   ie-
                                                                                                                                         net function, anuria and hyperkalemia.
                                   mide or  ethacrynic  acid,  while  avoiding  the                                                         Wornirigs-Potassium  supplementation  may  cause  hyperkalemia   and   is   not   indicated
                                                                                                                                         unless a glucocorticoid. is also given. Discontinue potassium supplementation i           p6r-
                                   dangers of sudden fluid  or  electrolyte  deple-                                                      kalemia develops. Usage of anydrug  in  women  of  childbearing  age  requires  that  the  po-
                                                                                                                                         tenfial benefits of flw drug  be  weighed  against  its  possible  hazards  to  the  mtfw  and
                                   tion common with fast-acting diureti@cs.                                                              fetus.
                                                                                                                                            Precauflons-Potients  should  be  checked  carefully  since   electrolyte   imbalance   may
                                                                                                                                         occur. Although  usually  insignificant,  hyperkalemia  may  be  serious  when  renal  impair-
                                        Helpspreventdigitalistoxici,tydueto                                                low           ment exists;  deaths  have  occurred.  Hyponatremia;  manifested  by  dryness  of  the  mouth,
                                                                                                                                         thirst, lethargy and  drowsiness,  together  with  a  low  serum  sodium  may  be  caused  or,
                                   myocardial  potassium  levels   by   hel                                       p ing   to             aggravated,  especially  when'Aldactone  is  combined  with  other  diuretics   Elevation   of
                                                                                                                                         BUN  may  occur,  especiallywhen  pretreatment  hyperazotemia  exists.   Mild   acidosis   may
                                   retain    arrestors     myocardial     potassium                                                         cur. Reduce the  dosage  of  other  antihypertensive  drugs,  particularly  the  ganglionic
                                                                                                                                         blocking agents, bleat  least  5Gpercen.t  when  adding  Aldectone  since  it  may  potentiote
                                   through its                      action  on-the   kidney,   where                                     theiraction.
                                                                                                                                            Adverse   Reactions@Drowsiness,   lethargy,   headache,   diarrhea   and   other   gastroin
                                   it  blocks'aidosterone   action,   and   perhaps                                                      testinal   symptoms,   moculopopularcrerythematous   cutoneouseruptionsi    urticaria,    men'
                                                                                                                                         tal  confusion,  drug  fever,  ataxia,  gynecomaslia,.  mild  androgenic  effects,   including
                                   by direct cellular action'-as well                                      .....    In  con-             hirsufism, irreg                                                        are   infrequent   and
                                                                                                                                                        ular menses and deepening voice. Adverse reactions
                                                                                                                                         usually reversible.
                                   trast,  thiazides,  furosemide  and   ethacrynic                                                         Dosage and  Administration-For  essential  hypertension  in  adults  the  daily  dosage  is
                                   acid  cause  potassium  loss  which  can   paten                                                      50 to I 00 mg. in divided doses.  Aldoctone.may  be  combined  with  a  thiazide  diuretic  if
                                                                                                                                         necessary. Continue treatment  for  two  weeks  or  longer  since  an  adequate  response  may
                                   tiate. myocardial  potassium  ouif  low.                                                              not occur sooner. Adjust subsequent dosage occording-to res        se 0 pcitient.
                                                                                                                                            For edema, ascites or effusions in adults initial daily do      e is  100  mg.  in  divided
                                                                                                                                         doses. Continue medication for at least five  days  to  determine  diuretic  response;  add  a
                                                                                                                                         Ihi,,ide or  organic  mercurial  if  adequate  diuretic  response  has  not  occurred.  Aldoc-
                                   9  May  be   combined   with   other   diuretics                                                      tone  dosage  should  not  be  changed  when  other  therapy  is  added@  A  daily  dosage  of
                                                                                                                                         Aidactone considerablygreaterthan 75 mg. may begiven if necessary.
                                   for an additive effect                                 permitting     lower                              A glucocorticoid, such as 15 to 20 mg. of  prednisone  daily,  may  be  desirable  for  po@
                                   dosages  with  each  agent  while   helping   to                                                      tients with  extremely  resistant  edema  which  does  not  respond  adequately  to  Aldactone
                                                                                                                                         and a conventional diuretic.  Observe  the  usual  precautions  applicable  to  glucocorticoid
                                   maintain potassium balance.                                                                           therapy;  supplemental  potassium  will  usually  be  necessary.  Such   patients   frequently
                                                                                                                                         have an associated hyponatremia@restriction of  fluid  intake  to  I  liter  per  day  or  ad-
                                                                                                                                         ministration of mannitol  or  urea  may  be  necessary  (these  measures  are  contraindicated
                                                                                                                                         in patients with uremia or  severely  impaired  rencil  function).  Mannitol-  is  co6traindi-
                                                                                                                                         cated in patientswith congestive heart failure, and urea is  controindicated  with  a  history
                                                                                                                                         or signs of hepatic coma unless the patient is  receiving-antibiotics  orally  to  "sterilize"
                                                                                                                                         the gastrointestinal tract@
                                                                                                                                            Glucocorticoids should probably be given first to  patients  with  nephrosis  since  Aidec-
                                                                                                                                         tone, although useful for diuresis, will not directly affect  the  basic  pothologic  process.
                                                                                                                                            For children the daily dosage should provide  1.5  mg.  of  Aldoctone  per  pound  of  body
                                                                                                                                         weight.
                                                          Distributed by G. D. Searle & Co.                                                 References: 1. Dcivis, J. O.: Hosp. Pract. 5:63-76 (Oct.) 1970. 2.  Laragh,  J@  H.:  Hosp@
                                                                                                                                         Proct. 5:43-50 (Nov.) 1970.3.  Tourniaire,  A.,  and  others:  Lyon  M6d@  223:707-716  (March
                                   P.O. Box 51 10, Chicago, Illinois 60680                                                               29) 1970. 4. Seller, R. H.:  QuotIed  in  Medical  News  Section,  J.A.M.A.,  215@200-201  (Jan.
                                   Research in the Service of Medicine                                                                   11) 1971.


              death in this  country.  It  is  no  longer  hand, he  had  been  admitted  to  a  com-    wasteful  of  manpower   and   all   other
              acceptable   to   have    staff    rotation  munity   hospital   which   provided   ex-    necessary  resources.  The  plans  of  op-
              which results  in  a  urologist  or  derma-  cellent  care  for  his   myocardial   in-    eration should be  familiar  to  the  phy-
              tologist being on duty, unless  he  too  is  faretion  but   was   not   equipped   for    sicians before the fact of  the  patient's
              specially trained  to  meet  this  type  of  special studies of this  type,  he  should    heart  attack-or   before   a   new   baby
              emergency.   As   the    patient    reaches  be  transferred  to  a  reference   center    turns  blue.  Of  equal  importance,   the
              the   emergency   room,    the    coronary-  for  this  study  and  surgery.   Regional    public should  be  educated  to  recognize
              care  unit  or  the   intensive-care   unit  reference  centers   should   (1)   assist    the  signs   and   symptoms   of   serious
              must  be  alerted,  so  that  the   patient  with  regional   or   community   planning    disease  and  what   steps   they   should
              can be moved there as the next step.         for the stratified  system  of  care,  in-    take  to  enter  the  systems  of  strati-
               Type   H   Facifities.-The    next    step  cluding   the   development   of   quality    fied care. Patients  might  prefer  to  do
              has been designated as  a  type  II  facil-  control  for  emergency  vehicles,   life-    this under  the  guidance  of  their  pri-
              ity.  The  specifications  of   this   unit  support    units,    and     coronary-care    mary physician, but  in  his  abscence  or
              have  been  described  in  detail  in   the  units;  (2)  provide  consulting  services    inability to provide this  type  of  care,
              ICHD  report  of  May  1971.1   The   deci-  for physicians  and  other  hospitals  and    the patient  should  know  what  steps  to
              sion  as  to  whether  or  not  a  hospital  units within a region; (3) assist  in  de-    take  so  that  delay  will  not  be   too
              should   have   a   coronary   care    unit  veloping    continuing    education    and    costly.  Communication   at   each   level
              should  be  based  on  (1)   the   adequacy  training   programs   in    cardiovascular    should  be  easy:  patient  to  doctor  or
              and   availability   of   other   community  diseases  for  physicians,   nurses,   and    life-support  station  doctor   and   life
              facilities  providing  coronary  care,  (2)  allied  health  personnel;  (4)  serve  as    support   station   to   emergency   room-
              the availability  of  sufficient  qualified  centers  for  data  collection,  analysis,    to   coronary-care    unit-to    reference
              and   dedicated   physicians   and   nurses  and   possibly   registry   of    patients    center   for   consultation.   In   modern
              and  allied  health  personnel   to   staff  with  selected   cardiovascular   diseases    settings,  two-way  closed  circuit  tele-
              the facility, and (3)  the  number  of  pa-  for   administrative   and   epidemiologic    vision  is  already  being  used  for  the
              tients   admitted   annually   with    sus-  study  and  evaluation;  and  (5)  conduct    demonstration    of    electrocardiograms,
              pected   acute    myocardial    infaretion.  research   in   cardiovascular   diseases.    x-ray films,  and  other  pertinent  data,
              Hospital  size  alone  should  not  be  the  Many of them  will  be  related  to  medi-    thus  permitting  excellent  cons
              determining  factor  in  the  decision   to  cal  colleges  but  other  major   medical    tation  services  even   at   considerable
              establish  a  coronary  care   unit.   This  facilities  may,  if  well   staffed   and    distance.
              important  and   always   costly   decision  equipped, act as reference centers.            While   the   problem    of    myocardial
              should  be  made   only   after   analyzing    Stratified care of  a  similar  type  is    infarction  has  been  used  as   an   ex-
              the  medical   needs   of   the   community  in fact  in  operation  in  some  advanced    ample  in  this  discussion,  the  concept
              and  the  most  productive  role  for   the  areas in this country, but  it  is  almost    of  stratified  medical  care  should   be
              hospital  in  the   community   system   of  entirely  operating  informally   and   is    applicable to all types  of  serious  ill-
              coronary  care.  When   the   patient   has  limited in sco                                          . .ng     advanced     equipment
                                                                          pe.  Therefore,  many   pa-    ness requin
              reached a  plateau  of  stability  and  has  tients  fail  to  benefit  from  it,   and    and  personnel.   Other   examples   might
              passed  beyond  the  acute  phase  of   his  there  are  frequent  delays   which,   in    well  include  cancer   chemotherapy   and
              disease,  he  should  then  be  moved  into  some cases, are hazardous.                    radiation,     gastrointestinal     hemor-
              an  intermediate  care  unit-or   not   far    It  now  comes  through   clearly   that    rhage,  acute  respiratory  failure,   and
              from    the    coro-nary-care    unit-where  there is an urgent  need  for  such  plans    stroke.
              he  can   be   observed,   monitored,   and  of operation  to  be  established  in  all     This is all  happening  in  a  few  areas
              treated,  as   necessary.   After   several  regions  and  communities;   they   should    at  present.  It  will  be  generally  ap-
              weeks,  he  should  be  ready   to   return  be  developed  on  a  regional  or   local    plied in many areas  in  the  future.  The
              home to the care  of  his  primary  phys@l-  basis by the joint effort  of  the  physi-    challenge of  the  medical  profession  is
              cian,  who  may  or  may  not   have   fol-  cians,   community,   and   hospital   ad-    to take and  to  hold  the  leadership  in
              lowed    him    throughout    his    entire  ministrators,  together  with  public  of-    this  movement.  If  the  physicians  turn
              course,   depending   on   geography,   in-  ficials, including  the  Regional  Medical    away or fail in this regard,  others  less
              terest, and  other  factors.  All  of  this  Programs   Service   and   other    public    qualified  will  begin  to  control   this
              can  be  carried  out  in  a  well-equipped  health  officials,  county   medical   so-    type  of  operation.  The  ICHD  is   pro-
              community hospital.                          cieties,   American   Heart    Association    viding  expert  advice  which  is   avail-
                Type  M   Facilities:   Regional   Refer-  affiliates, and all other interested  par-    able to  all.  The  application  of  these
              ence   Center    Hospitals.-The    patient,  ties.  The  need  for  planning  and  coo@    guidelines  is  a  formidable  but  essen-
              however,  may   have   developed   a   ven-  eration    between    hospitals    becomes    tial task for the present  and  the  fore-
              tricular  aneurysm  or   have   intractable  preeminent.  It  can  no  longer  be  rec-    seeable future.
              angina   or   some   other   serious   com-  ommended   or    supported    that    each
              plication.  If  he  happens  to  have  been  hospital  provide  identical   competitive
              admitted initially  to  a  regional  refer-  services  in  an   isolated   and   auton-
              ene-e center hospital or  type  III  facil-  omous  manner  without   regard   to   the
              ity,  angiocardiography,  including   eine-  needs  of  the  community  or   the   pro-                   Reference
              angiograms   of   the    coronary    arter-  grams  and  plans  of  other  institutions     1. Resources for the optimal care of patients
                                                                                                         with acute myocardial infamtion: Report of the
              ies,  can  be  performed   and   corrective  in  the   same   or   adjoining   communi-    inter-Society Commission for Heart Disease Re-
              surgery  undertaken.  If,  on   the   other  ties.  This   approach   is   simply   too    soumes. Cir@tion 43:A-171 (May) 1971.
              JAMA, Feb 14, 1972 9 Vol 219, No 7                                                             Stratified Medical Care-Wright     893


                                   -en e
             Nvl           is o -c        mensions

                                   When it's mandatory
                              'to kee-p the postcoronary
                                atient calm, consider
                                  ium@ (diazepam).
                                   Although hes Promised
                                 take it easy back on the
                               ob, you know he's going
                              back to the same stressful
                              circumstances that may have
    contributed to his hospitalization. Your prescription for
    Valium can calm him. Lessened anxiety and tension can
    help in decelerating his former pace. During the period
    of readjustment, Valium can quiet undue, anxiety.
         For moderate states of psychic tension, 5-mg or
    2-mg Valium tablets t.i.d. or q.i.d. can usually provide


                       78                                           THE NEW ENGLAND JOURNAL OF MEDICINE                                                             Jan.   11,   1973

                       9. Feldstein MS: The Rising  Cost  of  Hospital  Care.  Cambridge,  Massachu-       land: The geographic distribution of facilities, resources and  personnel.
                        setts, Harvard Institute of Economic Research, 1970                                Boston,   Medical   Care   and   Education   Foundation,   Inc,   January,
                       10. The Organization of  Coronary  Care  Units:  A  report  on  a  preparatory      1972
                        meeting convened by the Regional Office  for  Europe  of  the  W,H.O.  Co-      13. Hill AB: Statistical Methods in  Clinical  and  Preventive  Medicine.  New
                        penhagen, World Health Organization, 1969                                          York, Oxford University Press, 1962
                       11. United  States  Department  of  Health,  Education,  and  Welfare,   Heart   14. Mather  HG,  Pearson  NG,  Read  KLQ,  et  at:  Acute  myocardial  infarc-
                        Disease  Control  Program.  Proceedings  of  the  National  Conference  on         tion: home and hospital treatment. Br Med J 3:334-338, 1971
                        Coronary  Care  Units  (PHS  Publication   No   1764).   Washington,   DC,      15. Hofvendahl S: Influence of treatment in a coronary care  unit  on  progno-
                        Government Printing Office, March, 1968                                            sis in acute myocardial infarction: a controlled study in 271 cases.  Acta
                       12. Keaimes  HW:  Coronary  Care  and  Intensive  Care  Units  in   New   Eng-      Med Scand [Suppl] 519:1-78, 1971

                                                                              MEDICAL PROGRESS

                                                                         THE GENITAL MYCOPLASMAS
                       WILLIAM M. MCCORMACK, M.D., PETER BRAUN, M.D., YHU-HSIUNG LEE, M.D., JEROME 0. KLEIN, M.D.,
                                                                         AND EDWARD H. KAss, M.D., PH.D.

                             INTRODUCTION AND MSTORICAL ASPECTS                                         in accordance with certain of their properties, or sim-
                       A LTHOUGH the first isolation of a mycoplasma                                    P!Y     L-forms,     resemble     mycoplasmas      in      colonial      mor-
                       IA    from    a     humaIn   being,   a   patient   with   a   genital    in-    phology   on   agar   and   also   lack   a   cell   wall.   Despite    these
                       fection,'  was  reported  in  1937,  it   is   only   in   the   past   few      morphologic      similarities,      such      cell-wall-deficient       forms
                       .Years    that     convincing     evidence     has     appeared     linking      are   related   to   their    bacterial    parents    and    are    unrelated
                                                                                                 -      to the mycoplasmas.
                       these   organisms   to   disorders   of   the    human    genital    tract.
                       Genital mycoplasmas have now                        associated         with         In    1937,    Dienes    and    Edsall'    grew    a    PPLO    in    pure
                       nongonococcal      urethritis,      acute      saIT)ingitis,      abortion,      culture    from    a    Bartholin's    abscess.     Since     then,     myco-
                                                                                                        plasmas    have    been    found    to    be    common     inhabitants     of
                       postpartum    fever    and,    most    recently,     with     low     birth      the       oropharyngeal       and       genital       mucous       membranes.
                       weight.   This    review    will    attempt    to    evaluate    critically      "II
                       the   role    of    the    genital    mycoplasmas    in    human    disease      t   nere   are    now    eight    recognized    species    of    human    my-
                                                                                                        coplasmas.    M.    pneumoniae    is    responsible     for     cold-aggluti-
                       and to indicate areas of future investigations.                                  nin-positive,     primary      atypical      pneumonia.6      M.      saliva-
                       Mycoplasmas      were       prominent       in       veterinary       medi_
                                                                                                        ri.um,  M.  orale   Type   I,   M.   orale   Type   II   and   M.   orale   Type
                       cine   long    before    they    were    implicated    in    diseases    of      III    are    oropharyngeal    commensals    and    have    not    as     yet
                       man.      Contagious      bovine       pleuropneumonia       has       been      been    implicated    in    any    pathologic    process.    M.     homz'nz's
                       recognized for centuries,' and the causative agent                  .    was     and       T-mycoplasmas       are       the       principal       mycoplasmas
                       grown    on    cell-free    medium     in     1898.'     This     organism,      that    have    been    isolated    from    the    human    genital     tract
                       now   known    as    Mycopl@ma    mycoides,    was    the    first    myco-
                       plasma   to   be   isolated.   As   similar    organisms    were    isolat-      @nd  thus   will   be   the   subject   of   most   of   this   review.   Al.
                       ed,     they      were      called      pleuropneumonia-like      organisms      Jermentans,     an     infrequently      isolated      genital      mycoplas-
                                                                                                        ma, will also be considered.
                       (PPLO).      The      term      mycopl,asma      was      suggested      by         Technics     for     cultivation     and     identification     of     the
                       Nowak' in 1929.                                                                  genital    mycoplasmas    have    improved,    so     that     the     clini-
                       In    1935,    Klieneberger'    reported    a    series    of     organisms         I
                       that   she   had   isolated    from    various    sources.    She    termed      cai    studies    must    be     evaluated     against     the     background
                       these  isolates   L   ,   1,   L,,   etc.,   for   the   Lister   Institute      of     improving     methodology.     Most      studies      before      1955
                                          1                                                             and   many    later    reports    refer    to    PPLO.    Most    of    these
                       where    she    was    working.    Most    of    these    isolates     were      isolations     probably      represented      M.      hominz's,      although
                       shown    to    be    animal    mycoplasmas.    However,    the    L,    or-
                       ganism,   which   was   isolated   from    a    culture    of    Streptoba-      cell-wall-deficient     bacterial      variants,      Mfermentans,      arti-
                       cillus   moniliformis,   was   eventually   shown   to   be    the    first      facts    of     cultivation     (pseudocolonies)     and     even     T-myco-
                       example     of      a      cell-wall-deficient      bacterial      variant.      plasmas    may    have    been    included.    In    this     review,     the
                                                                                                        term   PPLO   is    used    if    that    was    the    designation    chosen
                       These    variants,    now    called    protoplasts     or     spheroplasts,
                                                                                                        in  a  cited   study.   If   the   organisms   were   classified,   the   ap-
                       From  the  Charming  Laboratory,   Thomdike   Memorial   Laboratory,   Har-      propriate    species    designation    will    be    used.    In     general,
                       vard  Medical  Unit,  and  the  departments  of  Medical  Microbiology  and      also,    the    term    T-mycoplasma    will    be    used    to     indicate
                       Pediatrics, Boston City Hospital, the Department of Tropical Public Health,
                       Harvard School of Public  Health,  and  the  departments  of  Medicine  and      the T-strains of Shepard.'
                       Pediatrics,  Harvard  Medical  School  (address  reprint  requests  to  Dr.
                       McCormack   at   the   Charming   Laboratory,   Boston    City    Hospital,                       BIOLOGIC CHARACTERISTICS
                       Boston, Mass. 02118).
                       Supported in part by a research grant (HD-03693) from the  National  Insti-         A   detailed   analysis   of    the    biology    of    these    organisms
                       tute of Child Health and  Human  Development  and  by  grants  (Al-68,  Al-      is   beyond   the   scope   of   this   review.   Several    recent    publi-
                       1695, AI-23, and Al-1023) from the National Institute of Allergy and Infec-      -@ations    present     detailed     biologic     and     biochemical     in-
                       tious Diseases (Dr. McCormack and Dr. Lee are recipients of  United  States
                       Public Health Service Post-Doctoral Fellowships).                                formation.'-"


                                                                  ONARY-CARF UNITS-BLOOM AND PETERSON                                                                                 77
                       Vol. 288  No. 2                          COR
                       have  not   been   followed.   Units   have   been   replicated                 issue of the effectiveness of intensive care  is  not  settled.
                       without  attention  to  nearby  facilities  and  without   con-                 Under   these   circumstances,   randomized   clinical   trials
                       sideration  for  the   diseconomics   created   by   the   high                 to settle the efficacy of expensive  care  are  not  unethical.
                       costs of staffing and running units.                                            Is  it  ethical  to  spend  scarce  medical  dollars   on   un-
                       A 1969 study by the Tri-State Re                                                proved  treatment  when  these   funds   could   be   used   in
                       pam-staff concluded that the c@al                                               -other  areas  where  medical  care  is  known  to   be   effec-
                            units  in  its  area  were  sufficient  to  care  for   all                tive?  The  uncontrolled   growth   of   this   expensive   and
                       tht  anticipated  cases  of  myocardial  infarction,  as   well                 unpr  .oved  treatment  stands   in   marked   contrast   to   the
                       as  another  30  per  cent  of  patients  "suspected"  of  hav-                 requirement  for  proof   of   effectiveness   before   a   new
                       ing an  infarction,  or  those  with  false-positive  diagnoses                 drug is allowed on the market.
                       of infarction.' Between th     ublication   of    that    report    in          Since it will be  a  long  time  before  the  question  6f  ef-
                                                  c p
                       late 1969 and 197 1, the capacity of       the      units       increased       fectiveness  of  coronary-care  units  is  settled,  the   best
                       by  27  per   cent."   This   study   has   demonstrated   that                 that  can  be  done  is  to  suggest   second-best   solutions.
                       about half the patients  treated  in  the  units  do  not  have                 The  health  planning  agencies  seem,  to  judge  from   their
                       myocardial  infarctions.  A  few  of  these   are   "suspected"                 publications, to  believe  that  there  are  serious  shortages
                       of  having  infarction  and   should   be   admitted   to   the                 of  unit  staff.  This  studv  found  no  evidence  of  trained
                       units, but most have  a  variety  of  cardiac  and  other  dis-                 nursing  shortages,  but  it  did  find   many   administrative
                       eases; they  are  a  low-risk  group  for  whom  expensive  in-                 weaknesses.  The  official  and   voluntary   health   agencies
                       tensive care  seems  scarcely  necessary.  The  cost  of  coro-                 might  seek  to  help  individual  hospitals   achieve   better
                       nary-care Units  is  very  high  if  it  is  allocated  to  the                 administration  so  that  units  could  perform  as  effective-
                       patients having or   4 9suspected"    of     having     a     mvocar-           ly and economically  as  possible.  It  is  clear  from  recent
                       dial  infarction,  who  presumably  benefit  from  thi's  care.                 history  that  if  decisions  about  provision   of   coronary-
                       This  high  cost  has  naturally  been  passed   on   to   Blue                 care units are left  to  individual  hospitals,  excess  capac-
                       Gross,  to  Medicare  and  Medicaid  and  ultimately   to   the                 ity and inefficiency  will  result.  These  decisions  must  be
                       consumers   and   taxpayers.   The   absence   of   any    con-                 made  by  bodies  that  are  more  disinterested  and  have   a
                       straints  on  costs   and   encouragement   of   economies   is                 broader  view  than  that  of   a   single   institution.   The
                       evident.  It  now  remains  to  examine  the  scientific  basis                 certificate-of-need  legislation,  which   is   being   adopted
                       for this expensive care.                                                        by many states,  should  help  to  enforce  these  disinterest-
                       The  clinical  reports  that  stimulated   the   provision   of                 ed  decisions.  Certification  of  need  does   not   guarantee
                       intensive  care  for  patients   with   myocardial   infarction                 effective  service  performance  as  was  illustrated  by   the
                       were  based  upon  the  comparison  of   death   rates   before                 weaknesses    of    some    teaching-hospital     coronary-care
                       and  after  institution  of  coronary-care  units.  The   prob-                 units.   Services   such   as   radiation   therapy,    cardiac
                       lem with this  kind  of  evidence  has  been  succinctly  stat-                 surgery  and  coronary-care  units  that  are  likely   to   be
                       ed v Bradford Hill:  "It  is  rarely  ...  that  one  can  feel                 limited  by  certification  should  also  be  accountable   for
                       who        that these  past  observations  do  relate  to  a  pre-              data on patient  selection,  end  results  and  costs  so  that
                       ciselj     group  ofpattents.  This  is  a  most  difficult  thing              actual  performance  can  be   judged.   It   obviously   would
                       to prove ... yet it is the sine qua non if  the  comparison  is                 not be right  to  limit  services  without  evidence  that  the
                       to   have   any   validity   [italics   added].""   Before-and-                 better  patient  care,  which  it  is   assumed   certification
                       after   comparisons   are   inadequate   proof   of   treatment                 will assure, is actually obtained.
                       effectiveness in the 1970's, as they were, indeed               , in       the        We   are   indebted   to   Walter   H.   Abelmann,   M.D.,   Benedict    J.
                       1960's,  when  intensive-care  units  were  being  started   in                 Duffy,   M.D.,   Jacob   J.   Feldman,   Ph,D.,   and    David    D.    Rutstein,
                       great   numbers.   Coronary-care   units   were   quickly   ac-                 M.D., for advice.
                       cc ted by clinicians as good clinical practice               The        atti-
                       p
                       tude  that  randomized  clinical  trial  of   intensive   coro-
                       nary  care   was   unnecessary   and   unethical   had   become
                       common by the end of the 1960's.                                                                              REFERENCES
                       This  unsatisfactory  state   was   punctuated   in   1971   by                       I.                                        1: Coronary-care unit in a dis-
                       the  report  of  a  randomized  clinical  trial   conducted   b                                                                 971
                                                                                                       y     2.                                        The  coronary  care   unit:   new
                       Mather  et  al.11  In  this  comparison,  patients  with   myo-                                                                 88-198,1967
                       cardial   infarction   randomized   into    home    care    had                       3.                                         et at: A coronary-care  unit  in
                       slightly lower, though  not  statistically-  significant,  case                                                                  ial  infarction.  Lancet  2:109-
                                                                                                             114,1967
                       fatality  rates  t  an  those  randomized  to  hospital   coro-                       4. Lown B: The  philosophy  of  coronary  care.  Arch  Klin  Med  216:201-241,
                       nary-care   units.   In   a   second,   nonrandomized   Scandi-                       1969
                                                                                                             5. Peterson OL, Duffy BJ: A Report on  Coronary  Care  in  the  Tri-State  Re-
                       navian  study  by  Hofvendahl,'@,   patients   were   allocated                       gion.  Boston,  Medical   Care   and   Education   Foundation,   Inc,   No-
                       to intensive care  or  ward  care  entirely  on  the  basis  of                       vember, 1970
                                                                                                             61. Bloom  Bs,  Peterson  OL,  Martin  SP:  Radiation  therapv  in  New   Hamp-
                       bed availability. The results of  this  study  show  a  statis-                       shire, Massachusetts and Rhode Island:  output  and  co;t.  N  Engl  J  Med
                       tically  significant  advantage  for  the  patients   receiving                       286:189-194, 1972
                       intensive  care.  Clearly,  when  the   most   rigorous   stud@                       7 ,Neuhiauser  D:  The  Relationship  Between  Administrative  Activities  and
                                                                                                             Hosp tal Performance (Resear@h Series  29).  Chicago,  University  of  Chi-
                       shows  no  advantage  for  intensive  care  and  another   less                       cago, Center for Health Administration Studies, 1971
                       rigorous  but  carefully   conducted   study   disagrees,   the                       8. G-Uide issue. Hospitals 45(15): Part 2, August 1, 1971


                         76                                                        THE NEW ENGLAND JOURNAL OF MEDICINE                                                                                Jan.    11,     1973

                         Table     6.      Occupancy      Rate,      Discharges      per      Nurse      and      Dis-      economic         measures,         including         patient          selection,          case
                         charges     per     Bed,     by     Hospital     Group,     October     1,      1969,      to      fatality        rates,         occupancy         rates,         personnel         productivity
                                                       September 30, 1970.                                                  and      treatment      cost      by      spell      of      treatment.      In       general,
                             HOSPITAL GROUP            No.      OF           %        DISCHARGES/      DISCHARGES/          the      units      in      university       hospitals       demonstrated       the       best
                                                      HOSPITALS   OCCUPANCY'                  NURSE'         BED'           performance        by        both        medical         and         economic         measures
                         University related                  7           78.8                   34.3         64.3           with     the     other     teaching     hospital     group      in      a      middle      po-
                                                                    (71.1-96.4)         (21.2-42.8)   (52.3-79.8)          sition       and       the       nonteaching       hospital       group       having       the
                         Other         teaching              5           76.9                   29.8         62.3           poorest       record.       Although       the       group       means       for        rfiost
                                                                    (66.2-87.1)          (20.5-46.6)   (49.7-95.5)          measures         showed         striking          and          important          differences,
                         Nonteaching                        20           70.6                   27.3         48.5           these       were       seldom       statistically       significant.       For        example,
                                                                    (27.6-92.6)          (10.0-46.8)   (16.0-95.     5)
                         All hospitals                      32           74.3                   29.8         56.0           the        discharges        per        trained        nurse         were         impressively
                             'Chi-square      5.85  (p  =  O@055).       'Chi-square  =  8.64  (p  =   0.015).              greater     in     the      university      than      in      the      nonteaching      hospi-
                             'Chi-square      4.42 (p not significant),  'Figures in parentheses are ranges.                tals,      but      these      differences      were       not       significant       because
                                                                                                                            of     great      variation      within      each      hospital      group.      The      only
                                                                                                                            measures       that       were        significant        were        patient        selection,
                         parent.     Nurses     in     many     of     the     units      with      part-time      di-      o .ccupancy     rate     and     discharges     per     bed.     The     lack      of      sta-
                         rectors     offered     opinions     that     were      critical      of      its      admin-      tistical       significance       between       these       striking       group       differ-
                         istration           (inappropriate           patient           admissions,            nurses'      ences     is     disappointing;     it      is      the      great      within-group      dif-
                         authority       that       was       not       commensurate       with       their        re-      ferences that make them not significant.
                         sponsibility,      and      credit      taken      by      physicians      for       success-          It      was      often       possible       from       personal       observation       to
                         ful      outcomes,      with       the       nurse       given       the       responsibility      explain       such       great       variability.       One        university        hospital,
                         for     the     failures).     It     appears     that     there     were     three     types      for      example,      treated      a      very      low      percentage      of      patients
                         of     units-,     those     with     full-time      directors      with      strong      di-      with     myocardial      infarction      (37      per      cent)      because      it      was
                         rection;      those      with      part-time      directors       with       strong       di-      sharing      patients       with       a       small,       nonteaching       hospital       a
                         rection;       and,       finally,        those        with        part-time        directors      few     minutes      away.      The      area      had      insufficient      patients      to
                         with      ineffective      direction.      Since      we      do      not      have      sys-      support      two      units.      The      reason      for      some      variability      was
                         tematic      information      on      the      distinction       between       the       last      clear    from     the     data.     Only     50.4     per     cent     of     all     patients
                         two     classes,     we     have     compared      the      units      with      a      full-      treated       in        coronary-care        units        had        myocardial        infarc-
                         time      director,      where       these       complaints       were       not       heard,      tions.     Simply     stated,      too      many      facilities      have      been      pro-
                         and      all       others       using       the       various       measures       previously      vided. The data also demonstrated important dii
                         presented      (Table      7).      The      units       with       full-time       directors      ences    that     were     related     to     unit     size.     Among     the     28     Tri-
                         are     clearly     different     by     every     measure     -     by      disease,      by      State  and  Vermont  hospitals,  there  were  on y                                          ur
                         efficiency       and       by       cost.                                                          units     of     more     than     four     beds,     the     size     at     which     econo-
                                                                                                                            mies of scale became apparent.
                                                             DiscussION                                                         Perhaps     one     of     the     most     useful     aspects     of      this      study
                             This         studv         has         demonstrated         important         differences      lies     in     its     illustration     of     the     effect     of     developments      on
                         in      the       mean.performance      of       coronar-y-care       units       in       uni-    the    cost    of    medi'c'al     services.     It     also     illustrates     the     weak-
                         versity,         othei,         teaching         and          nonteaching          hospitals.      ness     of     our     policy     in     dealing     with      new      medical      develop-
                         These     groupings      also      tend      to      reflect      hospital      and      unit      ments.
                         size,    which    was    also    related    to    the     efficiency     of     the     oper-          Feldstein       has       pointed       out       that       between       1950        and
                         ation.      The      differences      are      shown      by      both      medical       and      1968,     the      consumer      price      index      rose      by      45      per      cent
                                                                                                                            while      hospital      costs      rose      292      per      cent.      He       concluded,
                                                                                                                            "Increasing      demand       has       been       identified       as       the       primary
                         Table    7.    Patient     and     Economic     Measures     According     to     Type     of      reason     for     the     unusually     rapid     rate     of     cost      increase      ...
                                                                 Director.                                                  Higher      demand      has      induced      a      change       in       the       technolo-
                                        MEASURE                     FULL-TIME                      PART-TimE                gy    of    hospital     care     to     a     better     but     more     expensive     prod-
                                                                    DIRECTOR                       DIRECTOR                 uct.""       The       provision       of       coronary-care       units       has        un-
                         No.    of    hospitals                     6                              26                       doubtedly       contributed        to        this        more        expensive        product.
                         Total patients                      2,305                                 5,710                    The      evidence      for      a      better       product       will       be       examined
                         Mean   no.   of   beds                     6    (4-8)*                    4   (2-13)               below.
                         % with myocardial                       57.0    (36.7-85,O)               47.5t   (28.1-65.6)
                             infaretion                                                                                         Economy      of       services       was       not       a       major       consideration
                         Death    rate     from                  16.0    (10.0-29.0)               19.2t (5.9-48.0)         in     the     provision     of     intensive     care     for     patients     with      myo-
                             myocardial infarction                                                                          cardial     infarction.     These      units      have      been      built      in      large
                         Average length of stay                  4.6     (3.9-5.0)                 4.8 (2.9-8.8)            hospitals         where         medical          and          administrative          staffing
                         Discharges/bed                          62.3    (52.3-71.2)               54.4 (16.0-95     .5)
                         Occupancy         rate                  79.0    (71.1-96.4)               7016 (27.6-94.4)         was      ample      and      also      in      small      hospitals       where       critical
                         Discharge/nurse/yr                      32.6    (21.2-42.8)               28.7 (10.0-46.6)         staff,     such     as     cardiologists,      might      be      lacking.      Few      units
                         Cost/patient                        468.00*     (349-817)           481.00*   (289-1,138)          have      taken      the      necessary      steps      to      assure      competent      se-
                             'Figures in parentheses  are  ranges.                                                          lection     of     patients      or      efficient      management      of      the      unit.
                             12 hospitals in which all patient records,"re incomplete or notavailable are not included      Published          guidelin@s,'O,"          which          could          help          assure
                         in  this  calculation.
                             'New York City hospitals deleted from wst calculations.                                        competent             management             or             economical             operations,


              Vol. 288  No. 2                                      CORONARY-CARE UNITS-BLOOM AND PETERSON                                                                                              75
                            Table 4. Total and Average Expenditures.                                                 rate, discharges per nurse and  discharges  per  bed  were
                                                                                                                     used as measures of  efficiency.  The  occupancy  rate  is
                  HOSPITAL GROUP          No. OF            To fAL             COST/          COST/                  used here as a measure of nonlabor  resources.  The  units
                                        HOSPITALS          EXPENDITURES        PATIENT    PATIENT         DAY        in teaching hospitals were larger, more often  part  of  a
                  University related           7           1,346,019           551.20         126.52                 large  hospital,  and  usually  located  in   metropolitan
                                                           ($872@673)'         ($438.53)      ($104.15)
                  Otherteaching                5           1,360,319           624@00         138.54                 areas, and were able to make more effective use  of  their
                                                           (683,341)           (445A6)        (102.31)               physical facilities, as evidenced by the  increasing  eco-
                  Nonteaching                 20           1,785,214           526.15         102.68                 nomic returns to scale  (p  equal  to  0.055).  The  coro-
                                                           (1@506,876)         (500.79)       (107.58)
                  All hospitals               32           4,4917552           560.39         118.69                 nary-care units are like hospitals in  this  respect:  the
                                                           ($3,062,890)        ($468,83)      ($105.38)              larger  hospitals  characteristically  have  higher  occu-
                  'Figures in parentheses show the costs when  the  New  York  City  hospitals  are  deleted.        pancy rates than the smaller ones.
                                                                                                                     Similar efficiencies were found in the use  of  labor  re-
                                                                                                                     sources  as  defined  by  the  number  of  discharges  per
                  ously ill group was $160  in  the  university-related,  $171                                       trained nurse per  year.  The  increased  productivity  is
                  in the other teaching, and  $232  in  the  nonteaching  hos-                                       most evident in the  university  hospitals.  Again,  these
                  pitals. These costs were 67 per cent, 7 2 per cent  and  190                                       were the largest hospitals with  the  largest  units.  The
                  per cent above the average  daily  inpatient  costs  in  the                                       nursing staffs in the  university-related  hospitals  were
                  three hospital groups.                                                                             on the average 15 per  cent  more  productive  than  those
                   The  distribution  of  costs  accor  ing   to   expenditure                                       in the other teaching  hospitals  and  26  per  cent  more
                  category  within   coronary-care   units   (Table   5)   was                                       productive than  those  in  the.nonteaching  hospitals  by
                  remarkably  similar  from  hospital  to  hospital   and   by                                       this measure.
                  groups. There  were  only  a  very  few  exceptions,  mainly                                       Discharges  per  bed  were  used  as   a   combined   mea-
                  in  small  hospitals,  which  did  not  affect   the   group                                       sure of labor and nonlabor efficiency - a statistic  wide-
                  means. Personnel accounted for  about  1/3  of  total  costs                                       ly used in Great Britain and occasionally  in  this  coun-
                  - a finding similar to that obsei  ved  in  general-hospital                                       try. The teaching hospitals had 30 per cent  greater  pro-
                  experience. Physician  costs  represented  a  lower  percen-                                       ductivity  than  the   nonteaching   hospitals   by   this
                  tage of the total  in  the  teaching  hospitals,  where  the                                       measure (p less than 0.02).
                  staff was usually salaried, as compared with  the  units  of                                       Increasing economics  of  scale  became  evident  as  unit
                  nonteaching  hospitals,   whose   physicians   were   always                                       size  increased  (beyond   four   beds),   and   continued
                  paid  on  a  fee-for-smice  basis.   Nonteaching   hospitals                                       through the largest unit in the  sample  (13  beds).  Even
                  tended  to  employ  fewer   ancillary   personnel   (techni-                                       though  the  large  units  had  more,  and  more   varied,
                  cians,  housekeepers  and  orderlies).  Supplies  and  fixed                                       staff, including a full-time director, interns  and  resi-
                  costs   (overhead   and   depreciation)   represented   very                                       dents, output rose faster than cost. As the  units  became
                  similar proportions of  total  expenditures  in  all  hospi-                                       larger, they seemed to be able to use their physician  re-
                  tals  and  hospital  groups.                                                                       sources, manpower  and  physical  facilities  more  effec-
                    Of the 32 Corona -care units  in  the  study,  12,  or  38                                       tively.  More  intensive   practice   evidently   improved
                                                 ry
                  per cent, made  a  profit.  In  nine,  it  was  substantial,                                       productivity.  There  was  no   important   relation   be-
                  amounting  to  more  than  10  per  cent  of  income.   With                                       tween per them  charges  and  hospital  profits.  However,
                  one  exception  these  profitable  units  had  four  to   13                                       there was some  relation  between  profit  and  labor  and
                  beds. Nine of the 12  profitable  units  were  in  hospitals                                       nonlabor productivity, although not  so  great  as  to  be
                  having more  than  200  beds.  In  three  hospitals,  income                                       important.
                  covered only 1/2 to 2/3 of cost.  Nine  hospitals  generated                                        The total investment  in  facilities  and  equipment  and
                  income sufficient to cover between 2/3 and 90  per  cent  of                                       the cost of operation of all coronary-care units  in  Ver-
                  the unit costs, whereas in the  remaining  eight  hospitals,                                       mont,   New    Hampshire,    Massachusetts    and    Rhode
                  income  covered  between  90  and  100  per  cent   of   ex-                                       Island has been estimated for 1970  from  the  study  sam-
                  penses.                                                                                            ple. The cost of building and equipping  units  was  small
                     When some  measures  of  efficiency  were  used  to  test                                       in relation to the annual cost of operation ($3.7  million
                  the  productivity  of  the  units,  the  teaching  hospitals                                       vs. $6.4 million).
                  were found to be more efficient in the  use  of  both  labor                                         During the course of  the  study,  the  substantial  dif-
                  and  nonlabor  resources.  In   Table   6,   the   occupancy                                       ferences in the administration of  the  units  became  ap-
                                                            Table 5. Total and Percentage Expenditures, According to Category,
                     HOSPITAL GROUP                        No. OF                             TOTAL                         NURSF. Cost      PHYSICIAN            OTHER        SUPPLIES            FIXED
                                                           HOSPITALS                             FXPENDITURES                                     COST       FERSONNEI.            COST             COST
                                                                                                                                                                   Cost
                                                                                           co,t             %                                     %               %                   %             %
                    University related                          7                      1,346,019            100.0                51.1             11.7             15.9               4'6           16.7
                    Other teaching                              5                      1,360,319            100.0                54.3             10.6             14.1               3.9           17.1
                    Nonteaching                                20                      1.785,214            100.0                52.0             14.5             11.7               3,4           18.4
                    All hospitals                              32                      4,491,552            100.0                52.4             12.5             13.7               3.9           17.5


                            74                                                    THE NEW ENGLAND JOURNAL OF MEDICINE                                                                            Jan.    11,    1973

                                                   Table 2. Length of Stay.                                              times     or      more,      mainly      owing      to      higher      salary      levels.
                                                                                                                         Their      deletion      from      all      financial      calculations      reveals      a
                            HOSPITAL   No.    OF     MEAN        No.   OF                 No. OF          AVERAGE        definite        pattern        among        the        New        England         hospitals
                            GROUP       Hospi-   No.   OF        PATMNTS                 PATIENT            LENGTH
                                          TAL,S     BEDS                                  DAYS           OF    STAY      (Table     4).     The     New     York     City     hospitals      have      been      in-
                                                             TOTAL      MEAN/     TOTAL      MEAN/                       cluded      in      other      tabulations      because      their      other       charac-
                                                                        HOSPITAL            HOSPITAL       days          teristics    were    similar    to    those    of    all    the    other     study     hos-
                                                                                                                         pitals.     When     the      atypical      New      York      City      hospitals      are
                            University        7     5        2,442      349       10,639      1,520     0)      4.4      deleted     from     the     cost     calculations,     the     variability     is     21/2
                            related              (3-8)*                 (157-509)          (779-2,26       (3.5-
                                                                                                           5.0)          times   in    the    cost    per    patient    spell    and    11/2    times    in    daily
                            Other             5     7        2,180      436       9,819       1,963        4.5           cost.
                            teaching             (4-13)                 (207-646)           (1,106-       (3.3-4.9)
                                                                                             3,140)                          The    range     of     daily     costs     was     great     -     from     $65     to
                            Non-             20     3        3,393      170       17,386      869          5.1           $215,    with    a    mean    for    all    hospitals    of    $119    per     day.     The
                            teaching             (2-10)                 (32-566)             (151-        (2.9-8.8)      difference      between      the      least       and       most       expensive       non-
                                                                                             3,379)
                            All  hospitals   32              8,015                37,844      1,183        4.7           teaching      hospitals      was      250      per      cent      whereas      in       the
                                                                                                                         other    teaching     group,     it     was     48     per     cent,     and     in     the
                            -Figures in  parentheses  are  ranges.                                                       university-related       group,       134       per       cent.        These        differ-
                                                                                                                         ences     were     due     mainly     to     different     staffing      levels.      There
                            admitted    to    the    units    were    similar    in     all     hospital     groups      was     no     relation     between      costs      and      case      fatality      rates.
                            (Table    3),     but     the     ranges     were     very     great.     The     death      The    mean    daily    patient    charges    were    about    $    1    00     for     all
                            rates     for      patients      with      myocardial      infarction      in      non-      coronary-care units, with a range of $64 to $250.
                            teaching     hospitals     (5.9     to     48.0     per      cent)      ranged      the          In    the    teaching    hospitals    costs    per     patient     spell     in     the
                            widest.     The     mean     case     fatality     rate     for     myocardial      in-      unit    (daily    cost    times    length     of     stay)     was     less     than     in
                            farction    in    the    units    of    all    study    hospitals    was     18     per      the         nonteaching         hospitals.         Teaching          hospitals          had
                            cent,      which      was      higher      than       most       published       rates.      larger      and      more      elaborate       staffing       patterns       and       pro-
                            One-half     the     units     had     case     fatality     rates     for      myocar-      vided     more     intensive     care     at     a     higher     daily     cost.      How-
                            dial    infarction    greater    than    20    per    cent,    and    16    per    cent      ever,      because      they      discharged      patients      sooner,      there      was
                            had     case     fatality     rates     above     35     per     cent.     Unfortunate-      a net saving to the patient or third-party payer.
                            ly,    no     information     on     severity     of     illness     was     collected,         The     average     daily     cost     for     all     patient     care     has     been
                            so    that    no    explanation     for     the     reasons     about     these     ex-      calculated    for     the     study     hospitals     by     means     of     total     an-
                            traordinary     differences     can     be     offered.      In      all      hospitals      nual      costs,      bed      days       available       and       occupancy       rates.'
                            the     death     rates     of     patients     with      diseases      other      than      The    average    daily    cost    for    all    inpatient     care     in     the     uni-
                            myocardial      infarction      were      extremely      low      -       about       I      versity-related     hospitals     was     7     per      cent      less      than      that
                            per     cent.     These     rates     were     lower     than     the      general-hos-      for     care     in     the     unit.*     In     the     other     teaching      hospitals
                            pital    inpatient    mortality    rate    of    3    to    4     per     cent.'             this    cost    difference    was    1     per     cent     whereas     in     the     non-
                            Financial      Data                                                                          teaching    hospitals    it    was     25     per     cent     less     than     in     the
                                                                                                                         coronary-care      unit.      It      appears       that       the       average       care
                            When    total     costs     were     viewed     in     relation     to     the     num-      given    in     teaching     hospitals     is     almost     as     intensive     as     in
                            ber     of     patients     discharged,     the     pattern     was     unclear     be-      the      intensive      coronary-care      units       when       judged       by       its
                            cause    of     the     three     New     York     City     hospitals     that     were      cost.     Only     in     the     nonteaching     hospitals     is     care     in      the
                            added     to     permit     examination     of     very      large      units.      The      unit clearly and substantially more expensive.
                            daily    costs    in    these    three    hospitals    were     far     higher     than         The     patient     population     to      be      used      for      cost      calcula-
                            those     of     any     of      the      New      England      hospital      coronary-      tions      presents      problems      since      three      distinct      groups       are
                            care     units     and     thus      skewed      the      averages      upward      two      involved      -      patients      with      myocardial      infarction,       a       sec-
                                                                                                                         ond       group       of       "suspected"       infarctions,       and       a       third
                            Table    3.    Deaths    from    Myocardial    lnfarction     and     Other     Causes.      of      low-risk       patients       with       other       cardiac       or       noncar-
                                                                                                                         diac     diseases.     Because     the      staffing      needs      of      units      are
                            HOSPITAL  No.  OF           ALL             PATIENTS WITH           ALL   OTHER              rigid    and    the    costs    are    fixed     whatever     the     census     or     the
                            GROUP        Hospi-      PATIENTS           MYOCARDIAL                 PATIENTS
                                           fAM                          INFARCTION                                       patient    mix    in    the    unit,    we    have     allocated     the     total     cost
                                                 TOTAL    DEATHS    TOTAL         DEATHS     TOTAL         DEATHS        of     the     units     to     the      patients      with      myocardial      infarction
                                                                                                                         and      other      seriously      ill       patients,       who       presumably       re-
                            University                                                                                   ceive    most    of    the    care.    t    When    the     cost     per     patient     in
                            related*          6  2,124       9.3        1,166     16.3       1,208         0.6           this     group     was     calculated     it     was     much     higher     than      that
                                                                               (14.3-29.0)-               (0.6-0.8)      calculated    for    all    patients.     The     daily     cost     for     this     seri-
                            Other             4  1,973       10.2       1,019     19.2       954           0.6
                            teaching*                                          (10.0-24.2)                (0.5-0.7)
                            Non-             20  3,393       9.5        1,588     18.7       1,805         1.4
                            teaching                                           (5@9-48.0)                 (1.0-1.8)                                             Total annual inpatient cost
                            All                                                                                             *Mean daily cost =
                            hospitals        30  7,490       9.6        3,775     18.1       3.965         1.0                                          Number of beds x 365 XI % occupancy
                                                                                                                           "  The  other  seriously  ill  group  includes  patients   with   coronary   insufficien-
                            11 hospital in each group deleted since no.  of  myo=dial  infarctions  &  deaths  from      cy  or  angina  pectoris  (the  usual   "?   myocardial   infarction"   or   false-positive
                            myocardial infaretions unknown or not  recorded.                                             infarction),  patients  with  higher  degrees  of   heart   block   or   serious   affhyth-
                            'Figures in parentheses are ranges.                                                          mias.


                                                                                                                                     73
             Vol. 288  No. 2               CORONARY-CARE UNITS-BLOOM AND PETERSON
             Nineteen  of  the  hospitals   combined   their   coronary-    3). For the other statistical manipulations  described  in
             care units with medical or surgical  intensive-care  units.    Tables 2 and  4  through  7,  the  Kruskal-Wallis  one-way
             In each of these hospitals  it  was  possible  to  separate    analysis of variance  by  ranks  of  the  observed  values
             coronary care from other intensive  care  for  this  analy-    was used.
             sis. This involved determination of  the  patient  days  of                             RESULTS
             care given annually in each part of the unit  and  the  al-
             location of costs on a pro rata basis. Since  no  important    Patient Data
             differences  were  found  between  the  separate  or   com-    In Table 1, the distribution of diseases  by  the  princi-
             bined coronary  and  intensive-care  units  they  are  ana-    pal diagnosis on  discharge  from  the  units  in  the  32
             lyzed together.                                                study hospitals is presented.  Myocardial  infarction  was
             Five of the  university-related  hospitals  and  one  other    by far the most frequent diagnosis (50.4 per cent  of  all
             teaching hospital had  full-time  directors,  staff  physi-    patients in all units). The differences in the  number  of
             cians and  interns  and  residents.  The  remaining  teach-    infarctions treated in  the  three  hospital  groups  were
             ing hospitals (two  university  and  four  other)  did  not    statistically significant (p less than  0.0005).  The  per
             have full-time directors or staff physicians but  did  have    cent of  patients  with  infarctions  varied  by  hospital
             residents and  interns  rotating  through  the  unit  on  a    LirouD, and the range was substantial: 37 to 85  per  cent
             regular basis. All  the  nonteaching  hospitals  had  part-
             time directors,                                                in university related, 39 to 66 per cent in other teaching
             The  study  population  included  all   patients   admitted    and 28 to 66 per  cent  in  nonteaching  hospitals.
             to  the  New  England  hospital  coronary-care  units   be-    The  university  group  included  one  eight-bed  unit  in
             tween October  1,  1969,  and  September  30,1970.  In  the    which only 37 per cent of  patients  treated  had  myocar-
                                                                            dial infarction. If this atypical hospital is deleted, the
             New York City units, data were  collected  for  the  calen-    proportion o,f infarctions treated  in  this  group  was  61
             dar year 1970.                                                 per cent, with a range of 44 to 85 per cent. With one  ex-
             The  data  recorded  for  each   patient   included   diag-
             nosis at discharge from the unit, length  of  stay  in  the    ception, the teaching hospitals had  fewer  patients  with
                                                                            diseases  other  than  myocardial   infarction.   Patients
             unit, and death or survival in the unit.  These  data  were    with  higher  degrees  of  heart  block  were  proportion-
             recorded from either the  departmental  log  or  the  indi-    ately twice as frequent  in  teaching  as  in  nonteaching
             vidual patient records.  Diagnostic  and  mortality  infor-    hospitals. If patients  with  manifestations  of  coronary
             mation on many  patients  could  not  be  obtained  in  two    heart disease other  than  myocardial  infarction  (higher
             hospitals, and they were omitted from  certain  tables,  as    degrees of heart block,  cardiac  arrest  occurring  else-
             noted. No clinical patient data  were  collected,  so  that    where  in  the  hospital,  serious  arrhythmias,  coronary
             there is no information on severity of disease  or  accura-    insufficiency or angina pectoris) are  added  to  the  pa-
             cy of diagnosis.                                               tients with proved or  probable  infarction,  the  propor-
              The  information   on   hospital   income   and   expendi-    tion of patients with serious episodes was 55 per cent  in
             ture pertaining solely to the coronary-care  unit  was  ob-
             tained from hospital fiscal records. Physician  costs  were    the nonteaching, 60 per cent in  the  other  teaching  and
             determined  from  hospital  records  or  Blue   Cross   fee    65 per cent in the university-related groups.  The  others
             schedules. The  methods  of  data  collection  and  defini-    were  a  low-risk  group.
                                                                             The  length  of  stay  in  the  coronary-care  units  was
             tions6used  have  been  described  in  an  earlier  publica-   shorter in the teaching hospitals and was shortest in  the
             tion. Unpublished details are available.                       university-related ones (Table 2). There  was  also  great
              All the  data  collected  were  separated  into  two  dis-    variability between  hospitals  within  each  group,  with
             tinct categories  -  patient  and  financial.  The  patient
                                                                            the widest  range  in  the  nonteaching  hospitals.
             data deal with  the  patients,  discharge  diagnosis,  out-     Overall, the mean case fatality rates  for  all  patients
             come and length of  stay.  Financial  data  concern  hospi-
             tal  income  and  expenditure  in  providing  care  in  the                 Table 1. Discharge  Diagnoses.
             unit only, and the  efficiency  with  which  care  was  de-
             livered. Nonhospital-related patient costs, such  as  wages          DIAGNOSIS         UNIVERSITY  OTHI!R        NoN-
             lost during the hospital stay, are excluded.                                           RELATED'    TEACHING'     TEACHING
               Although  data  on  personnel,  finances   and   patients                            no.   %     no.   %       no.    %
             were  abstracted  from  hospital  records,  no   systematic    Myocardial infarction'  1,166 54.9  1,019 51.6    1,588  46.8
             collection was  made  of  information  on  the  units'  ad-    Arrhyth-,a              308   14.5  378   19.2    520    15.3
                                                                            C..ge
                                                                                  's,@,@ heart failure 152 7.2  III   5.6     268    7.9
             ministration  and  organization.  In  the  course  of   the    Coronary insufficiency  48    2.3   109   5.5     214    6.3
             study,  conversations  with  personnel   in   the   various    Angina    pectoris      70    3.3   34    1.7     160    4.7
             units  uncovered  marked  differences  between  units  that    Heart    block          52    2.4   66    3.4     46     1.4
                                                                            Other cardiovascular    215   10.1  87    4.4     402    11.9
             ap  arently  led  to  important  differences  in  organiza-    All noncardiovascular   70    3.3   36    1.8     146    4.3
               p
             tional and  administrative  effectiveness  and  policy  im-    Diagnosis unknown       43    2.0   133   6.8     49     1'4
             plementation. Comments  in  this  area  are  noted  as  our       All hospitals        2,124 100.0 1,973 100.0   3,393  100.0
                                                                             'Records of patients with diagnoses of myocardial infarction & other heart diseases
             own opinions.
                                                                               incomplete or not available in I university & I other teaching hospital; data from
                Conventional tests of significance were  used  for  dis-    were    ' tals are omitted from this distribution.
                                                                            these 2 hospi
             charge diagnosis and  case  fatality  data  (Tables  I  and     'Chi-square - 31.54 (p<0.0005).


             Vol. 288  No. 2         FAILURE OF RUBELLA HERD IMMUNITY-KLOCK AND RACHELEFSKY                                                  71

                     Table 2. Attack  Rates  According  to  Grade.*             Table 3. Serologic Survey, Junior High School, February,  1971.

                GRADE        No. OF CASES    ENROLLMENT      ATTACK RATE'         GRA13E    RUBEI.LA      No. OF        SUSCEPTIBLE STUDENTS'
                                                                                            VACCINATION  SPECIMENS
                    7              57           1,120             5.1
                    8           162             1,115             14.5                                                 number         %
                    9           160             1,186             13.5              7    Vaccinated        238             5         2.1
                    10          180             1,141             15.7
                    11          152             1,015             14.9              7    Unvaccinated        93            37        39.7
                    12          155                918            16.9              8    Unvaccinated      335            101        30.1
                                                                                    9    Unvaccinated      298            53         17.7
              'All schools combined.                        'Cases/ 100 students.                                       -
                                                                                      Total unvaccinated   726           191         26.3
             February  from  964  of  the  1556  students  (62  per   cent).      Rubella hemagglutination-inhibition titer of <8.
             The results are  given  in  Table  3.  Of  726  previously  un-
             vaccinated  children  in  these  three  grades  191  (26.3  per    of  these  children  were  immune,  but   only   I   per   cent
             cent) had  rubella  antibody  titers  less  than  8.  Two  hun-    contracted    clinical    rubella.    However,    this     herd
             dred  and  thirty-three  (97.9  per  cent)   of   238   seventh    immunity in  itself  had  little  effect  on  the  perpetuation
             graders who had received vaccine were scropositive.                of the epidemic.  It  is  unlikely  that  a  higher  percentage
                On  May  24,  a  second   serum   was   obtained   from   83    of  immunity  in  this  age  group  would  have   substantially
             students  who  were  initially  seronegative.  In  14  (17  per    influenced the course of the epidemic.
             cent)  seroconversion   had   occurred,   and   10   of   these      Secondly,   in   comparison    to    measles    and    mumps,
             14 (71  per  cent)  gave  a  history  of  symptoms  of  rubella    to  which  85  to  90  per  cent  of  Americans  are  naturally
             since  giving  the  first  specimen.  The  ratio  of   apparent    immune  by  the  time  they   reach   adolescence,',"   rubella
             to inapparent infections  in  this  small  sample  is  2.5:  1.    immunity  is  generally  lower  at  this  age.  Serologic  sur-
                                                                                veys  done  since  the  1964  rubella   epidemic   have   shown
                                     DiscussiON                                 that   approximately   3/4   of   teenagers   have    serologic
                Rubella  control  in  the  United  States  is   based   pri-    evidence   of   previous   rubella   infection.    In    Tampa,
             marily   on   the   concept   of   "herd   immunity.115    Such    Florida,977percentofchildrenl5tol9yearsol                  were
             immunity  is   said   to   exist   when   the   proportion   of    found to be  seroimmune;  similarly,  76.6  per  cent  of  over
             immune  members  of   a   population   is   large   enough   to    I 000 students 13 to 18  years  of  age  in  Atlanta,  Georgia,
             reduce greatly the  probability  of  infection  of  susceptible    had  rubella  antibodies."  In  Casper,  a   similar   immunity
             members   of   that   population.'   A   unique    modification    level was shown to  exist  in  adolescents.  In  the  serologic
             of  the  classic  concept  of  herd  immunity  is  applied   in    survey  early  in  the  outbreak,  74  per  cent  of  unvaccin-
             rubella control because  of  the  inherent  risks  in  vaccina-    ated   junior-high-school   students   were   found    to    be
             ting post  ubertal  females  on  a  large-scale  basis.  It  is    seroimmune  to  rubella.  If  it  is  assumed  that  this  per-
                       p
             anticipated   that   immunizing   one   "herd"    i.e.,    pre-    centage  was  representative  of  the  immunity  of  all  teen-
             pubertal  children  -  will  greatly  reduce  the   spread   of    agers  in  Casper,  adolescents  living   in   this   community
             rubella virus in  the  community  and  will  protect  a  second    were  not  any  more  susceptible   to   rubella   than   other
             "herd"  -   susceptible   pregnant   women.   In   Casper,   70    U.S. adolescent populations previously studied.
             per  cent  of  prepubertal  children   had   been   vaccinated,      Thirdly,   the   rubella   vaccine   used   in   Casper   was
             and  an  estimated  70  to  75  per  cent  of  those  not  vac-    shown  to  be  effective  in  eliciting  an  immune   response,
             cinated  were   naturally   immune.   However,   despite   this    and  vaccine  failure  was  not  an  important  factor  in  the
             immunity,  a  large  r-ubella   epidemic   occurred,   and   at    genesis  of  the  outbreak.  Ninety-eight  per  cent   of   238
             least seven pregnant women were infected.            It is   ap-   recipients  of  vaccine  had  rubella  antibodies,   and   only
             parent  that  in   this   community,   the   presence   of   an    1.5 per cent  of  all  those  vaccinated  were  known  to  have
             immune,  prepubertal  "herd"  was   not   effective   in   pre-    had rubella during the outbreak.
             venting community spread of rubella.                                 The  main  reason  for  the  occurrence  of   this   epidemic
                There  are  a  number  of  possible  explanations  for   the    appears to be the fourth  consideration  -  i.e.,  the  failure
             occurrence  of  this  epidemic  in   the   presence   of   sub-    of the herd-immunity concept  as  it  is  applied  to  r-ubella
             stantial   immunity   in   younger   children.    The    number    control.   This    investigation    demonstrates    that    im-
             of  immunized  prepubertal   children   may   not   have   been    munity  to  rubella  in   one   segment   of   the   population
             high  enough  to  provide  a  herd   immunity   effect.   Also,    may have  no  influence  on  the  occurrence  of  this  disease
             the  percentage  of   adolescent   children   in   Casper   who    in  a  second  segment  of  that   population.   This   concept
             were  naturally  immune  to   rubella   before   the   epidemic    has been stated by Fox  et  al.1  in  a  mathematical  analysis
             may   have   been   unusuall   low.   Moreover,   the   rubella    of   herd   immunity.   They   showed   that   the    important
             vaccine  may  have   been   ineffective   in   preventing   the    determinants  of  an  epidemic  were   the   number   of   sus-
             disease.  Or,  finally,   the   concept   of   immunizing   one    ceptible  members  of  a  population   in   addition   to   the
             segment  of  a  population  to  prevent  illness   in   another    number   of   opportunities   for   their   exposure   to   the
             segment  may  not  be  valid  for  rubella.  These  four   con-    disease,   and   that   if   these   two   variables   remained
             siderations are discussed below.                                   constant,  the  total  number  of   immune   persons   in   the
                First  of  all,  the  relatively  high  immunity  level   in    population   had   no   influence   on   the   epidemic.   This
             children  one  to  12  years  old  appeared  to  be   effective    was  the  case  in  Casper,  where  rubella  spread  with  ease
             in  preventing  spread  of   clinical   rubella   within   that    among  susceptible  adolescents,  in  spite  of  the   previous
             particular  segment  of  the  population.  Over  70  per   cent    addition   to   the   community   of    children    vaccinated.


                                                                                                                                                                           Jan.      11,      1973
                        72                                          THE NEW ENGLAND JOURNAI@ OF MEDICINE
                        Although       the        vaccination        of        prepubertal        children                                REFERENCES
                        in     Casper     did     not     prevent     an     epidemic,     this     effort      1. Rubella Symposium. Am J Dis Child 110:345-476, 1965
                        undoubtedly      did      prevent      infection      ofa      number      ofpreg-      2. National   Communicable   Disease   Center.    Recommendation    of    the    Pub-
                        nant      women      after      the      epidemic      began.      If      younger      lic Health Service Advisory committee on Immunization                   Practices:
                                                                                                                Prelicensing  statement  on  rubella  virus  vaccine.   Morbidity   and   Mortali-
                        children     had     not     been     immunized,      the      outbreak      would      ty Weekly  Report  Vol  18,  No  15.  Atlanta,  Georgia,  The  Center,  April  12,
                        have    been    more    extensive,    and    t    e     number     of     exDOsed,      1969, pp 124-125
                                                                                                                       @or  Disease  Control.   Proceedings   of   the   Eighth   Annual   Immuni-
                        susceptible       women       would       have       been       much       higher.      3. Center
                                                                                                                zationConference,KansasCity,Missouri.Atlanta,Georgia,TheCenter,
                        Thus,       childhood        rubella        imniunization        remains        an      March. 1971, p I
                        important  method  of rubella  prevention;  ho                                          4. Immunoto2v   Series   2.   Edited   by   DF   Palmer,   KL   Herrmann,   RE   Lin-
                                                                                                    wever,      colni.  et  a@,Atlanta, Georgia, Center for Disease Control, 1970
                        because    of    the    potential    for    outbreaks    in     older     children      5. Meyer  H  M  Jr,  Parkman  Pi5:  Rubella  vaccination:  a  review   of   practical
                        this       procedure       should       be       supplemented       by       other      experience. JAMA 215:613-619. 1971
                        methods    of     rubell,a      control.      The      most       important       of    6. F@x  JP,  Eiveback  L,  Scott  W,  et  at:  Herd  immunity:  basic   qoncept   and
                                                                                                                relevance   to   public   health   immunization   practices.   Am   J    Epidemiol
                        these     is     the     identification     and     vaccination     6fsusceptible,      94:179-189. 1971
                        nonpregnant women in the child-bearing age.                                             7. Black  FL:  Measles  antibodies   in   the   population   of   New   Haven,   Con-
                                                                                                                necticut. J Immunol 83:14-82, 1959
                                                                                                                8. Krugman  S,  Ward  R:  Infectious   Diseases   of   Childhood.   Fourth   edition.
                        We   are   indebted   to    Dr.    Walter    Watson,    Miss    Sara    Suyematsu,      St. Louis, CV Mosby Company, 1968, p 194
                        and   other   members   of   the   Natrona   County    Health    Department    for      9. Witte  JJ,  Karchmer  AW,  Case  G,  et  at:  Epidemiology  of   rubella.   Am   J
                        assistance  in  the  investigation,  and  to  Drs.  Lyle   Conrad,   Shelby   Wyll      Dis Child 118:107-111, 1969
                        and  Spotswood  Spruance  and   Miss   Francis   Porcher   for   review   of   the      10. Wyll  SA,  Grand   MG:   Rubella   in   adolescents:   serologic   assessment   of
                        in   cript,                                                                             immunity levels. JAMA 220:1573-1575, 1972
                                                                            0 -  t%
                                                                                     SPECIAL                           ARTICLE
                                     END RESULTS, COST AND PRODUCTIVITY OF CORONARY-CARE UNITS
                                                     BERNARD S. BLOOM, M.A., AND OSLER L. PETERSON, M.D., M.P.H.
                        Abstract    The    use    of    coronary-care     units     for     the     treat-      ductivity      and       efficiency.       These       important       differences
                        ment     of     patients     with     myocardial      infarction      has      in-      were    often     not     statistically     significant     because     of     the
                        creased     explosively     with      little      attention      to      efficacy,      great variation within hospital groups@
                        need, or cost.                                                                          Intensive      care      for      patients      after      myocardial      infarc-
                        IA   study   of   32    hospital    units    revealed    that    half    the    pa-     tion     should     be     planned     by     region,     not     by      individ-
                        tients     treated     did     not     have     myocardial     infarctions     and      ual      hospitals,      to      assure      effectiveness      and       economy.
                        were    a    very     low-risk     group.     Larger     units     in     teaching      Intensive     care     of      such      patients      presents      an      ideal
                        hospitals      with      full7time      directors      showed      lower      mean      model     for     regional     planning.      Finally,      proof      of      ef-
                        case     fatality     rates      from      myocardial      intarction,      higher      fectiveness      of      intensive      care      in      these      cases      is
                        percentages    of    patients     with     infarction     and     greater     pro-      lacking.
                        @URING     the     past     decade     the     use     of     specialized     cor-      different   types   of   units;   (2)    to    ascertain    mortality    in    the
                              onary-care    units    for    the     treatment     of     acIute         myo-    units;    and    (3)    to    describe    the    diseases    for     which     pa-
                        cardial       infarctions       has        expanded        rapidly.        Current      tients were treated.
                        practice    reflects    a    belief    that    treatment    in     these     units
                        reduces       mortality       through       monitoring       and        prevention                                  STUDY DESIGN
                        or     prompt     treatment      of      arrhythmias.      Clinicians      justify       A    sample    was    randomly     selected     from     all     hospitals     in
                        this    intensive    and    expensive    therapy    by    a     definitely     re-      New        Hampshire,        Massachusetts        and         Rhode         Island
                        duced     inhospital     case     fatality     rate.     Research      on      the      that    reported    that    they     had     units     for     intensive     coro-
                                                                                                                na            5
                        units    has    centered    mainly    on    end    results    of    clinical    ex        ry     care.     The     universe     was      stratified      according      to
                        perience    "before    and    after"    institution    of    a     unit     within      number    of    beds    for    coronary    care    (three    beds     or     less,
                        a     hospital'-'     or     -on     preventive      and      therapeutic      ad-      four   or   five    beds',    and    six    beds    or    more)    and    teaching
                                  4
                        vances.    This    paper    will    present    the    findings    of    a    corn-      function     (university      related,      other      teaching      and      non-
                        arative    output    and     cost     analysis     of     diverse     types     of      teaching).    One    third    of    the    hospitals    in    each    cell    were
                        p
                        units providing this care,                                                              randomly     selected     with     a     minimum     of     two     ho@      itals
                                                                                                                                                                                        p        .
                                                                                                                examined    per    cell.     In     one     cell,     the     "other     teaching"
                                                        OBJECTIVE                                               with   three   beds   or   less,   there   were    no    hospitals.    In    addi-
                          The    purpose    of    this    investigation     was:     (1)     to     deter-      tion,      all      Vermont      hospitals      having       a       coronary-care
                        mine    the    true    hospital    cost     and     economic     efficiency     of      unit   were    studied.    Since    there    were    very    few    large    units
                                                                                                                (eight beds or more in large hospitals)                      in     these     four
                         From  the  Department  of  Preventive  and   Social   Medicine,   Harvard   Medi-      New    Englancf    States,    four     more     were     added,     three     ran-
                        cal  School,  25  Shattuck  St.  Boston.  Mass.  02115,  where  reprint   requests      domly    selected     from     New     York     City     hospitals     and     one
                        should be addressed to Mr. Bloom.                                                       in    Connecticut.    Thus,    a    total    of    32    units    were    included
                          Supported  by  the  Tri-State  and  Northern  New   England   Regional   Medical
                        Programs.                                                                               in the survey.


            Like   many   U.   S.   does,   I   re2ulariv    read    arid    usually    enjov
        lFvin" Pale's editorials in illo@ill-i                                                     individualized   le@irnina   experience   of   a    week    or    lonaer    with    a
                                                    -17    medicine.    However.    I     nu'
                                                                                            St     Pilysici@ill of t
                                                                                                                     ficir  choice  in  a  li(.)spitzil  Of  their   choice.   A   total
        admit   I   didn't   enjov    the    recent    one    Ile    %Vrotc    about    RNIP,      ol' 43" Plivsici@ins a
        Usuallv a seasoned observer of tile medical scene                                                 -
        .. .                                                                                                    I            iid   allied   licaltil    personae!    llavl-    completed
        Ellis case, fired off in many directions                            Dr.   Paue,    in      such PrccLPtt)fsf'iPs at 16 hospitals ill '-'2 fields.
        PILNIP.                                               -   including   a   bla"st   at             (2)      Under      R-NIP      auspices,      Seattle,      Kin,,      County,
           Actually,   I   am   most   distressed    at    his    lack    of    understanding      Wasliin(Itoji  and  Alaska  physicians
        of   the   R.NIP   proaraill.   If   fie   doesn't    understand    what    we    are      Alaska and @Vasili,                               have      visited      tlir6ucllout
                                                                                                                                                                              c
                                                                                                                          I,,ton   on   te@lcliiiilj   and    consultation    inissions.
                                                                                                                                                C,
                                             'nust    be    even    more     confused.     if      comniunities    arid    tile     Seattle-Kiiio@     CoLl@Iltv     medical     complex
        about.  then  many  others  I                                                              These   visits   I)AVLI   served   to   nitrate   Iiiika(les    between    Peripheral
        P,NIP's -oals are not we
                                      11    understood,    tile    confusion    may    result      arid were of considerable value in establisl'
                                        a                                                                                                                  line    the    WA,%IL    plan
        irom one of the follower,, four reasons:                                                   for re,c,lionaliziii(, medical education.
                                                                                                                      C,
              (1)   Tile    Original    legislation    did    not    provide    a    specific            (3)    Coiitinuiii(y    medical    education    was     advanced     by     the
        blueprint, rather, it was deliberatell, peri-nissive.                                                               0
                                                                                                   appointment     three     years     a,o     of'     1-5     continuing      education
              (2) Local autonomy has led             to somewhat different              deals      coordinators.    Under    the    joifit    sponsorsli-i-,)    of     tile     medical
        in each of the 56 R-NIP Re@ions.                                                           school,    @VS@NIA     and      R,%@l P,  these      Physicians       serve        as
              (3)   As   the   R.NIP   legislation   has    been    extended,    its    goals      coordinators   of   educational   efforts   in   tile    19    areas    in    wilicil
        have been moditied.                                                                        they     Practice.     Ori!zinallv     concerned     more     with     atidiO-ViSLial
                                                                                                   teaciiiii- -tids, tl)e@, have                                       to        medical
                                                                                     I                                            now turned their attention
              (4)   R,\IP    is    I'nost    successful    when    it    maintains    a    ow                                                                    hospitals          have
        profile,   servin,,    as    a    catalyst    heaping    to    coordinate    I    alt      audit  Or  patient  care  appraisal  and  in  ten
                         C,                                                       le        II     initiated such programs.
        efforts of others.
        Consortium                                                                                      (4)    Residents    in     internal     medicine     from     the     Universitv
                                                                                                   proaram    were    introduced    to    community    practice    for     the     first
         After    six    years    of    existence,    I    think    the    RNIP    mav     be      titne@   when   the   Universitv   @vas   CIICOLII-aE!ed   by,   R.NIP    to    place
        described    as    a    consortium    of    providers    responsive     to     health      them in local community hospitals. In :addition to LIP-
                                                                                                                                                                               ..radiii-
        .ie,-ds    and    problems.    It    provides    a    framework    witi-Lin     which      care    in    these    cominuiiitit-s,    the    Guest    Residency    proaram    has
        health   providers   can    come    together    to    meet    health    needs    that      alreadv   led   to   the   decision   bv   some   medical   residents    to    return
        -a,inot     be     met     by     individual     practitioners,     hospitals      or      to   these   areas   to   practice.   i%vedisli   Hospital    in    Seattle,    which
        .)rE!ani7ations    acting     alone.     It     gives     health     providers     an      liostcd    the    first    medical    resident,    was     sufficiently     impressed
        )ppc)r,ur,ity    to    addr@     fiealiff     problems     arid     provides     them      with   tile    results    that    it    now    funds    two    full-time    residents
        yeah the financial means for doin- so.                                                     t   rou-ii   the   Uiiiversit   ,   and   Sacred   Heart    Hospital    in    Spokane
                                                                                                      0                     y
        O,ri@ativ     directed     at     heart     disease,     cancer,      stroke      and      fundsone resident.
        elated   diseases,   RMP   now   shares    %vitli    other    health    droops    the
                                                                          cp                          (5)     By     coordinating     relations     between     the     hospital      in
        @road -oals of:                                                                            Willapa   Harbor   arid   Vir-inia    Nltson    t%ledical    Center,    R.@NIP    has
           (Ij   Iiicreasin-   the    availability    of    care,    (2)    Eiihancin-    its      helped  to   stren-tlieii   the   services   of   a   small   hospital   and   helped
        uality, (3) ,@ioderatina its costs.                                                        to   relieve    tile    physician    sliorta-c    in    tl)at    coriii-nuiiity.    A
        -\Ioreover. contitiuiii- education li@is been and continues                        to      pharmacist   reor@@i,,iized   their   r.)Iiariiiacy,   cuttijic,   their    inventory
        a major R   \[P thrust.                                                                    in   lialf   by   eliiiiiii,,itin-   duplications    arid    discarding    out-of-use
                                                                                                   drugs.    In-servicc    training    pro(,rains     of     iiurses,     administrators
        few examples of W/ARI\IP activities follow:                                                and   tecliiiiciii)s   have   been   stzirted@   specialists   from    tile    \Iason
           (1)     A      preceptorsliip      project      li@is      enabled      practicing      staff   have   field   teaciiiii-   seminars   for   the    fai-nilv    practitioners
        ,\@sicians   from   all   parts   of   Wasliin,,toii   and   Alaska   to   have    an      in the area.

                                                                                                                                                                                       I 17T


       Va5hon and Darrhigton                                                        serve  as  an  effective  channel  tliroucli  which  any   physician   in
                                                                                             t,                              C,          We   iiivite    your
          The  Com!iiunitv  HcaltFi  Servics  Procram,  oil-.  of  R.Nil's  six     this  -e-iO"  call  express  I-,-s  convictions.
       broad  grouping  of  activities.  involves  the   Uni@,ersitv   at   the     comment and SLlgclestions.
       gass root level in  tryinc.,  out  innovative  ways  to  deliver  health
       services and in utilizin- new types of personnel.                            UIV - RMP Relation
          On  Vaslion  and  inlaurv   Islands,   where   only   one   physician        In October, 1968, the        University   of   Wasiiiiicton   took   a
       practices,  CHS  asked  the  University  of   Washin-ton   Division   of     significant  step  toward  broader   participatioii   in   the   re-ion's
       Coiiiniunit@,  Development  to  help   the   6,000   residents   conduct     health  care  system  bv  siizniti-  a  riiemoranduin  of   understanding
       their  o%vn  health  survey.   The   residents   documented   the   need     with the @@lasliiiigtoii/Alaska RNIP.
       for   emergency   and   weekend   services   and    found    that    the        With  the  sigiiinc,  of  the  memorandum,   the   Universitv   a2reed
       majoritv  of  people  would  %welcome  such  services   bv   new   types     to administer -funds  for  activities  aimed  at  solving  loc'al  health
       of  personnel,  such  as   the   piiysiciaii's   assistant   and   nurse     care   problems   originated   bv   health   leaders    and    practicing
       practitioners                                                                physicians as well as  orditiar\,  citizens.  Vital  to  the  success  of
          Sometliina   similar   has    been    happeniii-    in    Darrinaton.     tili's  new  arranoeiiient  was  @lic  University's  early'  decision  to
       Unable to attract a physician, the residents        decided   to    form     participate in, but refrain from directiiig, the Program.
       their own  medical clinic and  to  staff it with  two.             nurse        Both  the  RI%IP  and  the  University  bei,,efit  by   this   unusual
       practitioners  to  provide  primarv   care.   With   R.%IP   assistance,     arran-enient.  I;LNII),   workin-   directly   with   practitioners   and
       ti-te  residents  elected  a  local  Board  of   Trustees,   nci!otiated     providers  of  health  care,  benefits   bv   havin-I   access   to   the
       ageements   for   supervision   and   bick-up   by   physicians   in   a     University's  'facu]tN,  -  its  storehouse  of   knowledge,   experience
       neighboring   area   arid   obtained   approval   by    the    Snohomish     and resources; the    Ujiiversitv  benefits  bv'  the  buildinc,  of  the
       County   Nledical   Societv.   Preceptorsliips   for   the    RN's    to     two-wav    communication    systems    brid-i'nc,    the    aa    between
                                                                                                                                @  0        c: p
                                                                                            arid practic .          Z,   -
       prepare them for  their  new  role  are  beinc,  arran-ed  throu2ii  the     theor,.              e Worki'nc, toaetlier, the   two       oreanizations
       Uliiiversitv  Division  of   Fa@ly   Nledicine   and   the   School   of     are  able  to  explore  and  test  new  ways  of   improving   both   the
       Nursin,,,.                                                                   quality  and  the  delivery  of  health  care  tlirou-liout  the  re-ion.
       Winds of change                                                                Goals,  policies  and  priorities  for  the  R-NIP  are  set   by   its
         Today  few   doubt   that   innovative   approaches   to   the   study     40-iiieiiiber voluntary Re-
                                                                                                                 lional     Advisorv     Committee.     which
       a@id  delivery  of  health  care  are  necessary.  Both  tlic-RNIP   and     also  reviews  all  proposals  submitted.  The  bNplaws   specify   "that
       the  Universitv  are  facin-  into  the  winds  or   chance.   To,,ether     no particular 2roup, profession, or2anizat       ion,   institution    or
       they stand ready to work     with  the  private   sector   of   medicine     acourapliic area sliall hold a majority of seats" on RAC.
       to  assist  as  appropriate  in  itifluencina  the  direction  and   the      While  the  RAC  is  the   policy   and   procyrain-makina   body,   the
       effectiveness of that clianu                                                 University administers all funds and        L
                                                                                                                            is  responsible   for   financial
       Honest broker                                                                and grant administration and personnel practices.
         I  think  there  is  a  need  on  the  American  health   care   scene
       for  the  R.NIP  to  serve  as  a  coordinator   or   "Honest   broker",
       brin2in-   toactiler   the   various   health   providers   for    local
       plann@ia  arid  action,  arid  servin-  as  an  effective  link  between
       the federal, state  and  local  -overninents  and  the  private  sector.                 Dotial R. Sparkiiiati, ILD.
       By  these  means,  R.NIP  can  help  bring  about  those  Cllall!ZCS  in                    Program Director,
       health  care  that  physicians  and   other   health   providers   think                    Washington/Alaska
                                 ,-toii  and  Alaska,  your  R.\IP   tries   to                    Reaional Nle(fical Program          L.-@@
       are necessary. In l@Iiishin

       March, 197--)


            Special  Communications

            Health Care Financing
            and Delivery in the Decade Ahead

            Walter J. McNerney

                 ne    hundred    eighty-six    years  are responsible for high  hospital  costs   out  that  the  three  states  with   the
                   ago,    Robert    Burns    pleaded  by  keeping  patients  too  long  and  by   highest  ratio  of   MDs   to   patients-
            0   that   we   might   be   given    the  not using facilities and services  in  an   states with the  most  attractive  living
            power to  see  ourselves  as  others  see  economical way.                             conditions-receive  half  of  all   Medi-
            us. If that plea proves anything,  it  is     Washington,   DC,   February    1972.-   caid funds and a third  of  all  Medicare
            that  18th  century  Scotland   was   not  The    Kennedy    health     subcommittee   funds, even  though  only  one  fifth  of
            blessed with  the  newspapers  and  tele-  has  subpoenaed  records  of  the   Joint   the  persons  eligible  for   both   pro-
            vision news broadcasts  that  we  in  the  Committee  on   Accreditation   of   Hos-   grams live there.
            United  States   enjoy   today.   Through  pitals  and  will  subpoena  records   of     Washington,    DC,    August    1971.-A
            them,  we  have  indeed  been  given  the  the  California  Medical  Association  to   report  submitted  to  the  Secretary  of
            power  to  see  ourselves  through.   the  evaluate the quality  of  hospital  care.   HEW  calls   for   a   two-year   morato-
            eyes of others. All  we  have  to  do  is     Boston,   March   1972.-Wilbur   Mills   rium on all licensing laws,  more  strin-
            read or listen.                            said  the  time  is  ripe  for   national   gent  standards  for   license   renewal,
              For example:                             health   insurance,   without   confining   and  representatives  of   consumers   on
              Rochester,    NY,    November    1971.-  ourselves to any one system.                licensing boards.
            Surveys in the.  area  were  reported  to     Washington   DC,    December    1971.-     The  next  two  are  also   interesting
            show that because  of  a  lack  of  area-  A   reporter   berated    the    American   when seen side by side:
            wide planning, 309o' of all hospital  and  Medical  Association  for  deploring  the     Chicago,  May   1972.-The   editor   of
            nursing   home   patients   should   have  rise in  malpractice  suits  rather  than   "Action Kit of  Hospital  Law"  said  the
            been cared for elsewhere.                  acting to reduce their  causes,  such  as   time has come  to  recognize  that,  each
                                                       eliminating needless surgery.               person  has  a  constitutional  right  to
              -k'or ("Iiiori(ii t-oitiiiii,tit s(,(, p(ige I 1 79. San  Jose,  Calif,   February   1972.- receive a certain level of care.
                                                    -  Representative   Roy's   assistant,   Dr.     Boston,   March   19721,--A   New   En-
              Chicago,   February   1972.-Dr.   Hunt-  Biles, said there are too  many  special-   gland Journal of  Medicine  article,  and
            ley,  of  the   Department   of   Health,  ists  and  not  enough  general  practice   letters of  response  from  readers,  re6
            Education  and   Welfare,   said   60,000  physicians.                                 flected the  belief  of  MDs  that  their
            lives could be saved  annually  if  pres-     I call your special attention  to  the   services should go to  the  highest  bid-
            ent  knowledge   about   emergency   care  following two items:                        der and that  no  one  has  an  automatic
            were  put  into  effect.  He  added  that     Chicago,   May   1972.-The    American   right to be treated.
            only  eight  to  ten   communities   have  Medical  News  reported  that  the  Pres-     And finally  .  .  .  Washington,.  DC,
            proper emergency services.                 ident's  manpower   report   said   there   March 1972.-A bill  to  establish  a  new
              Toledo,  Ohio,  June  1971.-The  presi-  will be  enough  MDs  by  1980  to  over-   National Institute of  Health-  Care  De-
            dent  of  the  local  Academy  of   Medi-  come shortages.                             livery was introduced.
            cine said  doctors  and  hospitals  alike     In   January   1972    the    American     To these  specific  items  we  can  add
                                                       Medical  News  reported   that   Geoffrey   some   general   assertions   that    are
                                                       Moore,   US   Commissioner   for    Labor   made  time  and  time  again:  that  hos-
              Mr. McNerney is president of the Blue  Cross Statistics,  said  the  total  number  of pitals  and  physicians  are  not  inter-
            Association, Chicago.
              Read before the Foram for  Medical  Affairs, MDs trained  in  this  decade  will  fall ested in productivity; that  health,.  is
            Amen'ean Medical A@ation, San  Francisco,  short of the need.                          better in other  countries  than  it,  is
            June 18,1972.@                                Chicago,   May   1972.-Discussing   MD   here;  that  prepayment  plans  and   in-
              Reprint requests to 840 N Lake Shore Dr, Chi@
            eago 60611 (Mr. McNerney).                 distribution,  Chicago   papers   pointed   surance   companies   have    excessively
            1150    JAMA, Nov- 27, 1972 o Vol 222, No  9                                                              Health   Care-McNerney


                    steroids with an increase  in  the  diffu-                 The    importance     of     high-dosage              reasons  including  a  significant   preva-
                    sion   capacity   is   previously    unre-                therapy  with  corticosteroids  in   con-              lence   of   positive    antinuclear-factor
                    ported.  Weaver  et   all   reported   the                nective-tissue  disease  has   been   em-              and latex-fixation  tests,  clinical  over-
                    only   other   unequivocal   response   to                phasized  in  recent  years.  Vignos   et              lap   with   seleroderma   and   rheumatoid
                    steroids    documented     by     symptoms                all,  emphasized  that  a  patient   with              arthritis,  and  its  presence   associated
                    and x-ray films of  the  chest  but  with-                polymyositis  should  not  be  considered              with   malignancy   in   about    15%    of
                    out change  in  diffusion  capacity.  Hep-                steroid-resistant until he has failed  to              cases.    Recently    autoimmune    delayed
                    per et al5 reported  a  case  in  which  a                respond to 80 to  100  mg  of  prednisone              hypersensitivity   has   been   an   impli-
                    dramatic  response  occurred  in   a   56-                daily.  Of  the  six  patients  who   re-              cated   mechanism.   Based    on    earlier
                    year-old  woman,   with   increased   lung                ceived corticosteroids  reported  in  the              work   in   animals   done   by    Dawkins"
                    volumes  and   return   to   an   asympto-                literature,  none  received  an  adequate              and  Takayanagi,"  Currie   et   all'   re-
                    matic  condition.  However,   the   diffu-                trial at this dosage. Although it is dif-              ported  in  1971  that  human  muscle   ho-
                    sion capacity  did  not  change,  and  ra-                ficult to evaluate the  effectiveness  of              mogenates  will  cause  blastic   transfor-
                    diologic   improvement   was    equivocal.                corticosteroids  in  this   setting,   it              mation   in   lymphocytes   from   patients
                    It  was  our  distinct   impression   that                seems certain that a trial  at  high-dos-              with  polymyositis  but  not  in  controls.
                    this  patient  continued  to   deteriorate                age  levels  is  warranted.  Recent   re-              Also,  these   same   lymphocytes   destroy
                    while receiving 40  and  60  mg  of  pred-                p6rts'l-1-5   suggest   immunosuppressive              human  muscle  cells  in  tissue  cu  ture.
                    nisone  daily,  and  then  quickly  had  a                drugs will be found  efficacious  in  pa-              If  these   considerations   of   pathogen-
                    subjective   symptomatic   response    af-                tients   with   steroid-resistant   poly-              esis   of   polymyositis   are   confirmed,
                    ter being  placed  on  a  regimen  of  100                myositis,                                              the  response  of  patients   to   cortico-
                    mg  daily.   One   may   argue,   however,                 The response  of  polymyositis  to  cor-              steroids    and    other     immunosuppres-
                    that   improvement   started   with    the                ticosteroids    and     immunosuppressive              sive  agents  would  be  more  easily   un-
                    lower   dosage.   This   subjective    im-                agents is not surprising in view  of  re-              derstood.
                    provement  was  soon   followed   by   ob-                cent  work  studying   _the,.etiolog@'-of
                    jective   improvement   as   muscle    en-                this  prob_l@.  --P-6lymyositis  is   now
                    zyme    levels    and    vital    capacity                -                ked  with  the   connective-             This  investigation  was  supported  in  part   by
                    returned toward normal.                                   t                es  for   several   indirect          Public Health Service grant AI-00028.

                                                                                                References
                                          ews  WH:   Interstitial   pneu-      7. Turiaf J,  Bas@et  F:  Les  fibroses  pulmonary    Polymyositis.   Arch    Intern    Med    114:263-277,
                    r                       yositis.    JAMA    160:1467-     interstitelles diffuses des  collagenoses.  Pneumon    1964.
                                                                              Coeur 12:663-681, 1965.                                   14.   Malaviya   AN,   Many   A,   Schwartz    RS:
                      2. Goldfischer J,     bin   EH:    Derrnatomyositis      8.   Sandbank   M,    frunebaum    M,    Katzenel-    Treatment    of    dermatomyositis    with     Metho-
                    with  pulmonary  lesions.  Ann  Intern  Med   50:194-     lenbagen   I:   Dermafpmyositis   associated   with    trexate. Lancet 2:485-488 1968.
                    206, 1959@                                                subacute  pulmonary  fibrosis.  Arch  Derm  94:432-       15.  Sokoloff  MC,  Goldberg   LS,   Pearson   CM:
                      3.  Hyun   BH,   Diggs   CL,   Tione   EC:   Derma-     435, 1966.                                             Treatment   of   corticosteroid    resistant    poly-
                    tomyositis with  cystic  fibrosis  (honeycombing)  of      9.  Weaver  AL,  BrundAge  BH,   Nelson   RA,   et    myositis   with   methotrexate.    Lancet    1:14-16,
                    the lung' @ Chest 42:449-463, 1962.                       al: Pulmonary  involvement  in  polymyositis-.  Re-    1971.
                      4.  Pace  WR,   Decker   JL,   Martin   CJ:   Poly-     port of a  case  with  respqnse  to  corticosteroid       16.  Dawkins  RL:   Experimental   myosins   asso-
                    myositis: Report of two @es with            pulmonary     therapy. Arth Rheum 11:760-773, 1968.                  ciated  with  hypersensitivity  to  muscle.  J   Path
                    function  studies  suggestive  of  progressive   sys-      10. Rubin EH, Siegelman  $S'  The  lungs  in  sys-    Bact 90:619-625, 19656
                    temic  sclerosis.  Amer  J   Med   Sci   245:322-332,     temic  diseases,  Springfieldi   III,   Charles   C       17.  Takayanagi  T:   Immunological   studies   of
                    1963.                                                     Thomas, p 100@ 1969.                                   experimental  myosins  in  relation  to  human  poly-
                      5.   Hepper   NGG,   Ferguson   RH,    Howard    FM      11.  Thompson  PL,  Mackay   14:   Fibrosing   al-    myositis.  Folia   Psohiat   Neurol   Japan   21:117-
                    Jr.  Three  types   of   pulmonary   involvement   in     veolitis  and  polymyositis.   Thorax   25:504-507,    127, 1967.
                    polymyositis@   Med   Clin   N   Amer   48:1031-1042,     1970.                                                     18. Currie  S.  Saunders  M,  Knowles  M,  et  al:
                    1964.                                                      12. Pearson  CM:  Patterns  of  polymylositis  and    Immunological  aspects  of  polymyositis.   Quart   J
                      6.  Garcia  EH,  Toledo  A:  Manifestaciones   pul-     their  responses  to  treatment.  Ann  Inte,@   Med    Med 40:63-84, 1971.
                    monares  en  an  ewo  de   dermatomyositis   en   al-     59:827-838, 1963.                          1 @',
                    nino. Medico 13:43-47, 1964.                               13 Vignos PJ, Bowling GF, Wat                )d@P,
                                                                                                                      kins

                    JAMA, Nov 27, 1979 * Vol 222, No 9                                                                              Pulmonary Fibrosis-Webb & Currie                  1149


                    high  retentions  and  exorbitant   prof-      judge priorities, and achieve  both  bet-          Basic Issues Underlying
                    its;  that   prepayment   and   insurance      ter access  and  higher  productivity  in               Current Debate
                    fail to provide coverage  for  the  poor;      the field.
                    and   that   prepayment   and   insurance      Third,  it  is  equally  essential   that     The  second   essential,   after   estab-
                    exert  no  influence  over  providers  in      we gain  a  broad  understanding  of  the     lishing a basic philosophy, is  to  iden-
                    the,area of  costs,  but  merely  act  as      public  policy  framework  within   which     tify  the  underlying  issues  that   are
                    conduits  of   money   from   subscribers      we want  to  operate,  and  that  we  es-     not  always  apparent  in   public   dia-
                    and policyholders to providers.                tablish  clear   programs   within   that     logue.  I  want  to  mention  a  few   of
                    From   those   and   many   other   e-om-      framework.                                    them.
                    ments  and  criticisms  heard  from   ev-      I  should  now  like  to  cover  each  of     At  the  outset,  we   have   to   return
                    ery side,.it is apparent that the  health      those three considerations.                   to   a   fundamental   economic    truth:
                    field is restlessly  in  transition.  The                                                    Health  is  a  unique  market.  If  there
                    future is not in  sharp  focus.  The  di-       A Philosophy of Health Care                  were any doubt about  it,  we  proved  it
                    rection is not carefully  laid.  New  is-      First, the  matter  of  an  overall  phi-     in  1966.  Medicare  and  Medicaid   made
                    sues-many   of   them    directly    con-      losophy. Without  fanfare,  such  a  phi-     it clear  that  we  cannot  solve  health
                    tradictory-are   raised   almost    every      losophy has been  jelling  in  the  midst     problems   by   merely   spending    more
                    day. Bad news  about  the  field  heavily      of the debate over  national  health  in-     money.   Increased   demand    can    and
                    overshadows the good news.                     surance.  The   following   points   have     did produce substantial in'flation.
                    It is important that  all  of  us  recog-      come to light  and  have  received  wide-     It is true that the  health  field,  with
                    nize those issues and criticisms. But  it      spread  acceptance  inside  and   outside     its  large  labor  component,  is   pecu-
                    is  even  more  important  to   recognize      the health field:                             liarly vulnerable to the  forces  of  in-
                    that they are not the basic  issues  fac-      *  No  individual  should   be   deprived     flation-as are  all  service  industries.
                    ing   voluntary   hospitals   and    pre-      of health  care  simply  because  of  his     But complicating this is  the  fact  that
                    payment plans.                                 inability to pay for it.                      the basic supply  and  demand  forces  of
                    Furthermore,  they   do   not   represent      o  Every  person,   regardless   of   his     the classic market  are  weak,  or  apply
                    the key to the  future.  Solving  all  of      circumstances,  should  be  able  to  re-     unevenly.  Thus,   quality,   efficiency,
                    the  problems   raised,   and   answering      e-eive high quality care, and receive  it     and  effectiveness  do  not   materialize
                    all of the  criticisms  made  against  us      with dignity.                                 in the  ordinary  course  of  events  be-
                    will not guarantee  the  kind  of  future      *  Families  should  not  suffer   finan-     tween   purchasers   and   providers   of
                    all of us want to see.                         cial deprivation because of illness.          service.  They  must  be  built  in.  How
                    The   things   I   have   been    talking      o   Systems   must   be   responsive   to     that can  be  done  is  a  major  manage-
                    about are  symptoms.  They  are  not  ba-      changes  in  medical  science  and   man-     ment  challenge,  and  the  answer   will
                    sic illnesses. If we in the health  field                                                    not be found easily.
                    use  up  our  time  responding  to   each      agement  knowledge,   not   freeze   past     A  second  underlying   force   is   that
                                                                   or present practices.
                    one,  then  our  field  will  drift  more                                         I          health is caught up  in  a  raging  revo-
                                                                   0  Financing  should  be  linked  to  ae-     I ..
                    than  before;  will   become   more   ex-                                                    iution  of  rising  expectations.  Seeing
                    pedient-oriented;  will  fragment  itself      iivery  to  achieve  greater   effective-     that more can be done, people  first  ex-
                                                                   ness and efficiency  within  the  system.
                    further, and eventually  find  itself  at      o  Programs  of  financing   and   deliv-     pect  more.  Then   they   demand   more.
                    war with its own elements.                                                                   Consequently,  new  social   policy   may
                    The  assaults  from  outside  are   inevi      ery should be easy to administer.
                                                                                                                 help solve the problem  as  it  is  today
                    table,  and  with  them  the   contradic-      o  Programs  must  be  so   designed   as     but at the  same  time  may  well  change
                    tions. But there is no reason for  us  to      to be  acceptable  to  professionals  and     and expand the problem itselL
                    accept all  of  them  as  gospel  and  to      to the people as well.
                                                                                                                 It  has  been  pointed  out   that   Swe-
                    permit ourselves  to  be  pushed  to  and      9   Physicians    and    other    profes-     den-with  a  more   moderate   range   of
                    fro with every  change  of  direction  of      sionals must be  motivated  by  the  sys-     social   problems   than    the    United
                    our critics.                                   tem to work within  the  system,  and  to     States-has  a  tax  budget  which   takes
                    Instead,  if  we  truly  accept   respon-      accept  and  respect   leadership   other     inIore  than  40%  of  the  gross   national
                    sibility for the financing  and  delivery      than   their   own   in   many    circum-     product.  And  new  items  are   emerging
                    Of health care services, if  we  want  to      stances.                                      that will raise  the  percentage  higher.
                    be positive, if  we  want  to  give  some      o  There  must  be  a   reasonable   plu-     For  example,  only  a  small  proportion
                    predictability  to  the  1970s  and   the      ralism-a  diversity  of  methods  of  de-     of  the  population  goes  on  to  higher
                    ears  bevond.  then  we  must  meet  eer-      livering,   receiving,   and    financing     education,  and  housing  is   in   short
                    y
                    tain basic conditions:                         health care.                                  supply.
                    First, it is essential  that  we  develop      Before I go  on,  I  would  like  you  to     The  point  is  made  to  indicate   that
                    and  embrace  a  basic   philosophy   re-      answer, silently,  whether  you  as  phy-     even  under  higher  taxes,  social   de-
                    garding the  delivery  and  financing  of      sicians  can  accept  those   points   of     mands  would   continue   to   press   on
                    health care.                                   view.                                         public   resources-especially   in    the
                    Second,  it  is  essential  that  we  un-      Even   though   many   of   those   ideas     face  of  growing   pressure   for   eco-
                    derstand  the  real  -issues   underlying      are  general,  and  all  are  not  unani-     nomic  as  well  as  political  equality.
                    the  events  that  take  place.   Without      mously  accepted,  they  represent  prog-     That   realization   brings   us   firmly
                    such an   understanding,   we   lack   refer-  ress  and  a  significant  momentum  that     against the fact,  of  limited  resources
                    ence  points  by  which  to  set   goals,      should not and cannot be ignored.             and a need for hard priorities.
                    JAMA, Nov 27, 1972 o Vol 222, No 9                                                                 Health Care-McNerney           1151


             A  third   underlying   consideration   is   way or it cannot help him.                    mented  in  adding  one  piece  of  legisla-
           the    increasingly    important-and    usu-     The  fourth  underlying  issue   is   the   tion  onto  another  in  response  to  vari-
           ally   ignored-questio'n:   What   is    the   relationship of  private  and  public  sec-   ous    interests-such    as    Comprehensive
           relation,  if  any,  between   health   ser-   tors.  The   two   are   working   together   Health    Planning,     Regional     Medical
           vices  and   the   health   of   the   popu-   now,  but  only   awkwardly.   (The   mate-   Programs, Hill-Burton, an           o
           lation?                                        rial  from   this   section   [relationship                      criticize   weak    state
             That  is  a  tough  relationship  to   un-   of  public  and  private   sectors]   draws   regulation   of   health   prepayment    and
           ravel.  We  do  know   that   in   countries   on  testimony  by  me   before   the   Com-   insurance,   let   us   recall   that    the
           where   infectious   diseases   no    longer   mittee    on    Ways    and    Means,    US   McCarran Act is a federal law.
           predominate   as   the   causes   of   death   House   of    Representatives,    Nov    1,      Little  is  gained   from   viewing   the
           (the    United    States,    for    example,   1971.)  Unfortunately,  too  much  of   the   problems   of   health   care    from    the
           where they are  only  one  of  the  top  ten   current  debate   about   national   health   single   vantage   point   of   either   the
           causes), it is difficult  to  demonstrate  a   insurance  tends   to   set   the   govern-   public  or  the  private  sector.  Both  are
                                   between        long-   ment and private sectors agai                 needed. Each has its stren
           strong  relationship                                                            nst    one                                  gths      and
           evity  and  the  amount  spent   on   health   another  in   regard   to   both   delivery   weaknesses.  It  is   time   we   got   away
           services.  The   amount   spent   can   vary   and financing  of  care.  Our  fo'cus  must   from   name-calling   and   down   to    the
           as  much  as  1009'o,  yet   longevity   can   be  on  results,   on   what   works.   The   business    of    solving    problems     by
           vary only from 5% to 10%.                      public  has  been   the   object   of   too   strengthening   both   sectors   and    tak-
             The  question  appears   to   be   whether   many    unfulfilled    promises    already-   ing  full  advantage  of  each  one's  capa-
           the  solution  lies  in   expanding   tradi-   from  both  sides.  Now  we  need  to   let   bilities.
           tional  health   care   (malting   more   of   everybody  know  how   things   can   real-      The  health  field  is  deeply   imbedded
           the   same   available   to   everyone    at   ly be.                                        in  many  subjective,  as  well  as   objec-
           lower  cost),  or  in   taking   a   broader     We  have  all  heard  attempts  to   dis-   tive,  issues,  and   is   enmeshed   in   a
           ecological view of health.                     credit  private   prepayment   and   insur-   strong  tradition  of  professionalism.   It
             It  is  worth  noting  that  in  1951  un-   ance  in  justifying   the   need   for   a   demands   an   unusual   degree   of    both
           der  the  British   National   Health   Ser-   totally    federal    financing     system.   sophistication   and    flexible    adminis-
           vice in Scotland,  there  was  a  300%  dif-   However,  our   current   health   problems   tration.   A   monolithic   posture    would
           ference   in   infant    mortality    ratios   cannot  be  that  easily  simplified.  They   strain  the  political  bonds  of  the  sys-
           between  the  highest  and   lowest   social   result  from  the  interplay  of  strengths   tem,  if  not  its   administrative   struc-
           classes. In  1969,  after  the  maturing  of   and   weaknesses   throughout   the    sys-   ture  as  a  whole.  In   another   posture,
           the  national   health   service   and   the   tem,   involving   both    sectors.    Both   however, the system could flourish.
           enactment   of   substantial   social   wel-   have  strengths.  And   both   have   weak-      It  is  government  that  can  best   set
           fare  programs,  there  was  still  a   266%   nesses,   which   have   become   apparent.   national  goals,  set   important   resource
           differential.                                    The  private  sector,  for  example,  has   priorities,  monitor  and   regulate   over-
             The  answer  seems  to  be   that   impor-   been  slow  to  develop  delivery   systems   all    performance,    and    protect    the
           tant  factors  in  health  lie  outside  the   such   as   health   maintenance    organi-   rights  of  all  citizens  through  constant
           traditional  boundaries  of   health   care.   zations   (HMOs)   designed   to    deliver   pursuit of social justice.
           If  we   are   to   -avoid   spending   huge   comprehensive   care   to   defined   popu-      The   private    sector    cannot    come
           sums    of    money    unproductively,    we   lations,  with  heavy  accent  on   primary   close  to  meeting  the  health   needs   of
           must  attack   factors   such   as   income,   care.   Areawide    planning    has    been   the   country   without    strong    govern-
           housing,    nutrition,     and     education   slow  to   develop.   Carriers   have   not   ment     leadership     and     involvement.
           along   with   improving    actual    health   monitored  use   of   services   as   ener-   And,   parenthetically,   do   you    accept
           care services. It is only  in  such  an  ap-   getically as they should have.                that  concept?  I  think  acceptance  of  it
           proach  to  total  health  that   we   shall     But  the  public  sector  also  must  ac-   is  mandatory  if  the  private  and  public
           find  the  answers   to   health   problems.   cept its share of  the  responsibility  for   sectors  are  truly  to  work  together  ef-
             Unfortunately,   this   whole   issue   is   the problems as  well  as  of  the  glories   fectively to get  done  the  job  that  nei-
           surrounded    by    some    very     popular   of considerable accomplishments.              ther can do alone.
           myths. For example.                              The  excess  number  of  costly  beds  in      Equally   important   is   the    accept@
             o   The    greater    the    technology'of   some   sections   of   the   country    and   ance  by  government  of  the   talents   of
           care, the  better  the  care  provided.  Ac-   overpreoccupation      with       inpatient   the   private   sector,   which   can   best
           tually, some of  the  best  health  care  is   care  @  relate.  to  the  enthusiasm  with   provide   managerial    ability,    diversi-
           simply   primary   care   received   by    a   which  public  programs  met   bed   short-   ty,  and  a   capacity   to   innovate   and
           person  who  stays  close  to  his   family.   ages  by  equating   better   health   care   change.  The   private   sector   can   meet
                                                                                                                                       essive   con-
                Increasing   the    number    of    MDs   with  bricks   and   mortar.   Failure   to   accountabilities so that eicc   '
           will   automatically   improve   the    unit   control  costs  and  restructure  the   de-   servatism  does  not  result;  and  it   can
           cost  and   productivity   of   the   field.   livery of care  can  be  seen  in  Medicare   be  a  guard  against  the  restricted,   or
           There  is  no  evidence  so  far  to   prove   and Medicaid as  clearly  as  they  can  in   restrictive, budgets of government.
           that contention.                               private financing programs.                      Whatever   the   nature   of   the   pri-
             o   And   in   some   glorious   millenni-     If the  private  sector  has  been  frag-   vate-public    relationship,    we    should
           um, all  health  care  must  be  coordinated   mented  in  response   to   myriad   neigh-   not  expect  it  to  be  mutually   uncriti-
           by  a  controlling  system.  Actually,   the   borhood   and    local    pressures,    the   cal.  Ideally,  it  should  involve   honest
           patient   must   meet   any   system   half-   government   has   been    equally    frag-   adversary    relations.    Progress     will
           1152     JAMA, Nov 27, 1972  o  Vol  222,  No  9                                                                 Health     Care-McNerney


                  come  from  a   frank   admission   of   dif-        Students    demonstrating    for    more    Need    for    Public    Policy    Framework
                  ferences  rather   than   a   pretense   that   power   in   running   their   high   schools
                  there   are    none.    There    should    be   and colleges.                                      The  shadow   of   national   health   in-
                  healthy   conflicts   of   ideas,    methods,      *   Teenagers   seeking    sexual    free-    surance,    which    grows    longer     and
                  and  perceived   needs   reflecting   differ-   dom.                                             touches  more  of  us  every   day,   brings
                  ent points of view.                                9   Younger    children    seeking    more    into sharp focus  the  need  for  a  pub  ic
                    The     Medicare      contract      between   equality in the family.                          policy   framework   and   careful   consid-
                  Blue   Cross   and   the   Social    Security      9   Women    demanding    equality    with    eration  of  programs  to  be  carried   out
                  Administration    (SSA)    is     an     out-   men.                                             within that framework.
                  standing    example    of    the     dynamics      o    Patients    wanting     decision-mak-      National    health    insurance     itself
                  that  can  be  developed  to   get   a   huge   ing powers over their physicians.                can  be  divided  into  two   major   parts-
                  job   well   done.    Differing    viewpoints      *    Consumers    wanting    more    power    the    framework    and    the     programs.
                  clearly  stand   out   during   current   ne-   over   what    products    are    made    and    With  regard   to   the   framework,   three
                  gotiations   on   a   new    Medicare    con-   sold.                                            patterns   are   emerging:   (1)    Building
                  tract:                                             The   movement    is    affecting    every    more  incentive  into   the   present   sys-
                    On  its  part,   the   SSA   wants   exten-   institution-profit   and   nonprofit,    pri-    tem  (such   as   the   proposals   of   the
                  sive   prior   approval   rights   on    con-   vate   and   governmental.   It   cannot   be    American     Medical     Association     and
                  tractor  expenses   and   wants   the   right   ignored.  And   it   is   moving   more   and    the    commercial    insurance    industry).
                  to   change   the   contract    during    its   more  into  the   health   field   as   young    (2)   Moderated   pluralism,   with    vary-
                  term.  In  effect,  in   other   words,   the   citizens cite health  care  as  a  right  and    ing  approaches  to   varying   needs   (the
                  SSA   wants   to    manage    the    contract   demand   that   medicine   become   a    pub-    Byrnes   proposal).   (3)   Public   utility
                  functions rather than the contract.             lic service. It must be incorporated.            (exemplified   with   respect   to   financ-
                    On  its  own  part,  the  Blue  Cross   As-      Our   response    to    the    consumerism    ing  by  the  Kennedy  bill;  with   respect
                  sociation    wants    the    government    to   movement  is   one   of   the   most   impor-    to delivery by the Ullman bill).
                  set  goals,   to   establish   expected   re-   tant   issues   we   face   in   the   months      The first seems to be  osing
                  sults,   and   to   define   standards    and   ahead.                                           because  it  lacks  the  power  to   improve
                  guidelines   by   which    the    implementa-      Number   six   of   the   underlying   is-    access  or  productivity  and   because   it
                  tion  of  the   contract   can   be   judged.   sues  is   profit   vs   nonprofit   in   the    avoids  some  of  the  real  issues.  I  can
                  However,  our   view   is   that   the   con-   health  field.  Which  way  should   we   go?    foresee   a   day   when   the   AMA    will
                  tractor   must   manage    the    job,    and   The health field is  filled  with  19th  cen-    move  its  position  away  from  its   pres-
                  have   a   decent   term   of   contract   in   tury    idealists    who    proclaim     that    ent  proposal  toward  a   more   far-reach-
                  which to do its whole job.                      profit has  no  place  in  it.  At  the  same    ing program.
                    The   final   results-the    signed    con-   time,  the  more  pragmatic  see   a   short-      Regarding  the  other  two,   hard   deci-
                  tract-should   prove   to   be   an    inter-   age  of  capital  for   building   facilities    sions must be made.
                  esting  example  of  just   how   well   pri-   and   increasing   the   numbers   of    ser-      The  public  utility  approach   has   its
                  vate  and  public  sectors  can  mesh   their   vices  needed  to  provide   more   care   to    advantages   and   disadvantages.   In   its
                  efforts.                                        more people than ever before.                    favor is  the  fact  that  we.see  it  work-
                    Having   listed   four    underlying    is-      Finally, there  is  the  issue  of  compe-    ing  well  in  the  telephone,  water,   and
                  sues  in  the   health   debate-the   unique-   tition-of     jockeying     for     position-    electric  fields;  that  it  can  provide  a
                  ness of  health  as  a  market,  the  revolu-   among    physicians,    hospitals,    govern-    high   level   of   access,   with   minimum
                  tion  of  rising  public  expectations,   the   ment   agencies,   and    private    carriers    standards  for   participation;   and   that
                  relationship    between    health    services   for  definition  of  their  roles  and  their    it  can  reduce  wasteful   competition   by
                  and  the  health  of  the   population,   and   responsibilities,  as  well   as   of   their    eliminating  overlap.   Against   it,   how-
                  the   relationship   between    public    and   privileges, in the total field.                  ever, is the fact that  it  can  be  a  cap-
                  private  sectors-I   have   three   more   to      Some   promote   HMOs   and   some    pro-    tive  of  its  own  constituents   and   de-
                  cover only briefly.                             test   them.    Some    favor    Professional    tailed   regulations.   Those    regulations
                    The   fifth   is   the   issue   of    con-   Standards      Review       Organization-type    cover  such  areas   as   exclusionary   li-
                  sumerism.  We   see   the   effect   of   the   plans   and    others    vigorously    oppose    censing,   franchising,    proper    financ-
                  consumer    movement    in    newly    shaped   them. What it  all  boils  down  to  is  that    ing,  and   the   complications   of   regu-
                  governing   boards   of   the   Blue    Cross   each  of  us-as  an  individual  or   as   an    lating the resulting monopolies. Su
                  plans,  in  hospital  boards,  in   the   ap-   institution-is     protecting     his     own    a system  in  the  health  field  could  bog
                  pointment   of   ombudsmen,   and   in    the   turf,    and    demanding    "no     trespas-    down.
                  wider   establishment   of   area    planning   sing" by the others.                               In   its    favor,    moderated    plural-
                  boards.  We  also  see  its  etTect  through-      We   must   face   these    controversies,    ism   can   have   a   greater   orientation
                  out the economy.                                and  we  must  negotiate  our  way   out   of    toward goals, make  full  use  of  the  pri-
                    Since  the  early   50s,   we   have   seen   them  if  we  are  to  succeed  in   building    vate sector  as  well  as  the  public  sec-
                  life, liberty, and  the  'pursuit  of  happi-   and  maintaining  a   strong   private   sec-    tor,  capitalize  on  what  each  one   does
                  ness   joined   by   demands   for    greater   tor.  If  we  spend  our  time  shooting   at    best,  and  provide  options  both  to   the
                  equality  in  other  areas   by   those   who   one  another  in  our   little   battles   of    public  and  to  professionals.   It   tends
                  have been less than equal:                      selfishness,  we   leave   the   field   wide    to focus  on  results  more  than  on  tech-
                    *  Blacks  agitating  for   racial   equal-   open   for   occupation   by    others    who    niques,  using  the  contract  as  a  device
                  ity.                                            might prove to  be  enemies  of  all  of  us.    for  getting  the  job  done.  And  it  more
                  JAMA, Nov 27, 1972 a Vol 222, No 9                                                                          Health Care-McNerney         1153


           neatly  fits   into   complex   situations   matter-let  me   give   you   some   views   will   be   required   within   the   HMO's
           and  services,  offering  consumer  choice   on  the  kinds  of  programs   that   must   subscriber  area?  It  appears   now   that
           among   controlled   alternatives   rather   be carried out. I  want  to  mention  only   we  will  follow  the  path  of  reasonable
           than  a  bureaucracy  or  the   wellspring   six.                                         flexibility  rather   than   rigid   ortho-
           of   innovation    and    adaptation    to     First  is   reimbursement.   There   are   doxy, desirably if not inevitably.
           changing   environments.   On   the    mi-   many  different  forms  now  in  use,  and      Fourth is peer  review,  which  is  best
           nus side, it can involve  excessive  over-   active   experiments   are   underway   to   illustrated,  perhaps,  by  the  growth  of
           lap and  fragmentation;  and  it  is  less   devise  newer   and   better   ones.   The   medical foundations.  It  certainly  is  in
           geared  to   the   guarantee   of   access   consensus  seems  to  be  that   providers   the interests of  medical  societies,  spe-
           than the public utility form.                must begin sharing  financial  risk  to  a   cialty  societies,  and  the  AMA  to   de-
            Difficult   decisions   must   be   made,   larger   extent,   rather   than    simply   velop   workable   standards   and   bound-
           and  they  must  be  made  with  one  car-   being  paid  for  whatever  services  they   aries  for   these   programs.   The   con-
           dinal  principle  in  mind:  The   choices   provide, regardless of cost.                 flicts  that  now  exist  regarding   rela-
           must be'tailored to the  field  of  health     We   will   see   more   experimentation   tive  roles   among   foundations,   hospi-
           care.  Concepts  and  ideas  can   neither   and  more   evaluation   of   systems   of   tals,  and   carriers   must   be   settled
           be  uncritically  adopted  nor   automati-   reimbursement,  with   some   states   go-   amicably   and    effectively    so    that
           @lly   rejected    because    they    have   i-ng one  way  on  regulation,  and  other   whatever is  the  best  kind  of  peer  re-
           proved  successful  or   unsuccessful   in   states  or  the  federal  government   go-   view   organization   approach    can    be
           other areas. The health field  is  -not  a   ing  another.   National   health   insur-   utilized for the benefit  of  the  nation's
           port  authority;  it  is   not   a   tele-   ance  will  undoubtedly   lead   to   more   people.    Whereas    areawide    physician
           communications  industry;  it  is  not   a   unity  of  method,  but  how  much   unity   groups  can  contribute  significantly   to
           Tennessee    Valley    Authority.    While   is a  question  that  remains  to  be  an-   better   quality   and   utilization,    we
           franchisement   of    health    facilities   swered. Clearly,  there  is  a  danger  in   don't need  a  duplication  of  claims  ad-
           may  have  merit,  territorial   exclusiv-   settling  on  one.  The  ultimate  valida-   ministration,  electronic   data   process-
           ity  may  or  may  not.   More   energetic   tion   of   any   method   is   comparison   ing   capacity,   and   other   well-estab-
           regulation   of    financing    mechanisms   with another method.                         lished mechanisms.
            for     example,      Blue      Cross-may     Second is benefits.@  Here    we    must      Fifth  is   areawide   planning,   which
           strengthen   the   market   without    de-   put  a  greater  accent  on  primary  care   hardly   needs   any   remarks   from   me.
           stroying  its  resolve-with   or   without   and  unrestricted  choice  to  avoid   ex-   The  ultimate   approach   to   this   pro-
           line-by-line regulation of providers.        cessive use of expensive  acute  care  fa-   gram  must  make  the  best  possible   use
             During  the  months   ahead,   the   is-   cilities and services.                       of  our  present  capital  structure,   and
           sues  must  be  debated  among  the   best     Third  is   the   HMO.   There   is   no   at  the  same  time  bring  some  kind   of
           minds  available-both  inside   and   out-   stampede  toward   the   group   practice,   order  out  of  the   present.   chaos   by
           side  the  field  of  health  care.   Cur-   prepaid  approach  to  primary   and   all   addressing   itself   to    manpower    and
           rently,  major  forces  seem  to  favor  a   other health care, but its  use  is  slow-   the  market  as  well  as  to  bricks   and
           compromise   between   the   two   schools   ly  growing.  The  -Congress   is   moving   mortar.
           of  public  utility  or  pluralistic   ap-   toward a practical bill to facilitate  its      Sixth  and  last  is  the  question  re-
           proa:ches.  What  finally   happens   will   growth.  The   American   Hospital   Asso-   garding   the   efficacy   of    preventive
           depend to a  significant  extent  on  your   ciation  and  the  Blue   Cross   Associa-   medicine  and   health   education.   Crit-
           collective-your   unified,   clearly   de-   tion  are  working  together  to   develop   icizing  either  of  these   concepts,   no
           signed, and clearly stated-resolve.          this kind  of  alternative  benefit.  Blue   matter  how  gently,   is   tantamount   to
             In  any  event,  HEW   must   be   reor-   Cross  now   has   13   operational   HMOs   kicking  the  sacred  cow  off  the   side-
           ganized  to   give   leadership   in   the   and  will  have  30  by  the  end  of  the   walk.  But  both  need  to  be  looked   at
           areas  of  both  delivery   and   finance.   year. By 1980 it  is  doubtful  that  more   carefully.    Many    people     apparently
           Areawide  planning   must   be   strength-   than 20% to 40% of  the  market  will  in-   are beginning to see  that  health  is  re-
           ened.  And  the  market  must   be   freed   volve HMO  services,  but  it  is  an  es-   lated deeply to life-style  and  the  envi-
           of  constraints  placed  upon  it  now  by   sential option to offer  the  consumer  if   ronment.   Emphasis   in   some    quarters
           r,mtrictive licensure  laws,  group  prac-   productivity is  to  be  achieved  reason-   has  happily  begun   to   shift   from   a
           tice laws, and the like.                     ably close to the  point  of  care  rather   focus   on   more   physicians   and   more
             Given  a  framework  within   which   to   than at some distant point.                  hospitals to  a  focus  on  a  better  gen-
           operate  under  national   health   insur-     There  are  many  factors  to  be   con-   eral life, a  realization  of  rights,  and
           ance,  effectiveness  will   be   achieved   sidered  in   the   formulation   of   HMO   an  interest  in   protecting   one's   own
           only  through  carefully  conceived   pro-   legislation,  including  these:  How  com-   health.
           grams   expertly    camed    out.    Natu-   prehensive  should  benefits  be  to   the      The   track   record   for   both   pre-
           rally,  the  programs  would  change   ac-   subscriber?  Should  rates  be  based   on   ventive   medicine   and   health    educa-
           cording to the framework.                    community    or     experience     rating?   tion  has  been  poor  so   far,   although
                    Important Programs                  What   kind   of   payments   should    be   undertaken   with   enthusiasm    in    se-
                     in Any Framework                   made   to   professionals   within   HMOs?   lected  instances  by   hospitals,   carri-
                                                        Should  they  be  profit  or   'nonprofit?   ers,  schools,  medical  associations,  and
             Keeping in mind that we         do   not   What  quality  of  care  should   be   the   others.
           have  all  of  the   answers-nor   do   we   minimum,  and  how   will   it   best   be      We  shall  see   renewed   interest   in
           know  all  of  the  questions,  for   that   evaluated?  What   breadth   of   services   programs  in  this  area  sparked  by  rec-
           1154    JAMA, Nov 27, 1972 *  Vol  222,  No  9                                                                Health    Care-McNerney


                  ommendations     now     being      compiled    building the future.  If  I  were  to  list   control of a lesser empire.
                  by    the    President's    Committee     on    dos  and  don'ts,   I   would   list   them      o  Produce   the   mechanics   of   public
                  Health Education.                               roughly like this:                            relations  without  a   sound   product   be-
                     There   is   no   single    answer,    of    Do:                                           hind it.
                  course,  as  to  whether  any  given   tech-      9  Orient  programs   more   toward   the      o   Overreact.   Learn   to   spot    pos-
                  nique can  work.  The  only  possibility  is    public  than  has  been  the  case  in  the   turing  and   harassment   in   contrast   to
                  to   continue   to   experiment   and   then    past.                                         a really substantive issue.
                  evaluate.                                         o   Work   from   facts    rather    than      The  AMA  is   doing   things   well   to-
                                 Conclusion                       wishes, to a greater extent.                  day,   attempting   to   broaden   its   mem-
                                                                    o  Stay  close  to  your  own   area   of   bership   and   supporting    various    fed-
                     Heat  will  continue  on   the   subjects    competence-the   practice   of    medicine,   eral    programs.    But    your     ultimate
                  of  health  delivery   and   financing.   It    its  quality  and  its  essence.  Your  in-   strength   will   come   through   productiv-
                  will  come   from   consumers,   from   man-    tegrity  here  will   produce   the   right   ity,   not   through   vocalizing;    through
                  agement,    from    labor,     and-certainly    pressures  on  the   political   and   eco-   meeting   demonstrable   need,    not    gen-
                  not   least-from   government.    The    is-    nomic environment.                            erating your self-image.
                  sues  are   complex   and   are   not   ame-      o  Be  consistent.  Can  you   preach   a      The  AMA  must   learn   to   be   respon-
                  nable  to  easy  solutions.  In  trying   to    free  market,  yet  not  provide  wide   o@   sive  and  to  negotiate   well.   Busy   MDs
                  develop   our   own   solutions,   we   must    tions  in  methods  of  delivery?  Can  you   can't  address  all  complex  issues   effec-
                  learn  to  live  in  a  brilliantly  illumi-    say  that   only   physicians   can   judge   tively. The  real  key  is  the  spirit  that
                  nated goldfish bowl.                            their peers, yet say it is too difficult to   animates    the    organism    and     stimu-
                     Those of us  in  the  health  field  must    do?  Can  you  fight  proprietary   exploi-   lates   organized    medicine's    participa-
                  accept  the  fact  that  we  need  a  viable    tation  by   insurance   or   drug   compa-   tion in  a  series  of  public  policy  deci-
                  NHI   bill.   Not   that   we   should   ae-    nies, yet  sanction  conflict  of  interest   sions  that   will   involve   consumers   as
                  quiesee to  the  proposals  of  others,  but    within proprietary hospitals?                 well  as  providers  in  a   reasonably   so-
                  that  we  should  realize   that   piecemeal      9   Become   committed   to    participa-   phisticated   merger   of   specific   inter-
                  approaches   will   not   work.   A   middle    tion   in   hospital   management    rather   ests.
                  ground   between   the    extreme    propos-    than  taking  shots  from  the   sidelines.      In  my  view,  if   we   make   reasonable
                  als   now   before   the   Congress    holds      9  Make  sure   that   the   AMA,   state   responses  to  the  basic  issues  we   face,
                  promise  as  a  rallying   point   for   the    societies,    Association    of    American   there   will   be   ample   opportunity   for
                  sound   exploitation    of    the    massive    Medical  Colleges,   specialty   societies,   solo  as  well   as   group   practice,   for
                  skills  in  both  the  public  and   private    and   foundations   don't   become   widely   fee  schedules  as   well   as   per   capita
                  sectors.   Key   decisions   will    revolve    fragmented   and    antagonistic.    Devel-   payments,    for     various     arrangements
                  around:   how   much    public    and    how    op effective liaison to  reinforce  all  of   within    HMOs    and    similar    organiza-
                  much     private     sector     involvement?    them  and  give   them   direction   toward   tions.
                  What   framework   and   what   tools   will    a successful, broad end result.                  The  practicalities   of   financing   and
                  be available to us?                             Don't:                                        delivering  health  care  point   this   way.
                     The   AMA   and   its   constituent   so-      *   Be   fearful.   Support   what    you   Only an unthinking response won
                  cieties  have  a  key  role   to   play   in    really believe in, even  if  it  gives  you   make it different.

                                                                         .............
                     Astronomer    Sets    Basis     for     Scienti-        20 POSTA ROMANA              on    physiology,    zoology,    and    botany.
                                                                                                          Galileo    invented    a    crude     thermome-
                     fic    Method    for     Medicine.-The     works   I   Jill
                     and   thoughts   of    Galileo    Galilei    led                                     ter   or   thermoseope    about    1593,    and
                     to   a   more   scientific   approach   to   the   0                                 later   he   conceived   the   idea   of    us-
                     study    of    medicine.    Medicine    becayffe                                     ing his own pulse to test the
                     experimental     rather     than      philosophy                                     chronous    character    of    a     pendulum"s
                     ical-observations     and      the      scienti-                                     vibrations;  this   led   him   to   the   con-
                     fie   method   could   be   applied   to   medi-                                     verse    proposition    of    measuring     the
                     eine.                                                                                rate   and   :variation   of   the   pulse   by
                                                                               SALILM GAUIEI
                        Galileo   was   born    in    Pisa,    Italy,                                     a pendulum.
                     in  1564   and   is   reported   to   have   re-                                       He   died   in   Arcetri    near    Florence,
                     6eived   an   MD   degree   from   the   University   of    Pisa    Italy,   in   1642   and   has   been   honored   philatelically
                     in   1589.   Forsaking   medicine   for    science,    he    be-    as  a   great   scientist   of   the   Renaissance   by   Italy,
                     came   the    greatest    astronomer    of    his    time    and    Hungary,     Czechoslovakia,     Romania,     Russia,      Para-
                     was   a   staunch   supporter   of   the   work   of    Coperni-    guay,    Nigeria,    and    Panama.    The    Romanian     stamp
                     cus.                                                                (Scott  No.  1647)  was  issued  in  1964  on  the   400th   an-
                        His   physical   researches    had    a    great    influence    niversary  of  his  birth.-M.  A.  Shampo  and   R.   A.   ]Kyle

                  JAMA, Nov 27, 1972 o Vol 222, No 9                                                                       Health Care-McNerney          1155


                                                             dft

                maCPodantin,'F (nitrofurantoin macrocrystals)
                is kind (to youp patients)
                Keeps youp ipeatment whepe
                the ppohlem is ... aVoldS the
                ppohiemsoiovepipeatment
                N Anti bacteria 1 action conf 1 ned to one tract only ...
                the urinary tract
                0 High urinary and presumably renal medullary
                levels
                N Does not suppress normal bacterial flora else-
                                                                                       'c
                where in the bodyt..does not foster resistant flora
                in the bowel which may cycle reinfection
                Unique macpocr7stals
                imppove gastpointesonal tolemnce

                MACRODANTIN'     Prescribing     Information     (nitrofurontoin    contrciindicatedforinfantsunderonemonthandinpregnant                ESTABLISHED.   IT   SHOULD   NOT   BE   USED   IN    WOMEN    OF
                mcicrocrystals).                                                    patients at  term.  The  drug  should  not  be  administered  to    CHILDBEARING    POTENTIAL    UNLESS    THE     EXPECTED     BEN-
                IND  ICATIONS:   Macrodontin    (nitrofurantoin    macrocrystals)   persons who  hcive  shown  hypersensitivity  to  nitrofurantoin.    EFITS OUTWEIGH THE POSSIBLE HAZARDS.
                is indicated  for  the  treatment  of  pyelonephritis,  pyelitis    WARNINGS:   Macrodantin   may   cause   hemolytic   anemia    of    PRECAUTIONS:  Peripheral  neuropathy  may  occur  A   fatal   ty
                and  cyst tis due to E. coli, enterococci, Staph.  aureus  or  a    the  primaquine  sensitivity  type,  apparently  linked   to   a    has  been  reported,  Predisposing  conditions  such  as   renal
                small  percentage  of  strains  of  Pseudomonas,   when   demon-    gluco@6-phosphcte    dehydrogenose    deficiency.    This    de-    impairment,    anemia,    diabetes,    electrolyte    imbalance,
                striated to be susceptible by in vitro  susceptibility  testing.    ficiency is found in 10 per cent  of  Negroes  and  in  a  small    vitamin  B  deficiency  and  debilitating  disease  may  enhance
                Also  for  treatment  of  such  infections  when  due  to   some    percentcige  of  ethnic  groups  of  Mediterranean   and   Near-    such occurrence.
                susceptible  strains  of  Klebsiello-Aerobocter   and   Proteus.    Eastern  origin.  Such  patients  should  be  observed   Closely    ADVERSE   REACTIONS:   Nclusea,   emesis   and   diarrhea    may
                It is not  indicated  for  the  treatment  of  associcted  renal    while  receiving  nitrofurcintoin.  Discontinue  the   drug   at    occur  reduction  in  dosage  may  alleviate   these   symptoms.
                cortical  or  perinephr  c  abscesses,  systemic  infections  or    any  sign  of  herrolysis.  Hemolysis  ceases   on   withdrawal.    Sensi;ization  appearing  as  cutaneous  eruptions  or  pruritus
                prostatitis, or in  any  genitourinary  tract  infections  other    Superinfections   may    occur,    most    commonly    due    to    has  occurred.  Hypersensitivity  reactions  resulting  in  non-
                than pyelonephritis, pyelitis and cystitis.                         Pseudomoncis.                                                       fatal   anaphylaxis,    angioedema,    pulmonary    infiltration
                CONTRAINDICATIONS:  Anuria,  oliguria   or   extensive   impair-    USAGE   IN   PREGNANCY:    THE    SAFETY    OF    NITROFURANTOIN    with  pleural  effusion  andeosinophilic  have  been   reported.
                menf of  rena  function  is  a  confraindication.  The  drug  is    DURING    PREGNANCY    AND    LACTATION     HAS     NOT     BEEN    Other possible reactions  are  chills,  fever,  jaundice,  asth-


               Vol. 287  No. 24           TECHNOLOGY AND HEALTH C;\IZL-NVIII'I'E E'I'Al,.                                          t223

                                                      SPECIAL ARTICLE

                                             TECHNOLOGY AND HEALTH CARE
                   KERR L. WHITE, M.D., JANE H. MURNAGHAN, B.A., AND CLIFTON R. GAUS, M.H.A., Sc.D.
               Abstract People's needs,  not  availability  of  technolo- widespread  adoption,  we  must  rigorously   test   and   eval-
               gy, should determine policies and priorities for its appli- uate  the  cost  effectiveness  and   acceptability   of   these
               cation in health services. Technology  can  improve  effi- applications.  Areas  offering  the   greatest   immediate   po-
               ciency and assist in  solution  of  problems,  but  cannot tential   for   technologic   applications    include    manage-
               "drive the system" or  cure  all  ills.  Fragmentation  of ment   information   systems    and    "do-it-yourself"    tests
               markets,  lack  of  organized  health-care  systems,   and and  devices  for   ambulatory   medical   care,   hospital-dis-
               absence of national policies  and  standards  are  serious charge    abstract    systems,    automation     of     commonly
               deterrents to  technologic  innovation.  To  avoid  costly performed   procedures   in   clinical    laboratories,    emer-
               failures, we should concentrate initially on  applications gency-care   systems   for   defined    populations,    restora-
               that reinforce services of demonstrated efficacy  and  af- tive  devices,  and  new   communications   media   for   health
               fect large  numbers  of  patients  and  providers.  Before education.
               IDESPREAD    interest,     discussion     and     advocacy      At least seven major  considerations  affect  the  choice
               W  of  aggressive  introduction   of   "technology"   into and  success  of   technologic   applications   in   the   imme-
               all aspects of the "health-care delivery system"  has  re- diate future.
               sulted in the establishment of no less than  nine  federal      The first is that health  care  is  not  a  manufacturing
               panels, task forces  and  committees  charged  with  exam-      industry, but  a  service  industry  in  which  the  per-
               ining the issues  involved.  Actual  and  anticipated  re-      sonal  aspects  are  valued,  and  health-care  organiza-
               ductions in the defense  and  aerospace  budgets  and  re-      tions  are  social  systems.  Technologic   methods   and
               sultant  unemployment  of   engineers,   the   Administra-      innovations should be  applied  to  health-services  sys-
               tion's interest  in  promoting  research  and  development      tems  not  because  these  methods  are   available   and
               in general to stimulate the economy  and  offset  the  un-      feasible, but because they  materially  assist  in  meet-
               favorable balance of  trade,  and  ur2ent  public  insist-      ing the needs and demands  of  people  for  health  care.
               ence that  we  improve  social-service  systems,  such  as      Technologic  innovations  that  do  not  serve   socially
               those  responsible  for  education,  housing,  transporta-      determined  ends  are  unlikely  to  contribute  much  of
               tion and  health,  have  all  contributed  to  making  the      practical  utility  and  can  add  substantially  to  the
               role  of  technology  in  medicine  an  important   public      costs of medical care.
               and professional issue. This concern is shared  by  virtu-      As  a  corollary  to  this  point,  the  needs  and   de-
               ally all industrialized countries.1.2                           mands of  people  must  be  specified  before  technolog-
               The purpose of  this  article  is  to  examine  the  imme-      ic  methods  can  be  successfully  employed.   Technolo-
               diate prospects in the United States for  large-scale  ap-        annot  solve   problems   that   require   other   mea-
                                                                               gy C
               placation of technology in the provision  of  health  ser-      sores such as the  creation  of  formal  health-care  or-
               vices.                                                          ganizations  with  defined  objectives.  Many   potential
               FACTORS AFFECTING THE USE OF TECHNOLOGY                         applications  of  technology  must  await  the   develop-
                                                                               ment of explicit  national  policies  and  standards  for
               At the  outset,  it  is  worth  examining  the  considera-      health services and the evolution of  centers  for  deci-
               tions and constraints that  should  guide  the  choice  of      sion-making  in  what  is   now   a   fragmented   indus-
               technologic applications in the field of  health  services      try.
               and determine the  direction  of  our  research-and-devel-      The  third  consideration  is  that   the   problems   we
               opment efforts. It is difficult to estimate how  much  ef-      tackle  initially  by  technology  should  affect   large
               fort and money has  been  invested  in  health-care  tech-      numbers  of  people  and  their   health   problems   and
               nology in the past decade  because  there  is  no  general      large  numbers  of  health  personnel  and   institutions
               agreement on the meaning of  the  term  itself.  But  even      rather than  events  affecting  few  people  and  provid-
               if we define health-care technology broadly  as  the  sys-      ers. There are a number of reasons for  using  this  cri-
               tematic application of the fruits of industrial, engineer-      terion': costs per episode of  illness,  health  problem,
               ing  and  communications  sciences  to  the  solution   of      or  person  cared  for  can  be  minimized  when   econo-
               practical problems in health care, it is fair to say  that      mics of scale and aggregation of  markets  exist;  skills
               progress has been disappointing and  success  stories  few      required to  achieve  established  standards  of  quality
               and far between.'  It  is  therefore  important  to  think      can  be  developed  and  maintained  when  large   batch-
               rather more closely about the generic  problems  of  tech-      es of services or products are  processed  by  technolog-
               nology and health care before  we  redouble  our  efforts.      ic  means;  changes  in  attitudes  and   behavior   that
                                                                               condition  the  applications  of  technology   are   most
               From the Department ofMedical Care and Hospitals, Johns Hopkins Uni- likely to occur  when  "critical  masses"  of  both  con-
               ver.sity School of Hygiene and Public Health, 6 1 @ N. Wolfe St., Baltimore, sumers and  providers  exist;  and  acceptance  of  tech-
               Md@ 21205. where reprint requests should be addressed to Dr. White. nologic  innovations  is  most   likely   when   accompa-


                  1224                                      THE NEW ENGLAND JOURNAL OF MEDICINE                                                  Dec.    14,1972

                    nied  by  increased  satisfaction  for  large  numbers  of             the  United  States  can  expect  to  benefit,  judging  from
                    providers and consumers.                                               available statistics on the  causes  of  admission.  Further-
                       Fourthly,  technology  can  and  should   be   used   to            more, the efficacy and cost effectiveness of these  units  in
                    enhance  efficiency  whenever  possible.  This  may   take             the total  scheme  of  care  for  cardiovascular  disease  is
                    the  form  of  economies  in  inputs  of  labor,  physical             being seriously questioned.' At this stage  it  is  virtually
                    capital   or,   perhaps    most    important,    expensive             impossible to retreat, and  it  may  be  that  the  hospitals
                    human skills.  However,  the  nature  and  extent  of  the             and  the  public  are  saddled  with  an  expensive  and  yet
                    proposed  savings  should  be  estimated   carefully   be-             frequently inappropriate mode of treatment.
                    fore   technologic   innovations   are   advocated.   Many                Multiphasic  screening  is  limited   by   our   knowledge
                    technologies  generate  new   and   unpredictable   costs,             of  the  efficacy  of  the  many  procedures  advocated.  Few
                    and  the  savings  can  prove  illusory.  Large   computer             have  been  adequately  field-tested  in  properly  designed,
                    systems,  for  example,  require  highly  skilled  person-             controlled clinical trials. One  critical  appraisal  of  the
                    nel  to  operate  and  maintain   the   systems,   back-up             evidence suggests  that  screening  is  worthwhile  for  only
                    systems in case of failure,  and  capital  funds  for  pe-             six  conditions:  dislocation  of  the  hip   and   phenylke-
                    riodic modernization.                                                  tonuria  in  neonates,  hearing  and  vision   in   children,
                       Fifthly, there is little hard scientific  evidence  that            and   rhesus   factors   and    bacteriuria    in    pregnant
                    many  of  our  medical  treatments,  regimens   and   pro-             women.' This  appraisal  is  based  on  the  availability  of
                    cedures are efficacious     . 5We  should   avoid   heavy   in-        adequate measuring instruments, scientific know                    ge
                    vestments  in  technology  that  automates  or   otherwise             of the  prognoses  for  patients  with  apparent  abnorma  i-
                    attempts  to  increase  the  efficiency  with   which   we             ties, and the existence of acceptable  and  effective  treat-
                    provide  services  of  dubious  efficacy  and  concentrate             ments  for  these  abnormalities.  Another  group  of  condi-
                    in  areas  where  the  underlying  methods  of   treatment             tions is  more  controversial:  carcinoma  of  the  bronchus,
                    have  been  demonstrated  to  prevent,   cure   and   ame-             carcinoma  of  the  breast,  carcinoma  of  the  cervix,  and
                    liorate disease.                                                       bronchitis.  Clearly,  much  research   and   evaluation   is
                       Sixthly,  technologic  applications  should   be   advo-            required  before  multiphasic  screening  clinics  are  wide-
                    cated  on  the  basis  of  evidence  that  they  are  both             ly advocated. This is  now  the  official  position  ta  n  y
                    46 worthwhile"  and  "practice  ready"  if  costly  failures           the   National   Advisory   Council   on   Regional   Medical
                    are  to  be  avoided.   They   should   be   preceded   by             P r2jr a_m s. *                               %- -
                    studies  of  clinical  and  administrative  efficacy   @nd                7o-mputerized    medical-information    systems    consti-
                    cost  effectiveness,  taking  into  consideration  operat-             tute an  inordinately  confusing  array  of  hardware,  so  -
                    ing  and  service  reliability,   safety   hazards,   per-             ware  and  fuzzy  thinking.  The   central   question   about
                    formance  standards,   calibration   problems,   and   re-             information  is  not  "How  can  we  computerize  the   medi-
                    dundancy   requirements.   Scientific   and    technologic             cal  record  and  all  available  data  generated  by  hospi-
                    work  leading  to  invention  and  development   of   pro-             tals,  laboratories,  physicians,  administrators  and  other
                    totypes  should  be  followed  by   related   studies   on             health  personnel?"  but  "Who  needs  to   know   what   and
                    marketability  and  acceptability  before  innovation   is             why?"  The  most  succinct  analysis  of  this   problem   is
                    advocated.                                                             contained in studies  of  the  potentials  for  computer  ap-
                       Finally,  controlled  field  testing,  evaluations   and            plications in the Scottish Health Service@8,        '    To    summa-
                    large-scale    applications    of    technology    require    ade-     rize   contemporary   thinking    in    this    field,    development
                    quate   numbers   of   suitably   sized   settings    each    with     of   health-services   information    systems    should    be    gov-
                    the  requisite  resources   to   support   the   effort,   trained     erned   by   four   P's:   the   data   should    be    parsimonious,
                    manpower   for    managing,    operating    and    servicing    it     problem-oriented,       person-specific        and        population-
                    and the interest and means to evaluate it.                             based.   From    these    elementary    beginnings,    larger    rou-
                    Applications   of   technology   in   health   care    that    are     tines  and  ad  hoc,   general   and   dedicated   systems   can   be
                  widely   advocated   at    present    are    physiologic    monitor-     evolved.
                  ing,    automated    multiphasic    screening,     and     computer-
                  ized   medical-information   systems.   It   is   not   our   inten-      IMMEDIATE PROSPECTS FOIR TECHNOLOGY IN HEALTH
                  tion  in  this  discussion  to  dwell  at  length  on  the   limited                                   CAFTE
                  potential   for   prompt   application   in    these    areas    but        Turning  now   to   particular   areas   that   appear   to   meet
                  rather   to   focus   on   major   opportunities    in    conformity     most   of   the   guidelines   summarized   above,   we   see   seven
                  with    the    guidelines    described    above.    However,    some     possibilities   for   the   widespread   application   of    technol-
                  comments seem indicated.                                                 ogy in the near future.
                    The    difficulty    with    physiologic    monitoring     svstems
                  is,  first  of  all,  that  they  are  largely  hospital  bas@d  and     Patient and Practice Management Systems
                  applicable  to   a   relatively   small   segment   of   the   total        Health-maintenance         organizations,          medical-society
                  burden  of  illness  in   the   population   and,   secondly,   that     foundation   plans,   group   practices,    and    other    organiza-
                  they  are  being  widely  installed  before   their   efficacy   and
                  costs   have   been    demonstrated.    The    largest    investment        'United States Department of Health, Education, and Welfare, Health
                                                                                           Services and Mental Health Administration, National Advisory Council on
                  has   been    in    hospital    coronar-y-care    units,    although     Regional Medical Programs. Report ofsubcommittee on Automated  Multi-
                  probably  less  than  1  per  cent  of  hospitalized   patients   in     phasic Health Testing, May 11, 1971 (mimeographed).


                                             -I'ECHNOLOGY  AND  HEAI,'I'H                                                           1225
            ol. 287  No. 24
                                                   care       of       defined for cervical cvto]OgY, sputum cytology and           pregnancy
            tional arrangements responsible for the                                                      us,  as  is  the  need  for   the
                                                 e       their        multiple testing. 'I'he market is enorn-io
            populations require systems to manag                            n- establishment  of  standards  and   regulations   to   assure
            practices and to care for their patients. They are esse
            tial   to   foster   preventive   medicine   by,   for    example, quality.
            keeping   track   of   appointments,   following    up    patients
            with    chronic    disorders,    and    monitoring    immunization Hospital Discharge Abstract Systems
            levels  of  populations.  They  are  also  essential  for  linking Utilization  and  peer  review  appear  essential  if  hospi-
            patients'  problems  with   services   used   and   their   costs. tals individually and collectively are  to  tackle  the  cen-
            Management    information    svstems    for    physicians'     of- tral issues of use, cost, quality, and  efficiency.  Parsimo-
            fices    that    incorporate    health'inventories,    patient-en- nious  collection  of  a  minimal  data  set,  through   uni-
            counter   data   (not   medical   histories),   laboratory   data, form  hospital  patient   discharge   abstracts   and   claim
            prescribing   data   and   charge   data   are   now    available. forms that  relate  persons,  health  problems  and  hospital
            Small   computers   can   handle   data    for    physicians    in charges   to   populations   and   institutions,   has   more
            group   practices   and   clinics   and   for   aggregations    of power to  influence  medical-care  costs,  hospital  utiliza-
            physicians  and  their  patients   at   the   local   level.   The tion,  standards  of  care,  and   health-services   planning
            packages  should  be   integrated   so   that   complete   systems than  any  other  health-information  system  likely  to   be
            will  provide   information   for   clearly   specified   purposes available in the foreseeable future. It is  the  only  infor-
            in   machine-readable   form.   The   market   for   these    sys- mation  system  that  will  permit  us  to  make  comparisons
            tems  is  expanding  rapidly,   and   they   urgently   need   de- in utilization, clinical  performance  and  charges  of  hos-
            velopment   to   the   point   of   marketability   and   applica- pitals   within   communities   and   between    communities.
            tion.                                                            Decentralized  systems  that  can  aggregate   data   accord-
            Laboratory Support for Primary Care                              ing to prescribed definitions  and  standards  for  a  varie-
                                                                             ty of  local,  state,  regional  and  national  purposes  are
            An   unknown    number    of    laboratory    tests    are    per- quite feasible. The content, terms  and  definitions  of  the
            formed   annually   for   ambulatory   patients.   Like    labora- minimal  data  set  have  been  established  by  the   United
            tory  tests  for  hospitalized   patients,   many   are   probably States  National  Committee  on   Vital   and   Health   Sta-
            of   "unsatisfactory"   quality."    Some    may    be    inappro- tistics,  and  the  computer  technology  exists.  Both  non-
            priate  or  useless,  and  a  few  may  be   harmful   or   unduly profit   and   profit-making   data-handling    organizations
            hazardous.                                                       are  available  to  develop  this  information  base  prompt-
            To  make  effective  use  of   technology   in   this   area,   we ly. The operating cost of  these  systems,  now  regarded  as
            must   first   establish   national   standards   for   diagnostic essential  by  other  Western  countries  with  sophisticated
            instruments, reagents, tests  and  test  kits  that  assure  effi- health-care systems, is less than 50 cents  a  discharge,  as
            cacy,  reliability,  validity   and   safetv.   The   absence   of compared to  an  average  hospital  bill  of  $664  in  t970,
            standards,   coupled   with   fragmentation   of    the    market, and  this  expense  is  readily  recovered  through   savings
            discourages  industry  from  investing   in   research   and   de- in   current   practices   for   preparing   discharge   sum-
            velopment   on   many   potentially   useful   products   in   the maries,  routine  indexes  and  claim   forms   in   hospital
            health  field.  Considerations   should   be   given   to   estab- medical-record  rooms  and  business   offices."   The   need
            lishing  regional  centers   to   regulate,   monitor,   and   en- is great, and the market vast; only  the  decision  to  stim-
            courage  the   use   of   laboratory   reagents,   equipment   and ulate or implement the systems is lacking.
            tests    (and    perhaps    therapeutic    instruments)    through
            combined  efforts   of   the   National   Bureau   of   Standards, Automated Clinical Laboratories
            the  Food   and   Drug   Administration   and   the   Center   for 'I'here  are  about  @000  hospitals   with   200   beds   or
            Disease  Control.  It  may  also  be   necessary   in   some   in- more and about 600  with  500  beds  or  more  in  the  Unit-
            stances  for  the  federal  government   to   identify   potential ed States  out  of  7000  hospitals.  The  market  for  fully
            opportunities  for  technologic   solutions   and   solicit   com- automated  clinical  laboratories  in  this  and  other  set-
            petitive  bids  and  ideas  through  the   use   of   RFP's   (re- tings is therefore small.  To  achieve  greater  versatility,
            quests  for  proposals).  This  stage  should   be   followed   by development  should  focus  on   sub-systems   as   well   as
            full  funding  for  the  construction  of  a  prototype   by   one complete   prototype   laboratories,   and   more   attention
            firm,  with  a  guarantee  that  a  sufficiently  large   quantity should  be  given  to  batch  processing  of  commonly   per-
            of  the  units  will  be  purchased   to   ensure   profitability. formed  tests  rather  than  to  multi-channel  analysis   of
            The  units  could  then  be  sold,  leased,  lent  or  donated  to single   specimens.   Cost-effectiveness   measurements    in
            organizations  or  systems  that   would   use   them   effective- relation  to  populations  served  and   patient-care   prob-
            ly.  This  is,  of  course,  the  approach  used  by  the  Depart- lems resolved are critical  in  determining  the  market  for
            ment  of  Defense,  and  there   seems   no   valid   reason   why automated laboratory equipment.
            it  should  not  be  employed   in   the   health-care   industry. Emergency Care
              Among   the    many    laboratory    applications    of    tech-
            nology   ready   for   widespread   development    or    use    in The  central  problem  in  the   provision   of   emergency
            ambulatory-care  practices  are   "dip-sticks"   and   test   kits care  for  defined  populations  is  identification  of   the
            that   include   reagents   and    sometimes    instruments    for agencv   or   institution   responsible   for   organization,
            physicians'   offices,   and   "do-it-yourself"   specimen    kits quality, command  and  control.  Transfer  to  civilian  set-


                     1226                               THE NEW ENGLAND JOURNAI, 01@' MEDICINE                                         Dec.          14,1972
                     tings  of  organizational   and   technologic   methods   devel-       and  modular  prostheses   and   devices   deserves   further
                                                                                            dy. It is  estimated  that  there  are  at  least  4  million
                     oped by the  military  depends  on  resolution  of  this  issue.       Stu           ited    States    with    severe    impairments
                     In   essence,   the   question   regarding    community    emer-       persons in the Un
                                                                                            mobility  due  to   neurologic   diseases   alone,   and   an
                     gency services is: "Who is in.charge?"  Is  it  to  be   any   or      in                                              ns.       The
                     all  hospitals  in  the  community,   the   health   department,       equal number of totally blind or deaf perso
                     the  fire  department,   private   ambulance   firms,   or   or-       benefit  from  improved  functional  capacity  and   related,
                     ganized  health-care  systems  that  provide  a  full  range  of       increases  in  employability  and  decreases   in   dependen-
                     services,  of  which  emergency  care  is   one   element?   The       cy  should  be  substantial.  As  with  laboratory   supports
                     problems  of  authority  and  organization   are   critical   to       for primary medical  care,  industry  is  deterred  from  in-
                     the  full  application  of  technology   for   these   services.       vesting in restorative devices  because  of  the  absence  of
                     Two developments merit further detailed study:                         national standards for  efficacy,  reliability,  and  safety,
                     Centralized crist's centers.  Poison  control  centers  in  hos-       high  costs  of  development,  and  uncertainties  about  the
                     pitals  provide  an   organizational   base   for   centralizing       size  and  stability  of  the  markets.   Collaboration   be-
                     both   emergency   calls    and    medical-reference    services       tween  the  federal  government  industry,   and   university
                     needed  by  the  public   and   physicians.   A   common   tele-       schoo Is of medicine and engineering offers  the  best  pros-
                     phone  number  (91  1)   directing   all   calls   automatically       pects for  increasing  the  effectiveness  of  technology  in
                     to the  center  nearest  the  caller  could  start  with  verbal       this   area.   Regional   biomedical   engineering    centers
                     responses  to  inquiries  about  sources  of   information   and       supported  in  part  by   governmental   funds   could   pro-
                     services.  The  initial  system  could  be  expanded  in  a  va-       vide the setting for this co-operative effort.
                     riety  of  ways  to  include,  for  example,   dispatching   and       Health Education
                     monitoring   of    ambulance    calls,    answering    inquiries
                     from  physicians   about   adverse   drug   reactions,   optimal       Recent  advances  in  audiovisual   systems   and   the   ad-
                     therapy   or   potentially   hazardous   therapy   for   readily       vent. of "wired cities" offer new possibilities  for  provid-
                     diagnosed    conditions,    or    providing    computer-assisted       ing health education  for  the  general  public,  instruction
                     replies  to  inquiries  about  the  management   of   relatively       of  patients  with  common  acute  or  chronic  diseases   or
                     common   but   potentially   complicated   problems   such    as       health  problems,  and  continuing   education   for   physi-
                     electrolyte   imbalances,   allergic   reactions   and   cardiac       cians.  Commercial  firms,  the   National   Medical   Audio-
                     arrhythmias.   Further   extensions,   which    could    include       Visual   Center,   Regional   Medical    Programs,    medical
                     terminals  in  physicians'  offices  with   on-line,   real-time       societies  and  voluntary  agencies  have  all  had   experi-
                     computer  access,  could   be   extremely   costly   but   might       ence in  this  field.  The  technology  is  fully  developed,
                     be warranted  in  the  long  run  as  part  of  a  support  sys-       but the problem  of  motivating  people  to  use  these  edu-
                     tem  for  physicians'  assistants,   nurse   practitioners   and       cational  opportunities  needs  further  study   before   the
                     other "physician-extender" personnel.                                  market can be  effectively  exploited.  This  market  can  be
                     The      knowledge,      technology      and      organizational       reached by  expanding  the  projects  of  medical  societies,
                     bases exist  for  this  development.  It  bui  s  on  the  pres-       hospitals,   universities,   and   Regional   Medical    Pro-
                     ent   capacity   to   meet   widespread   urgent    needs    and       grams.
                     could expand  in  a  variety  of  ways  in  different  settings.       Like  other  problems  in  health   care,   the   application
                     The   market   should   be   substantial,    and    requirements       of technology in the  interests  of  meeting  people's  needs
                     for   equipment   would   range   from    modest    to    highly       depends  upon  the   purposeful   organization   of   health,
                     complex.                                                               services. The reason we have a "crisis  in  health  care"  is
                      Rescue  and  recovery  services.  Integrated  emergency   serv-       that  biomedical  research  has  made  medical  care  effica-
                     ice  systems  for   managing   automobile,   industrial,   agri-       cious. We must now  make  if  effective,  equitable  and  ef-
                     cultural  and   domestic   accidents   require   prototype   de-       ficient.  To  these  ends,  technology,  like  improved   fi-
                     velopment  in  communities  where   the   issues   of   authori-       nancing   and   health-insurance   mechanisms,   can   assist
                     ty  and   responsibility   have   been   resolved.   Technology,       but it cannot  "drive  the  system."  Services  must  be  re-
                     particularly  as  developed  by  the  military,   can   contrib-       lated  to  the  needs  of  populations,  and   organized   to
                     ute  not  only  to   the   design   and   equipping   of   ambu-       meet them. As  in  other  facets  of  human  endeavor,  tech-
                     lances,  helicopters,  minibus   rescue   units   and   emergen-       nology  can  become   an   extremely   effective   means   to
                     cy  rooms,  but  also  to   the   problems   of   communications       worthwhile ends. It is not an end in itself.
                     and  transportation.  These  services,   in   turn,   could   be                            REFEIIENCES
                     expanded  to  embrace   broader   systems   for   all   patients       1. Decision Making in National Science Policy. Edited by A  de  Reuck,  M
                     se  ed by a health
                      rv                   -care organization.                              Goldsmith, J K@ight. Boston, Little, Brown and Company, 1968
                       The  development,  testing  and   evaluation   of   a   series       2. Special  issue  on  technology  and  health  services.  Proc  IEEE  57
                     of  prototype  systems  in  suitable  urban  and   rural   corn-       (11):1799-2050, 1969
                                                                                            3. Gross PF: Development and  implementation  ofhealth  care  technology:
                     munities   should   precede   their   widespread   linkage    to       the U.S. experience. Inquiry 9 (2):34-48, 1972
                     centralized  crisis  centers.  Each  of   the   two   kinds   of       4. Schon  DA:  Beyond  the  Stable  State.  London,  Temple  Smith,  1971
                     modules   could   be   linked   to   health-maintenance   organ-       5. Cochrane AL:  Effectiveness  and  Efficiency:  Random  reflections  on
                                                                                            health services. London, Nuffield  Provincial  Hospitals  Trust,  1972
                     izations or other forms of health-care systems.                        6. Mather HG, Pearson NG, Read  KLQ,  et  al:  Acute  myocardial  infarc-
                                                                                            tion: home and hospital treatment. Br Med 1 3:334-339, 1971
                     Restorative Aids and Devices for the Handicapped                       7. Cochrane AL, Holland WW: Validation of screening procedures. Br
                                                                                            Med Bull 27:3-8, 1971
                       The  market  potential  for  sensory   aids,   mobility   aids       8. Ockenden JM, Bodenham KE: Focus on Medical Computer  Develop-


                   \,'ol. 287   No. 24                                       SURGERY OF THE HANI)-CHASE                                                                         1227

                       ment. London, published for the  Nuffield  Provincial  Hospitals  Trust  by    10. Schaeffer M, Widelock D, Blatt S, et al: The clinical laboratory  improve-
                       Oxford University Press, 1970                                                      ment program in New York City. 1.  Methods  ofevaluation  and  results  of
                   9.  Bodenham  KE,  Wellman  F:  Foundations   for   Health   Services   Manage-        performance tests. Health Lab Sci 4:72-89, 1967
                       ment. London, published for the  Nuffield  Provincial  Hospitals  Trust  by    11. Murnaghan  JH,  White  KL:  Hospital  patient  statistics:  problems   and
                       Oxford University Press 1972                                                       prospects. N Engl J Med 284:822-828, 1971

                                                                  -W        T                    T-
                                                                                                 9
                                                                      s                          r e c,
                                                               Bc,s,tc,nj  Mas,-,.
                                                                                                 c                1 0      @51
                                                                                            DE'-'    4 '72


                                ROCKY MOUNTAIN MEDICAL JOURNAL - December 1972

              Consumer health education*

              ,4 rural reconnaissance

              Donald L. Erickson, MPH, MEd,t Cheyenne, Wyoming

              SINCE   ITS   INCEPTION   IN   1966,    the    Mountain     health activities in this region.  However,  as
              States Re onpl@ Medical Pro                                 a  health  planner  committed  to  the   educa-
                         gi                     I  gram  has  been
              slowly, but deliberately, developing  the  capa-            tional process as the sine quo non to
              bflity  of  health  workers  and  consumers   to            sirable social change, I remain optimistic that
              design programs for  improving  the  quality  of            consumer responsibility for health  and  we,  -
              health care  in  the  mountain  states  of  Wyo-            being is an attainable goal.
              ming,  Montana,  Nevada,   and   Idaho.   During
              the past five  years,  our  program  development            The Rural Area
              efforts in these states have  enriched  our  un-               The  geographic  area  stretching  from   New
              derstanding  of  consumer  concerns   and@   in-            Mexico and Arizona  to  Idaho  and  Montana  is
              terests as well as  health  manpower  needs  and            punctuated by plains,  mountains,  and  desert.
              problems   of   organizing    and    maintaining            Sparse population, I i in i t e d  metropolitan
              health  care  services.  Promoting  a  sense  of            areas, rugged terrain, vast distances, and  in-
              "health  consumer  citizenship"  in  the   Rocky            adequate transportation  give  rise  to  unique
              Mountain region  has  been,  and  will  continue            problems for those of  us  who  are  attempting
              to be, a herculean task, particularly  consider-            to improve the  accessibility  and  quality  of
              mg  the  paucity   of   community   and   school            health care  services.  Health  planning  on  a
                                                                          regional  basis  is  compounded  by  vast  dis-
              *Condensed from statement Presented to the  President's     tances,  unpredictable  weather  patterns,  and
              Committee on Health Education at Public  Hearing,  Jan-
              uary 17, 1972, Denver, Colorado.                            poor   commercial   transportation    services.
              tMr. Erickson is  Associate,  Educational  Development,     Consequently,  smaller  communities   tend   to
              Western Interstate  Commission  for  Higher  Education,
              Mountain States  Regional  Medical  Program,  Cheyenne,     be provincially oriented.
              Wyoming.


                 Although  health  personnel  appear   to   be    A  closer  examination  of  consumer  character-
              flocking to the few metropolitan  areas,  it  is    istics will shed some light  on  the  complexity
              becoming  increasingly  difficult   to   attract    of health care planning in rural areas.
              physicians and other health  workers  to  small,
              isolated  communities.   Long-standing   statis-    Consumer Characteristics
              tics give vivid testimony to the  general  move-
              ment  of  physicians   away   from   communities       Who is the  consumer  of  health  care  serv-
              of less than 2,500,  creating  serious  gaps  in    ices in the four-state area  and  what  does  he
              the availability of primary care services.  This    actually know  about  health  and  health  care.
              lack  of  physician  services  is   particularly    To  seek  answers  to   these   questions,   the
              acute   in   Montana,   Idaho,    and    Wyoming    Mountain  States   Regional   Medical   Program,
              where approximately 45  per  cent  of  the  pop-    with  the  assistance  of  the  System  Develop-
              ulation lives in communities of 2,500 or  less.'    ment  Corporation   of   Santa   Monica,   Cali-
              This discussion is directed  to  conditions  and    fomia,  conducted  a  mail   survey   of   9,600
              concerns in these states in  which  the  popula-    households   in   Wyoming,   Montana,    Nevada,
              tion is primarily rural.                            and Idaho. Nearly 50  per  cent  of  the  house-
                                                                  holds responded. The full  report  of  the  sur-
                 Wyoming,  Montana,  Idaho,  and   Nevada   by    vey has been published    4 and  the   principal
              numerous  definitions  are   "medically   under-    findings and  conclusions  will  be  summarized.
              served". In 1969, the  national  ratio  of  phy-
              sicians per 100,000 population was  163;  within    Economics of Health Care
              the four-state area the  rate  was  105.1  While
              older  physicians  offering  primary   care   in       The  average  yearly  income   for   consumer
              rural areas are retiring,  young  physicians  do    households studied  was  found  to  be  slightly
              not  replace  them.  Instead,  they  settle   in    above $6,000. There is  a  consistent  relation-
              urban  areas.3  Maldistribution   of   personnel    ship  between  income   and   attitudes   towar(
              results in insufficient  numbers  and  kinds  of    health care and ability to meet  the  costs  as-
              health workers in extensive rural sections.         sociated  with  that  care.  Those  with  annual
                                                                  incomes below  $9,000  (61.5  per  cent  of  the
                 Few   organized   community   health    units    respondents)  expressed  disproportionate   con-
              (local  health  departments)  exist   in   these    cem  that  medical  care   is   toG   expensive,
              states. To illustrate  this  point,  in  Wyoming    regular  dental  checkups  are  too   expensive,
              there are  23  counties.  Of  this  number,  two    and regular physical examinations  are  too  ex-
              counties have local  health  units,  neither  of    pensive.  Those  households  with  total  annual
              which employ a  full-time  health  officer.  Ten    incomes under $6,000 also were,  by  and  large,
              Wyoming  counties  are  without  public   health    underinsured.  Throughout  the  region   approx-
              nursing  services.  None  of   Wyoming's   local    imately 40 per cent felt that  they  had  insuf-
              health units nor  the  State  Health  Department    ficient financial means to cover  the  costs  of
              employs a public  health  education  specialist.    major health and medical expenses.
              Needless  to   say,   developing   comprehensive
              consumer health education in  rural  areas  will       Looking at the same  questions  from  a  pop-
              req,uire considerable tooling-up of  health  care   ulation perspective, a similar  pattern  is  re-
              services and  personnel.  It  is  doubtful  that    vealed-the   smaller    the    community,    the
              traditional public health units  (local  or  re-    greater is the  economic  impact  of  preventive
              gional  health  departments)  are  feasible   in    medical  care.  This  fact  is  most  pronounced
              these  states.  Lack  of  financial   commitment    in communities  with  populations  of  1,000  or
              for health affairs, sparse population,  and  the    less. Remote  ruralness  has  other  interesting
              unwillingness of health care personnel  to  live    impacts. While  approximately  15  per  cent  of
              and work in rural  areas  are  major  obstacles.    the respondents for the  entire  region  claimed
              Establishing  behavior  patterns  conducive   to    they had to travel too  far  for  medical  care,
              "consumer  health  citizenship"   is   therefore    almost  half  of  all  consumers  whose   house-
              dependent   on   approaches   which    recognize    holds are in conununities of 1,000 or less  face
              and effectively  deal  with  these  constraints.    this  problem.  These  people  normally   travel


           out of state for medical care at  a  rate  three     90 per  cent  of  the  consumers.  The  majority
           times greater  than  do  residents  of  communi-     of  the  consumers  felt  that  information  re-
           ties with population of  25,000  or  more.  They     ceived  from  their  physicians  was   adequate,
           are also at a  disadvantage  when  it  comes  to     although approximately 17  per  cent  felt  that
           hospitalization. Only 17  per  cent  are  within     not  enough  time  or  not  enough   information
           ten miles of a  hospital  and  such  a  facility     was  given.  Primary  sources   of   information
           is at least 25  miles  away  for  more  than  50     were  listed  as  magazines,  television,  news-
           per cent of the households.                          papers, radio, and special literature, in .    t
              Knowledge  levels  and  practices   of   this     order. These, however,  are  not  the  preferred
           rural public  pose  some  cogent  questions  for     media. Special literature  was  at  the  top  of
           those   concerned   with   consumer    education     the list,  followed  by  television,  magazines,
           and preventive  medicine.  Greatest  familiarity     educational  movies,  and  talks   with   health
           is  expressed  with  the  warning  signals   for     professionals.  The  rural   consumer   selected
           cancer (57 per cent),  next  for  heart  disease     adult education courses  and  contacts  by  vol-
           (42 per cent), and IF--ast for  stroke  (28  per     untary health workers  in  a  higher  proportion
           cent).$  Education  level  enhances   knowledge,     than  did  consumers  residing  in  the   larger
           but even so, only 65 per  cent  of  the  college     cities.
           attendees  are  familiar  with  cancer  signals,        The  Mountain  States  consumer  feels   that
           49 per cent with heart disease signals,  and  33     medical  services  are  generally  satisfactory;
           per  cent  with  stroke  signals.  Age  makes  a     but for  approximately  25  per  cent  of  co-n-
           difference  in  familiarity  with  warning  sig-     sumers,  the  preventive  measures  that   would
             ,Is. The middle age  group  (40-54)  was  most     alleviate  long-range  socioeconomic  costs  are
           familiar with all  three.  However,  the  young-     considered to  be  beyond  the  consumer's  eco-
           est group (under  40)  was  more  familiar  with     nomic  grasp.  Those  who  claim   they   cannot
           cancer signals than the oldest  (over  55),  and     afford medical care are  most  likely  to  indi-
           the opposite held  true  with  regard  to  heart     cate dissatisfaction with the care they  do  re-
           disease  and  stroke.   Approximately   80   per     ceive.
           cent  considered  regular  medical  and   dental
           examinations  to  be  necessary,  while   almost        Finally, the consumer's desire for  more  in-
           one-half  have  neither  regular   medical   nor     formation,  his  behavior  in   seeking   health
           dental  examinations.  More  than  nine  out  of     care, and his assessment of available  care  all
           ten claim that  smoking  is  hazardous,  but  43     suggest  further  analysis  particularly  on  an
           per cent reported that they smoked.                  area basis within  the  region.  Variations  ob-
              The  educational   needs   from   these   re-     served in ten-ns of population  groupings,  edu-
           sponses are apparent. Moreover,  the  data  sug-     cational levels,  and  income  levels  highlight
           gests  that  differential  approaches  to   con-     the need for more refined analysis.
           sumer education may  be  in  order.  These  dif-
           ferential approaches  would  consider  the  type     Recommendations
           of method as well  as  its  content  and  should        In regard to the  need  for  consumer  health
           be examined for  appropriateness  on  the  local     behavior  analysis,  health  planners  and   of-
           level. For  smoking  dangers  and  for  the  im-     ficials  are  poorly  informed  about   consumer
           portance   of   preventive   examinations,   the     health  knowledge,   misconceptions,   opinions,
           disparity  between  belief  and  practice   sug-     and attitudes. Of course, there are  broad  gen-
           gests  the  need  for  imaginative,   aggressive     eralizations  advanced  -about  consumers,   but
           programs.                                            for the most  part  our  understanding  relative
              Desire  for  information  pertaining  to  the     to consumer  predispositions  and  knowledge  is
           prevention  and  detection  of  heart   disease,     wholly  inadequate.  Hence   my   first   recom-
           cancer, and  stroke  is  high  and  surprisingly     mendation is  the  establishment  of  a  network
           uniform for all areas  within  the  region  with     of  Consumer  Health  Behavior   Study   Centers
           interest  being  expressed  by  between  80  and     affiliated with schools of  public  health  and/
           IQuestion pertained to woman signals of cancer, heart or  other  health  science  education   centers.
           @isease, and stroke; other diseases and conditions were not These study  centers  should  be  geographically
           included in the question.


               placed  so  as  to  assure  analysis   of   multiple         My  final  comments  relate   directly   to   the
               consumer groups and life styles.                         Panel    and    the    President's    Committee    on
                   A    second    recommendation    pertains     to     Health   Education.   Throughout   the   years,   nu-
               schools  of  public  health,  which   unfortunately,     merous   federal   health   projects   were   created
               are  reluctant  to  place  graduate   students   for     to  improve  our  nation's  health.   A   large   per
               field practice  in  rural  areas  with  limited  re-     cent of  these  national  efforts,  such  as  chronic
               sources.  Although   their   reasoning   is   under-     disease   control,   matemal   and   child    health,
               standable,  i.e.,  students  will   not   obtain   a     migrant  health,   Indian   health   services,   com-
               fully  rounded  experience,  this  stance  is   most     prehensive   mental   health    centers,    immuniza-
               discouraging.   Public   health    students    could     tion   programs,   and    others,    have    consumer
               be  helpful  in  identifying   health   care   needs     health   education    components.    This    approach
               and   stimulating    rural    consumers    to    get     has led to health education through bits an
               actively  involved  in  health   affairs.   Further-     pieces  rather   than   fostering   a   comprehensive
               more,  when   public   health   trainees   graduate,     health    education    program.    Fragmentary    ap-
               they  might  be  willing  to  move  to  rural  areas     proaches  often  have  low  payoff.  It  seems   that
               if  they  were  exposed   to   the   advantages   of     the   President's   Committee    on    Health    Edu-
               rural life.                                              cation is in a  position  to  make  a  positive  con-
                   The  small  community  hospital  is   the   sub-     tribution  to  the  physical,   mental,   and   moral
               ject  of   a   third   recommendation.   The   corn-     well-being   of   the   American   public.    History
               munity  hospital  is  an  ideal  setting   for   the     will  tell  us  whether   the   Committee's   contri-
               placement  of  health   education   specialists   to     bution  is  productive  or  irrelevant.  The   charge
               develop   comprehensive   health    education    ac-     is clear;  we  can't  have  more  of  the  same.  The
               tivities  in  rural  areas.   A   complete   program     time  has  come  for  us  to.  be   accountable   for
               could   be   developed   which    would    harmonize     our efforts.
               patient  information  needs   with   school   healtg         Those  of  us  in  the  public  health  education
               instruction,  adult   education,   and   traditional     enterprise, if I  may  call  it  that,  are  striving
               public   health   education   activities.   To   en-     hard  to  do  our  job.  We  would  all  agree   that
               courage  hospitals  to  carry  out   this   function
                                                                        we  are  quite  busy.  However,  in  the   words   of
               of    comprehensive    community    health    educa-     Thoreau:  "It  is  not  enough   to   be   busy;   so
               tion, financial assistance  at  the  national  level     are  the  ants.  The  question  is:   What   are   we
               would be essential.                                      busy about?"

                                                               REF'ERENCF,S
                           11970 Census of Population, U. S. Department of Commerce, November 1970.
                           2 Pocket Data Book U.S.A., 1971. U. S. Department of Commerce, 148, 1971.
                           3 Grizzle, Claude O., et al.: The Wyoming Doctor. Rocky Mountain Med. J. 66:65-68, July 1969.
                           4 Report of a Survey of Consumers of Health Care. WIC@Mountain States Regional Medical
                             Program, 1969.

                                                                                                         Reprinted  from  the
                                                                                  ROCKY     MOUNTAIN     MEDICAL      JOURNAL
                                                                                   December 1972, Vol.  69,No. 12, Pages 40-43
                                                                                              Copyright, 1972. Colorado Medical  Socieq
                                                                                                             "P.@inted in  U.S.A."


                                    Reprinted froM ANNALS OF INTERNAL MEDICINE Vol, 78, No. 1, January 1973
                                                                  Printed in U.S.A.
              Hypertension: Def icient Care of the Medically Served

                               STEPHEN B. LANGFELD, M.D., F.A.C.P., Philadelphia, Pennsylvania

              Deficiencies in the detection, treatment, and control of        beit done  in  a  somewhat  selected  population,  confirm
              hypertension  before  hospitalization  have  been  shown        previous  studies  and  provide  new  incentive  for   the
              by a survey of 185 patients admitted for various                detection and  evaluation of  all  individuals  with  ele-
              surgical procedures unrelated to hypertension. From             vated  blood  pressure,  the  long-term  control  of  mod-
              their current status or previous history, 51 patients           erate  to  severe  hypertension,  and   the   therapy   of
              were classified as hypertensive. Twenty-six of these            selected cases  of  mild  or  labile  hypertension.  Corn-
              were currently hypertensive; 10 of these (6 of whom             plementinc,, these studies is the  report  of  the  Inter-
              were previously unrecognized) had never received                Society   Commission   on   Heart    Disease    Resources,
              treatment, and 8 had discontinued therapy. Among 25             which  describes  a  protocol  for  detection,  follow-up,
              patients currently under treatment, 8 were                      and management of hypertensive patients (4).
              hypertensive, and 10  others  had  blood  pressures  above       In  addition  to  these   considerations,   the   Greater
              normal. These conditions could not be attributed  to  lack      Delaware    Valley   Regional      Medical         Procram
              of access to medical care, since all but three  patients
                                                                              (GDVRMP)   has   a   special   interest    in    hyperten-
              had visited a primary source of medical care within the         sion. Hypertension  is  a  major,  treatable  factor  con-
              past year. Discontinuation of treatment by the                  tributing  to  morbidity  and   mortality   from   cardio-
              physician or patient was the predominant reason. A              vascular  and  renal  disease  (diseases  on   which   the
              change in both physician and patient behavior is                Regional  Medical  Program  continues   to   focus).   Its
              critical for the success of hypertension-control                prevalence,   especially   undetected   and   uncontrolled
              programs.                                                       hypertension,  is   presumably   high   because   of   the
                                                                              greater  proportion   of   medically   underserved   among
                                                                              the   region's   population.   Educational   programs   on
              THE  vALuE  of  treating  patients  who   have   hyperten-      hypertension,  especially  for  the  continuing  education
              sion  has  been  asserted  in   numerous   reports.   That      of  physicians  (a  familiar  role  for  Regional  Medical
              morbidity  and  mortality   from   hypertension   can   be      Programs), could  be  helpful  in  its  control.  Finally,
              reduced  has  been  shown  by  the  often-cited  VetIerans      allied health professionals can play  a  significant  role
              Administration studies, in whi                                  . the control of hypertension.
                                                ch  not  only   severely      in
              hypertensive  patients  (patients  with  diastolic   blood        Since  prevalence   data   were   available   from   the
              pressures  over  1  1  5  mmHg)  benefited  from   therapy      National  Health   Survey   (5),   it   was   deemed   un-
              (1)  but  also   patients   with   moderate   hypertension      necessary  to  survey  the   region   anew.   Rather,   it
              (diastolic  blood  pressure,  90   to   114   mmHg)   (2).      seemed  appropriate  to  adjust   these   data   according
              Further analysis of the latter group in        ated   that      to  the  age,  sex,  and  race   make-up   of   our   pop-
              the effectiveness of therapy  was  related  to  the  level      ulation.  Although  the   data   confirmed   our   assump-
              of  blood  pressure;  it  was  more  consistent  in  those      tion that the prevalence of hypertension  in  the  Greater
              with diastolic  blood  pressures  in  the  range  of  from      Delaware  Valley  region   was   higher   than   for   the
                                                                              U.S. (16.6%  versus  15.3%,  for  ages  18  to  79  years;
              105  to  1  1  4  mmHg  but  variable  and  dependent   on
              associated factors such as age, a          prior   card'        and  23.5%  versus  21.6%,  for  ages  35  to  79  years),
                                                     nd              to-
              vascular,  renal,,..or  central  nervous   system   abnor-      the degree  to  which  the  disease  was  undetected,  un-
              malities in those  patients  with  diastolic  blood  pres-      treated, or inadequately  treated  was  still  unresolved.
              sures of 90  to  104  mm  Hg  (3).  The  VA  studies,  al-        There   were   alternative   approaches   to   answering
              @ From Program Development  and  Operations,  Greater  Delaware  Val- these questions, such  as  screening  programs,  inpatient
              ley Regional Medical Program, Haverford, Pa.                    and  outpatient  chart  reviews,  or  surveys  of   office
              Annals of Internal Medicine 78:19-23,1973                                                                               19


                                                                                                    r  analysi  .  Beca  se  of  the  small  number   of   patients
                          tice; the   one   chosen   was   to   study   those    persons            pute       s       u
                      who   had found   their   way   into   the   medical   care   sys-            the analysis was actually done manually.
                      tem.  Whatever  the  degree  of  deficiency   found   for   those             Classification
                      in  the   system,   there   was   undoubtedly   a   greater   de-
                      ficiency   in   the   general   population.   This   report   de-             The  classification  of   patients   was   based   on   history
                      scribes the methodology and results of the study.                             as well  as  current  status.  This  identified  patients  pre-
                                                                                                    viously  treated  for   hypertension   who   were   either   no
                                                                                                    longer   hypertensive   or   normotensive   under    treatment,
                      Methods                                                                       as  well  as  the   currently   hypertensive   or   borderline-
                      One   hundred   and   eighty-five   patients,   age   35    years             hypertensive  patients.   Although   a   history   of   hyper-.
                      or  older,  were  studied  in  four   hospitals   before   under-             tension   could   not   always   be   confirmed   by   previous
                      going  various  surgical   procedures,   none   of   which   were             blood  pressures  recorded  in  the  chart  or  known  to   the
                      for   treatment   of   hypertension.   The   hospitals   were   a             patient,  it  was  assumed  that  a  patient   who   had   been
                      representative  sample,  selected  by  size,   geographic   loca-             treated  for  hypertension  had  an  elevated  blood   pressure
                      tion,  and  presence  or  absence  of  house  staff   and   medi-             at the  time  the  treatment  was  initiated.  When  a  classi-
                      cal school  affiliation.  The  willingness  of  anesthesiologists             fication  of  borderline   or   hypertensive   was   based   on
                      to participate was also  a  factor  in  the  selection.  A  four-             current  status  only,  at  least  two  blood  pressure   read-
                      part   questionnaire*   was   completed   by    the    anesthesi-             ings were required to be  assigned  to  these  classifications.
                      ologist    during    his    preyperative    examination.     This             The  classifications  were   made   by   the   anesthesiologist
                      method   was   chosen   because   it   was   assumed   that   the             and  reviewed  by  the  author.  The  classifications,  by  the
                      anesthesiologist    would     @ormally     obtain     information             blood  pressure  criteria  of  the   National   Health   Survey
                      about  hypertension  and  related   drug   therapy   during   his             (5), were as follows:
                      routine  preoperative  visit,   and   he   therefore   would   be             Hypei-tensive  (A  systolic   blood   pressure   greater   than
                      able  to  complete  the  questionnaire   with   a   few   minutes             or equal to  160  mm  Hg  or  a  diastolic  blood  pressure  of
                      additional   time.   If   time   permitted,   the   questionnaire             95 mm Hg or greater, or both.)
                      was   completed   each   day   for .all   patients   seen   preoper-                 1 .All   patients   with   hypertensive    blood    pressure
                      atively   by   the   anesthesiologist.   When   this   was    not                    this admission.
                      possible,  a  number  was  assigned  to  each   patient   to   be                    2. Regardless   of   blood    pressure    this    admission,
                      seen  on  rounds,  and   a   predetermined   total   of   numbers                    all   previously   hypertensive    patients    who    had
                      was   drawn   at   random   from   a   "goldfish   bowl";   these                    been or were currently under treatment.
                      were   the   patients   whose   questionnaires   the   anesthesi-             Borderline-Hyperteiisii,e   (A    systolic    blood    pressure
                      ologist  completed  on  that  day.                                            less  than  160  mm  Hg  and   a   diastolic   blood   pressure
                       The  questionnaire  consisted  of   four   parts:   1,   identi-             less  than  95  mm  Hg,  but  not  a  systolic  blood  pressure
                      fying  information;  II,  chart  review-  III,   patient   inter-             less  than  140  mm  Hg  with  a   diastolic   blood   pressure
                      view; and IV,  classification.  Parts  11  @d  III  provided  the             of less than 90 mm Hg.)
                      information   for   Part   IV.   The   history   and   mode    of                    1. All   patients   with    borderline-hypertensive    blood
                      detection  of  the  hypertension,   drug   therapy,   source   of                    pressure   this   admission   but   not   previously   or
                      medical   care,   and   current   blood    pressure    recordings                    currently treated hypertensive patients.
                      were  noted.  A   pretest   of   the   questionnaire   was   con-                    2. All   patients   with   normal   blood   pressure    this
                      ducted   on   26   patients   at   one   of   the   participating                    admission    who    were    previously     borderline-hy-
                      hospitals.  An  average  of   15   to   20   minutes   additional                    pertensive  and  who   had   been   or   were   currently
                      time  was  reoiiired  for  its   completion,   but   considerably                    under treatment.
                      less   time   was   needed   for   the   normotensive   patients.             Normotensive  (A  systolic  blood   pressure   of   less   than
                      Since  only  a   slight   modification   in   the   questionnaire             140  mm  Hg  and  a  diastolic  blood  pressure  of  less  than
                      was  made  after  the  pretest,  the  data  on   these   26   pa-             90   mm Hg.)
                      tients are included in the totals.                                                   1. All   patients   with   normal   blood   pressure    this
                        Data   from   the   questionnaire   were   coded   for    corn-                    admission    who    were     previously     normotensive.
                        * Questionnaire available -from the National Auxiliary  PubUcations                2. All   patients   with   normal   blood    pressure    who
                      Service of the American Society  for  Information  Science,  c/o  CCM                were    previously    hypertensive     or     borderline-hy-
                      Information Corp.i 866  Third  Ave.,  New  York,  N.Y.  10022.  Order
                      Document NAPS 01953, renu'tting $2.00 for a microfiche or  $5.00  for                pertensive    but    who    were    not    previously     or
                      a photocopy.                                                                         currently under treatment.
                      Table  1.  Age  and  Sex  Comparison  in  185   Hospitalized   Study   Patients and the GDVRMP Populations*
                            Age                              Men                                           Women                              Both Sexes
                                                  Patients         GDVRMP                   -.Patients         GDVRMP                  Patients                  GDVRMP
                        yr                                                                                 %
                      35-44                            8.7             12.6                         22.2          13.5                    30.9                26.1
                      45-54                            9.2             13.4                         15.1          14.7                    24.3                28.1
                      55-64                           11.9             10.4                         12.4          11.9                    24.3                22.3
                      65 or older                      9.7                9.6                       1018          1 3-  9                 20.5                23.5
                          Total                       39.5             46.0                         60.5          54.0                    100.0                   100.0
                          GDVRMP       Greater Delaware Valley Regional Medical Program.            % - percent of total population age 35 years or older.
                      20      January 1973    Annals of internal Medicine    Volt!me     78 Number    1


                 Table 2.  History  of  Hypertension  of  51  Untreated  and  Treated  Hypertensive  Patients
                    Age                                         Untreated                                                        Treated
                                            With                 Without                    Total                 With               Without                  Total
                                          History*               Historyt                                     History*               History t
                    yr                         +-                                                     110.
                 35-44                        4                      0                        4                      4                   0                      4
                 45-54                        4                      2                        6                      5                   0                      5
                 55-64                        9                      2                       11                      9                   0                      9
                 >65                          3                      2                        5                      7                   0                      7
                    Total                      20                    6                       26                      25                  0                     25
                      History of hypertension from chart, interview, or from both chart and interview.
                    t No history of hypertension from either chart or interview.
                 Results                                                                      line-hypertensive   patients   than   it   was   for    the    normal
                                                                                              patients,   although   the    difference    was    not    significant
                    Table   1   shows   the   age   and   sex   distribution   of   the       (P   >   0.6).   Comparison   of   the   treated   with    the    un-
                 survey    population,    with     comparative     data     for     the       treated   groups    of    hypertensive    patients    who    had    a
                 population    of     the     Greater     Delaware     Valley     area.       history    of    hypertension    (Table    4)    shows    that    the
                 These   data   indicate   that   the   sample   of   the    population       treated patients were more likely to have              been      seen
                 surveyed    conformed    closely    to    that    of    the     entire       for   hypertension   within   the   past   3   riionths.   It   would
                 region,   with   the   exception    that    white    men    aged    35       be    anticipated    that    patients    under    treatment     would
                 to   54    years    were    under-represented    and    white    women       be  seen   at   more   frequent   intervals,   but   the   relatively
                 Of from 35 to 44 years of age over-represented.                              large    number    of    known,    untreated     hypertensive     pa-
                    The    distribution    of    the    survey    population    accord-       tients  not  seen  for  at   least   a   year   suggests   inadequate
                 ing   to   the   classifications   previously   described    was    as       follow-up.
                 follows:   51   patients   (27%)    were    classified    as    hyper-          In   further   analyzing   the   causes   for   lack   of   treat-
                 tensiv@,    26    (14%)     of     whom     were     not     currently       ment,    however,    failure    of     follow-up     ranked     among
                 under    treatment;     26     patients     (14%)     were     border-       the   lowest.   Of   the   26   patients   not    under    treatment,
                 line-hypertensive,    none    of    whom     were     under     treat-       there  was  failure  of  follow-up  in   only   1.   Nine   patients,
                 ment;    and     108     patients     (58%)     were     normotensive.       one    currently    borderline    and    eight    currently    hyper-
                 The   27%    classified    as    hypertensive    is    greater    than       tensive,    had    either    discontinued    treatment     themselves
                 the     23.5%     anticipated     from     the     National     Health       or   by   the   advice   of   their   physicians.    Treatment    had
                 Survey   data,   which   were   adjusted   for   the   age   of    our       been    discontinued    in    another     five     patients     whose
                 study    population.    But     the     National     Health     Survey       blood   pressures   had   returned   to   normal.   Of   the    other
                 data   were   based   on   current   status   and   did    not    take       11   patients    not    under    treatment,    6    did    not    ave
                 into   account   a   previous    history    of    hypertension    (see       a   history   of    hypertension    and    presumably    were    pre-
                 below).                                                                      viously    undetected    hypertensives,     treatment     was     de-
                    The   presence   or   absence    of    a    history    of    hyper-       ferred  pending   further   evaluation   in   1,   and   the   reason
                 tension    among    the    51    hypertensives    is    analyzed    in       was   unknown   in    4    patients.
                 Table   2.    AR    patients    currently    under    treatment    and          Table   5   shows   the   current    status    of    the    survey
                 77%    of    those    not    currently     under     treatment     had       population.   In   contrast   to    the    previous    tables,    the
                 either   been   told   they   were    hypertensive    or,    as    in-
                 dicated   in   the   hospital    chart,    their    physicians    were       Table 3. Patient Visits In Past Year to  Primary  Source  of  Medical
                 aware    of    the    presence    of     hypertension.     The     six       Care
                 patients   without   a    history    of    hypertension    were    all       Primary       Normal
                 currently    hypertensive,    and    none    had    received    treat-       Source of     Blood       Borderline          Hypertension
                 ment at any time.                                                            Medical       Pressure  Hypertension     Untreated          Treated
                    To   determine   why    patients    were    not    being    treated         Care     Visit      No  Visit   No
                                                                                                                 visit         Visit  Visit   No      Visit      No
                 @for   hypertension,    several    factors    were    analyzed.    One                                                       Visit           visit
                 factor   was   the   possible   lack   of   a   primary   source    of                     4                      no.
                 medical    care.    AU    patients,    however,     whether     hyper-       Physician     83       10   23     2       20     2       22      1
                 tensive   or   not,   identified   a   primary   source   of   medical       Hospital
                 care   (Table    3).    Furthermore,    the    percentage    of    pa-         clinic      9        3     0     0       2      0        2      0
                 tients   who   had   visited   their    primary    source    in    tie       Other         3        0     1     0       2      0        0      0
                 past   year   was   higher   for   the   hypertensive   and    border-         Total       95       1 3  24     2       24     2       24      1
                                                                                                                           Langfeld   Care in Hypertension      21


                    Table 4. Interval Since Last  Visit  to  Physician  or  Clinic  For  Hy- which   could   be   anticipated   from   the    small    numbers
                    pertension:  Untreated  and  Treated  Patients  with  History   of   Hy- in  each  group,  despite  the  finding  that  the   distribution
                    pertension                                                             of   the   survey   population   conformed   closely   to    that
                               Interval                          Patients                  of  the  entire  region.  It  is  evident  that  a  larger  study
                                                          Untreated             Treated    would  be  necessary  if  we  wished   to   direct   our   atten-
                                                                                           tion  to  one  or  more   of   these   individual   groups,   but
                                                                     no.                   the   data   obtained   from   the   survey   strongly    suggest
                    Less than I month                            3             4
                    1 to 3 months                                4             15          that these methods could be used in such a study.
                    More than 3 to 6 months                      2             4           With  respect   to   the   main   objective,   the   study   con-
                    More than 6 months to I year                 0             1           firmed  our  assumption  that   the   extent   of   the   problem
                    More than I year                             5             1
                    No data                                      6*            0           of    the    detection    and    management    of    hypertension
                    Total patients with history of                                         in  the  Greater  Delaware  Valley  area  is  the  same   as   in
                    hypertension                                 20            25          other   parts   of   the   country.   Wilber   and   Barrow   (6)
                    Total patients hypertensive at
                    admission                                    26            25          have   reported   on   a    survey    conducted    in    Atlanta,
                    * All six seen by primary sources in past  year,  not  ne,  ssarily  for Georgia.  A   comparison   of   the   results   of   this   study
                    hypertension.                                                          with  those  of   the   Wilber   and   Barrow   (6)   study,   in
                    classification  of   these   data   is   based   on   the   blood      which  the   criteria   were   adjusted   for   age,   and   with
                    ressure   readings   at   the   time   the   survey   was    con-      data   from   the   study   of   Wilber   and   colleagues   (7),
                    p                                                                      where  the  criteria   were   unadjusted   as   in   our   study,
                    ducted,   irrespective   of   previous   history.    With    this      is  shown  in  Table   6.   Our   data   compare   more   closely
                    selection  of   blood   pressure   values   for   classification,      with  that  of  the   adjusted   data   of   the   Wilber   study
                    which  provide   data   comparable   -to   those   of   the   Na-      because  of  the  process   of   selection   in   both   studies.
                    tional  Health  Survey,  26  (14  %  )  of  our   patients   were      Making   the   criteria   for   hypertension    more    stringent
                    hypertensive,   a   prevalence   less   than   the   23.5%    ex-      for   the   unselected   population   of   the   Georgia   survey
                    pected   for   the    Greater    Delaware    Valley    population      had  an  effect  on  the  results  similar   to   that   of   the
                    of   age   35   and   older.   Comparisons   within   each   age,      selection  in  our  survey  of  a  population  in   the   medical
                    sex,  and   race   group   indicated   that   the   fewer   older      care   system-namely,    a    decrease    in    the    percentage
                    and    fewer    black    hypertensive    patients,    and    more      of   patients   with   undetected    hypertension    and    hence
                    middle-aged,   white   male   hypertensive   patients   in    the      an   increase   in   the    percentage    receiving    medication
                    survey   population   accounted   for   the    differences.    Of      and  under  control.   On   the   other   hand,   selection   had
                    particular   importance   were   the   findings   that,   of    a      n, o  effect  on  the  percentage  of  patients  receiving  medi-
                    population    of    26    currently    hypertensive     patients,      cation  who   were   under   control,   since   the   same   cri-
                    hypertension    was    unreco    'zed    in    6    (23%);     10
                                                  gm                                       teria  for   control   were   used,   and   all   such   patients
                    patients,   including   these   6,   (39%)    had    never    re-      were   obviously   receiving   medical    care.    Thus,    where
                    ceived    treatment;    and    8    (31%)    had     discontinued      selection  was  not  a  factor,  all  three  sets  of  data   are
                    therapy.  An additional       29          borderline-hypertensive      quite comparable.
                    patients   (16%   of   the   survey   group)   were   not   under
                    treatment.   Furthermore,   8   (32%)   of   the   25    patients
                                                                                           Table 5. Current Status* and History of Hypertension of  185  Pa.
                    under  treatment  were       still    hypertensive,    and    ten      tients
                    (40%)    had    blood    pressures    that     remained     above         Current Status         History of     No  History   of   Total
                    normal levels.                                                              of Patients        Hypertension   Hypertension
                    Discussion                                                                                                          no.
                      The  main   objective   of   the   study   was   to   determine      Never treated
                    whether   the   extent   of   undetected,   untreated,   or   in-         Normal                        2               106            108
                    adequately   treated   hypertension   in   the   Greater    Dela-         Borderline                    5                21            26
                                                                                              Hypertensive                  4                 6            10
                    ware   Valley   area   was   comparable   with   that    reported      Previous but not
                    by  other   studies.   A   secondary   objective   was   to   de-          current treatment
                                                                                              Normal                        5                 0            5
                    termine   the   reliability   of    the    survey    methodology.         Borderline                    3                 0            3
                    Although   the   study   was   not   undertaken   to    determine         Hypertensive                  8                 0            8
                    the  prevalence,  of  hypertension  in  the   area,   the   meth-      Under treatment
                                                                                              Normal                        7                 0            7
                    ods  used  in  the  study  did   show   an   overall   prevalence         Borderline                    10                0            10
                    of   hypertension   acceptably   close    to    that    expected.         Hypertensive                  8                 0            8
                    When    prevalence     data     were     compartmentalized     by      Total                            52              133            185
                    age,  sex,  and   race,   there   was   a   poorer   correlation,         * Based on current  blood-pressure status.
                    22     January 1973 -  Annals  of  Internal  Medicine  -  Volume  78  -Number    1


                         Table   6.   Comparison   of   Hypertension    Surveys                            can  reduce  the  number   of   undetected   hypertensive
                                                                                                           persons.  But  unless  the   follow-up   and   management
                                                        GDVRMP                Wilber    Study*             protocols    suggested    in    that     r.eport  are  carried  out,
                                                           Study*       Unadjusted             Age-        there will  not  be  an  appreciable  reduction  in  mor-
                                                                                           Adjusted        bidity and mortality. For, as this study  has  confirmed,
                         Patients examined, no.             185            6012                6012        it is necessary that the  physician  recognize  the  need
                           Elevated blood                    22.9             28.5           22   .6
                              pressure t, %                                                                for initiating treatment of hypertension  and  that  both
                           Taking medication for             13.4             13             13            he and the  patient  recognize  the  need  for  effective
                             hypertension, %                                                               control of the blood pressure  over  an  extended  period
                         Hypertensive patients t, no.        43            1713                1358
                           Unknown, %                        14               27.1           19.4          of time.
                           Taking medication, %              58               45.4           57.3          ACKNOWLEDGMENTS:    The    author    is    indebted    to    Drs.     Dana
                           Under control t, %                39.5             28.6           36            Cox,  Anthony  Fazio,  Sing-In-Song,  and  Mario  TronceIliti   for   com-
                           Taking medication under           68               62.9           62.9          pleting  the  questionnaires  and  to  Drs.  Judith  Mausner   and   Hyman
                             control t, %                                                                  Menduke  for   their   advice   on   the   design,   implementation,   and
                                                                                                           analysis of the study.
                            The definition of hypertension for   the  GDVRMP   and   Wilber   unad-          Supported  by  grant  #5   G03   RM   00026-03AI   from   the   Regional
                         justcd studies was a blood pressure    greater than  or  equal  to  160/95        Medical  Programs  Service,  U.S.   Department   of   Health,   Education,
                         mm Hg for  all  ages;  for  the  age-adjusted  Wilber  study  hypertension
                         was defined for ages 15 to 39 years as greater than  or  equal  to  160/95        and  Welfare,  Washington,  D.C.  The  conclusions  do   not   necessarily
                         mm Hg, for ages 40 to 64  years  as  greater  than  or  equal  to  170/100        represent the views of the granting agency.
                         mm Hg, for ages  of  65  years  or  more  as  greater  than  or  equal  to          Received  24  July  1972;   revision   accepted   11   September   1972.
                         180/110   mm   Hg.   GDVRMP   =   Greater   Delaware    Valley    Regional
                         Medical Program.                                                                  0-  Requests  for   reprints   should   be   addressed   to   Stephen   B.
                           t  Includes  borderline-hypertensive  patients  and   normotensive   pa-        Langfeld,  M.D.,   Greater   Delaware   Valley   Regional   Medical   Pro-
                         tients currently under treatment.                                                 gram, 551 W; Lancaster Ave., Haverford, Pa. 19041.
                           t For all studies control  was  defined  as  less  than  160/95  mm  Hg.
                                                                                                           References
                           Unlike  reports  such  as  that  of  Frohlich  and  col-                        1. VETERANS   ADMINISTRATION     COOPERATIVE      STUDY      GROUP      ON
                                                                                                             ANTIHYPERTENsivE   AGENTS.   Effects   of   treatment    on    morbidity
                         leagues  (8),  who  have  audited   hospital   charts   to                          in   hypertension.   Results   in   patients   with   diastolic    blood
                         determine  deficiencies  in  the  detection,   evaluation,                          pressures   averaging   115   through   129    mm    Hg.    JAMA    202:
                                                                                                             1028-1034i 1967
                         and  treatment  of  hypertension  during  hospitalization,                        2. VETERANS     ADMINISTRATION      COOPEMTIVE      Snmy      GROUP      ON
                         our  study  used  a  hospital  population  to  obtain  in-                          ANTIHYPERTENSIVE   A(;ENrs:   Effects   of   treatment   on    morbidity
                                                                                                             in  hypertension.  11.  Results  in  patients   with   diastolic   blood
                         formation  concerning  these  deficiencies   before   hos-                          pressure   averaging   90   through   114   mm   Hg.   JAMA    213@1143-
                         pitalization.  Our  study  thus  reflects  the  status  of                          1152, 1970
                                                                                                           3. VETERANS     ADMINISTRA'NON      COOPFRATWE      SUMY      GROUP      ON
                         hypertension in the  ambulatory  setting,  and  therefore,                          ANTIHYPERTENSIVE   AGENTS:   Effects   of   treatment    on    morbidity
                         our results bear directly  on  the  place  where  the  de-                          in.hypertension.  111.  Influence  of  age,  diastolic   pressure,   and
                                                                                                             prior  cardiovascular  disease;  further  analysis  of   side   effects.
                         tection  and  proper  management  of   hypertension   must                          Circulation 45:991-1004, 1972
                         be  conducted-in  the  c@c  or  the  physician's   office.                        4. HYPERTENSION    STUDY    GROUP    OF    THE    INTER-SOCIETY     COMMIS-
                                                                                                             SION   FOR    HEART    DISEASE    RESOURCES:    Guidelines    for    the
                                                                                                             detection, diagnosis and management of hypertensive po               pu-
                         Conclusion                                                                          lations. Circulation 44:A263-A272, 1971
                                                                                                           5. tJ.S.    DEPARTMENT    OF     HEALTH,     EDUCATION,     AND     WELFARE
                           The  study  has  shown  that  even  among  a  group   of                          NATIONAL    HEALTH     SURVEY:     Hypertension     and     Hypertensive
                         currently  hypertensive  patients  who   had   visited   a                          Heart   Disease   in   Adults.   United    States-1960-1962.    National
                                                                                                             Center  for  Health  Statistics.  U.S.  Public   Health   Service   Pub-
                         primary  source  of  medical  care  in  the   past   year,                          lication  No.  1000,  Series  11,  No.  13.  Washington,  D.C.,   Super-
                         hypertension  was   often   unrecognized   or   untreated.                          intendent of Documents, 1966
                                                                                                           6. WILBER   JA,    BARROW    JG:    Hypertension-a    community    problem.
                         Furthermore,  when  treatment  was   initiated,   it   was                          Am J Med 52:653-663, 1972
                         frequently  discontinued  or  ineffective.                                        7. WILBER  JA,  BALDWIN  MD,  CAPITON  D,   et   al:   Ile   Atlanta   high
                                                                                                             blood   pressure    program.    Methods    of    community    screening.
                           Screening   programs   for   the'detection   of   hyper-                          Circ Res. In press
                         tension, as  recommended  by  the  report  of  the  Inter-                        8. FROHLICH   ED,   EmmoTr   C,   HAMMERSTEN   JE,   et   aI:    Evaluation
                                                                                                             of  the  initial  care  of   hypertensive   patients.   JAMA   218:1036-
                         Society  Commission  on  Heart  Disease   Resources   (4),                          1038,1971

                                                                                                                                       Lansfeld     Care In Hypertension         23


                                               BY NIARGARET A. NEWCOMBE

   Okfter nearly eight years of advertising,                          "Darringt n Needs a                 Doctorilt
                                                                                     0
                             the sign at the town limits                   now reads,
                              "WELCOi-VIEF- GRETCHEN                   and LYNN!"

                                     verybody in the district knows   that the  greeting
                                  Eis for two registered nurses       who   operate    the
                                  Darringtoii Clinic and  are  available  for  emergencies
                                  24 hours a day.  Besides  the  1100  residents  of  this
                                  small lumbering town,  tucked  into  the  western  slope
                                  of  the  Cascade  Mountains  in  northwest   Washington,
                                  the nurses'  patients  also  include  the  1300  farmers
                                  and lumbei-ers in the surrounding area.
                                    Since  April  10,  1972,  when  most   of   the   town
                                  turned  out  for  the  Clinic  openin-,  complete   with
                                  cookies  and  cake,  the  two  RN's  have  recorded   an
                                  average  of  600  patient  visits  a  month.  They  have
                                  been loaded  aboard  a  helicopter  to  reach  an  acci-
                                  dent deep in the Woods. have  rid(len  the  town's  fire
                                  engine-ctim-ainbtilance   for   emergency   calls,   and
                                  have delivered a baby that wouldn't Wait.
                                    All the Nvhile they have been  under  the  microscopic
                                  inspection  of  health  planners,  state  agencies   and
                                  other comi-niinities, not to mention tile lights of  the
                                  TV  camei-,is  and  the  barrage   of   questions   from
                                  newspaper reporters from  big  cities  and  small  towns
                                  alike.
                                    What  makes  the  Darrington  Clinic  interesting   to
                                  all       @t-oiti)s ;s II(-); j@nly tilit it is tlic,, fil@st rural
                                  Clinic ]II tile st@itt-@ to ol-)er,,ttecl by 1)i-iiiiziry care


                  nurses,  nor  that  it  points  a   new   way   to   delin-ei-                        ed   addit'                     for  the       two
                                                                                        ai%-,i@,  1)ro@'id         joiial  training
                  medical care    to   isolated   communities,   but   that   the       litil'se pioneers and gT@inted    three  n-iontli's  seed   men-
                  Clinic,    like    its    signs,     is   homemade            and     C)r to put the Clinic into operation.
                  homegrown.                                                               liotli the town and  the  I-ILirses  are  happy  -%vith  the
                     This small   comniuiiit%, or-anized itself  to  fiii(i  its                        The iiiii-ses  deal  -,with  da),-to-day  prob-
                  own solution.    In an effort to  entice  a  resident  1)li%si-       lenis, from sutures to -,vell-bab,,%,  clinics.  They  consult
                  cian,  it  built  and  equipped  a  modern  clinic  in  19()7.        frequent]),  with  the  I)ack-tip  physician   in   Arlington,
                  It made its     pliglit   known   by   advertising   far    and       refer  patients  to  their   own   personal   physicians   and
                  wide. Finally   in the  fall  of  1971,  it  called  upon  the        to the Arlington hospital when necessary.
                  Mlashington/Alaska Re,-,ioiial @%ledical               am    for         'I'Iiir(I-I)ai,ty  payment  is  one  of  the  biggest  rocks
                  help;   an   organization    which    wrestles    almost    dailN,    in  the  road.  At  present  the  Clinic  paN?s  75   percent   of
                  with the maldistribution of doctors problem.  .                  ,    its  i%-a),.   FLind-i-aisin(y   events   and   ilonatioiis   from
                     This   Regional   Nfedical   Program   (RNIP),   one   of   the    coiiii-niiiiitv   businesses   and   industry    make    up    the
                  56   in   the   country,   covers   territory   that   encompasses    difference    teinporaril),.    The    Clinic    receives     pay-
                                                                                        iiieiits from private instii-,tii
                  one  fifth  of  tIie  land  mass  in  the   U.S.   Its   area   of                                     ce       companies,State     Dt'vi
                  activity   includes   medical    communities    spread    fartlier    sioii   of   Social   and   Health   Services    (Nvelfare)    and
                  apart   than   Los   Angeles   and   Chicago.   The    ratio    of    '.\Ie(licaid,   and   from   the   State   Department   of   Labor
                  physicians   to   population   varies    enormously.    For    ex-    and  Industries,  but   is   still   unable   to   collect   Medi-
                  ample,  the  physician  ratio   in   the   densely   pol-)tilatecl    care  1).t\.iiients  as  regulations  require   a   physician   to
                  Greater  Seattle  area  is  one   for   380   persons   while   in    be 1)IiN,sically present.
                  smaller   Washington   and   Alaska    districts    there    ma-,.       The    congressmen    from    the     Darrin(rton     district,
                  be only one M.D. for 8,000 persons.                                   with  another  IVasliin@toii   State   collea-tie,   is   pressing
                     The    community    health    service    program     of     the    Social   Security   to   make    A@'ashingtoii    a      emonstra-
                  RMP  was  organized   in   1970   to   provide   help   to   local    tion   area   and   allow   ',\Iedicare   payments   to   properly
                  communities   outside   the   large   metropolitan    areas.    It    ot-,anized   and   supervised    nurse    practitioner    clinics.
                  maintains  a  staff  of  seven  field   representatives   to   aid    Because   many   elderly   people   live   in    the    lower-rent
                  communities    in    ideiitif%ling     their     health     needs,    rural areas, this is an important point.
                  documenting    them    and    organizing     to     meet     them.       Already    other    communities     are     trying     Darring-
                  One   representative   was    assigned    to    answer    Darrina-    toii's  health   iiianl)oiver   Solution.   Two   nurses   operate
                  ton's call for help.                                                  a  cliiiic   for   6,000   residents   on   Vashon   and   i%faury
                     Together with       the   community,   all    possible    aN-e-    Islands  ill   -Puget   Sound.   Residents   there   conducted   a
                  .nues for delivery     of  health   services   ivei-c   explore(].    liotise-I)N--liotise  stii-N,ev and     formed      a      community
                                                                                                 I                 I
                  such as a National     Health   Services   Corps    assi(,rnmeiit,    Board  of Trustees. A         physician    from     the     "main-
                  use  of  a  Medex,   sh,-triii-   of   pli)?sicians.   Eventutllx.            in nearby Seattle     attends  the  clinic  two  (lays   a
                  having  elected   a   Board   of   Trustees,   the   commtjiiit-,-    week   and   idditional   backtip   is   provided    by    several
                  decided   to   try   the   nurse   practitioner    soltition.-RN's    hospitals ill Seattle.
                  willing  to  live   in   Darrin-ton   and   participate   in   the       Fai-tlicr  north  in  Pticet   Sound,-   in   the   tinincorpo-
                                                -reeved.    Two    public     health    rated  -area  of  Lon,@bi-ancli,  a  t ir         nurse     clinic
                  experiment were  interN                                                                        0
                  nurses  were   selected,   the   Clinic   was   refurbished,   and    Opened   Iite   in   Octol)ej-.   It,   too,   is   a    community
                  the sign was repainted.        In   April,   ten   months    after    effort,  the  Result  of  a  health  stir,.@ev  by  local  voltin-
                  RMP   was   first    contacted,    the    Clinic    opened.    The    teers.    It    is    open    Friday    and    Saturday     during
                  Board   has   responsibility   for   the   operation,   pron,i(les    dantiiiie   hours   and   serves   seven    smaller    communities
                  maintenance,     bookkeeping     and     promotional     services,    in  the  area   that   are   ivitliotit   public   transportation.
                  struggles  with   the   bills   and   untangles   the   miles   of    A  public health     'nurse  is  N7oltinteerino,  her   time   for
                  inevitable red tape.                                                  the  first  three  months  to  -et  it   started   and   residents
                     RMP  helped   explain   the   function   of   the   Clinic   to    hope to find a retired nurse to take over later.
                  doctors and public               o,,fi(i@ils,         the                                  effect (loes i,.ot stol) N%,itli iie@v  clin-
                  up services  of  a  I)[-i)sician  in  Arliii,,toiir  37  iii@Ic.,,    i(.s. 'I'lic %%'asliiii-toti  St.tie  'N'Llrses  Association  will


          attempt to revise its Nurse Practice Act  in  the  1973  An old parsonage in the Puget Sound back country
          state legislature session to give legal status to  this  is refurbished into a clinic with help from
          new  nurse  practitioner,  as  California,  Idalio  and  volunteer Roger  Hill and Nurse Jeanne Brodsack.
          New  York, have already done.
            The School of Nursing  at  the  University  of  Wash-
          iiigton, recognizing the growing need  for  such  prac-
          titioners in rural  areas  and  for  the  provision  of
          long-term care as well, prepared a proposal  to  train,
          place and evaluate nurses in  their  independent  role.
          The   proposal   was   approved   by   the   W/A   RMP
          Advisory  Board  and  awaits  funding  decisions  next
          Ma
             Y.
            Nlakin health care available and accessible  to  the
                  9
          majority of our  citizens,  wherever  they  happen  to
          live, is a vast problem. There are  many  pathways  to
          this goal. IVith the groNving conviction on  the  part
          of many, including some physicians,  that  the  doctor
          cannot be the sole provider of medical  services,  the
          role of other health personnel  will  change  and  ex-
          pand. The nurse clinic is  one  answer  to  a  compli-
          cated problem.
          Ms. Newcombe   is a coniiiiiinication specialist on the
          staff of the Was
       @rof.!: M@.

                                              IL

                                                                                          Vashon Island Clinic
                                                                                          and RMP staffs
                                                                                          discuss the nurses'
                                                                                          new role.


                                                                    A System of  Patient  Care
                                                                          Based on  Patient  Needs

                                      In this "Nurse Utilization: A  Patient  Care  Systems  Project,"  the
                                      emphasis was on starting with the patient  and  his  needs  and  then
                                      designing systems to meet them. As the authors point out, ". . . if pa-
                                      tient needs are designed for, the nurse will be utilized correctly.                                  @)

                                                                                 JANET      M.      KRAEGEL      o      VIRGINIA       SCHMIDT
                                                                          RAMESH     K.     SHLTKLA      *      CHARLES      E.      GOLDSMITH

              HE    primary      purpose of   a   hos-  their  decisions  will   meet   patients'   recovery,   regardless   of   the   excel-
           Tpitat   or   extended   care    facility,   needs  in  the  best  possible  way,  and   lent  "disease  care"  he   may   receive.
           it is generally  recognized,  is  to  meet   without  increasing  the   already   high   The  question  then  to   be   asked   is:
           the   patients'   needs.   People   within   costs of hospital care.                     what occurs to so    radically   displace
           the institution  work  within  their  dis-     But are  the  patients'  needs  actual-   the best intentions   and   decisions   of
           ciplines  or  departments  to  carry   out   ly  being,  met?   This   is   debatable.   hospital personnel   and    professionals
           this  purpose  directly   or   indirectly.   Hospitals subject  the  patient  to  bed-   as   they   endeavor   to   meet   patient
           Thus,    physicians    write    diagnostic   lam,  according   to   Friesen.'   Taylor   needs  in   their   everyday   work   sit-
           notes  and  therapeutic   orders;   nurses   speaks  of   the   dehumanizing   effects   uations?
           specify  how  the  care   process   should   of  the  admission  process.2  Duff   and      Patient   care   systems   within   the
           be   carried   out;   and   administrators   Hollingshead  report   how   the   socio-   hospital  are  complex.   Every   decision
           and    department    heads    decide    on   psychological  dimensions  of   the   pa-   made   with   the   intention   of   meet-
           policy,   procedures,    and    equipment.   tient  care  process   are   ignored   by   ing   patients'   needs    has    numerous
           All   of   these   persons   expect   that   the  health  team.3  When  the  staff  of   ramifications,   some   of    which    may
                                                        the  project   to   be   described   here   create  problems   elsewhere   or   cancel
                                                        asked   100   senior   nursing   students   out   the   effectiveness   of   decisions
           The  four  authors  composed  the   inter-   if they felt  patients'  needs  were  be-   made  by  another   area   of   operation.
           disciplinary team for the project     de-
           scribed in  this  article.  MRS.  KRAEGEL    ing met in  the  various  clinical  set-    An  example  is  the  way  in   which   a
           and   MM   SCEMIIDT,   both    of    them    tings,  only  one  student  answered  in    new   unit    management    system    can
           nurses with  masters  degrees  from  Mar-    the affirmative.                            be  disruptive.  Often,  when  unit   man-
           quette  University,  Milwaukee,   Wiscon-      If the hospital  organization  is  in-    agement    starts     making     unaccus-
           sin,  served  as  project  director   and    deed  not  meeting  its   primary   pur-    tomed  demands   on   ancillary   depart-
           associate  director,  respectively.   MR.    pose,  there  is  reason   for   tremen-    ments,  the  resulting   resistance   ma-
           SHUKLA, with  a  thasters  in  industrial
           engineering  from   the   University   of    dons  concern.  Basic   needs   are   at    neuvers  can   cause   even   more   com-
           Wisconsin,  Madison,  was   the   systems    once     biochemical,     neuromuscular,    plex   procedures   to   be    developed,
           design   engineer,    and    DR.    GOLD-
           SMITH,   who   holds   a   doctorate    i.n  and psychological  states.  And  a  hos-    thereby   increasing   everyone's    work
           clinical  psychology  from  Boston   Uni-    pital's  failure  to  provide  effective    load.
           versity, was  the  project  psychologist.    systems  to  meet  these   basic   needs       Those   who   are   called   upon   to
                                                        can retard the  patient's  progress  and    make  institutional   decisions,   there-

           APRIL, 1972    VOL. 20, NO. 4                                                                                                  257


              fore,  need  some   way   to   assess   all    cesses  it  establishes  to  meet  patient     e@i(Lnal     Medical     Program,     Inc.
              aspects  of  the   situation,   to   under-    needs,  but  also  attests  to  what   can     (WRKffj-,-n@d-f   n@iri-g-   a@s    a@pro-
              stand  the  intricate  inter  lay  of   the    be   accomplished   when   a   group    of     priated   through   WRMP   as   of    Sep-
                                          p
              various   parts   of   the   total   sysem.    dedicated    professionals    work     to-     tember 1969.
              Of   greatest   importance,    they    must    gether   in   their   own   community   to       An  initial  search  of  the  literature
              be  able  to   identify   and   acknowledge    make   changes   in   the   delivery    of     revealed  that  most   nurse   utilization
              the  primacy  of  the  patient's  need  re-    health care.                                   studies   were   concerned    with    what
              quirements   when   a   decision    between       When   the   hospital    administrators     the  nurse   was   doing   and   how   she
              alternate  solutions  is  called  for.   It    in  the  Hospital   Council   of   Greater     perceived  her  role,  but   only   rarely
              is the inability to  do  this  that  causes    Milwaukee    Area    decided    to     "do     was  any  objective   rationale   present-
              the  discrepancy  between  the   ideas   of    something   about   the    nurse    short-     ed  for  what  the  nurse  should  be  do-
              the   hospital   organization    and    the    age,"    members    of    the    Milwaukee     ing.  Neither  was   there   clear   iden-
              actual process of delivering care.             League   for   Nursing   (now    a    Com-     tification    of    the    complex     and
                                                             munity    Action    Group)    asked     to     interrelated   factors   that    prevented
              A SYSTEMS APPROACH                             work   with   the   administrators.    The     the  optimum   use   of   nursing   skills
                This  article  describes    a      demon-    result  was  a  joint  committee  of   six     even   when   the   nurse   was   relieved
              stration  project  that  used  a   specific    members   (three   from    each    organi-     of many non-nursing tasks.
              systems  approach  to  identify   the   re-    zation),  who  worked  together   in   ar-       In  order  to  study  the  factors  that
              lationship   between    the    hospitalized    riving   at    a    mutually    determined     affected  the  nurse's   functioning,   we
              patient  and  what  is  required  to   meet    course of action.                              decided  to   use   a   systems   approach
              his   needs.   A   multidisciplinary   pro-       In the  process,  they  identified  two     in the structuring  of  the  project,  and
              ject  staff,  assisted  by  the   personnel    factors:  (1)  the  probability  that  the     sought  the   assistance   of   industrial
              on   the   study   unit,   1)    identified    nurse   shortage    resulted    as    much     engineers  in  WRMP  to  find   the   most
              needs   of   the   hospitalized    patient;    from   poor   utilization   as   from    a     appropriate    systems     method.     The
              2)  followed  a  specific   design   strat-    numbers  shortage;  and   (2)   the   lack     IDEALS   Concept,   a    systems    design
              egy   to   determine   the   best   systems    of   perceivable   benefit   from    nurse     strategy, was chosen.4
              to  meet  these  needs;   and   3)   imple-    utilization studies  to  date.  They  con-     IDEALS CONCEPT
              mented  these  systems  of   patient   care    cluded  that  a  project  should  be   de-
              on  a  39-bed  medical-surgical   unit   in    veloped  to  demonstrate  a   total   plan       This   approach    emphasizes    design-
              a community hospital.                          and  model  of  efficient  and   effective     ing  for  the  function   to   be   accom-
                The   care    systems    were    designed    patient  care.   The   model,   once   de-     plished  by   the   system.   (The   words
              outward   from   the   patient   into   all    veloped,  would  be  used   for   learning     "function"   and   "purpose"   are    used
              parts  of  the  hospital  rather  than  or-    and  actual  work   experience   by   bos-     interchangeably  in  this  design   strat-
              ganizationally,    department    by     de-    pitals throughout the state,  it  was  de-     egy.)  It   soon   became   obvious   that
              partment;  in  other   words,   we   start-    cided.                                         the  function  of  the   hospital   system
              ed   with   what   the   patient    needed,      Step  by  step,   this   committee   en-     is not to  utilize  nurses,  but  to  take
              rather  than    how     the     departments    listed  the  resources   of   the   commu-     care   of   patients.5   Therefore,    the
              and    their    personnel     traditionally    nity.  It  enlarged  its   membership   to     focus  of  the  project  gradually  turned
              functioned.  This   approach   turned   the    obtain  a  broad   working   base,   using     from   nurse   utilization   to    patient
              entire   focus   of   hospital    processes    representatives   from   varied    nursing     care.   The   assumption   was   that   if
              onto   total   patient   requirements   and    educational     programs,     the    state     patient  needs  are  designed   for,   the
              resulted   in   the   development   of   16    board  of  nursing,  the   hospital   area     nurse will be utilized correctly.
              unique    systems    designed    to    meet    planning  council,  a  physician,  a  con-       As  a  result,  the  project's  original
              patient  needs-a  sleep   and   rest   sys-    sumer,     additional      administrators,     title,  "Nurse  Utilization,"  was   main-
              tem,    a    sociopsychological    observa-    and  a  hospital  public   relations   di-     tained, but with the addition o
              tion  system,  and  an   orientation   sys-    rector.   The   administrator    of    St.     Patient  Care  Systems  Project,"  to  re-
              tem   among    others.    And,    as    the    Mary's   Hospital,   Milwaukee,    Wiscon-     fleet  the  new  focus.  This  focus,  to-
              many   systems   were    interrelated    to    sin, offered the facilities of  that  hos-     gether  with  the   original   intent   of
              form   a   unified   whole    for    imple-    pital   for   the   demonstration    unit.     setting  up  a   demonstration,   resulted
              mentation,    basic    concepts     emerged    The   dean   of    the    University    of     in  two   purposes:   1)   to   design   a
              which  can  be  applied  in  the   restruc-    Wisconsin-Milwaukee         School      of     system   of   patient   care   based    on
              turing of any care setting.                    Nursing  offered  a  home  for  the   pro-     patient  needs;  and  2)  to   demonstrate
                                                             ject,  and   faculty   appointments   were     this  system  to  hospital   health   care
              BEGINNINGS OF THE PROJECT                      provided    by    the    University     of     personnel in Wisconsin.
                This  project,  we  believe,   not   only    Wisconsin-Milwaukee     and      Marquette       Three    features    of    the    IDEALS
              speaks   to   health   care   professionals    University.   A   project   proposal   was     Concept     design      strategy-designing
              in  terms  of  the   decision-making   pro-    drafted,   approved   by   the   Wisconsin     towards   a   meaningful   and   necessary

              258                                                                                                                NURSING       OUTLOOK


              function,   using   the   deductive    meth-                 Second,     the     deductive      method               should  help  design  it.   To   this   end,
              od,  and  involving  people   in   the   de-               asks,   in   essence:   "Forgetting    what               project   staff   met   in   weekly    work-
              sign     process-made     this      approach               exists,  what  would  be  the   ideal   way               shops  with  all  unit  personnel   (nurses,
              highly   appropriate   and   effective   for               )f   accomplishing   the   purpose?"    In-               clerks.,  aides,  as   well   as   patients)
              our    project.                                            stead   of   studying   things   as    they               and    with    support    department    per-
                 First,   designing   towards   a   partic-              exist  and  then   attempting   to   change               sonnel   (dietitians,    pharmacists,    and
              ular  purpose   focuses   on   the   results               them,  a  "best  conceivable"   system   is               so  on)  when  the   latters'   areas   were
              to  be  obtained,   not   the   problem   to               developed,        and   what         exists        is     related   to   the   system   being   devel-
              be   solved.   The   question,   "What   are               brought as close  to  this  ideal  as  pos-               oped,  A  total  of  2500   manhours   spent
              we   really   trying   to   do?"    (purpose               sible.  The  creativity  of  this   method-               in    these    workshops    over    a    12-
              of  the  system)  is   asked,   instead   of               ology,  we  believe,  enabled   the   proj-               month   period   resulted   in   the   rough
              the   more   customary,   "What    is    our               ect to  blast  its  way  out  of  the  deep               design   of   16   patient   care   systems.
              problem?"  As   a   result,   the   planning               ruts of patient care tradition.                              The   contributions    of    the    study
              group    begins    immediately    to    seek                  Finally,     the     IDEALS      Concept,              unit  personnel   toward   the   design   of
              the  system  that   ought   to   be   there,               with  its  emphasis   on   meaningful   in-               our   new   patient   care    systems,    we
              and  does   not   merely   try   to   change               volvement  of  people,  states   that   the               found,   were   the   most   essential   re-
              the system that is there.                                  people   who    work    in    the    system               source  in   the   project.   The   exposure
                                                                                                                                   of  the  same   information   to   a   vari-
                                                       PATIENT           NEEDS                                                     ety   of   persons   gave   a   many-faceted
                                                                                                                                   orientation   to   the   problem   and   as-
                 1.  Air                                                                                                           sured   a   decision   based   on   a   wide
                 2.  Rest
                 3.  Sleep                                                                                                         range   of   information.   At   the    same
                 4.  Food                                                                                                          time,  as  personnel   found   their   ideas
                 5.  Fluids                                                                                                        being   incorporated   into   a   new    way
                 6.  Elimination
                 7.  Maintenance of body heat                                                                                      of   doing   things,   they   readily    ac-
                 8.  Maintenance of integument                                       PHYSICAL                                      cepted  innovations,   and   in   many   in-
                            a) Physical hygiene
                            b) Safety (A SURVIVAL NEED)                                                                            stances  could   barely   tolerate   waiting
                 9.  Quiet                                                                                                         until the changes took place.
                 10. Mobility
                 11. Freedom from pain and discomfort                                                                              PATICENTS' NEEDS
                 12. Sensory stimulation
                 13, Autonomy   (freedom   of    choice:                                                                              If  we  are  ever  to  develop   an   ef-
                            power to control one's  life, as                                                                       fective   approach   to   health    care,    it    is
                            long as it does not interefere
                            with others)                                                                              PATIENT      our   belief   that   that   approach   must
                 14. Challenge                                                                                         HEALTH      stem   from   man's   basic   physical   and
                            a) Achievement                                                                              NEEDS
                            b) New things                                                                                          sociopsychologic     needs.     An     early
                 15. Security    (A    SURVIVAL    NEED)                                                                           step  in   the   project,   therefore,   was
                 ,16. Cognitive clarity (knowledge or                                                                              to  identify  those  needs,  as   shown   in
                            satisfactory interpretation of
                            the situation and the future to                                                                        the diagram on the left..
                            enable the person to act)                                                                                 Drawing    on     the     concepts     of
                            a) Orientation
                            b) Health education                          -SOCIOPSYCHOLOGICAL                                       Malinowski,  Murray,  Maslow,  an
                            c) Communication with outside                                                                          Montague,   we    first    identified    the
                               world                                                                                               basic   physical    needs.6-10    We    then
                 17. Humanism (recognition, acceptance,
                            respect, and approval)                                                                                 added       the        sociopsychologic        compo-
                            a) Status                                                                                              nents,   some    of    which    have    been
                            b) Success                                                                                             identified  by   Sidney   lourard   as   re-
                            c) Self-esteem
                            d) Dignity                                                                                             quiring   satisfaction   if   an    organism
                            e) Identity                                                                                            is   to   develop   and   maintain    mental
                            f) Kindly concern by others                                                                            health  through  a  time  of   illness   and
                            g) Privacy
                               (i)  Physical                                                                                       recovery."      Then      we      formulated
                               (ii) Confidential information                                                                       these           sociopsychologic           components
                                                                                                                                   in    terms    of    the    patient's    needs    for
                 18. Reliability (dependability)                                                                                   autonomy,       challenge,       security,       cog-
                 19. Simplicity                                                                                                    nitive    clarity,     and     humanistic     attrib-
                 20. Flexibility                                                       -ENVIRONMENT                     NEEDS      utes.
                 21.     Cost
                            a) Economic                                                                                               The    overall    rationale    for    this     set
                            b) Societal                                                                                            of    needs    was    found    in    the    project's
                 22. Safety of others                                                  I                                           emphasis      on      maintaining      the      sense

                 APRIL,     1972   VOL.   20,   NO.    4                                                                                                                             259


                                                                                                  PATIENT CARE SYSTEMS

                                                                                               Observe, Interpret and Regulate Patient's
                                                                                               Physical and Sociopsychological Functions
                                                                                                          to Meet His Needs

                                                                                                                                                                                                       ce
                                                                                              D(                  p Plan                 Meet            Meet                                          up
                                                                Gathe                                             f                    Physica    Sociopsychological                                   rces
                                                              Informal                        Pro ems        Future Care                Needs           Needs                                    (Pay Bill)

                                           Transport
                                             Patient

                                                                                                                                                                                         cognitive
                                                                                                                                   Rest                                                   Clarity
                                                                                                                                   F I u,7d           Food           Same       Communication
                                                                                                                                                                        I     I (Outside Wori@
                                                                                                                                                     Urination         as
                                                                                                                                                                      for

                                                                                                                                                                     routine

                                                                                                                               Maintenance                           needs,
                                                                                                                                                                        I
                                                                                   E                                                of           F  Sensory          plus ...
                                                                                                                                Body Heat          Stimulation"

                           NOTES:                                                                                                                 Environmental
                           (1) Overall Sequence:                                                                                                  Cleanliness"
                                 Initiate                                                Terminate

                           (2) Sequence (Initiate):
                                 Info.- Assign-Transport
                                                                                                                                                               Waste7
                           (3) Sequence (Observe):                                                                                                            Disposal             [:M:e
                                 Info.-Communicate
                           (4) Sequence (Interpret):
                 z               Diagnose-Actions-Schedule@Communicate                                                                                                      F, - VI    I
                 c:

                 z
                 C)         -These components will not be specifically designed for unless the needs
                 0           are insufficiently met by other systems.
                 c                                                    11 to the others; however,
                           "These components are not "logically similar
                 r           they are sufficiently important parts of most of the others that they
                 0           can be designed more effectively as a separate component.
                 0


            of  the  person   as   an   individual   in     function  of  the   hospital   system,   as    ute   toward   meeting    patient    needs.
            patient   care.   A   specific    rationale     shown in the diagram on the left.                 Four     systems     were     completely
            was   developed   for   each   need,    but       it  was  not  possible  to   design   all    implemented.      Because      transmission
            space  limits   us   to   describing   only     of  the  systems  identified,  but   devel-    of   patient   information    within    the
            one as an example.                              opment  of  this  overall   structure   di-    hospital  was   quickly   revealed   as   a
               Autonomy-Taylor     recognized      that     rected   attention  to  the        relative    fuzzy,    haphazard,     and     unreliable
            there is  a  technique  which  turns  "sick     importance  of   the   parts   within   the    process,  the  plan  of   care   and   com-
            people  into  patients.1112  This  process,     structure   and   helped   us   to   inter-    munication     systems      became      two
            she   explains,   methodically   moves    a     relate  the  various  subsystems   into   a    areas   of   strong   concern.   We    also
            person  from  autonomy-that  is,  a   sense
            of  freedom  of  choice-to   a   sense   of     total  and  effective  system  of   patient    concentrated   heavily   on   the   patient
            dependency,   exemption,    undesirability,     care.   The    following    systems    were    medication   system,   because   the   tra-
            and temporality.                                roughly    designed:    Admission,    Sleep    ditional  system  is  so   time   consuming
               One  way   that   patients   can   exert
            control  over  what  fiappens  to  them  is     and  Rest,  Food  and   Fluids,   Plan   of    that  its  continuation  would  have   left
            to  influence  the  decisions  about  their     Care,     Communication,     Verbal     Ob-    little  time  for  personnel  to  meet  pa-
            care that are made by  the  staff.  It  has     servation,   Vital   Signs,    Sociopsycho-    tient  needs  within  the  other   systems.
            also been shown  that  those  patients  who                                               -    The  materials  supply   system   was   the
            were told  of  anticipated  unpleasant  ex_     logical,    Physical    Hygiene,    Elimina
            periences and  led  to  expect  they  could     tion,    Materials    Supply,     Infection    fourth   area   of   concentration.   Keep-
            take  actions  to   influence   what   hap-                                                                                       se,   we
            pened  had  shorter  hospital  stays   than     Control,   Patient   Orientation,   Patient    ing supplies at the point of u
            patients   who   were   not   given    such     Education,     Medication,     and     Dis-    found,  would   not   only   increase   the
            expectations.13                                 charge.                                        efficiency  of  the   other   systems,   it
               In addition   to  the  22  needs   iden-       Each   system   included   the    inputs,    would   also   keep   patient   care   per-
            tified,  we  recognized  that  the  project     outputs  (including        communications),    sonnel  in  close  proximity  to  the   pa-
            design   must   take   into   consideration     procedures,     equipment,     environment,    tient at all times.
            the    need    for    communication    with     and   workers   required   to   meet    the      T e patient       an   o   care    system
            patients  of  widely   varying   socio-eco-     specific  purpose  for  which  it  was  de-    evolved  as  the   necessity   to   coordi-
            nomic     and     cultural     backgrounds.     signed. A list  of  specific  criteria  was    nate   patient    care    activities    was
            The  impact   of   family   structure   and     developed  for  each   system,   with   the    identified.  Patient  care   problems   are
            family  relations  on  disease  and  stress     identified   needs   playing   an    impor-    entered  on  t  e  care  plan,  w  ic  con-
            was  also  considered.   Then,   with   the     tant  role.  For  example,  the  need   for    sists of  two  81/2  x  1  11'  pages,  en-
            addition   of   five   universal    systems     privacy  was  a  prime  criterion  in   the    cased  in  a  flexible   plastic   backing.
            requirements     (environmental     needs),     elimination   system,   safety    in    the    This  is  always   kept   with   each   pa-
            we were ready to begin designing                medication   system,   and   security    in    tient,  This  care  plan,  whic   re   aces
                                                            the sleep and rest system.                     the   usual   Kardex,   is   developed   by
            PATIENT CARE SYSTEMS                              The roughly designed       systems    in-    the   professional   nurse   and    written
               The    project     incorporated      the     eluded  a  myriad  of  ideas   and   detail    in  pencil  to  allow  frequent   updating.
            identified  needs  into  an  overall   sys-     Everything    from     requiring     physi-    It  includes  expected  length   of   stay,
            tem  that  would  carry  out   the   unique     cians'  orders   when   an   elective   ad-    so   discharge   can   be    planned    for
            purpose  of  a   hospital,   The   system's     mission  is  scheduled   to   stating   the    from  the  day  of   admission,   and   has
            purpose   was   stated   as   follows:   to     bed  height  that   will   allow   a   weak    spaces   for   the   patient's   individual
            observe,   interpret,   and   regulate    a     patient  to  sit  up  and  ambulate.   Just    preferences,   special   observations   re-
            patient's   physical    and    sociopsycho-     the  idea  of  placing  a  pad  and  pencil    quired,   diversional    activities,    and
            logical  functions  to  meet   his   needs.     at  every  bedside  made  it  possible  for    daily schedule.
               This    functional     statement     was     patients  to  jot  down   their   questions      An  adjunct  to   the   care   plan   are
            broken    down    into    components    ar-     as   they   occurred,    thereby    meeting    signs  written  by  the  nurse  and  placed
            ranged     according     to , the     steps     their need for cognitive clarity.              by  her  on  the  wall  at  the   head   of
            through   which   the   patient    proceeds       As    the    component     parts     were    the  bed  to  provide   basic   information
            during    the    care    process-admission,     gradually  pieced together  to         form    that   should   be    known    by    anyone
            observation,    interpretation    of    ob-     the  final  systems,  we  were   all   sur-    approaching   the   patient.   The   infor-
            servations  by  the  health   team,   regu-     prised  at  what  emerged,   for   we   had    mation  is  specific  to   each   patient's
            lation,     and     discharge-and     these     started   without   any    hypothesis    or    requirements:   "Use   log   roll,"   "Vis-
            components   were   divided    into    even     preconceived    ideas;    the     functions    itors  allowed  only   10   minutes,"   and
            smaller    components     to     facilitate     and    procedures    evolved    from    the    the  like.  Since  the  professional  nurse
            their  handling  in   the   several   work-     design   process.   We   ended   up   with-    places   the   information    there,    she
            shop   sessions.   Each    component    had     out a nu  .rses'  station,   for   instance,   has  the  opportunity  at  the  same   time
            its    own    functional    statement    in     because   it    never    became    evident,    to  orient  the  patient  to  why   it   is
            terms   of   patient   needs,   and   these     throughout  the  entire   design   process,    there  and  how  it   can   contribute   to
            always   contributed   to    the    overall     that   such   an   area   could    contrib-    his therapy.

            APRIL, 1972     VOL. 20, NO. 4                                                                                                      26


                                                                                                                                 r7l
                         "MW

                           Replacing the traditional nursing station is a central communications console manned by a specially pre-
                           pared person who responds to calls from both within and outside the unit and notifies appropriate personnel.

               The   unit   personnel    are    divided     group  members   matched   to   the   care    medication  to  the   right   patient   at
             into   small   work   groups,   each   one     requirements  of  their   patient   group.    the right  time  is  placed  on  the  per-
             totally responsible  for  a  limited  num-       Standard  supplies  are  kept  in   each    sons   most   knowledgeable   about   this
             ber of patients.  The  rationale  is  that     patient room  in  a  dual-access  (patient    therapy-the    pharmacists.     A     med-
             in-depth  knowledge  of   a   small   num-     room   and   hallway)   Supply    cabinet.    ication profile  of  the  patient,  devel-
             ber   of   patients   is   preferable   to     On   rounds,   the   work    group    MeM-    oped   by   the   pharmacist   from    the
             superficial   knowledge   of   the   total     hers  jot  down  on  an  @'on-call"   card    doctor's   original   transcription,    is
             unit popLilation. Since  all  patient  in-     the  treatment   trays,   dressings,   and    kept  in  the   pharmacy,   and   an   up-
             formation,  including  his  chart,  is  in     other  nonstandard  items  that   may   be    dated  photocopy   is   brought   to   the
             his  room,  intershift  reports  are  very     required  during  the   next   24   hours.    unit  daily  by  the   medication   clerk,
             brief,  and  personnel   begin   the   day     These  cards  are  collected  by   a   ma-    who  places  it  on  the  inside  of   the
             with  "plan  of   care   rounds."   These,     terials  supply  clerk,  who  places   the    supply    cabinet    door.    When     the
             we  feel,  are  the  heart  and  soul   of     specified  items  in  the  cabinet  during    nurse   gives   the   medication(s),   she
             the project  in  terms  of  quality  care.     twice-daily   rounds,   The   clerk   also    has  only  to  initial  the   time   given
             PLANNING TOGETHER                              carries  a  pocket  pager   so   she   can    on  the  copy.  Then  she  sets  a   timer
                                                            bring  supplies  to  the  room  upon   re-    for  the  next  time   a   medication   is
                On  rounds,   the   members   of   each     quest throughout the day.                     due  for  that  patient,  at  which   time
             work   group   approach   their   patients       The  cabinet  contains   the   necessary    a  light  will  go  on  outside  the  room
             with  the  care  plan  in  hand.  The  pa-     linens,  gowns,  charts,  care  plan,  pa-    door  as  a   reminder.   The   nurse   is
             tient, the  professional  nurse,  and  her     tient  hygiene  articles,  ind  a   locked    thereby   relieved   of   ordering    rou-
             nurse    assistant   and/or      practical     medication  drawer   for   each   patient.    tine   medications,    transcribing    and
             nurse  then  plan  their   activities   of     There is a  scaled-off  disposal  bin  for    checking    orders,    charting    medica-
             the  day   together.   Introductions   are     plastic  bags  of   soiled   linen,   used    tions  given,   and   sorting   medication
             made,   questions   exchanged   and    an-     equipment,   and   discarded    materials,    tickets  for  use.  Because      narcotics
             swered,    schedules    explained,    care     which  is  emptied  daily   by   the   ma-    and  sedatives  are  kept  in   the   med-
             plans  and  wall  signs  updated,   I.V.'s     terials supply clerk.                         ication  drawer,    she   can   also   re-
             and   drainage   systems   checked,   pri-       In  the   patient   medication   system,    spond to  a  patient's  request  for  pain
             orities set, and the skills  of  the  work     the responsibility of  getting  the  right    relief without leaving his bedside.

             262                                                                                                               NURSING  OUTLOOK


              chart  is  kept  in  an  unlocked   drawer    cus  on  patient  needs,   other   tangen-         The strength of the    project,     we
              in  the  cabinet;  the  latter,   however,    tial  needs  siphon  off   resources   and    believe,  has  been  in   the   "rightness"
              has  an   outside   label   which   states    energy  to  the  detriment  of   the   pa-    of  starting  with  the   patient.   Formal
              "for    authorized    personnel    only.")    tient.                                        evaluation  of   the   demonstration   unit
              The   physicians   also   sorely    missed      our  systems   were   designed   to   be    will  soon  be   completed   by   an   out-
                                                                                                          side   consulting   firm,   MEDICUS,    In-
              the  central  nursing  station  where   in    self-coordinating-to   adjust   and    re-
              the past ,nurses   were   readily    avail-   adjust  themselves,  as  needed.  In   the    struments   from    the    University    of
              able  to  meet  their   needs.   Now   the    former   fragmented    systems,    "break-    Michigan   studies   will   allow   compar-
              nurses   are   out    meeting    patients'    downs"   often    resulted    in    nurses    ison  of  the   demonstration   unit   with
              needs.   Gradually,   though,   most    of    stepping  into  the  breach   and   "hero-    a  control  unit  in  St.  Mary's  and   55
              the  doctors  have  come  to  accept   the    ically"  carrying   out   responsibilities    units in  eight  other  hospitals.  By  the
              new   system,   and   a   few   have   be-    which   may   or   may   not   have    met    end  of  the  project,  August   1972,   we
              come  so  enthusiastic  about   the   care    patients'  needs,  but  which  other  hos-    expect  to  have  gained  a   much   great-
              given  there  that   they   request   that    pital   personnel   relinquished,    know-    er  understanding  of   what   should   be,
              their  patients   be   admitted   to   the    ing that the nurse  would  fill  in  these    not  only  in  the  patient  care   process
              study unit.                                   gaps.    When    breakdown    occurs    in    but   also   in   nursing   education   and
               The   nursing   personnel    had    their    these   self-coordinated   systems,   how-    the  designing  of  hospitals   in   accor-
              adjustment  problems,   too.   The   tran-    ever,  accountability  can   be   directed    dance   with   their   primary    function:
              sition  from  task  orientation  to  clin-    to   the   persons   or   factors    which    to take care of patients.                11
              ical  practice  and  decision  making   is    cause  it  to  occur,  thereby  increasing
              most  difficult  for   nurses   who   have    the integrity of the total system.                        REFERENCES
              worked   in   the   traditional   environ-      In   essence,   an    environment    has         1. FRIESEN,  G.  A.  Transportatioii  and
              ment.  The  nurse  tended   to   use   her    been    developed     which     completely         Communication   Systems   in    Hospi-
              free   time   to   "help    her    aides,"    supports   the   nursing   personnel   who         tals.   Washington,    D.C.,    Gordon
              rather than direct  her  aides  as  a  re-    must   meet   the   complex    care    re-         Friesen  Associates,   1966.   (Micro-
                                                                                                               film)
              source  to  herself  as  she  carried  out    quirements   of   their   patients.   With         2. TAYLOR,    CAROL    D.    Sociological
              her  clinical  role.   Occasionally,   one    an   environment   and   procedures   that         sheep  shearing.  Ntirs.Foritm   1:79-
              still  sees  a  nurse  making  a  bed   in    put  everything  at  the  nurse's  finger-         100, Spring 1962.
              an   empty   room.   We   feel,   however,    tips, she can truly  function  as  a  pro-         DUFF, R. S., AND  HOLLINGSHEAD,
                                                                                                               A.  B.  Sickness  and   Society.   New
              that the staff  nurses  on  the  unit  are    fessional,  making  decisions   based   on         York, Harper and Row, 1968.
              now  aware  of   the   job   satisfactions    her  scientific   knowledge   and   first-         4. NADLER,  GERALD.  Work  Systems
              that    can    come    from     thoroughly    hand   experience   with   the    patient,         Design;    The     IDEALS     Concept.
              knowing    their    patients,     directly    and  appropriately  utilizing  her   high-         Homewood,  Ill.,  Richard  D.   Irwin,
                                                                                                               1967.
              using their skills,  and  seeing  patients    ly  developed  skills   in   meeting   pa-         5. ABDELLAi-i, FAYE G., AND LEYINE,
              respond  positively   to   the   kind   of    tient  needs   for   knowledge,   therapy,         EUGENE.  What   patients   say   about
              care  possible  in   this   new   environ-    and  understanding.  Of   equal   if   not         their nursing care.  Hospitals  31:44-
              ment.  Their  role  is  now  clearly   de-    greater    importance,    the    patient's         48, Nov. 1, 1957.
              fined,  and  they   have   become   strong    needs  for  identity,  dignity,  security,         6. MALINowski,   BRONISLAW.    Scientific
                                                                                                               Theory  of  Culture  and   Other   Es-
              enough   to   occasionally   tell   others    and  orientation  are  met   because   the         says. Chapel  Hill,  N.C.,  University
              in  the  hospital  that  they  are  caring    care   process   truly   revolves   around         of  North  Carolina  Press,  1944,  p.
              for  patients  and  will  not  be   caught    and  includes  him.   The   total   effect         74.
              in  the  fetch,  carry,   transport,   and    is  patient-centered  care  at   the   pa-         7. MURRAY,  H.  A.   Facts   which   sup-
                                                                                                               port the concept  of  need  or  drive.
              interdepartmental    coordinating     they    tient's  room,  not  chart-centered   care         J.Psychol. 3:27-42, 1937.
              were formerly engaged in.                     at a central nursing station.                      8.         Explorations  in   Persoii-
                                                              To  broaden  the  effect  of  what   has         ality.  New   York,   Oxford   Univer-
              CONCLUSION                                    been  learned  in  the  project,  we  have         sity Press, 1938.
                                                                                                               9. MASLow, A. H., ED.  Motivatioti
                In   placing   primary    emphasis    on    given  slide  presentations,   tours,   an         and Persotiality.  2d  ed.  New  York,
              patient    needs,    our    project    has    in-depth   counseling   to   health   care         Harper and Row, 1970.
              stressed  the  human  factors  in   health    professionals,   architects,    engineers,         10. MONTAGUE,  A.   Direction   of   Human
              care. It  has  demonstrated,  we  believe,    and   students   throughout   the   state.         Development.  rev.   ed.   New   York,
              that  patient  needs  can  be  identified,    Two  hospitals  are   committed   to   de-         Hawthorn   Books   Publishers,   1970,
                                                                                                               p. 117.
              assessed,  and  responded   to   in   such    signing  the  concepts  into   their   new         11. JOURARD,  S.   M.   The   Transparepit
              a  way  as  to  move  a  patient   through    facilities.  Currently,  we   are   devel-         Self.  2d  ed.  New  York,   Van   NO-
              an  experience  of  health   care   toward    oping  a  course  and  manuals,  so   that         strand Reinhold Co., 197 1.
              a  higher  health  status.   When   health    what  has  been  learned  by   our   group         12. TAYLOR, OP. Cit., P. 1.
                                                                                                               13. HEALY,   K.   M.   Does   preoperative
              care   delivery    systems,       whatever    can be taught to  facilitators  in  health         instruction   make    a    difference?
              their  scope,  neglect  this  primary  fo-    care settings.                                     Am.J.Nurs. 68:62-67, Jan. 1968.

              264                                                                                                               NURSING       OUTLOOK


               Our    hardware    communication    sys-    exciting   but   hazardous   venture.    A     to  the  unit  as  usual,  and  the   per-
            tem   not   only   allows   two-way    com-    glimpse of this  is  seen  in  a  descrip-     sonnel  were  completely  at   sea   with-
            munication    between     the     patient's    tion of opening day.                           out  a  nurses'  station  and  a   Kardex.
            room   and   a   centrally   located   con-                                                   Two  days   later   the   patient   census
            sole,  but  also  has  a  "people   finder"       The  study  unit  opened  to  six   pa-     was  up  to  20,   and   by   January   12
            feature   which    directs    the    appro-    tients  January  5th.  On   January   6th,     we  were  in  full   operation   with   36
            priate  group  member  to   the   patient's    two  of  the  five  project   sta)y   mem-     patients on the study unit.
            room.   Personnel   register   into   rooms    bers were ill with  the  flu.  The  filled
            by   punching    a    color-coded    button    food  trays  were  too   small   for   the     With  this  for   a   kickoff,   you   can
            at  the   doorway.   This   is   programmed    slots  in  the  refrigerator   and   ended     imagine  the   stresses   that   we   have
            into  the  central   console,   which   can    up  in  a  heap   at   the   bottom;   the     been  coping  with  on  the   study   unit
            then  show,   at   any   given   time,   in    laundry  cart  would   not   fit   through     and  throughout   St.   Mary's   Hospital.
            which   rooms   what   types   of   person-    the  door  of  the  area  where  it  would       From   the   beginning   of   the   pro-
            nel are working.                               be   stored,-   the   physician's   orders     ject,  a  valiant  and  persistent  effort
               When  the   patient   places   a   call,    would   not   copy   through   the    tem-     was  made  to   involve   medical   staff,
            there  is  an   immediate   response   from    porary  triplicate   forms   being   used.     through    monthly     lunch     meetings,
            the    communicator    who    asks,    "May    Someone  burnt  out   the   coflee   maker     widely   distributed   minutes   of    the
            I    help    you?"    (The    communicator,    because   the   instructions   were   mis-     meetings,   appointed    liaison    repre-
            located  in   a   central   control   area,    laid,  the  handles  on  the  supply  cab-     sentatives,  and  so  on.  When  the   re-
            is  not  a  nurse,  but  a  person  trained    inets   were   mi.ssi.ng   so   they    could  designed   unit      opened,      however,
            to  screen  calls  and   direct   them   to    not  be  used  from  the  outside,   there     most  of  the   doctors   were   surprised
            the   appropriate    nursing    personnel.)    were  no  lights  in  the   cabinets   for     and   upset.   Their   greatest    concern
            When   the   patient   states   his   need,    medication    giving,     the     computer     seemed  to  be  the  relative   availabil-
            the   communicator       activates      the    printout   sheets   were   not   delivered     ity of the  chart  to  the  patient.  (The
            "people  finder"  on   the   console,   and
            can   then   speak   through   the    door-
            side  unit  to   the   staff   member   re-
            sponsible  for  that   particular   patient
            and  able  to  meet  his  need.   The   pa-
            tient's  signal,  registered  at  the  con-
            sole,  remains  ]it   until   someone   en-
            ters  the  room   and   registers   in   by
            punching  the   button.   There   is   also
            a   doorside   speaker,   which   can    be
            used  by   nursing   personnel   who   wish
            to   obtain    information,       supplies,
            medication,   or   additional   help   from
            their   group   members   without   leaving
            the patient's presence.

            IWLEMENTATION
              The     environmental     and      equip-
            ment  changes   required   for   the   sys-
            tems  meant  that  the  unit  had   to   be
            vacated   for   two   weeks    in    Decem-
            ber,   1970.   During   this   time,    the
            unit  personnel   were   given   22   hours
            of    orientation    to    the     expected
            changes.
              When   the  unit   reopened,   the   tra-
            ditional    centralized          medication
            room,  supply  room,   and   nursing   sta-
            tion   had   disappeared;    the    concept
            of   decentralization   had   been   accom-
            plished.   Anyone   who   has   tried    to
            make   change   knows   that    the    real
            world   of   implementation   can   be   an           A dual-access cabinet in each room contains th e patient's care plan as
                                                                  well as all the linens, supplies, and medications needed for his care.

            APRIL, 1972    VOL. 20, NO. 4                                                                                                   263


                                                                       Rtfer to: Frct          in    Californit.       k SLcio-Econ-,itiic Pvr. t
                                                                                  of t?., 'i @Au ,f Researcli  s       .!!,ng, C;klif(,fnii
                                                                                  Ass          C41if  Med   iit,      i, Apr 1972

                              Medical  Ec'onomics

                                              Free Clinics in                                                  California, I!@)71

                                                         A Socio-Economic Report of the Bureau of Research ind Planni                                    iig@
                                                                                    California       N fedical Association

                              THE     F-,%fER(;ENCF,     DLIRING     THE     LAST     several      years       sub-culture.   In   addition   to   this   group,   free   ciiii-
                              of    a    (irug-oriejited    sub-cultur     'c    in    American    so-         ics  often  pi-o-v-ide  care   to   the   poor   of   all   ages,
                              (if-t,.,   his   influenced   the   development.   of    a    new                i-niiiorit-Y  persons,  and   outliers   to   \\@liom   the   es-
                              kind   of   center   for   the   deli-%,etv   of   health    care                tiblislie'd svst(,nis  of  li(l@@iltli  ctre  (lelivenr  are  not
                              services,   the   free   clinic.    During    the    summer    of                reitdi]N@ available or \\-Iio are iiii\%,illiiig           or      unable
                              1967,  the   Ilaiglit-Ashl)tir,,@   Free   Clinic,.   under   the                to s(@ck- care in traditional lic@iltli care               centers      or
                              direction   of   DiN,id   Smith,   NI.D.,   opened   its    doors                through plin,siciaiis in private pricticc.
                              to    San    Frincisco's    "street    people."    Since     that
                              tijiti.@.   a   niiiyiber   of   similar   clinics   have    been                   Free clinics  are each  designed  to                    meet      tile
                                                                                        %I                     iiVeds of a particuLir coniiiitinit@- and                     therefore,.
                                          offering  a  wide  variet,.,   of   ser'   ices   their
                                                                                                               iiice  coi-niniiiiit%,,  needs  N-ary,   so   do   the   clinics.
                                                   is   frequent]N,    referred    to    as    the                                    I
                                                                                                               13eciiii,;e of tf)i,.;, tber,? (!,),L-s not               to  !;L  -.n,,,
                                                                                                               one   feature   tli@,tt   citecrorizes   a   particular    opera-
                                Tb(.    importance    of    this     new     phenomenon     for
                              the  dcli%,erv  of   health   care   services   to   a   selected                tioii   as   a    "free    cliiiie."    Jerome    S(.,IiNN-arz    of    the
                                                                                                               Department   of   Pre%,eiiti%,c   '\Ic(liciie   at   West   N'ir-
                              population       group       in       California       suggested       the                                                        I
                                                                                     C)                        ginia    School     of     Nle(liciiie     fomitilit(,d     the     follow-
                              need    for    more    defiiiitiN,e     data     about     the     various
                                                                                                               itig  as  a   -,-,-orkiiig   d(-fiyiitioii   of   a   free   cliiiic   @@i:
                              clinics        currently        functioning.        This        Socio-Eco-
                                                    I                                                          a tiatioii%%@ide                        a     pro@i-am     which     pi-()-
                              tioitiic      Rei)ort      contains      highlights      of       findings
                                                                                                               vidcs     medical,     deiital,     psychological     or     drug      care
                              frf)tii      a      questionnaire       survev       conducted       among                   charges  or red         Itape."'         Excluded          from
                              ;ill   sti(-Ii   clinics   in   June   1971.   In   addition   to   g(@ii-       his      definition      are       iii-resid(@nce       and       methadone
                              cral     ii)forinatioii,     it     provides     examples     of      four       programs,     coutiselina     1)),      ministers,      drop-in      refer-
                              distinct    t@-pes    of    free    clinics    found    in     California.
                                                                                                               ral    centers,     and     pro(,i-aTiis     aimed     at     a     defined
                              The    detailed    i-c@port    of    findings    will     be     published
                              in the near future.*                                                             population or i categorical diseise.
                                                                                                                 The     Southern     Californi@i     Council      of      Free      Clin-
                              Origin and De,,.-elopmeiit of the                                                ics      in      Los      Angeles       r@tri-cts4"ili@'-(f-@g@'Ciii-i-iTfa
                              NioN,ement                                                                       free    clinic    to    a    licensed,    private,    nonprofit     neigli-
                                Although     free     clinics     began     in     'reco(ynitioii     of       borhood      health      and      social      service      center.      Ex-
                                                                                        0                      cluded      are      health      centers      operating      under      the
                              the    need    for    treatanciit    of    drug    abuse     and     drug-
                                                                                                               sponsorship    of    a    cit,,-    or    coui)tnr    go",criuneiit,     or
                              related     problems,     they,     are     no      longer      restricted
                                                                                                               a federal agenc@-.  In          both     cases,     the     concept      of
                              to providii)g services to the dru@-ori(Inted,
                                                                                                               a free (,]iTiie imnlic@,        it                +0
                               Repric@t it,lucsts t(,: CMA bureau of Rcstir      @h and   Planning,   693                             I'
                              Sutter Street. San Francisco,'Ca. 94102                                          cliarg(-s    per    patient     x-isit,     confidentiality,     and     as
                               *Included in this report will bc- a listing  of  all known  free   clinics      tion-iiiciginejital    a    climate    as    is    possible    in     staff
                              throughout the state, detailed statistics nn sponsorship, and  sources  of
                              income and sff,i@es proided, as well  as  the  survey  questionnaire  used       attitudes to%N,,ir(-Is patients.
                              to empire the information.

                                  106       APRIL  1972             1 16     4


                                                                                 TAIILE  I.-Age  Distribution  ol  Population  Served   at
             'Data about Clinics Compiled by                                                        34 Free Clinics
                Questionnaire, Survey
                                                                                 .Age
                 In   June   1971   the   Division   of    Socio-Economi@        Under 15                  4,000                     12.7%
                and  lieseareli   of   the   California   Medical   Associa-
                                                                        .   1    15-19                     9,900                     31.6
                tion surveyed all 95 known clinics in Califo@n,,           a     2@24                      9,000                     28.6
                which  seei-ned  to  fall  into  one  of  the   above   aen-     @30                       4,700                     15.0
                liitions  of  a  free  clinic.  To   date,   54   have   re-     Over 30                   3,800                     12.1
                spor.ded;   nine   %vere   excluded   from   the    analysis         -A 0 t -Al           31,'900                   100.0
                because   they   do   not   provide   anv   medical    serv-
                ices  at  the  clinic,  but  rather  are  "drop-iif'  refer-
                ral centers, counseling centers,       or       in-residence
                treatment centers.                                               Age and Income Data             for
                  Of  the  45  qualified   respondents,   24   or   approxi-     Population         Served.
                isiatelv  53   percent   are   private,   independent   non-      A   total   of   34   respondents   indicated.the    aver-
                                                                                 age  number  of   persons   seen   at   the   clinic   each
                profit    corporations.    The    Los     Angeles     County     month   and   provided   an   estimate   of   age   distri-
                Health   Department    sponsors    six    clinics.    Others
                ire   sponsored   b\-   private   or   community    ori!ani-     bution  of   the   population   served.   Table   1   shows
                zatioiis,   churches    and    neighborhood    associations.     the  number  and  percent   of   the   total   31,400   pa-
                'One    respondent,     the     American     Indian     Free     tients  served   each   month   by   these   clinics,   ac-
                                                                                 cording   to   age   group.   Approximately   75    percent
                (.Iitiic,   is   sponsored   by   the    Federal    Economic
                                                                                 of  the  persons  seen  at  these   clinics   are   between
                Ati@l   l'outh   Opportunities    Agency.    The    Delta
              'I  lealth  Project  in  Sacrunento  is   sponsored   by   the     the  ages  of   15   and   30,   while   approximately   60
                                                                                 percent  are  bet-%veen  15   and   24   years   of   age.,
                Sacramento County Nledical Association.
                                                                                 Relatively  few  persons  under   15   or   over   30   are
                  Sources   of   income   for   the   free   clinics    vary     served  at  free  clinics.
                considerably.   Onlv    three    clinics,    the    American
                                                                                  A  total  of  36  clinics provided   estimates    of    the
                Indian   Free   Clinic,    Delta    Health    Project    and
                Long    Beach    Free    Clinic    receive    any    federal     Population  served   according   to   income   levels.   As
                         Another   ten   are    partially    state    tunded
                f unds.                                                              L@ bc cxp,-cAc", a        proportion    c@    -,^spcnd-
                and  ten   receive   count),   funds.   Other   source;   of     ents  (61  percent)  reported   that   most   or   all   of
                income   include   community   funds,    group    and    in-     the  population  they  serve   are   from   families   with
                (li@.i(iital   donations,   private    foundation    grants,     lower   income,   that   is,   less   than   $5,199.   Only
                ft.iii,f  raising  events  such  as   rock   concerts,   and     two  clinics  indicated  that  less  than   half   of   the
                strt-#-t  solicitations.  One  clinic,  the   Venice   Corn-     population   served   were   from   lower    income    fam-
                MiL,,itN,   Familv   Health   Center,   has   received   fi.     "'es  and  that  50  percent  or  more   of   the   popula-
                                                                                 tion   were    from    higher    income    ($7,600-$10,500)
                nancial   assistance   from   the   local    district    Los
                Angeles    Count\,    \Iedical    Association    and    from     families.
                Area   V   of   California   Regional   Medical    Programs.
                                                                                 Broad Range of          Service Provided
                Nlost Clinics Located in Major                                     Table 2 lists the     types   of   medical   and    other
                Metropolitan Areas                                               services   provided   at   the   45   responding   clinics,
                                                                                 along   Nvith   the   number   and   percent   of   clinics
                   From  the  45  responses  it  can  be  seen   that   free     offering   each   t)W   of   sen-ice.   Services   provided
                clinics  function  in  at  least  12  California   counties.     by  over  75  percent  of  the   responding   clinics   in-
                Los  Angeles   County   alone   accounted   for   20   clin-     clude  general   medical   care,   birth   control,   abor-
                ics,   while   San   Francisco    has    seven.    Responses     tion   coiLr@ling,   laboratory    work,    treatment    of
                were  also  received  from  four   clinics   in   San   Ber-     venereal   disease,   health   education,   and   iob   and
                nardino    countv,    three    each    in    Alameda     and     family counseling.  Although,..60,
                                  I                                                                                      percent   of    the
                Orange   counties,   two   in    Riverside    county,    and     clinics   provide   treatment    for    drug.abuse,    only
                one    each    in    Mendocino,    Monterey,     Sacramento,     three,  or  6.7  percent  of  the  totaL  have   outpatient
                San Mateo, Tulare and Ventura counties.                          methadone        programs.

                                                                                                 CALIFORNIA MEDICINE               107
                                                                                                 Tho Wetiorn Journal of Modicino


                                                            TABLE 2.@ftr@ Provided at 45 Responding Free Clinics
                             Afeiieel jervicti                                           Ptrc#xt     other                                      Nmmktr               Percexi
                             General medical care                             37         82.2%       Ilealth education                             37                82.2%
                             Emergency treatment                              29         64.4        Drug education                                31                68.9
                             Dental services.                                 13         28.9        Tutoring                                      10                22.2
                             Eye examinations                                 14         31.1        Counseling (job, family)                      38                84.1
                             Eat examinations                                 17         37-.8       Paramedical training                          15                33.3
                             Problem pregnancy      care                      24         53.3        1-4-gal services                              18                40.0
                             Pre-natal care                                   18,        40.0        Yotith social services                                          33.3
                             Well-baby care                                   16         35.6        Draft physicals                               6                 j3.3
                             Treatment of venereal disease                    35         77.8        "Rap" groups                                  29                64.4
                             Birth control services                           36         80.0
                             .Abortion counseling                             34         75.6
                             Laboratory work                                  34,        75.6
                             Psychiatric services                             27         60.0
                             Surgical                                         6          13.3
                             Treatment of drug abuse                          27         60.0
                             Outpatient methadone                             3          6.7
                             Detoxification                                   14         31.1

                             Clinics Classified into Three Types                                   fourth    type, the drug        abuse   treatment   center,
                              In his national survey of free  clinics,  Schwarz                    generally  does  not  provide  any  niedical   care
                             found that the clinics could generally be classi-                     services  such  as  general  medical  care,  erner-
                             fied  into  three  general   ty@:   neighborhood,                     gencv treatment unrelated  to  drugs,  and  treat-'
                             'hippie,'  and  youth.  Neighborbood-@pe  clinics                     ment  for  venereal  disease.  Numerically,  17  of
                             are     centers     providing     medical      and/Or      dental     t@e respondents  mav  be  classified  as  neighbor-
                             care to families in areas                        hcalltl-. services   hoof clinics,          as  l'iipuie               7  as   youth
                             are   not    readily    available.    The    population    served     clinics,    and    6    as    drug    treatment    centers.     Al-
                             is   often   from    a    particular    minoritv    group.    Few     though   these   classifications    are    not    totally    finite
                                                                              I                    in   terms   of   defining   clinics,    each    seems    generally
                             neighborhood    clinics     offer     treatment     for     prob-
                             lems   relating   to   drug   abuse.   A   hippie-type    clinic,     more    representative     of     one     type     than     another
                             on   the   other   band,    is    one    that    provides    some     and has been so classified.
                             type   of   drug    care    (often    including    detoxification
                             or   rehabilitation)   and   serves    many    patients    ,k,ith     Exai-nples  of Neighborhood  Clinics
                             drug-related   illnesses.   Youth-tv   c   clinics    are    also
                                                                  lp
                             organized   to   give   some   drug   care,   although   it    is       Two       examples       of       neighborbood-type       clinics
                             often    limited    to    education    and    counseling.    How-     are    the    Telegraph    Hill    Medical    Clinic     in     San
                             ever,   these   clinics   differ   from    hippie-type    clinics     Francisco    and    the     American     Indian     Free     Clinic
                             in    their    sponsorship,    having    generally    been    de-     in:Compton.    The    former     serves     the     North     Beach
                             veloped    and    sponsored    by    adults,    service     clubs     area    of     San     Francisco,     a     community     consistin'g
                             or    other    community    groups    concerned    with     prob-     largely   of   poor   Chinese   f,,unilies,   The   c    inic    is
                             lems    of    drug    abuse    among    high-school     students.     staffed   by   one    full-time    and    one    part-tune    nurse
                             These  last  t7,vo  types   of   clinics   also   provide   some.     and   a   part-time    registrar    who    are    paid    by    the
                             types of general medical services.                                    city    of    San    Francisco.    Volunteer     physicians     in-
                                                                                                   clude    two    pediatricians,    two    internists,    an     oph-
                                                                                                   thalniolog@st,    an    orthopedist,     a     gynecologist     and
                             Drug        Abuse        Treatment         Centers
                                                                                                   a   dermatologist.    It    functions    from    9.00    a.m.    to
                             Also Surveved
                                                                                                   5:00   p.m.,   five   days   a    week,    to    provide    general
                             These  three  types   of   clinics,   as   well   as   a   fourth     medical     care,     emergency      treatment,      eye      exam-
                             type,   a   center   organized   solely   for    the    treatment     iiiations,    and    light    laboratory    work.     The     cit),
                             of   drug   abuse,   were   included   in   the    survey.    The     Department    of    Public    II(-alth     utilizes     the     c@c

                             108      A P R I L  1 9 7 2  I 1 6    4


              facilities once a             for   well-I)ab),   care.    In    ;ir(,  staffed  to  offer  drug  detoxificatioii.  The   ma-
              addition   to   these   medical   services,    the    ciiiiic    jority  of  the  population  served  at   each   clinic   is
              offers   classes   in    h(-altli    education,    counseling    I)t@t%veen the ages of 15 tiid 2,5.
              services,  %louth  social   services   and   informal   "rap"       The  flaiglit-Ashl)tiry  ivie(lical   Clinic,   the   na-
              groups.                                                          tional  pilot  project  for  all  free  clinics,  is   spon-
                 An   estimated   340   individual   persons    are    seen    sored   by   Youth   Projects,   Inc.,   a   private,   non-
              at  the  clinic  e;tcli  month;  they  average  a  total   of    profit    comorition.    Primarv    sources    of     income
              9')@:)   medical   care   visits.   The   majoritv   of   the    for  the  clitiic  include  funding  from   private   fouii;
              population   (94   p(@rceiit)   are   from   a   lower   eco-    dation   graiits   for   education    and    research    and
              nomic   group.   Approxii-natelv   30    percent    of    the    patient donations.
              population  served  are  tinder   15   vears   of   age   and       Although    originally    developed    to    study    and
              30  percent  are  over   30.   The   principal   source   -of    treat  the  abuses  of   psvebedelic   drugs,   the   health
              funding  for  the  clinic  is  the  CitN-   and   County   of    care   needs   of    the    population    served    demanded
              San  Francisco.  If  the  Patient   can   afford   it,   how-    rapid   expansion   of   the   facilities    and    services
              ever.  a  minimui-n  fee  of  $1.00  is  charged  in  or   er    pro-N,ide(l.  At  present  the  clinic   is   divided   into
              to  help  defray  the   clinic   costs.                          six   separate   sections:   (1)   medical   care   (includ-
                 III  janut@   1970   a   group   -of Indians,  %%.itli  fi-   iti@r  birth  control   and   abortion   counselinc,),   (2)
              nan(.ial and    technical    assistance     from     Regional    dentistr-,,,  (3)   psychiatric   care,   (4)   heroin   de-
              NWical ProLranis Area           V,   initiated   the    plan-    toxification,  (5)   treatment   for   (]rug   abuse   other
                    stages  for   tli(@   American   Indian   Free   Clinic    than   heroin,   and   (6)   a    publications    department
              nino,
              with   the purpose of providing medical,              dental,    which    periodically    publishes    The     Journal     of
              legtl  and  other   related   services   to   ari\,oiie   Te-    Psyclie(lelic   Drugs.   Like    all    clinics    surveyed,
              questing them, but primaril\          to    the     estimated    the   Ilaight-Asbbtiry   Free   Clinic    makes    referrals
              60,000 American Indians  of           Los     Angeles     and    to  other  health  agencies,   hos   itals   and   voluntary
                                                                                                                 p
              surrounding     communities.     Three     months      later, i  agencies such as VD treatment centers.
              under   the   direction   of   an   all-Indian    board    of
                                                                                  The  clinic  is  one  of  the  largest   in   California,
              directors   and.an   Indian   administrator,    the    clinic    with  an  average  of  3.000   cliciit-visits   ner   month.
              beLyan    i)rovidin    telephone    information    and    re_
                                 9                                             The  professional   staff   includes   one   full-time   ind
              ferral services   five   afternoons   a   week   by   trained
                                                                               30   part-time    volunteer    physicians.    Other    staff
              Indian  aides.  In   October   of   the   same   year,   tlae    include over 100 nurses, psN
                                                                                                                 7c liologists,  lay   ther-
              clinic facility   was   equipped   and   staffed    to    To-
                                                                               apists,   other   paramedical    personnel    and    coinmu-
              vide  medical,   dental,   clinicil   and   le,-al   services
                                                                               nitN,   volunteers.   Although   some    paramedical    per-
              two   evenings   a   week.    At    present,    approximately
                                                                               sonnel  are  paid,  most  services   are   provided   on   a
              300  persons   are   seen   at   the   clinic   each   month;
                                                                               voluntary basis.
              250  of   them   seek   medical   care.
                                                                                  The   Long   Beach   Free   Clinic   is    the    largest
                Approximately 50 percent           of    the     population    free    clinic    in    Southern    California,    averaging
              served  bv  the  clinic  arc   under   15   Nlears   of   age    2,300   monthly    visits    by    appr    iniately    1,600
                                                                                                                     ox
              and 20 percent are over 30.          The     remaining     30    persons.  Although  no  record   is   kept   on   the   eco-
              percent    are     approximately     equa]INI     distributed    nomic status of the population        served, it is    esti-
              within  the  15   to   29   Nlear   age   group.   Half   the
                                                                               mated that the majoritv are from families               with
              population  is   estimated   to   be   from   families   with    lower   income.   Approximately   46   percent    of    per-
              incomes  of   less   than   $5,199.   Persons   of   moderate    sons  seen  are  between  the  ages  of  15   and   20   and
              @ind   higher   income   comprise   30   and    20    percent    33  percent  are  between   21   and   24.   Only   4   per-
              of   the   population,    respectively.                          cent are under 15 years of age.
                                                                                  The  Long   Beach   Free   Clinic   is   currently   or-.
              Examples of "Hippie" Clinics                                     ganizing    a     m@lical     advisory     coininittee-Vhose
                The   Haigbt-Ashbury   Free    Clinic    in    San    Fran-    function   will   be   to   advise   th&-@iedical   director
              cisco  and   Long   Beach   Free   Clinic   are   t-%vo   ex-    on  policies.   medical   functions,   and   how   to   deal
              amples   of   Schwarz's   Iiippic-type   cliiiie.   An    im-    with    problems    in    providing    medical     services.
              portant  concern  of  each   is   the   treatment   of   drug    The   Clinic   draws   from   the-services    of    appro;a-
              abuse    and    drug-related    illnesses.    Both    clinics    mately   60   .,oluiiteer    physicians    representing    a

                                                                                              CALIFORNIA MEDICINE               109
                                                                                              The Western Journet *f Medicine


                             %,arietv of specialties. Ad(ilijorialIN7        ,    aplirf)xiiiittelv      h(,alili   director,   one   iitjl),itioiiist,   and    one    labora-
                             40 nurses. 50 to (jC) ()tli(-i                           p(@i@soi)iiel      tor@  t(,(-]iTiieian   are   r(,ijrtl)tirs(,d   for   their   services
                             ancl 300 (-oii)ii)iiiiit) \%@o3.k(,rs                  tl)"ir  s(@l.v:      on iiii hourly basis:
                             ices to the clinic oil a part-time 1),isi,,.                                   I'()titli   Service   ('ejit(,j   @)f   Riverside,   Inc.,   is   a
                                                                                                         priN,@it(,,   nonprofit   coip'()t-iitioti.   Fiiiidin(,    for    the
                                Besides    regular    i-ncclicall    (jelitll     and     ps%,clii-
                                                                                                         cej)t(@r comes from a                   of      sources      including
                             attic   services,   the    clinic    ]),is    in    extensive    (Irti
                                                                                                  9                                        ,t(ytie,    and    the    Califoniia
                             abuse   program.   In    jaiiuarx,    1969    the    (.1-Iiiiie    be-      United Fund, junior I,(,, @
                                                                                                         Council   oil   Crimiiiiil   jii,@tic(,.   The   center    also    has
                             cwne tli  -first'flicilitA, in Los                     (,ollllt%"   to
                                                                                                         a   contract   Nx,ith   the   Ri%,ersitle    Unified    School    Dis-
                             d@-0-ti-t-p-aticiit lici-oiii detoxificitioii    iiid     in     Jinu-      tri(-t   to    t(@acli    remedial    reading    skills    to    high-
                             ani   191@l,   the   first    iioii-cron,crniiieiit    facilit),    in
                               I                                                                         school     students.     A     part-tiiii(@      medical      director
                             Southern    C,,,Iiforni@i     to     do     outpatient     barbiturate      and a medical ad%-isorN!           committee       meets       iiifor-
                             detoxificatioii.     I)et(.)xification      includes      plin,siciaii
                                                                                                         niallv    oil    an    "as    needed"     basis.     The     committee
                             prescribed      noii-iiircotic      medication      and      psn!clii-           I
                                                                                                         also   acts    as    liaisoii    NN-itli    the    Riverside    County
                             atric crisis an(] group couiiselitig is well as                  c(,r-
                             tain   social   services.   The   clijiie    also    offers    cotiii-      Nlcdical     Association,      ,N,hich      has      endorsed      the
                                                                                                         clinic.
                             seling    and     medical     services     for     amphetamine     and        Witli   tile   exception    of    one    person    who    is    paid
                             psychedelic drug abusers.
                                                                                                         on  an  liourl%,  basis   to   kerl)   ,i(.-etirate   inveiitorn,   of
                                                                                                         equipment     and     supplies,      all      persons      pron,i(ling
                             F,xaniples  of Yotith  Clinics                                              services     at     the     center     are     volunteers.     Profes-
                               Two examples  of Nlouth-type                free     clinics     are      sional    volunteers     include     al)proxiinateIN,     :)Z     phN-
                             the    Youth    Service    Center    of    Riverside,     Inc.     and      sicians,    25    iiurses    and     five     ps%-cliologists.     The
                             the N'aii NuN,s Youth Clinic.                                               center    has    over    200    c-oiiiniiiiiitn,    volunteers,    in-
                                                                                                         eluding     95     reniedial      readiiii-,      instructors      and
                              The   Nlan   Nu%,s   Youth   Clinic    is    one    of    five    re-
                                                                                                  -v,    other    paraprofessionals    trained    at     the     center.     In
                             spondents     sponsored     bN@     the     Los     Angeles      Count
                                                                                                         addition     to     regular     medical     services,     ps%-chiatric
                             Health    1)(Tartment.    'file    other     four     include     lia-      and    legal    services,    the    center     offers     a     summer
                             v,.Paiiaii    Gardens    Youth    Clinic,     Santa     Fe     Springs
                             Youth      Clinic,       Northeist       Health       Center       and      Damping     program     and     an     older     -      brother-sister
                                                                                                         program.     All     services     are     free,     N,oluntarv     and
                             Southeast     I-lealtli     Center.     Each     clinic     has      a
                                                                                                         confidential.
                             clinic     coordinator     or      administrator      -,vho      func-
                             tions    tinder    the    health     department's     Youth     Cliii-      One  Exainple  of a  Di-Lig  Clinic
                             ics Niedical Director.
                              Approximatelv     1,700     persons     are     seen      at      Van       Although   not   al-,vavs   referred    to    as    fre(,    clinics,
                                                                                                         drug-tn,pe    clinics    were     included     in     the     -tir%t,N
                             Nuys       Youth       Clinic        each        month.,Approxfinatcly
                                                                                                         because   of   the   many   common   clo@ils   ;iiid    ii)t(6iti@t--i
                             80   percent   are   between   the   ages    of    15    and    2::-),                                               1
                             Nvitli  just   5   percent   tinder   15   vears   of   age.   It   is      they   share   with   free   ciiiiies,   such   as   (--oticeni    for
                                                                                                         voung     alienated     members     of     societN,.      Frc-(Iuentlv
                             interesting    to    note    that    75     percent     of     persons
                                                                                                         services    offered     b@-     drug     treatment     centers     in-
                             served    are    from    higher    income    fai-ndies    and     only
                             5    percent     are     from     the     lowest     income     group.      elude   all   those   of   the   free   cliriies   with   the   excep-
                             This   is   not   the   case,    lio%vever,    in    tl@e    of    the      tioii    of    general    medical    care    and     deiital     care.
                                                                                                         Oiic     such      organization      that      is      philosophically
                             other    Los    Angeles    Couiitv     voutli     clinics     respond-                                                                           I
                                                                                                         and    organizationally    very     sinilar     to     the     hippie-
                             ing    to    the     stirvev,     (flawaiian     Gard(@iis,     North-
                                                                                                         t),-pe   free   cliiiic    is    Do    It    No%%,    Foundation    in
                             cast    and     Southeast),     ,N7here     low     income     persons      llollvwood.    This    is    a     national,     educational     foun-
                             comprise    betnveen     70     and     100     percent     of     the         I
                                                                                                         dation,     supported     through     the     sales     of     printed
                             population      sci-Ned.       Statistics       on       socioeconomic      and     other     tN,pcs     of     educatio;i     material      about
                             background     are      not      available      for      Sante      Fe
                                                                                                         drugs.   The   foundation    in    Iloll@-,,k!ood    has    a    nied-
                             Springs Youth Clinic.
                                                                                                         cal director o-@i call 24 hours t                and      a      medi-
                             The     volunteer     staff     of     Van     Nu%,s.Youth      Clinic      cal    advisorv    comi-nitte(@,    on     research     and     treat-
                             includes     nine     therapists,     s'LX     coi-nmunity     workers      ment of drug-iiiduced medical problems.
                             and     five     social     workers.     Nine     pbN,sicians,     two      The    staff    of    the    center    includes     one     ph%-sician
                             nurses,    t-%vo    psychologists,    one    social    worker,     one      in    @)iiimunihf    medicine    and    30    interns    iiid    resi-

                               I 10       APRIL  1972  -  116  --4


                (ii.-iits from  the,  Uiii%-ersit%@  of  Southern  California     fund  raising,   public   relations   and   lc(,al   affairs.
                Nif.,@lical  Center.  t%ko  psychologists,  five  lay   ther-     sccFc   has   received   financial    support    from    R(!-
                apists, 15 pariiiiiedicai'  p(@rsoiinel  %%,itli  (-@xtensive     gioiial \Iedical I"ro(yrams Area N' tncl the
                                                                                                                                              f
                drug  experience  and   six   coiiiiiiiinit\-   ,,olunt(!ers.     no@ic'    ail(]    Yoi-itli    Opportunities    Afyc-cN'    o
                All sci-\-ices provided at the center relate to the,              Greater Los Angeles.
                use   of   (]rugs,   Gcii(@ral   medical   care   for   drug-
                related   illnesses   and    eiiiergenc\@    treatment    for     lielationships witli        Nle(lical Societies
                ,li-iig o\-cr(losc is pro\,id(,(I. L,,ii.)orator%- aiial%,sis
                                                                                    Among the          als  Of   SCCFC   is   furtlieriny   the
                ,jf drugs, (It-u,f  (-otjiis(@iiiig  and  encotiiit(@rs,  and                        'O                                0
                                0                                                 acc(@ptal)ilit@.,'al,,Yd  cooperation  of  the  medical  aiid
                (Ictoxificittioii  are  also  pi-o,,7ided  -,it  the  center.
                                                                                  general    corhi-ntinities.    Sur%,cv    respondents    were
                The   foundation   is   cui-rcntl\,   developing   an    out-
                                                                0                 asked %\,Iictlier tli(@v  had   sought    the    advice    or
                patient    methadone    program.    Other    services    111-
                                                                                  assistance   of   their   coun@,    medical    society.    Of
                clude   some   txpc@s   of   health   education,    extensive
                                                                                  Eric 45 respondents,     27    (60    percent)    had    done
                drug   education,   paramedical   training,    legal    serv-     so.  The  tN-pes   of   assistance   and   cooperation   free
                ii-(-s and suicide pre%,ei)tion.
                                                                                  clinics   would   like   tli(,@   medical   coniniunit),   to
                  lltil)lications   of   the   Foundation   include    paiii-     T)ro%ride is reflected   iii their comments.
                plilt@ts (lisci  ssiiig  the  abuses  of  various  kinds.  of       Three    responding    clinics    have    received     some
                       @iieli as  an)plit.itaiiiii)cs"   barbiturates,   hcro-
                                                                                  assistance   or   have   been   endorsed   by   their   local
                iii,  aii,l  %pe(@(1-1  a   cartoon   publication   developed     medical   societies.   One,   the    Delta    Health    Proj-
                especiall@-  for  a(,(@s  8  tljrouoh  12  as  an   effective     ect,   is    sponsored    I)N,    the    Sacramento    County
                approach   to   preventive   drug    education;    and    cd-
                                                                                  .\,Iedical   Soci(@t%,.   As    mentioned    above,    Venice
                ucatioiiall  peci--oricxitcd   record   album   %%,itli   mu-     Community   Fiinil%l   Health    C(,iit(@r    is    partially
                sic I)v cont(@iiiporar%-,       k-no%%-ii   musicians,    and     funded   b%!   the   local   medical   society.   A   spokes-
                a special packet of edi.icational material                for     man for 'the Youth Service Center           of      Riverside
                teachers,    couiiselors     and     t(lministrators.     The     stated, "NN'e are p
                                                                                                        roud   to   be    endorsed    bv    the
                foundation   also    publishes    ,i    newspaper    contain-     Riverside    Countv    Nledical    Association    an'd    en-
                ing peer-group facts and news about drugs.                        joy a good            of   comniunication   -%%,itti    their
                                                                                  officers."   Two   other   clinics   reported    that    they
                                   Ciiii PreN-ent                                 have occasionally     contacted    local    medical    socie-
                NN'asted Enei-gies                                                ti.es  for  referral  purposes  or   for   ,,oluiiteer   pliysi-
                 The  priman?  goal  of  all  free   clinics   is   to   pro-     cians or supplies.
                                I                                                  The    remaining    15     respondents     Nvbo     comment-
                -,,aide  patients  with  quanta,   health   care   arid   re-
                                                                                  ed   on   this   question   indicated   that   medical    so-
                lated   services.   Since   the   mox-eiiient   began,   how-     cieties  are  reluctant  to  support  free  cliiiie   facili-
                ever,  cliiiies  have   had   to   f@ice   continual   crisis
                situations    in    funding,    staffing    and     community     ties.   One   respondent    'attributed    this    reluctance
                relations.   NVith   each   cliiiie   struggling   to   main-     to  a  lack   of   knowledge   or   misconceptions   of   the
                tain   its   own   existence,   problems   may   also   arise     extent   of   the   problems   and   goals   of   the    free
                                                                                  Clinics.  The   willingness   of   most   free   clinics   to
                bet-%veen   clinics-sucli    as    competition    for    com-
                munity   support,   gc-o(rrapliic    location    and    over-     provide   the    California    Medical    Association    with
                                         b                                        information   concerning   theiiiseIN?es    suggests    their
                lapping   services.   Ili   19'10   the   free   clinics   in     desire   to   icquaint    members    of    organized    medi-
                Southern   California   developed   a   council    of    free
                                                                                  cuie   with   the   problems   and   needs   of   the    free
                clinics  to  aid   in   solving   some   of   their   share(i
                problems.  Of prime import                                        ciinic   community.   Their   responses   to    the    survey
                                                  ance   to    the    council     also  seeni.to  in@icate   that   some   free   clinics   are
                was   the   preservation   of   each   individual    clinic's     not merely willing to accept,         but    may     actively
                independence arid in(liN-iduilit@,.
                                                                                  welcome, assistance from the          medical          commu-
                 The   Southern   California   Council    of    Free    Clin-     nity as it is represented by          county    and     state
                ic-s  (socFc)  consists  of   a   board   of   directors'com-     medical societies.
                posed   of    a    representative    from    each    of    22
                member    clinics    arid    an    advisory    board    whose                                    REFEREN@
                function  is  to   assist   and   advise   the   couilcj   in                                        I
                                                                                     Schwarz JL: Free  health  clinics:  w  tarc they?  Health  Rights
                areas    such    as    comprehensive     health     planning,     Nc'w', 4:), Jan 1971

                                                                                                 CALIFORNIA MEDICINE
                                                                                                 The Western Journal of Madicino


                                FROM THE MASSACHUSETTS DEPARTMENT

                                                                              of

                                                              PUBLIC HEALTH

                                                       THE LEMUEL SHA17UCK HOSPITAL

                          The    Massachusetts     Department     of     Public    bilitation  of  those  patients  with   cardiovascular
                       Health  has  seven  hospitals  equipped  for   a   broad    diseases.
                       range of  clinical  services,,  intended  especially  to
                                                                                     Guidelines for the improvement         in  diacnosi.
                       meet  the  needs  of   patients   with   long-term   but                                                    0
                                                                                   and treatment of vascular patients      have   alreadi
                       remediable disability. As a result     of the  iiicreas-
                       ing  demand  for  health  services   in   an   expanding    been   stated   by   the   Commission   which   define
                       population,  the   seven   hospitals   have   begun   to    the  delivery  for  optimal  health  care  at   tlirei
                                                                                   levels:  the   phvsician's   office,   the   community
                       assume  a  more  direct  role  in   serving   the   com-    hospital, and t@e regional vascular center.
                       munities  in  which  they  are  located.  This  includes
                       preventive,   therapeutic   and   rehabilitative    ser-      Patients  referred  to  the  Shattuck  %%ill   ha%,i
                       vices that are not always available                         access  to  highly  developed   diagnostic   procedure
                                                                                   and  some  forms  of  treatment  not  available   else
                          Lemuel  Shatt,-ick  Hospital  in  Jamaica  Plain   is    where. S,-co.-.dlv,. ,he goal. of  the  center  is  t,
     w                 the first Regional Vascular Center.                         establish  properly  staffed  vascular   coiisultatioi
                                                                                   services  in  the   state   and   community   hospital
                                                                                                         be
                                                                                   which will directly     nefit   many   more   patients
                                       Cardiovascular Diseases

                          The  Lemuel  Shattuck  Hospital   was   selected   as                     Chief Death Dealer
                       the  regional  center   because   of   its   exceptional      Much effort    needs  to  be  concentrated  in  thi@
                       staff  and   its   recently   expanded   facilities   in
                       anpography  and  in  the   diagnostic   laboratory   for    area   since   coronary   and   cerebral   thrombosis.
                       thrombosis   and   vascular   diseases.   The   -    new    peripheral  artery  and  vein  thrombosis,   and   em.
                       center is  located  in  the  Hospital's  Vascular  Labo-    bolism  together  constitute  the  number  one   caust
                       ratory,  where  work  on  the   causes   of   thrombosis    of death in the United States.
                       has been in progress since 1963.
                                                                                     The   establishment   of    vascular    consultatior
                          The  purpose  of  the  new  center  is   to   upgrade    services  in   hospitals   at   the   community   leve
                       the  quality  of  care  for  vascular  patients  and  to    would  require  the   purchase   of   some   equipment
                       encourage  the  addition   of   vascular   services   in    but  more  important  is  the  concern  on  the   pari
                       hospitals throughout the Bay Sr-,ite.                       of medical sta     to  establish  such  services.  Th(
                                                                                   Shattuck   Hospital   is   now   ready    to    conduc
                          The   new   program    coincides    with    recommen-    courses   that   would   help   implement   such   pro
                       dations  made  recently  by  the  I.ntet-Society   Corn-    grams in Massachusetts hospitals.
                       nussion  for  Heart   Disease,,Resources   calling   for
                       the   establishment   of   regional   vascular   centers
                       throughout  the   nation.   The   Commission,   a   ere-      Glidden  L.  Brooks,  MD,  superintendent   of   th(
                                                                                   Shattuck  Hospital,  said  that   the   expertise   ir
                       ation  of  the  Federal   Regional   Medical   Projzrams
                       Service,   is   charged   with   the   development    of    thrombosis  and  vascular  care  at  the  new   centei
                       guidelme-s  for  medical   competence   and   r,-iedical    can  greatlv  improve  the  deliverv  of  health  car,
                       facilities  in  the  prevention,  treatment  and   reha-                     (Cotilipitied oit Page 71)
                                                                                                            i

                       fiti Mnccarhurpftc Phvcician  Abrit 1972


                fcontinued from Page 66)                  acute intensive care, long-term  rehabilitation  and
    rou,jh this special program. He said that it is  a    physical medicine.
    od example  of one state  hospital  in  the  State
    blic   Health   Department    extending    special      At  the  same  time,  the  Outpatient   Department
    mpetence to  other  state   hospitals,   community    has  been   expanded.   There   are   now   complete
    ,-@pit,ais, iiursiiia homes and to  physicians  in    facilities for  pulmonary  function,  x-ray,  patho-
                                                          logic and bacteriologic studies. Patients  sent  for
    .ictice.
                                                          evaluation  of  pulmonary  problems   are   returned
    Expansion  of  other  services   into   outpatient    to the referring physician  unless  he  specifically
    d  home  care  programs  is  accelerating  at  the    requests treatment.
    ,,itluck.  The  Hospital   maintains   an   18-bed
                                                            The  Lemuel   Shattuck   Hospital   also   has   a
       'fication unit for  alcoholism  rehabilitation.
    toxi                                                  program  for  the  care  of  patients  with  chronic
     obtain  admission,  a  patient  must   be   spon-
                                                          renal failure, the first such  program  in  a  state
    red by an agency or an  individual  who  offers  a
                                                          public health  hospital  in  the  country.  Patients
    risible  follo%v-up  treatment  plan.  The  Lemuel
                                                          who   can   benefit   from   chronic    hemodialysis
    @attuck  Hospital,  working   closely   with   the
                                                          either  in  holding  for  transplantation  or  as  a
    -.3nsor,  provides  'deto.xification,  health  and                                               . .                       @l,
    %-chiatric evaluation, correction of  most  health    long-term prospect  are  accepted  for  training  in
                                                          home dialysis. About  60  patients  are  cuff  ently
    ,iblems,    and    makes    recommendations    for
    habilitation. The average hospital  stay  for  pa-    on the program.  Artificial  kidneys  for  home  use
    ,nts is nine davs.  Individuals  who  seek  admis-    are  provided  by  either  the  Massachusetts  Reha-
                                                          bilitation   Commission   or    the    Massachusetts
    )n should be in a problem  phase  of  drinking  at
                                                          Renal Disease Program.
    e time.
                                                            These  programs  at  the  Lemuel   Shattuck   Hos-
                     Home Dialysis                        pital reflect the changes that are  taking  place  in
    An additional  program  for  the  reversible  corn-   all  the  Department  of  Public  Health   Hospitals.
                                                          The task of caritig for the Iona-term  T,)atient  and
    iications  of  alcoholism  is  also  underway.  The
                                                          the   multi-problem   patient    has    traditionally
    c)spital staff is particularly  interested  in  pa-
                                                          fallen to these institutions.  The  turn  toward  the
    ents  with  the  clinical  diagnosis  of  alcoholic
                                                          development of the Lemuel       Shattuck    Hospital,
    -patitis   and    who    show    hyperbilirubinemia
                                                          as well as the other public  health  hospitals,  into
    eater than  5  mgm  percent.  These  patients,  who
                                                          comprehensive    community    resources    represents
    ia-%. or may not experience  the  complications  of
                                                          the  Department's  responsiveness  to   the   demands
    astrointestinal   bleeding,    encephalopathy    or
                                                          and  needs  of  the  citizens  of  the  Commonwealth,
    6otemia, will  receive  intensive  care  from  both
                                                          and its intent to  improve  the  quality  of  patient
    iedical  and  nursing  personnel  with  a   special   care  in  accordance  with  new   concepts   in   the
    "terest  in  the  management  of  alcoholic   hepa-
                                                          field of medicine.
    tis problems.

                       Expansion
    Special programs include      the   evaluation   of
    ierapeutic agents for control  of  gastrointestinal
    @oblems   resulting   from   alcoholism.   Patients
    iltable for these programs    may   continue    in-
    :)spital treatment until liver function   has   been
    tisfactorily  corrected.  Investigators  anticipate
    iat the patients selected for study  will   require
    least several,%veeks in the hospital.
    The Lemuel Shattuck Hospital         recently   re-
    Dened a limited number of beds        to  be   used
    Delusively  for  the  care  of  patients  with  all
    )rms  of  chronic   pulmonary   disease.   Patients
    III  be  accepted  if  some  benefit  from  therapy
    taN@ be  expected.  The  services  offered   include:


              -Editor's Noteboo
                    TO BE SUCCESSFUL, our organized syst
                    based on cooperative teamwork, the lack of  which  has  been  the  topic  Of
                    discussion at many recent meetings of concerned professionals.
                    The consensus  seems  to  be  that  health  professionals  must  be  trained
                    as a team if they are to function as a team. At  a  recent  meeting  of  the
                    American Association of Dental Schools, Dr.  Charles  R.  Jerge  called  for
                    a consolidated master plan  that  would  unify  the  efforts  of  the  "many
                    diverse institutions training people for the health field." He believes that
                    because  current  health  education  programs  are   a   "non-system"   they
                    produce "the non-system  of  health  care  that  presently  exists  in  this
                    country."
                    With  an  apt  analogy,  Dr.  J.  Richard  Gaintener,  chief  of  staff   at        MEDICAL LAB
                    University-McCook Hospital,  depicts  Dr.  Jerge's  thoughts:  "It's  almost
                                                                                                         MIAMI, RA.
                    as if the New York Yankees were to train their pitchers  in  Arizona,  their         MONRHLY CIRC. Tq. AVAIL.
                    catchers in Florida, their infielders in Georgia, and their  outfielders  in
                    Texas and then bring them all together in New  York  City  and  say,  'Okay,
                    let's function as a team.' "                                                     MAR         i972        V&
                    Possibly,  schools  of  allied  health  professions  can  best   provide   a
                    concept of teamwork for  students.  In  these  schools  an  opportunity  for
                    formal instruction in the "health care system" is  available.  Perhaps  more
                    importantly,   students   share   common   course   work,   use   the   same
                    facilities, know the same instructors, are familiar with the same  patients,
                    and have  the  opportunity  to  informally  discuss  their  experiences.  In
                    both ways, students gain a clearer understanding of  the  roles  each  plays
                    in caring for the  patient@  Each  can  form  a  picture  of  the  composite
                    showing the function of his own area as well as overlapping areas.
                    A  PROBLEM  EXISTS  in  these  schools  of  allied  health,   however.   Dr.
                    Joseph Hamburg, College of  Allied  Health  Professions  at  the  University
                    of  Kentucky,  explains  that  "The  development  of  a  college  of  allied
                    health has a  tendency  to  separate  programs  from  their  sponsoring  and
                    supporting   departments-medical   technology   from   pathology;   physical
                    therapy  from  medicine,  etc."  This  problem,  he  pointed  out,  concerns
                    many who  are  involved  in  laboratory  allied  health  training  programs.
                    Dr.  Hamburg  described  Kentucky's   Medical   Center   as   dedicated   to
                    collaborative  effort  (see  RMP  article,  page  20).  "The   Colleges   of
                    Medicine and Dentistry, the  major  involved  units,  have  given  of  their
                    time, their staff, their space and their budgets in support of  the  College
                    of Allied Health Professions." However, he  thought  is  was  impossible  to
                    deny a type of schism was created, although  they  have  tried  to  minimize
                    the fracture as much as possible.
                     "It may be that  in  other  places  where  circumstances  are  not  so  fa-
                    vorable a coordinated ap roach to  allied  health  education  could  be  po-
                                             p
                    tentially disruptive," he  emphasized.  Schools  should  seek  changing  the
                    climate, he urged, rather  than  disrupt  the  functional  relationships  a-
                    mong the allied health fields.
                    REGIQN  L MEDICAL-                 AMS-(page  18)   may   help   bring   our
                             AL     I
                    hi@if@ ctre-s@tiff in'to -a more cohesive unit. Programs  such  as  RMPs  in
                    which health professionals  must  work  together  to  establish  goals,  set
                    priorities, and put projects in motion stimulate  this  sense  of  teamwork,
                    helping cement relationships among the various specialities.
                     At continuing education course set  up  for  allied  health  administrators
                    and educators, the  concept  of  teamwork  is  also  projected.  In  one  of
                    these  course,  the  students  emphasized  that   gaining   an   added   ap-
                    preciation of other allied health field was  equally  as  important  as  the
                    technical  matter  they  had  learned.  Instead  of  perceiving  only   dif-
                    ferences in their specialities, similiarities were brought to the fore


                         Regional Medical Programs
                                   And The Technologist

          0  Medical  technologists,  seeing  the   referred  from  smaller  hospitals   to   training    programs,and     coordinate
          success of  their  first  efforts,  are   regional   hospitals   to    university   facilities,    manpower    and    other
          showing    increasing    interest    in   centers   (depending   on    the    in-   resources.   One   program    in    New
          setting  up  more  extensive   projects   dividual   problem).   "This    concept   York   provides   weekly    educational
          in Re                          S.         also calls for  a  flow  of  education,   conferences   for   technologists    in
           "TE                          care   in   consultation   hnd   back-up   services   over   50    participating    hospitals
          the   U.S.   may    be    substantially   from   the   university   through   the   (Medical  Lab,  Jan.,   1971).   In   a
          changed    through    regionalization,"   chain," pointed out Dr. Willard.          cooperative   project    between    New
          stated    Dr.    Daniel    L.    Weiss,     A strengthening  of  this  system  is   York   Upstate   Medical   Center    at
          Professor   of   Pathology    at    the   necessary on  both  an  individual  and   Syracuse,  and  the   New   York   RMP,
          University  of  Kentucky   College   of   institutional     basis,      symposium   audio-tapes  with  coordinated   slides
          Medicine,  Lexington,   at   a   recent   members   agreed.    "More    knowledge   are  made  by   the   Upstate   Medical
          College   of   American   Pathologists'   and     an     expanding     technology   Center  and  sent  to  area  hospitals.
          meeting    on    Regionalization     of   demand narrower fields  of  effort  for   Each  institution  can  then   set   up
          Medicine.  With  continuing  stress  on   each specialty  in  the   health   care   their   conference   at    their    own
          regionalization   as   a    means    of   system,"  Dr.   Weiss   explained.   As   convenience.
          solving some  of  our  nation's  health   fields   become   more    limited    in     In   addition   to    helping    area
          care   problems,    M.T.'s    knowledge   breadth,   but   deeper,   all   health   hospitals  improve   their   laboratory
          and    involvement     are     becoming   personnel, general  care  institutions,   services,   the   program    underlines
          more   crucial.   There   are   several   and   specialized   facilities   become   the  role  of  the  University  Medical
          areas  where  their  RMP  projects  are   more   dependent   upon   each   other.   Center  as   a   consultant,   referral
          beneficial:    Area-wide     continuing     This, interdependence  is  a  key  to   institution.   "Medical   technologists
          education  institutes;   expansion   of   a  new,  adequate,  functioning  health   throughout     central     New     Yrok
          training    programs;    systems    for   care   system.    One    problem,   Dr.   contact  us  with  any  problems   they
          consultation    and    referral;    and   Weiss  said,  is  that,   despite   our   encounter,"  points  out   Bettina   G.
          sharing specialized facilities.           familiarity    with    a     type    of   Martin,     coordinator      of     the
           Regionalization   is    proposed    as   regionalization,  we   have   not   yet   Program.
          one   means   of   providing   adequate   come   to    grips    with    our   in-     In  setting  priorities,   RMPs   are
          health care for all. It is hoped  that,   terdependence.   We   still    do   not   deliberately  designed  to  take   into
          through     regionalization,     under-   quite  know  how  to  deal  with   what   account local  resources,  patterns  of
          utilization  of  facilities  and   man-   lies ahead.                               practice  and   needs.   Depending   on
          power will  be  reduced,  and  needless     As  explained  by  Dr.   Herbert   B.   the  needs  of  a  particular   region,
          duplication  of  facilities   will   be   Pahl, Acting  Deputy  Director  of  the   different  kinds   of   programs   have
          prevented  without  sacrificing   gains   RMP Service,  RMPs  are  a  first  step   been developed.
          of sophisticated medicine.                in   formalizing   an    interdependent     For   example,    physicians    prac-
            The   working   relationships   among   regional system.  The  initial  concept   ticing  in  small  towns  and  isolated
          university-affiliated           medical   of RMPs was to  provide  a  vehicle  by   rural areas  of  Alabama  have  instant
          centers,             non-medical-school   which   new    techniques,    concepts,   access   to    specialists    at    the
          hospitals,    and    smaller,     local   and systems  could  be  transported  to   University   of   Alabama    at    Bir-
          hospitals    form     a    type      of   all   health   professionals.   Through   mingham     through     the     Medical
          regionalization, said  Dr.  William  R.   RMPS,  plans  are  set   up   to   meet   Information   Service   via   Telephone
          Willard,  Special  Assistant   to   the   health needs  which  cannot  be  filled   (MIST). Calls can  be  placed  free  of
          President for  Health  Affairs  at  the   by  individual  practitioners,   health   charge  from  any  point  in   Alabama,
          Kentucky   university.    The    system   professionals,   hospitals,   or    any   at  any  time  on  the  MIST   circuit,
          operates  when   patients   with   dif-   institution working alone.                where   switch-board   operators    are
          ficult   and   complicated   diagnostic     To  accomplish   these   ends,   RMPs   trained to locate  specialists  in  all
          and    therapeutic     problems     are   learn  of   new   techniques,   provide   fields  on  split-second  notice.   The

                                                                                                                         Medical Lab


           project  set  up  to  investigate   the    Discrepancies  in   the   magnitude   of   hormone   extracted    from    pituitary
           comparative  diagnostic   efficacy   of    growth    hormone    levels    following   glands. Patients  receive  3  injections
           each  of  the  insulin   and   arginine    these   stimuli   may    represent    an   a week until they reach a  height  of  5
           stimulation tests, it  was  found  that    individual variation is  in  sensitivity   feet,   or   until    puberty    ensues.
           23 children out of a group of  60  fell    of    the    hypothalamus    to    these   "Treatment  is  cut  off  at  this   ar-
           into  a  range  between  the  peak  and    stimuli,  supporting  the  concept  that   bitrary point because  of  the  lack  of
           diminished levels.                         insulin-induced     hypoglycemia     and   hormone,"    Dr.    Kaplan     explains.
            After    administration     of     the    arginine   stimulate   growth    hormone   "The  shortage  of  growth  hormone   is
           stimulant,   serum    growth    hormone    release      through           different   so  acute  that   some   children   must
           levels of less than 3 or greater than 7    hypothalamic receptors.                    wait for treatment,  often  as  long  as
           mmcg/ml   are    considered    to    be      However, Dr. Kaplan      warns,    the   a year."  Five  feet,  she  went  on  to
           deficient   and    normal    responses,    significance    of    these    disparate   say, is an  unusual  height  for  growth
           respectively.    Of    the    23    un-    responses  remains   speculative   since   hormone    deficient    children.    Un-
           classifiable   children,    some    had    they   do   not   simulate   physiologic   treated, they grow to be  only  3112  to
           hormone  responses  of  more   than   3    conditions. She  also  points  out  that   41/,2 feet tall.
           but less than  7  to  both  stimuli.  A    a  primary   hypothalamic   lesion,   in     The     therapeutic     hormone     is
           minimal  increase  following   arginine    which  secretion   of   growth   hormone   extracted  from  pituitary  glands  that
           infusion  but  a  normal  response   to    releasing  factor  may   be   deficient,   have  been  donated  to   the   National
           insulin  administration   resulted   in    cannot   be   differentiated   from    a   Pituitary     Agency.     A     national
           several  children.  The  rest  gave   a    primary   pituitary   deficit    through   organization  has   been   set   up   to
           normal    rise    following    arginine    the  use  of  stimulation  tests  alone.   encourage   donations    of    pituitary
           infusion, but  no  rise  or  a  minimal                                               glands  to   the   Agency.   The   Human
           one    following       insulin      ad-    Test conditions                            Growth   Foundation,          as     the
           ministration.                                At the clinic,  test  conditions   are   organization  is  called,   also   funds
             "It is important to  point  out  that    stringently   regulated    because    so   basic    and     clinical       research
           on the basis of a single test, some  of                                               programs,     and     helps      provide
           these  23  children  would  have   been    many  factors  may  affect  the  release   treatment   for   children   from    in-
           classified    as     growth     hormone    of   growth   hormone.   Stress,   exer-   digent families.
           deficient,"  points  out  Dr.   Kaplan.    cise,  sleep  and  some  disease  states     "And  there  is  an  educational  aim,
           "It  is  essential  that  at  least   2    such   as   thyroid   disorders,   dien-   too,"  says  Dr.  Kaplan.  "We  want  to
           stimulation  tests  be  used   in   the    cephalic      syndrome,      acromegaly,   make   the   public   aware    of    the
                                                      and  nutritional  deficiences  may   all   problems   that   can   occur    through
           evaluation  of  children  with   growth    influence test results.
           retardation." In a few cases,  she  has      In   children   with    hypothyroidism   hormone   deficiencies   and   to    let
           found,   precise   diagnosis   may   be    the   growth   hormone    response    to   people  know  what  is  being  done  for
           possible only  when  stimulation  tests                                               youngsters with the problem.
           are performed   after   estrogen    ad-    stimuli is  often  less  than  that  ob-     "Research  is   providing   more   and
           ministration,  or  after   observations    served  in   euthyroid   children.   The   more  encouraging   findings   and   new
           of  growth  rate   during   a   6-month    effect  of  hypothyroidism   on   growth   potential   approaches   for   treatment
           couse  of  therapy   of   growth   hor-    hormone    responsiveness     is     not   of   growth   problems.   We   do    not
           mone administration.                       related   to   the   severity   of   the   h ve all  the  answers  by  any  means,"
                                                      hypothyroidism,    length    of     time     a
             It is believed that  children    witn    before diagnosis,  or  the  age  of  the   she continued.
           disparate    or    blunted    responses    child. Because of  this,  children  with     Another   UCSF   scivntist,   Dr.   C.
           probably  represent   a   heterogeneous    hvi)othyroidism    are    tested     for   H.  Li,  has  succeeded  in  determining
           population  with  respect   to   growth    er@wth      hormone       responsiveness   the   structure   of   growth   hormone.
           hormone   secretary    capacity.    The    following   treatment   with    thyroid.   Synthesis    has    also    been     ac-
           decreased   responsiveness   to    both                                               complished.       However,          bulk
           insulin-induced    hypoglycemia     and    Treatment protocol                         production  of  the  hormone  is   still
           arginine   infusion   may   reflect   a      Children   diagnosed   as   having   a   too costly. Any possibilities  of  using
           diminished capacity  of  the  pituitary    deficiency   of   growth   hormone   are   it  for  routine  treatment  are   still
           to     secrete     growth      hormone.    treated  with   injections   of   growth   quite remote.

           AA.@,h 10711                                                                                                                17


          Interdependence is the key to improving our health care system

          program   was   developed   through    the    ones  is  a  critical  way   to   overcome    Kentucky,   explored    one    of    these
          cooperative   efforts   of   the   Alabama    the     maldistribution     of     certain    situations   during   the   CAP   meeting.
          RMP,  the   University   of   Alabama   at    resources.   Almost   half   the    nearly    "Students    who    come     from     more
          Birmingham,     and      the      American    6000   short   term   hospitals   in   the    rural   or   distant    homes    have    a
          Medical    Association    Education    and    country   are    now    affiliated    with    tendency      to      seek      employment
          Research Fund.                                RMPS;  and  about  60   percent   of   the    closer to our campus," he said.
            Generally,    programs    are    related    nearly    500    medical-school-affiliated      As  a  solution  to  this  problemi  Dr.
          to   3   broad    areas:    Health    care    hospitals participate.                        Hamburg    proposes     development     of
          organization    and    systems,     health      In   rural   areas,          especially,    necessary    programs    within    systems
          professionals,   and   patient    services    regionalization    can    give    valuable    of    community    colleges.     "Students
          and target groups.        Virtually    all    aid    to    M.T.s.    Montana     medical    who   receive   their    education    near
          RMPs   list    educaiton    or    manpower    technologists    formed    a    continuing    their  homes   have   more   of   a   ten-
          as   a   major   regional   need,    while    education   program   with    RMP    help.    dency to  stay  in  that  area,"  he  said
          disease     prevention      and      early    There    projects    provide     workshops    their   survey   studies    showed.    "In
          detection,  health  care  for  the   poor,    on    new     techniques,     particularly    addition,  as  new   systems   of   health
          and  urban   health   and   rural   health    continuous   flow    analysis,    (Medical    delivery  are  generated  and   the   most
          problems   are   close   contenders    for    Lab,  April   1971).   With   no   medical    distant     outposts     become      func-
          top prioroity.                                school  center  in  their   state,   these    tioning  satellites,  there  could  be   a
             Hospital  participation  is  I  key  to    technologists    must    provide     their    tendency  for  health   professionals   to
          development     of     RMPS.      Building    own     sources      of         continuing    find  such   rural   settings   more   ap-
          and   strengthening   effective    working    education and consultation.                   pealing  to  them  for  work   than   some
          relationships    among    hospitals    and      Rural  areas,  even  those   that   have    of the urban complexes.
          medical   centers   are    among    pnmary    health  care  facilities,  have   an   ad-       However,"   he   observed,   "it    may
          concerns   of   the   programs.    Linking    ditonal      problem.      Dr.      Joseph    be  that,  with  our   improving   network
          of  less  specialized   health   resources    Hamburg,   College   of   Allied    Health    of   communication,    even    the    most
          and  facilities  with   more   specialized    Professions   at   the    University    of                        continued on ptige  22

                      What Are Regional Medical                                                       Programs?
                Fifty-six      Regional      Medical       To   assure   the   RMP    represents      stitutions,     organizations,      and
              Programs   now    operate    in    the     the  entire  geographical   region,   a      with the medical center.
              United  States.  They  are         the     Regional     Advisory     Group      is         Beyond    Regional,    Local     and
              result of the 1964 Report of       the     required.        Members        include  I   Area     Advisory      Groups,      all
              President's       Commission        on     private    practitioners,     community      regions   have   a   number   of   task
              Health   Disease,  Cancer          and    -hospitals,    allied    health     per-      forces     and     committees     which
              Stroke,       which           included     sonnel,        and             consumer      have major responsibilities           r
              development         of        regional     representation.       The       primary      project       development        and/or
              complexes   of   medical    facilities     function  of the     Regional       Ad-      review  of  projects.  Nearly  all   of
              and resources among        35    other     visory  Group  is    to       determine      them   assist   in   establishment   of
              recommendations.                           overall     scope,      nature      and      objectives    and    priorities     for
                The   first    operational    grants     direction   of   the   program.    Each      program activities.
              were   approved   by   the    National     Regional    group    must     determine         Nearly      25,000       individuals
              Advisory    Council    of     Regional     policies,   establish   criteria    and      representing   both    consumers    and
              Medical  Programs   in   1967.   Since     priorities,    allocate    RMP    grant      all   facets   of    health    provider
              then   RMPs   have    been    extended     funds    accordingly,    and     review      organizations   and    interests    are
              twice  by  Congress,   most   recently     operational projects.                        involved.   They    identify    service
              in  1970   for   3   years.   Expanded       Most   regions   also   have    Local      needs,  establish  priorities  at   the
              provisions  of  the  latter  bill  in-     and      Area      Advisory      Groups      local  level,  allocate   and   realign
              cluded  emphasis   on   primary   care     which      assist     in        project      resources,   and   seek   Federal   and
              and    regionalization    of    health     development            and          im-      other  funds  to   support   activities
              care   resources;    added    emphasis     plementation     to      meet      com-      and   specific   projects   which   are
              on   prevention   and   rehabilitation     munity needs and      to     strengthen      self     -determined     and      self-
              concepts.                                  relationships    among    local     in-      operated.

                                                                                                                                  Medical  Lab


                DOW DIAGNOSTICS

                              for ACID PHOSPHATASE determinations

             Method tested at Blo-Science Lat
             Alkaline Phosphatase Reagent Set also available
             For more information, write or call us (collect) today.

                                                                                                                    Dow Diagnostics, Dept. 50-M-3
                                                                                                                    The Dow Chemical Company
                                                                                                                    P. 0. Box 1656
                                                                                                                    Indianapolis, Indiana 46206
                                                                                                                    (317) 638-2521 (Ext. 392)
                                                                                                                    In Canada:
                                                                                                                    14 Dyas Road
                                                                                                                    Don Mills, Ontario, Canada

                                                                           Get more info! Circle Reader Card No.  106
             March, 1972


                                                                                                               RMP
                                                                                                                 ntinued from page 20
                                                                                                               co

                                                                  MEDICAL LAB
                                                                                                               rural   student   will   be   lured   away
                                                                  MIANII, FLA.
                                                                  @IONTHLY CIRC. N. AVAIL.                     from his home never to return."
                                                                                                                                 d  that   the   RMP   in
                                                                                                                 He also note
                                                                                                               the   Kentucky   area   had   been   found
                                                              MAR          1972
                                                                                                               to be  relatively  insensitive  to  allied
                                                                                                               health  needs.   Except   for   supporting
                                                                                                                 veral     continuing           education
                                                                                                               se
                                                                                                                                                  allied
                                                                                                                                   interest in
                                                                                                               proposals, their
                                                                                                                                                  d    on
                                                                                                               health    has    been    concentrate
                                                                                                                                                  "The
                                                                                                                hysician assistant programs.
                                                                                                               p
                                                                                                                                        Council     still
                                                                                                               Regional  Advisory
                                                                                                                     representation   from   any   allied
                                                                                                               lacks
                                                                                                                                     he  reported.
                                                                                                               health discipline
                                                                                                                  His   observations   are   echoed    in
                                                                                                               the   Allied Health           Professions'
                                                                                                               national      conference             recom
                                                                                                               mendation:   Greater   participation    of
                                                                                                               allied  health  groups  in  the  structure
                                                                                                               of  RMPS.   Support   of   allied   health
                                                                                                               by   RMPS,   the   association   believes,
                                                                                                                           ry to reach    our       mutua
                                                                                                               is necessa
                                                                                                                                 hensive     health  care.
                                                                                                               goal  of compre


        McDonough,,  Georgia

                                                                                                                   e
                        enin,z                                                           s to                           a.                          are
                  p
                                                                                                                                ity
                                          a @ur                                          otntnun
            Two Atlanta Physicians
            Open Health Outpost  for
            Underserved Rural Area
                                                                                        f7
              .%Iany  people   feel   that   delivery   of
            health care services in  the  nation's  small,
            rural  communities  is   one   of   the   most
                        -id difficult issue
            sipwicant a.                   s  waiting   to
            be resolved by the medical         profession.
              The  concentration  of        health     re-
            sources.     manpower     development      and
            the   focus   of   major   developmental   at-
            tention  in  the  nation's  urban  areas   has
            created  a  gap  in  rural  health  care   de-
            liv@  that  leaves  a  sizeable   se-ment   of
                 pulation   in   our    "country    towns"
            the po
            often far worse-off than their        big-city
            cousins.
              It  was   this   disparity   that   prompted
            Drs. Louis    C    Brown    and    Calvin    A.
            Brov6-n of  Atlanta  to  begin  a  project  in
            ,NicDonoupli,  Georgia,  which  will  give   a                                    T-
            large   se@nt   of   the   area's   population
            its  first  measure   of   readily   available
            health care services. If successful                t@
                                                   in  its
            mission  of  health  care  work  by   a   team
            of  n  @,  the   project   wiU   be   an   im-
                Ur
            portent   demonstration    of    how    nurses
            and other for
                           many   trained   health    pro-
            fessionais can improve services      i
                                                  n    cur
            rently urderserved areas.
              '.%IcDonough   Georgia,  is          located
            approximately        38   miles    south    of
            Atlanta,   L-i   Henry   County,    population
            25.000.  Henr%-  County   has   a   total   of
            five physicians. Twice a week this
                                                      num-
               n's-,s to seven. Those are the         days
            her
            Drs. Louis and Cal%-in Brown hea
                                                 d    down
            higli%%-3y  75  on  the  35-minute       drive
            from Atlanta.
              Their  destination  is   the   basement   of
            a    theater-turned-furniture-store    located
            on  one  corner  of  the   NicDonough   public
            square. where  a  sign  at  one  side  of  the
            bui:ding  indicates   this   as   "The   Henry
            County ti"th Care Access Station."
              Lntil  the  station  was set up          last
            %I.uch,  one  public  clinic   was   the   onl
                                                         y
            health  care   facility   in   Henry   County.                                          't"
            There  are  no  h  spitals  and  there  is  no
                             0
            ambulance   service   The   nearest   hospital
            is in neig.-,bo.-ing Spaulding    County,    but
            Henry   and   Spaulding   Counties   do    not
                                                                     1..4
            have  a  hospital  service  arrangement,   and      Shiro Brovvn takes the Pnc-zagc oi a tiew atid close-bil health care scri-ice to the community. but
            many  people   go   to   Atlanta   when   they      educating people to come for health care when "they don't feel bad" has proven to be a difficult
            become seriously iU.                                assignment.


                                                                                                                   Calvin   A.   Brown,   4f-D.:
                                                                                                                   "They   don't    even    know
                                                                                                                A  how to get on welfa7e.

                                                                                                 -T
       Louis C. Brown, M.D.: "fole are trying to open new avenues
                    for a population that has been by-passed by
       to health care
       modem medicine.
                                                                        Barbffa Burroughs, R.N.,  and  Virginia  Nelson,  L.P.N,  watch  as  Dr.  Louis-  Brown
         The     significance     of     the     Henry                  confers Militia a patient. Nurses  have  had  special  training  in  gathering  nwdical
       County  Health  Care  Access  Station  is   its                  histo?y and counseling.
       role  as  a  "new   breed"   of   health   care
       facility, reaching  people  in  a  grossly  un-     the     major     medical     problems      en-    people  start  talking  about   their   own   ex-
       derserved     community      and      providing     countered   by   the   station   are   anemias,    periences  at  the  station,  I  think,  we  will
       health care  services  in  a  far-reaching  ex-     overwieght   and   hypertension.   ",Nlost   of    move   rapidly    toward    our    patient    en-
       pcriment  in  which   nurses   play   a   major     the  anen-tias   seem   to   be   nutritional,"    counter goal."
       role  'tn  improving  health   care   services.     said  Dr.  Brown,  "and  we  think  the   over-       Shira    Brown,    who    is     administrator
       Beyond   that   is   the   crucial   test    of     weight  problem  may   also   be   a   function    for  the  center,  also  handles   the   job   of
       whether  such  a  facility   can   obtain   the     of  diet.  There   is   an   excess   of   car-    community     outreach.     "One      of      the
       5-to-6,000    patient    encounters    annually     bohydrates   and   a   shortage   of    protein    major     problems     is     just      downright
       which the  physicians  feel  "will  make  it  a     here.   Worms   and   other   intestional   in-    apathy,"    he     says. "There     hasn't     been
       significant  factor  in  the  health  care   of     festations  are   not   uncommon,"   he   said,    much   done   for    the health   care   of   these
       people in NtcDonough."                              "and  there  is  a  lot  of   ignorance   about    people  in   the   past, and  thev  are   not   go-
         "What  we  are  trying  to  do,"   says   Dr.     health care.                                       ing to form  good  health  habits  over-
       Louis  Brown,  "is  to  give  the   people   of       Right  now  the  doctors   are   looking   to    night.   So   what    we have to do  is  eo   out
       McDonough   -   mainly   the   poor   -   their     the  time  when  the   station   achieves   its    into    the    community    and    spread     the
       first   avenue   into   health   care.    Nlany     patient   load   capacity   of   40    to    50    word  that  there  is  a  health   center   close
       adults  here  have  seen   a   physician   only     patients   daily.   "And   this    brings    in    by where anyone can have         his     problems
       two or three times  in  their  lives.  lt's  so     another  point,"   says   Dr.   Calvin   Brown,    cared  for  with   a   minimum   of   difficulty.
       difficult here to see a  doctor,  that  if  you     11 and  that  is  if  the  center  has  sufficient If  we  can  get  people  interested  in   taking
       hJv@   Problems   with    transportation    and     traffic,  it   might   encourage   some   young    better  care  of   themselves,   we   will   feel
       money,  you  don't  see  a  doctor  until   you     physician  to  choose  this  area  to  set   up    that    we    have    accomplished    something,"
       art  critically  W.  The   health   care   goal     his practice,  and  that  in  itself  would  be    he continued.
       here fight now,  is  to  get  people  into  the     an accomplishment.                                     But  Shira  Brown  is   not   so   optimistic
       center  so   we   help   them   get   treatment         You  have  to  understand   that   one   of    that    he    sees    these    things     hanp@ng
       (Of  the  tremendous  backlogs  of  ills   that     the  major  problems  that  anyone  in  a  sit-    without  some  other  siriul          .   taneous
       they  have  been  carrying  around            ...   uation like this is  going  to  be  faced  with    changes.    "Housina    and     economic     con-
                                                                                                                                     v
       there's a lot  of  catching  up  to  do  around     is  the  difficulty-  in  getting   people   to    ditions   for   some   people   here    are    in
       here.-                                              realize  what  the  station   is   all   about.    pretty  bad  shape.  A'e   need   to   see   some
          In  the  few   months   since   the   center     Another  difficulty  is  in  getting  them   to    changes  in  these  areas  that   parallel   work
                                               I   .I-     ---- @-                   ri.,. -, 'in  th@t       in   henith   care.    This  t)roiect  is    also


                                   @,7

                                                                                                                              and on a rainy. stor?ny  SalurdLIY  n*-f,
                                                                                                              vement end$.
              Health care accessibility has been Slow in coming to the people who live "beyond where the pa
                                                it is best to not become critically i(L
              when the road is soft a?id slippery,

              Health Access Station                               clinical     screening     -     blood     tests,
              Continued                                                                   pressure,        diabetes
                                                                  urinalyses,  blood
                                                                          g and similar work.
              attempting   to   help   people   here   b    eak                               es to us for th
                                                       r          screenin
                                                                    "When a person      corn
              out  of  the   poverty   cycle   through   better                                                   e
              health   care   and   through   other    avenues.   first  time,  our  nurses   begin   compiling   a
              We  ho  e  to  work   with   other   groups   who   medical   history   and   a    medical    evalua-
                   p
              have   the   experience    and    expertise    to   tion.   Where   necessary,   consultation    with
              give   a   kind   of    social    and    economic   a  physician  is  sought  and   standing   treat-
              dimension   to   what   is   now   basically    a   ment  orders  are  given   appropriate   to   the
              health   program."    "Niany    of    the    poor   situation.  In   some   cases   we   have   found
              people  in  parts  of  this   area   don't   even   it   necessary   to   transport    an    incoming
              know   how   to    get    welfare    assistance,"   patient    immediately     to     the     nearest
              said Dr. Calvin Brown.                              physician  or  hospital.  We   have   a   vehicle
                What   kind   of   health   care    does    the   for this Purpose.
              station   provide?   According   to   Dr.   Louis      In addition to th
                                                                                          e   mission   of   health
              Brown,  the  station   is   not   attempting   to   care  delivery,  the  doctors   feel   that   the
              compete  with   the   few   physicians   in   the   work   of   the   station   should   include    a
              area.  "After  all,  the  people  we   see   sel-   patient    education    program    and    medical
              dorfi,  if  ever,  go  to  a  private  physician.   careers  recruitment.  "if  we   can   get   some
              Actually,   our   nurses   who   run   the   pro-   people   here   motivated   and   involved,    we    Alurse Barbara Btirrouglis and the staff of  t,!
              gram   on   a   day-to-day   basis   have    con-   hope   that   eventually   they   can   be    the    Station  provide  patients  with  competent,  um
              tinuous   contact   with   physicians   in    the   ones   running   this   center,   and   this   in    derstanding     and     dignified      hana7ikg-
              arC3   and   can   call    on    them    whenever   itself   will    be    a    significant    accom-    technique which is winning the facility
              necessary,    and    they     have     continuous   plishment.                                           ftiendship of the community.
              contact    with    Dr.    Calvin    Brown     and
              myself.
                 We   are   not    attempting    to    position
              ourselves   as   an   emergency   medical    care
              facility,   although   we   will,   of    course,
              provide  emergency  first  aid.   In   fact,   we
              have   neither   the   kind   of   equipment    n
                                                              or
              the  space  to think we can s             e   all
                                     -v problems in
                                                    olv
              health care deliver.                            this
              area.  What  we  are  hoping  to  do   is   bring      1
              people into the health care system              and
              provide,  at  the  minimum, a  I
              health   care    which    makes    it    possible for
                                                           evel of                                                                                               -
                                                                                                                                                      I
              the   poor   people   of   this   area   to    be in                                                                          IV
                      -ith motiirif hpln nn ,i continuine


      -New',Tickle Cell Test
                                                                Howard Opens  Cellular  Biology  Laborator%,
      Announced by Firm
                                                                                                                   A   new   research   labor3tOr-%.    has    @n
         A   Philadelphia   firm   has   developed   an                                                         opened   at   the   Howard   Ur,;Ve7S-.r-@   Cot-
      electronic  device   which   it   terms   as   "a
                                                                                                                lege   of   Nledicine   to   condu@.    a    a@@e
      practical   advance   in   the    screening    of
                                                                                                                range  of  studies  in  the  field  of  cc'-lular
      people  on  a  mass   basis   for   sickle   cell                                                         biology.
      disease."                                                         7
         The    new    instrument    was     introduced                                                            Named  in  honor   of   Er-rest   J.   J,.:st.
      by   Bio/Data   Corporation    and    has    been                                                         the   laboratory    was    developed    as    ran
      called   by   i(s   designer,    Bio/Data    Vice                                                         of    the    College    of    \Iedicipe's    DL@-
      President  Michael  Sokol,   "the   first   piece                                                         ment of Anatomy.
      of    equipment    available     for     low-cost                                                             According  to  Dr.  L.   V.   LLakL-,   r,-o-
      mass screening."                                                                                          fessor   and   chairman   of   t'@.-    D---'@,t-  I
         Described as     the    "Sickle/Scan,"     the                                                         ment   of   Anatomy,   the    labor-ito-N-    wiU
                                                                                                                be engaged in a number of re'
      instrument  was     first     demonstrated     at                                                                                                 _e
                                                                                                                projects  in  "a  wide   ran--e   of            s
      Phfladelphia's      \Iercy-Douglas      Hospital.
                                                                                                                to   further   our    understanding!    of    -@e
      According  to   a   statement   from   the   man-
      ufacturer,     the     new     instrument     (1)                                                         total   development   and   function    of    the
                                                                                                                human body."
      reduces   the    positive    recognition.    time
      from  five  minutes  to  less   than   one   min-
      utes;  (2)  reduces   the   amount   of   reaaent
      used   by   85   percent;   tests   two   samples
      simultaneously;   (3)   uses   a   blood   sample
      drawn   by   a   finger-stick   (4)    eliminates                                                         Dr.  Lee  V.  Leak,  director  of  the  E@r  Just
      problems   of   sample   identification,   trans-                                                         Laboratory.
      portation and storage.
         "in     operation,"      the      announcement
      reports,   a   7   x   70mm   test   tube    con-                                                           Therman   E@,ans.,\LD.
      taining    the    blood    samplelreagent    mix-
      ture   is    inserted    into    one    of    the              SPECIAL OCTOBER                              To New Manpo-,-.-er Post
      Sickle/Scan's   two   test   wells.    The    in-                     FEATURE
      strument   automatically   begins   its    scann-                                                               Therman     Evans,     NI.D..     has     b-@n
      ing  process,  measuring  the   rate   of   solu-                                                           named  Special  Assistant   for   B',--@-k   C,-,@
      bwty   of   the   negative   blood   sample    in                   "The Nature of                          oerns  in  the  Office   of   Health   Ni---7-ower
      the  reagent.  The  reaction   is   detected   at           Community Health Centers"                       Opportunity,  Bureau  of  H@zh               Nian-
      Its onset,  giving  a  negative  reading  in  ten                                                           power Education.
      to  twenty  seconds.  If   no   reaction   occurs       An address to first-year residents of                   The   Office    was    recentlv    established
                                                                     The University of Miami
      within   60   seconds    the    instrument    re-                                                           to    strengthen    the     represe..tztion     of
      cordsa positive indication."                                        Medical School.                         disadvantaged people and                      -in
         Since   the    machine    is    designed    to                                                           the health professions. @, @-                    a
      screen  out   negatives,   there   is   virtually           By George A. Simpson, IND.                      component     of     HEN@"s      Nat;o-@-      Ir-
      no  possibility  of   a   positive   being   mis-          Director, Family Health Center                   stitutes   of   Health,   supports
      read   as   a   negative,"    the    announcement                    Miami, Florida                         of   physicians,   dentists   and   other   health
      said.                                                                                                       professionals.

                                                           Contined from page 10.                                 charges  are  mimimal   -   SI   for   an   office
                                                               Another     major     task      which      the     visit  and  S2  for  any  type  of
                                                                                                           is         Also   in   anticipation    of
                                                           station has assumed, Dr. Brown says,
                                                           that   of    being    a    "peoples    advocate.,,     management,      a       communit,;       --avsorv
                                                             Nothing  can   be   done   of   great   si-nifi-     council is being prepared to                  re-
                                                           cance    here    until    housing,     sanitation,     sponsibiiity for operation               5-@@--ort
                                                           water    treatment     and     sewage     problems     of  the  station.  "We  are   here   to   4--t.-o-
                                                           are  solved,  and  we   want   to   keep   contact     duce  people   to   health   care.'   cz-%-s   D-.
                                                           with   the   proper   officials   to   see    that     Louis   Brown,   "to   get    them            Li
                                                           these needs are met."                                  running  this  station.   and   to   '.-e7r   trtn
                                                               Recently,    the    station    was     removed     them  to  operate  it,  and  then   we':l   r7.ovc
                                                           from   the   Georgia   Regional   Nledical    Pro-     on to another project."
                                                           gr        '.temporary"   funding   list    to    a         Nfeanwhile,     Shira     Brown      cont;rues
                                                            __Am's..
                                                           ..perm@ent     funding"      category.      Nfean-     the routine of regular 6isits V611til
                                                           while,   however,   the   two    physicians    are     who  live  across  the  railroad   '73C'@'S   2::d
                                                           looking    toward     the     day     when     the     down   beyond    where    the    p3ve:ntnt    ends
                                                           station   is   completely    or    mainly    self-     -   an   effort    which    brirzs    SliZc@    Li
                                                           supporting.   "Right   now   we    are    charging     small,  but   highly   rewardirL,   do@   to   t@e
      Joiinttyjuiipz5uit atiduam, Baiicit.                 a  small  fee  to  see  if  the   community   will     people   receiving    and    deLiv@-z    ;--eaL!lh
      Staff members prot-ide nurses assistance             support    the    station     financially.     The     care in this small, rural community-
      ,end hindip                 fn, up etatir)n


                             regional medical
                                               programs

                             JAMES   W.    CULBERTSON,    M.D.
                               CUlffON    BRADDOCK,     M.A.T.
                                                       Memphis
                                                                  MEMPHIS

                 The 75  county  medical  referral  region        Demonstration Projects
                      served  by  the   Memphis   Regional
                Medical Program  includes  parts  of  five          Currently  operating   projects   funded   by
                   states. In  seeking  improved  delivery        the Program include the following.
               of health care for this area, the  Program           A  stroke   center,   incorporating   disease
                 has f unded a  variety  of  demonstration        treatment  and  prevention,  research,   commu-
                                                                  nications  and  public  education,   and   con-
                  projects in urban  and  outlying  areas.        tinuing education for physicians and  other
                           Services of  the  Program  staff       health care professionals in the Region.
                 emphasize  planning  for  future   needs,          A regional  laboratory  for  gastrointestinal
                 based on  identification  and  definition        mucosal suction biopsy, serving as  a  referral
                            of  problems,  and   continuing       facility for diagnosis of  cancer  and  precan-
                     education   of   health    professionals.    cerous  conditions  and  providing   continuing
                                                                  education for physicians.
                                                                    Two  cardiovascular  care  projects,  one  in
                                                                  Memphis and one  in  a  small  town  in  north-
                                                                  eastern   Arkansas,   demonstrating   treatment
                                                                  procedures  and  serving  as  regional  medical
                                                                  and paramedical educational centers.
                   he   Memphis   Regional   Medical   Program       A  research  project  studying  skin  cancer
               Tserves  a  75  county  medical  referral   re-    and its epidemiology as  an  endemic  condition
               gion, including  parts  of  western  Tennessee,    in a rural area of western Tennessee.
               northern Mississippi, eastern Arkansas,  south-       Two  multiphasic  screening  projects,   one
               eastern Missouri,  and  southwestern  Kentucky.    dealing with  the  poor,  black  urban  popula-
               The  Progra@s   two   principal   efforts   are    tion  of  Memphis  and  one  dealing  with  the
               demonstration projects in  urban  and  outlying    poor,  white  rural  population   in   northern
               areas and multidisciplinary professional  staff    Mississippi.
               services, including extensive planning  to  de-       A hospital-based home  health  care  project
               fine and  meet  future  problems  arising  from    in northeastern  Arkansas,  providing  nursing,
               present conditions.                                dietetic, and physical therapy services.

                                 Reprinted from POSTGRADUATE MEDICINE, Vol.  51,
                                      No. 4, April 1972, @McGraw-Hill, Inc.


                                                                                Multidisciplinary Services

                                              JAMES W. CULBERTSON                  To provide  a  wide  variety  of  services  and
                                              Dr. Culbertson is                 to  permit   a   multidisciplinary   approach   to
                                              coordinator and director of       problems,  the  Program  staff  consists  of  per-
                                              the Memphis Regional              sons   from   many    professional    backgrounds-
                                              Medical Program, with
                                              headquarters in Memphis.          medicine,  nursing,   rehabilitation,   economics,
                                                                                education,   medical   social   work,   journalism
                                                                                and   graphic   arts,   sociology,   epidemiology,
                                                                                mar    ting,    management,    library    science,
                                                                                physical therapy, nutrition and others.
                                                                                   Planning-Staff   services   include   extensive
                           CLAYTON        BRADDOCK                              planning  to  define   and   meet   future   prob-
                                                                                lems  in  health  care.  Working  with  the   Pro-
                           Mr. Braddock is  chief,                              gram staff to  provide  an  organizational  frame-
                           section of  information                              work  for  these  efforts  are   practicing   phy-
                     services,  Memphis   Regional                               '  ians,  faculty  members  of   The   University
                                Medical   Program.                              sic
                                                                                of  Tennessee  Medical  College,  and  representa-
                                                                                tives  from  other   segments   of   the   regiona
                                                                                community.
                                                                                   The   Regional   Advisory   Group    for    the
                                                                                Memphis   Regional   Medical   Program   is    the
                            A facility for diagnosis and treatment       of     Mid-South   Medical   Center    Council    (MMCC),
                         emphysema    and    cor    pulmonale,    accepting     which   is   the   comprehensive   health-planning
                         referrals   from   throughout   the   Region   and     agency  for  a  major  part  of  the  Region.  The
                         providing  continuing   education   both   locally     MMCC    membership    is    composed    of    both
                         and in outlying community hospitals.                   providers  and  consumers  of  health  care,  with
                            A  streptococcal  disease   center,   providing     a predominance of the latter.
                         services  directed  toward  control  of  rheumatic        In  planning,  the  Program  operates  on   the
                         fever and acute glomerulonephritis.                    premise   that   solving   problems   must   begin
                            A  regional  referral  center  for   peripheral     by realistically identifying  and  defining  them.
                         vascular disease, offering consultative  services,     For  instance,  physicians  in   Oxford   and   in
                         demonstration  of  rehabilitative   methods,   and     Lafayette  County,  Mississippi,   requeste   that
                         special education.                                     the  Program's  staff  conduct  studies  of  medi-
                            A  project  in  computer-aided   electrocardio-     cal practice  and  patients'  needs  to  determine
                         graphic  monitoring,  with  a  view   toward   de-     if all legitimate health  care  needs  were  being
                         veloping  apparatus  suitable  for  use  in   com-     met  and  how   better,   more   complete   health
                         munity hospitals.                                      care   could   be   provided.    Other    examples
                            A  series  of  cardiovascular  disease  clinics     are   research   into   problems   of   delivering
                         throughout    northern    Mississippi,    bringing     health  care  to  the  urban   poor   in   Memphis
                         cardiologists   to   county   health   departments     and surveys of  attitudes  about  planned  parent-
                         for consultation and teaching.                         hood  among  persons  from  all  ecomonic   levels
                            A  research  project  investigating   hospital-     in  Memphis   and   surrounding   Shelby   County.
                         acquired  infections  threatening  patients   with        One  staff  member  has  conducted  a   county-
                         chronic  diseases,   directed   toward   improving     by-county  survey  of   current   health,   educa-
                         presently available monitoring procedures.             tion, welfare  and  recreation  programs,  facili-


               ties  and  leaders   in   metropolitan   Memphis,     physicians submit three to five  case  histories
               eastern  Arkansas,  southeastern  Missouri,   and     to the voluntary consultant  in  the  designated
               southwestern    Kentucky.    Directories     have     specialty.  The  consultant  prepares  his   re-
               been  published   for   these   areas   and   are     sponse to the topic and to the  individual  case
               planned   for   northwestern   and   southwestern     histories. Such  conferences  are  informal  but
               Tennessee and northern Mississippi.                   intense. The first-phase goal of  reaching  phy-
                 Continuing   education-In   addition   to   the     sicians in  20  mid-South  towns  has  been  ac-
               sizable educational  component  in  each  of  the     complished ahead  of  predictions,  many  repeat
               demonstration  projects,  the  Program  plays   a     sessions  have  been  held,  and  many   confer-
               major  role  in  continuing   education   through     ences are scheduled for the future.
               sponsorship  of  a  continuing  series  of  work-       The   Program's   regional   library   service
               shops,  conferences,  and   in-service   training     often acts as an adjunct  to  the  ACC  program.
               sessions  for  nurses  and  members   of   allied     In The  University  of  Tennessee  Library,  the
               health  professions.  The   Program   also   pro-     Program's  three  research   librarians   accept
               vides staff consultation and assistance, as  well     collect telephone calls  from  anywhere  in  the
               as  funding  support,  for  workshops  and   con-     Region.  They  then   provide   a   bibliography
               ferences  sponsored  by  such   voluntary   agen-     or photocopies of any material  desired,  usual-
               cies as heart associations,  nutrition  councils,     ly within 24 hours.
               rehabilitation  groups,  and  local  branches  of     Comment
               such  organizations  as   the   American   Cancer
               Society,  Inc.,  and  the   National   Hemophilia       Perhaps  the  most  important   functions   of
               Foundation.                                           the    Memphis    Regional    Medical    Program
                 Especially   designed   to   help   rural   and     have been to  serve  as  a  meeting  ground  for
               small-town  physicians  is  the  Advanced  Clini-     all  members  of  the  health  care  professions
               cal   Conference   (ACC)   program,   in    which     in the Region and as  a  focus  for  efforts  to
               small  groups  of  physicians  meet   with   con-     meet  the  needs  of  the  unserved  and  under-
               sultants  in  local  hospitals  to  grapple  with     served.
               problems  selected  by  the   physicians.   After     Office address: 1300 Medical Center Towers, 969  Madi-
               choosing  the  conference  topic  and  date,  the     son Avenue, Memphis 38104.


                     14 HIP9,TONI
                     'i@OOMLY 43,t)00

             @iA            11171,
        Grant Sparks Big CIMIC Growth
                      Medicql Grotip News                          ments     of      a      development      neighborhood    two   fulltime   social    workers,    two    community
        EAS'I'        LANSING,        Mich.-Dramatic        ex-    housing  nearly  half   of   Pontiac's   black   popu-    health  workers,  a  nutritionist,   a   health   edli-
        pansion   of'   a   community   health   care    center    lation.                                                   cator,  a   public   health   nurse,   and   additional
        in   Pontiac   has   been   assured   with   acceptance      With  the  RMP  grant,  the   center   will   triple    nursing personnel.
        of  a  $200,000   federal   grant   from   the   Michi-    its   staff,   an7-this   month   is   moving   to   a       Plans  call  for  12   treatment   rooms   and   two
        gan    Association    of    Regional    Medical    Pro-    building   containing   10   times   the   space   now    large    medical    suites    for    daily    specialty
        ,granis.                                                   available   in   the   converted    apartments.    The    clinics.  About  an  eighth  of  the  center  will   be
          The  aA,ard  enables  a,.)   increase   in   patients    building  was   recently   purchased   by   the   city    devoted   to   mental   health    services.    Lakeside
        tr(.)m  the  present  5,200  to  a   potential   25,000    of  Pontiac,  with  the  aid  of  a  grant  from   the    will  continue  to  provide  a  clinical  setting   for
        a    ;car    at    Lakeside    Comprehensive     Health    U.S.    Department    of     Housing     and     Urban    training medical students.
        Care      Center,      an      ambulatory      teaching    Development,    to    permit    expansion    of    the       "Medical    students    as    members     of     the
        tacilitn,  operated  bv   the   Michigan   State   Uni-    clinic.                                                   faniilv  health   team   at   Lakeside   are   involved
        @ersit)'    College    of     Osteopathic     Medicine.      The   new   home    will    enable    Lakeside    to    in  a   comniunity   program   to   help   them   learn
        1,@ikeside   Health    Center    opened    18    months    provide    radiology    services,     dental     care,    what   it   really    means    economically,    psvcho-
        ago    in    two    converted    two-bedroom     apart-    clinical   laboratory   services,   and   help    from    logically, and socially  for  a  patient  to  be  ill,"

                                                                                                                           said     Prof     James     P.      Howard,      acting
                                                                                                                           chairman   in   the   department    of    family    and
                                                                                                                           Community    medicine    at    MSU,    and    executive
                                                                                                                           director   of   Lakeside.   "We    know    that    low-
                                                                                                                           income   families   often   do   not    seek    medical
                                                                                                                           attention  until  an   emergency   arises,   or   until
                                                                                                                           the  baby  is  about  to  be   born.   This   kind   of
                                                                                                                           care   costs   more   and   may   be   too   late    to
                                                                                                                           help."


                                                                                     AMERICAN MEDICAL NEWS 0 MARCH 27, 19;2
             '7ypical consumer' described
                                                                                                                       Most      frequently      mentioned      com-
                                                                                                                       plaints  were  high   costs,   long   waiting
             Survey in Colorado                                    Nine   out   of   every   10   survey   respon-     times    for     appointments,     impersonal
                                                                 dents   said   that   they    or    someone    in     medical  care,   shortage   of   specialists,
             provides health  data                               their  family   were   covered   by   some   kind     and  excessively   long   travel   times   to
                                                                 of   health   insurance;   and   31%   of   those     reach  health  care  facilities-in  that  or-
                                                                 with   health   insurance    listed    membership     der.   About   20%   of    the    complaining
             The    typical    Colorado    health     consumer   in more than one plan.                                households had multiple gripes.
             is in his late  20s,  lives  in  an  urban  area,     WHEN    ASKED    TO    SPECIFY    their    cov-     "MEDICAL    CARE    is     too     expensive"
             is  white,  and   occupies   a   household   with   erage,  however,   only   75%   of   the   house-
             2.1 other people.                                   holds  turned   out   to   have   hospitalizatiop     was  the   most   frequently   checked   com-
             He   waits    five    days    for    appointments   insurance;    while     70%     had     surgicai-     plaint in eight of  the  state's  12  regions
             with  his  physician,  17  days  for   a   dental   medical   insurance;   less   than    half    had     and it  ran  second  in  the  remaining  four
             appointment,  can  get   to   a   doctor   or   a   major    medical    coverage;    and    only    a     Cost   complaints   were   most   nur'rierou!
             dentist  in  30  minutes  or  less  by  car,  and   fraction mentioned dental insurance.                  in urban areas.
             has    relatively    few     complaints     about     The    average    yearly    expenditure     for     "Must  travel  too  far  to   receive   medi.
             health services in his area.                        health   insurance   was    $240    per    house-     cal care" led  the  protest  list  in  Pegior
             These   are   some   of   the    possible    gen-   hold  in  1969.   About   45%   of   the   house-     9,  where  one  family  in  four  lives  moro
                                                                 holds    reported    employer    premium     con-                                        t    physi
             eralizations   that    can    be    drawn    from   tribLItions in the $100 range.                        than an hour from the neares
             findings in  the Colorado      Health        Con-     Nearly   half   of   the   families    surveyed     cian's  office,  hospital  or  hospital  emer
             sumer Survey, a 240-page      volume         com-                                                         gency  room.  Lengthy   travel   was   hardl,'
             piled     by     the     Colorado-Wyoming     Re-   said   they   had   incurred    hospital    costs     mentioned at all in Regions 2, 3, or 4.
             gional  Medic l@Pro                           ngs   during  1969.  The  average   total   was   $520,     "Flave  to  vvait  too  long  for   a,)Poirit
                                                                 of   which   $285   was   covered    by    health     ments" was  far  and  away   the   most   fre
             are base    on  intir-,                       on-   insurance.   For   every   five   families   with     quently  checked  complaint   in   Region   5
             naire    responses    from    2,913    Col(    do   hospital   bills,   one   was   completely   cov-     where families   claimed   they    wait    al
             residents    who    were     canvassed     during   ered   by   insurance,   and   one   was    cor?-     average of  12  days  to  see  a  doctor,  al
             May and June of 1970.                               pletefy   unprotected.   The    largest    singer     imost  a  month  to   see   a   dentist.   Lon
                                                                 hospital   expense    was    $70,000,    reported     '                      ped   the    coniplair
                                                                                                                       Iwaiting times also top
              CO-SPONSORED       by        the        Colorado   by a household in Region 3.                           list  in Region     7      and-oddly      enoug
             Office    of    Comprehensive    Health     Plan-     About   four   families   in    10    mentioned     -in   Region    8,    where    survev-t,,ikei
                                                                 surgical  costs  in  1969.  The   average   total     found   below-average   waits   for    medic@
             ning,    the    survey    covers    demographics,
             economics,     manpower     distribution/     and   was  $130,   of   which   $56   was   picked   UP     appointments.
             consumer attitudes.                                 by health insurance.
                                                                   Nearly   70%   of   the    households    listed     ON    THE    SUBJECT    of    manpower     an
               Findings  are  given  for  the   state   as   a   physician   costs   for   1969.    The    average     facilities, almost six  families  in  10  sa,
             whole,  and  for  each   of   the   12   regional   total   was   $230   per   household,   and   in-     a  need   for   more   general   practitioner
             planning   areas   mapped   out   in   1970    by                                                         while  one  family  in   four   stressed   t@
             the state planning office.                          surance  paid  $53.  Only  one   family   in   20
               Viewed  in   terms   of   gross   generalities,   was completely covered by insurance.                  importance   of   more   iripatient   hospita
             the   study   paints   a   comparatively   bright                                                         facilities and more dentists.
             picture  of   Colorado   health   services,   but     ABOUT    SIX    HOUSEHOLDS    in     10     re-     On  the  basis  of  findings  in  the   study
             ,i  close  inspection  of   regional   data   be-   ported  dental  bills  during  the   year   prior     survey-takers  judged   only   six   of   th(
             trays   significant   variations   from    state-   to  the  survey.  The  family   average   totaled     state's  12  planning  regions  to  be  "well
                   iveri,-es.                                    $130.  The   impact   of   insurance   was   neg-     defined  service  regions  with  a   potentia
               Statewide,     for     example,      Colorado's   ligible   on   the   statewide    sample,    with     @or  existing  regional  health  service  cen
             -1970   health   manpower    ratio    stood    at   only   one   family   in   200   reporting   100%     ter."
             about   150   physicians   per   100,000    popu-   third-party payment.
             lation.  But  most  of  the   state's   MDs   and     When   asked    if    they    were    satisfied
             Dos   were    concentrated    in    and    around   with  the  mf@rlical   cire   they'd   been   re-
             Denver,  causing  moderate        .to    critical   ceiving,  64',.,  of  those  responding  to   the
             manpower   shortages    in    outlying    regions   question    answered    with    an    unqualified
             (see map).                                          "yes."    Another    9%     indicated     partial
               This   Uneven   physician   distribution    ap-   satisfaction;    and    27%    answered     "no."
             pears   directly   related   to   many   of   the     Urban    areas     produced     the     highest
             responses     given     by     consumers      who   satisfaction   rates,    while    the    opposite
             were surveyed (see chart).                          was   true   in   predominantly   rural    areas.
                                                                 Negative   responses   topped    35%    in    Rc-
                                                                 gions  1,  8,  1),  10,  and  11.  Region  9  led
                                                                 the   gruryibling    with    a    44%    negative


                                                                      Responses by region

                                                                      100%

                                                                      80%

     Regions.                                                         60%
     and physician density
                                                                      40%

                                                                      20%-

                                                                                                                                                      j
                                                                      Regions 1        2     3     4     5     6      7    8     9     10 lLl        12

                                                                             Excluding Denver,       families   who   must    leave region or
                                                                             state to  reach "secondary"        physician    or specialist
                                                                                                                                   (465      responses)
                                                                             Households reporting regular use          of     chiropractic     services
                                                                                                                                (2,913       responses)
     1970 Colorado MDs and DOs per            100,000                        Households  located 30  minutes            or more from  a
     people                                                                  physician's  office                                (2,897       responses)
     0 60-70                 91-100            [3 131-140                    Adult females reporting they've never had a Pap smear
     E] 71-80             E) 101-110           0 Over 350                                                                       (2,734       responses)
     [] Under 40


                                                                         If the nurse or doctor hact a t)usy aay wlin
                                                                         sick patients, no teaching  occurred.  Even  if  a  pa-
                                                                         tient   attended   organized   programs   at   LDS   or
                              UTAH                                       Primary   Children's   Hospitals,   it   was   doubtful
                                                                         whether  the  five  hours  of  instruction  were   suf-
                                                                         ficient.  They  agreed  with  the  conclusion  of   the
                                                                         1970 local study: "It is evident that  the  individual,
           Intermountain Regional Medical Program                s       ad lib teaching is, at best, mediocre."
           Diabetes Center                                                  Dr.  Clark,   Dr.   Rallison;   and   Mrs.   Prater,
                                                                         working   in   conjunction   with   the   Intermountain
              What's  a  person  to  do?  Recently   diagnosed   as      Regional   Medical   Program   (IRMP),   formulated   a
           having  diabetes  mellitus,  the  new  diabetic  is   @t      program  to  meet   the   Utah   need.   The   proposed
           best  inadequately  informed  and  unadjusted.   He   is
                                                                         project  was  submitted  for   approval   November   1,
           told his disease  is  manageable  and  that  he  carries      1970, and  was  funded  by  the  IRMP  April  1,  1971.
           a  major  amount  of  medical  responsibility  in  main-      The program is  similar  to  and  based  on  an  exist-
           taining  and  regulating  his  health.  While   in   the      ing regional  center  for  diabetic  and  medical  per-
           hospital the  new  diabetic's  physician  directs  nurs-      sonnel  education  established  in  Minneapolis,  Minn-
           ing  and   dietary   personnel   to   make   information      esota, in 1967. The  objectives  of  the  Utah  project
           concerning  diabetes  self-care  available  to  the  pa-      are  the  same  as  those  of  the  Minnesota   center:
           tient. The diabetic  is  instructed  in  insulin  admin-      (1) to provide the  practicing  physician  with  a  new
           istration and  urine  testing.  His  physician  is  able      resource  center  that  can  assist  him  in  the  man-
           to  give  him  limited  instruction  and  encouragement.      agement  of  his  diabetic  patients;  (2)  to  improve
              With  this   introduction   and   orientation   about      the health of diabetic patients  by  stimulating  their
           his disease,  the  diabetic  is  charged  with  his  own      interest in and knowledge  of  their  disease  and  its
           urine  testing,  injecting  his  own  insulin,   regula-      management; (3)  to  establish  an  educational  center
           ting his activity, choosing his diet,  and  even  alter-      where  nurses,  dietitians,  and  physicians  can   ob-
           ing  his  insulin  dosage  on  occasion.  He  must   act      tain   comprehensive   training   in   the   management
           as his  own  laboratory  technician,  nurse,  dietitian,      of diabetic patients;  and  (4)  to  assist  physicians
           and even to  a  great  extent,  physician.  Finding  and      in the early identification  of  the  diabetic  and  to
           taking time  to  assist  40,000  Utah  diabetics  (there      educate  the  general  population  in  regard  to   the
           are more than  three  million  known  diabetics  in  the      nature and prevalence of the disease.
           United  States),  and  in  most  cases  their  families,         Located  in  Salt  Lake  City  at  1002  East  South
           in adjusting  to  a  new  life  style  are  the  medical
           profession's  major  obstacles  in  achieving   adequate      Temple  Street,  the   Diabetes   Center   opened   its
           diabetic self-care.  Properly  controlling  the  seventh      doors February  7,  1972.  The  remodeled  third  floor
           leading  cause  of  U.S.  deaths  requires   time,   pa-      east  wing  of  the  Holy  Cross  School   of   Nursing
           tience, a great deal of repetitious effort, and a  close      Bu Iilding houses the  Center.  The  facility  will  not
           patient-physician    relationship    which    must    be      only offer classes and  information  to  diabetics  and
           fostered   by   mutual   understanding   and    coopera-      their families  but  will  provide  a  unique  five-day
           tion.                                                         living-in experience for  participants.  While  at  the
                                                                         Center   personalized    self-management    instruction
              A  1970  University  of  Utah  Medical  School  study      and  counseling  will  be  given  by  a  team  of  Uni-
           of the  extent  to  which  hospitalized  diabetics  were      versity of Utah  physicians,  nurses,  and  dietitians.
           being   educated   in   Salt   Lake   County   hospitals
           showed "only  about  50  per  cent  of  these  diabetics         Patient classes will  be  conducted  at  the  Center
           receive  more  than  a  token   amount   of   teaching".      on a  scheduled  basis,  with  enrollment  limited   to
           Regional  and  national  studies  conclude  that   long-      twelve patients and  one  member  from  each  of  their
           time  diabetics  have  only  a   limited   understanding      families.Patients  and  family  members   will   reside
           of their  disease  and  that  with  greater  understand-      at  the  facility  during  the  five-day  course.   The
           ing,  problems  of  reactions  and  acidosis  could   be      small  patient   number   permits   significant   indi-
           avoided.                                                      vidualization  in  teaching   and   allows   adaptation
              Aware  of  the  situation  because  of  their   I)ro-      of  a  diabetic  management  program   to   the   indi-
           fessional interest, knowledge, skill, and their    -          Vic [Ual patient needs  rather  than  altering  the  pa-
                                                               par-      tient's  way  of  life  to  a   rigid,   uncompromising
           ticipation  in  and  coordination  of  an  annual   Utah
           diabetic  summer  camp,  University  of   Utah   College      therapeutic schedule.
           of  Medicine  assistant  professors  Dana  Clarke,   MD;         The Center's services will  be  available  to  newly
           Marvin  J.  Rallison,  MD;  and  Mrs.  Barbara   Prater,      discovered  diabetics  as  well  as  established   dia-
           MS,  assistant  professor  at  the  University  of  Utah      betics  whose  knowledge  of  their  disease   is   in-
           College  of  Nursing,  began  seeking  solutions.  After      complete  or  whose  self-care   and   management   are
           investigating  local,  state,  and   regional   diabetes      a problem,  The  program  will  be  open  to  all  dia-
           education  programs  it  was  found  that  the   quality      betics  in  the  Intermountain  Region  (juvenile   on-
           and quantity of  instruction  varied  greatly.  In  most      set,  adult  onset,  insulin  requiring'.   non-insulin
           hospitals,  where  there  are  no  organized   programs,      requiring, labile, stable, mild  or  severe).  But  all
           the nurses'  and  doctors'  teaching  time  was  at  the      patients  must  be  referred  by  their  private   PhY-
           mercy of many  required  tasks  in  the  daily  routine.      sicians or primary care facilities.
                                                                                                                              77
           for MARCii 1972


                       During  his  stay  at  the  education  center,   the        pendent, paid  him  tribute.  The  newspaper's  De-
                     patient  will  undergo  thorough  re-evaluations   in-        cember 30, 1971 editorial  noted,  "Thousands  have
                                                        ,   an   assessment        benefitted from his  medical  and  surgical  skills
                     eluding a general physical exam                                          ars. He, and our  other  local  doctors,
                     of the late manifestations  of  diabetes,  an  evalua-        through the ye
                     tion of his social situation,  educational  background        have always carried a heavy load  of  work,  making
                     and intelligence, and an evaluation of  the  level  of        many and great sacrifices in their personal  lives.
                     "control"  of  the  disease.  Throughout  the  course,        Their efforts have resulted in saving  hundreds  of
                     each patient  will  test  his  urine,  have  indicated        lives, as they have used their skills unselfishly.
                     blood sugars drawn, select foods  from  liberal  cafe-        "The magnitude of  gratitude  felt  by  the  people
                     teria  assortment,  discuss   food   selections   with
                     health professionals,  be  involved  with  adjustments        of the valley was  expressed  on  November  21,  1969,
                     in both  insulin  dosage  and  dietary  regimen,  have        when 490 persons turned out to  honor  Doctor  Tre-
                     available recreational and exercise  facilities,  par-        loar at a special appreciation dinner to  mark  the
                     take in discussions with other  diabetics  and  Center        40th anniversary of his medical practice. The high-
                     personnel, and function in  the  usual  activities  of        lights of his medical career, as well as his  civic
                     daily living and self -care. At the end of the  course        contributions, were reviewed  and  many  fine  tri-
                     the patient will be referred  back  to  his  physician        butcs were paid to the doctor and his  good  wife."
                     with  an  evaluation  of  his  progress  and  a   sum-        Dr. Treloar, who has  limited  his  practice  since
                     mary of his accomplishments.                                  1955 because of  ill  health,  has  been  extremely
                       The Center will also facilitate  an  education  pro-        active in Afton civic affairs. "He has always  been
                     gram for allied health personnel.  A  five-day  course        an energetic and vigorous leader  in  pressing  for
                     designed and  directed  to  further  the  training  of        pi-ogress and improvement."
                     nurses, dietitians, nutritionists, and others who  are
                     involved in the care  of  diabetic  patients  will  be
                     available.  The  curriculum  is  designed  to   convey        Wyoming Meml)er A Guest Lecturer
                     the  most  current  knowledge  and  teaching  technics        Loran  B.  Morgan,  MD,   a   Torrington,   Wyoming
                     to those concerned with diabetic instruction.                 ophthalmologist was recently a guest  faculty  mem-
                        It is hoped that this training will  help  by  both        ber at the University of California Medical School.
                     strengthening  existing  hospital  diabetic   teaching        He lectured in a short course entitled, "Recent Ad-
                     programs and  by  facilitating  the  establishment  of        vances  in  Ophthalmology",  where   he   presented
                     other   training   programs   in   the   Intermountain        two formal  papers,  one  of  which  concerned  the
                     Region. The Diabetes Center, a first  for  the  nation        origin and uses of  the  Morgan  Therapeutic  Lens,
                     as well as Utah and the Intermountain          Region,        which he recently developed.
                     offers a service and is a  primary  resource  for  the
                     physician and diabetic patient.

                                                                                                       EW MEXI

                                         WYOMING
                                                                                   Dean  of   School   of   Medicine   Presented   Award
                       Dr. Treloar Lauded for                                       Robert S. Stone,  MD,  dean  of  the  University  of
                       Years of Medical Service                                    New Mexico  School  of  Medicine  was  presented  the
                                                                                   First  Annual  New  Mexico  "Citizen  of  the   Year"
                         Dr.  0.  L.  Treloar  of  Afton,   Wyoming   retired      Award  by  the  Albuquerque  Board  of  Realtors   on
                       February 1  after  42  years  of  practicing  medicine      January 20. In citing  Dr.  Stone  for  his  achieve-
                       in Afton. Since he started  practice  in  Star  Valley      ments, Mr. Jack  Elliott,  president  of  the  Board,
                       in 1929, he has  delivered  more  than  3,200  babies.      said that through Dr.  Stone's  efforts  "New  Mexico
                         The 70-year-old  general  practitioner  set  up  his      is expected to develop  into  a  major  world  center
                       office on Afton's  Main  Street  in  1929  and  a  few      for research and  treatment  of  cancer.  Recognizing
                       years later established the  Valley  General  Hospital      the  scientific  impact  of  the  Los  Alamos   Meson
                       where he practiced with the late  Dr.  S.  H.  Worthen      Physics Facility, Dr. Stone organized the  scientists
                       and later with Dr. 0.  D.  Perkes.  When  Dr.  Worthen      in the western region to supply this  new  scientific
                       was drafted into the U.  S.  Army  at  the  outset  of      tool to alleviate suffering in cancer victims. He  is
                       World  War  II,  Dr.  Treloar  provided  all   medical      responsible for  development  of  a  Regional  Cancer
                       care for the entire valley for four  years.  In  1944,      Research Center at the University,  a  facility  nec-
                       he delivered a record 181 babies, an  average  of  one      essary in providing a logistical base  for  treatment
                       every other day.                                            of cancer patients."
                          When  Dr.   Treloar   announced   his   retirement,        A native of New  York  City,  Dr.  Stone  has  com-
                       Afton's  weekly  newspaper,  the  Star  Valley   Inde-      piled  an  outstanding  record  in  contributions  to
                                                                                                -PnrTcy   MOITNTAIN   MEDICAL    JOURNAL


                                                ARIZONA       MAGAZINE
                                                February 20,  1972

           this is the lifewsaving
                making emergency                                      netivork
                mediml infomation
                and taped education                                  hospital team started  special  treatment.  In  a  few
                                                                     days the crisis had passed.
                immediately available                                  Being able to quickly get hold of  specialized  med-
                                                                     ical information is a new  experience  for  some  Ari-
                to all parts of                                      zona physicians, particularly those  in  rural  areas.
                                                                     The  Arizona  Medical  Library  Network  was  put  to-
                                                                     gether  by  the  Arizona  Regional  Medical   Program,
                the state
                                                                     an organization that  seeks  ways  to  improve  health
                                                                     care in the region.
                                                                       The network consists of five major  libraries  serv-
                                                                     ing  as  relay  stations  to  transmit  requests  from
                                                                     anywhere in the  state  to  six  "resource"  libraries
                                                                     where  information  may  be  found.  The  system  uses
                 t 4:55 p.m. on Friday. The teletype in the  Ari-    teletype and telephone so that a practitioner  in  the
                 zona medical Center library  at  the  University    remotest location can tap  into  the  system  quickly.
           Aof  Arizona  started  rattling.  The  field  librari-    In its first six months of operation more  than  1,200
           an for the Arizona  Medical  Library  Network  checked    requests for literature were received  from  all  over
           it. A doctor in Flagstaff needed information fast.        Arizona and more than  25,000  copies  were  seht  out
             He had a patient  who  had  attempted  suicide  with    on almost every conceivable malady.
           a drug overdose. The patient was in  a  coma.  It  was     A doctor in Bisbee calls the  network  relay  station
           an emergency  that  he  normally  could  have  handled    at nearby Cochise  College  and  asks  for  a  journal
           with little assistance, but  in  this  case  the  drug    article. The  relay  station  scans  the  network  and
           ingested was one that rarely turned  up  in  suicides.    finds the resource medical  library  at  St.  Joseph's
           No one could be found with  any  knowledge  of  either    Hospital in Phoenix has the article.  Cochise  College
           this particular type of  poisoning  or  what  kind  of    sends a teletype request for the article to the  Mari-
           therapy to use.                                           copa  County  Medical  Society  in  Phoenix,   another
             No wonder. The  field  librarian  immediately  spot-    relay station, which in turn telephones St.  Joseph's.
           checked the literature and found that only  six  cases    Within 24 hours, St. Joseph's mails  a  free  photoco-
           had been recorded  throughout  the  world.  Other  li-    py to the doctor in Bisbee. If he had  needed  a  book
           brary  staff  members   started   a   more   intensive    instead of an article, the entire  volume  would  have
           search.  Books  and  medical  Journals  were   scanned    been sent, to be returned later.
           for any -information that  would  help.  Minutes  sped     "Tbe Network  is  certainly  no  substitute  for  the
           by. Finally, in an obscure journal, a  way  of  manag-    good practice of medicine," Dr.  D.  W.  Melick,  Ari-
           ing the problem was located.                              zona  Regional  Medical  Program  Coordinator,   said,
             It was 5:30 p.m., less  than  an  hour  later,  when    "but it's a tremendous aid. In the old  days,  when  a
                                                                     doctor in a small town had a patient  with  a  partic-
           the librarian called the doctor  through  the  special
           network   hookup.   He   outlined   the    recommended    ularly  obscure  medical  problem,  often   the   only
           therapy and th-en quickly listed  the  other  articles    answer was to pack  the  patient  off  to  Phoenix  or
           available on the subject. Did  the  doctor  want  cop-    Tucson  where  the   sophisticated   medical   centers
           ies? Yes, and quickly.                                    are. It wasn't that the doctor lacked  capability.  He
             Using the regimen given him by  the  librarian,  the    was  just  handicapped  by  not   having   a   medical
           doctor  was  able  to  arrest  the  poison  which  was    reference library at hand  or  access  to  specialized
           rapidly spreading in the  patient's  system.  The  pa-    consultation. Now, with  the  network,  more  patients
           tient began to  respond.  Soon  the  promised  litera-    can stay at home and more  doctors  can  do  a  better
           ture arrived through the local relay  station  of  the    job because they have  the  same  resources  available
           library  network  at  Northern   Arizona   University.    as do their big city colleagues."
           Using  the  added  information,  the  doctor  and  the


                                                                                                              'more
                                                                                                               doctors can
                                                                                                               do a
                                                                                                               better job'

                                                                                                          Dr. D. W. Melick said, "Often
                                                                                                          the only answer was to pack
                                                                                          PAUL MILLER     the patient off to Phoenix or
        Arizona Western College at Yuma is a relay station for doctors' requests and the libraries' replies. Tucson."
             Dr.  R.  H.  Angell,  chief  medical  officer  for   the       riiibly  increases   following   field   consultation.   in
           Indian  Health  Service   at   Kayenta   on   the   Navajo       many  places  the  librarian  has  been   able   to   steer
           Reservation,  said,  "I   am   most   enthusiastic   about       people to  local  resources  that  they  didn't  know  they
           the  reference  services.  We  were  treating  a   patient       had.
           with   the   Richardson-Olsewski-Steele    syndrome    and         Another  resource   for   keeping   up-to-date   is   the
           it was a  simple  matter  to  call  the  Flagstaff  office       telephone,  due  to  a  spin-off  of  the  network   called
           and in a  reasonably  short  time  copies  of  six  recent       "Dial-A-Tape."   Melick   said,   "Out    here    distances
           articles  on  this  unusual  problem  were  sent  to   us.       tend  to  reduce  conventional  opportunities  for   learn-
           Excellent  articles   on   some   of   our   more   common       ing  about  new  developments,  such  as   attending   edu-
           problems  such  as  malnutrition,   alcoholism   and   in-       cational  programs  at   the   major   metropolitan   medi-
           fant  diarrhea  have  also  been  collected  and  sent  to       cal centers. So we  weren't  too  surprised  to  find  that
           us."                                                             the  library  network  was  being  used  not  only   as   a
             Getting  information  into  the  hands  of   those   who       reference tool for  specific  cases,  but  as  a  means  of
           need it is one of two  basic  functions  of  the  network.       educational  updating  as  well.  This  led  us  to  wonder
           The other is helping  local  hospitals  with  their  medi-       about  other  ways  to  quickly  disseminate   the   latest
           cal  reference  needs.  This  is  done  through  a  varia-       information  on  research  results   and   clinical   meth-
           tion on  the  old-time  circuit-riding  judge,  except  in       ods.   The   Wisconsin   Regional   Medical   Program   had
           this case, it is a circuit-riding librarian.                     had  some  success  with  a  system   they   called   Dial-
             Once a year  each  of  Arizona's  80-plus  hospitals  is       A-Tape, so we decided to try it in Arizona."
           visited  by  a  field  librarian   from   the   University         Dial-A-Tape  is  essentially  a  taped   medical   refer-
           Medical  Center  in  Tucson.  'Me  field   librarian   ad-       ence  library.  Also  located   at   the   Medical   Center
           vises  how  to  use  the  network  and  how  to  make  the       Library,  it  consists  of  two  rotary  telephone   lines,
           best  use  of  what  is  available  locally.  This  hasn't       two  cartridge  tape  players  and  a   library   of   more
           always been  easy.  In  one  report  he  noted  that  "the       than  300  cartridge  tapes.  Each  tape  is  recorded   by
           hospital  administrator  was  new  in  the  job  and   was       an expert in  each  subject  and  all  that  is  needed  to
           quite suspicious of me  at  first.  He  thought  I  was  a       listen  is  a  collect  telephone  call,  for   which   the
           traveling  salesman.  In  fact,  after  my   initial   de-       Regional  Medical  Program  picks   up   the   tab.   Dial-
           scription  of  the  library  network,  he  asked  me  'How       A-Tape is  available  24  hours,  seven  days  a  week  for
           much does all of  this  cost?'  So  I  explained  that  it       doctors and nurses.
           was for free and he relaxed."                                      Dial-A-Tape  is  used   in   emergency   situations,   as
             The field librarian travels     more  than  3,000  miles       back-up  consultation  and  mostly  as  a  handy   way   to
           a  year.  Book  loan  figures  show  that   demand   inva-       keep  up  with  postgraduate  education.  "One   doctor   I
                                                                            know," Melick said,  "uses  it  in  a  particularly  inter-


                           'We have
                            helped to
                            narrow the gap'

                a subject from his directory,  calls  Dial-A-Tape,  and             rat
                listens to it before going to sleep.  At  first  I  was
                suspicious  that  he  was  using  it  to  PUT  him   to
                sleep, but he assures me  that  he  sometimes  gets  so
                interested in what he  hears  that  he  has,  on  occa-
                sion,  gotten  up  and  made  notes  to   contact   the
                library network the  next  morning  for  more  in-depth
                information."
                                                                                   An operator in Tucson prepares to play
                  While  neither  Dial-A-Tape  nor  the  network   sup-            a tape for a caller in rural Arizona.
                plant the  more  conventional  ways  of  getting  post-
                graduate  education,   they   have   become   important
                educational elements  in  rural  Arizona.  In  Kingman,
                for instance,  Dial-A-Tape  has  become  required  lis-
                tening for nurses at the Mohave General Hospital.
                  "Each  person  in  nursing  service  is  required  to
                listen to at least  one  Dial-A-Tape  program  a  month
                as part of continuing  education,"  nursing  in-service
                supervisor Robyn Bancroft  said.  "Each  level  of  our
                nursing staff absorbs  what  they  can  from  the  pro-
                gram. Certain areas have been set aside  in  each  area
                of  nursing,  instructions  have  been  posted  and   a
                Dial-A-Tape directory is availab e.
                  Another  community  hospital  was   so   taken   with
                the system  that  five  or  six  phones  on  a  special
                switchboard connection were  set  aside  so  that  sev-
                eral people could  listen  to  the  same  tape  at  the
                same time.
                  What  have  the  library  network   and   Dial-A-Tape
                really  accomplished  in  Arizona?  Melick  said,   "We
                hear a lot  today  about  the  uneven  availability  of
                quality medical care. Part of  the  problem  in  Arizo-
                na is  bridging  the  time  and  distance  gap  between
                where  knowledge  is  and  where  it  is   needed.   We
                have, I think, helped to  narrow  the  gap  with  these
                systems."
                  The  Health  Service  doctor  at  Kayenta  said   the
                network  and  Dial-A-Tape  are  "invaluable   services.
                They help us to  improve  our  medical  care  and  they
                serve as a welcome tonic  for  a  sometimes  oppressive
                feeling of medical isolation."                       n


                         liel)rititc(i frci7@i 'iffl] ANIFI@l(,AN JOL@IIN@@l. OI'NUIISIN(;, ]@)1-2, k'ol. 72, No. 3

                           The Cambridge-Council Concept
                                                                            or
                      Two Nurse Practitioners Mal,(e Good

                                   Council, Idaho, had two physicians, Cambridge, Idaho, none-not enough
                                      for both if they practiced in the traditional way. The Mountain States
                                  'Regional Medical Program helped to demonstrate to each community that
                                    these physicians' skills could be used more effectively, and health care
                                    greatly expanded in this 100-mile area by giving one specially prepared
                                      nurse in each town the opportunity to really practice what she knew.

                                         JOHN A. EDWARDS         JANE CURTIS       KAY ORTMAN         PHOEBE LINDSEY

                                                              At the Council clinic, Nurse Practitioner Jane Curtis screens patients,
                                                              treating some herself, referring others to physicians with whom she works.

                                                              The hand-lettered sign on the  door         in not-much-larger  Council,  Nurse
                                                              reads,  "Office  hours  9-5   Moii.-Fri."   Practitioner  Jane  Curtis   begins   to
                                                              and  the  waiting  room  in  the   former   screen patients coming to  that  clinic.
                                                              pool  hall  is  starting  to  fill   when   In  contrast  to  her   Cambridge   col-
                                                              Nurse  Practitioner   Kay   Ortnian   be-   league,  she  has  close  at  hand   the
                                                              gins to  see  her  patients,  'I'his  now   physicians   with   whom   both    work.
                                                              usual   and   accepted   occurrence    in   Still, she will refer only some  of  the
                                                              Cambridge,   a   rural   farming    corn-   patients to them. Others she  will  deal
                                                              munity  of  383  persons  in  west   cen-   with by herself.
                                                              tral   Idaho,   would   not   have   been     These     two    specially     trained
                         Patient John Williams and Nurse      conceivable  or  even  probable  in   any   nurse  practitioners   represent   major
                    Practitioner Curtis exchange warm         Idaho town a year earlier.                  changes  in  how  health  care  is  giv-
                      greetings on Council's main street,       A  winding,  hilly  22   rpiles   away,   en  in   the   Cambridge-Council   area.


                    in the Cambridge clinic, Nurse Practitioner Kay Ortman sees patients alone except for two afternoons
                    a @,,/eek when one of the physicians travels from Council to see patients.
                    They are the essential  elements  in  a        him  were  futile  despite  the  corn-        their continued  education  after  they
                    project  sponsored  b@,  the   Mountain        munity's activities to raise funds for        completed the course, and  the  project
                    States Regional Niedical Pro.-ram.             a new clinic facility,  as  a  special        director  of   the   Stanford   program
                                                                   attraction.  Increasingly,  it  became        proceeded to  select  the  two  nurses.
                    The Need                                       apparent   that   new   ways   of   extend-     The  Stanford   program   was   ideal
                       The  State   of   Idaho   encompasses       ing medical  services  @vould  be  the        -short   enough   (four   months)    to
                    some   83,000   square   miles    of    rug-   solution  to   the   area's   health   care   make it  possible  for  the  nurses  to  be
                           beautiful  terrain  with   a   POPLI-   problems.    The     ,NIOLintaiii    States   away,  and  flexible   in   its   prerequi-
                    1-@tion   of'   698,000   people   clustered   RNIP set out to     demonstrate        bow,   sites.   The   two   nurses   who   entered
                    in   small   tirban-rural   centers    along   through   the   use   of   nurse    practi-   the   program   are   of   varying    back-
                    the  rivers  and  valle@-s  of  the   state.   tioners.                                      grounds.  Jane   Curtis   is   a   graduate
                    As  in  most  of   the   nation,   most   of     One  of  the  first  steps  was  a  "town   of  a  3-year  hospital  school  of   nurs-
                    its   health          professionals-approxi-   meeting"   of   physicians   tiicl   nurses   ing  with   20   years'   experience,   in-
                    matel@,   90    percent-tend    to    locate   from  the  area,   including   the   nurses   cluding   four   years   as   director   of
                    in  urban  areas.   -@%lan@,   small   corn-   on  the  20-bed  Council  hospital   staff,   nursing  service  at   the   Council   Hos-
                    niunities   and   5   counties    have    no   and  others   concerned   with   the   pro-   pital.  Kay  Ortman  is  a  fairly   recent
                    resident physicians at all.                    gram.    Although    there    were     some   graduate   of    a    baccalaureate    pro-
                       Two    family     practice     physicians   reservations   about    the    scope    and   gram   with   experience   as    a    staff
                    who   live   in    Council    (pop.    900),   Outcome  Of  Such   a   ntirsc-practitioner   nurse  in   a   500-bed   urban   hospital,
                    serve   a   total   Population   of    6,000   project,  the  group  expressed   a   will-   as  well  as  nine  months  at   the   com-
                    dispersed  over  a  100-mile   radius,   in-   ingness   to   permit   a   well-controlled   munity   hospital    in    Council.    When
                    cluding    Cambridge.     During     twenty-   one to take place.                            the  project  began,   she   was   counsel-
                    four   years   of   practice,   the   senior     Stanford    University    Medical    Cen-   ing  in  a  satellite  mental  health  cen-
                    physician  lost  five  colleagues   to   the   ter,  in  cooperation  with  Area  III   of   ter in Cambridge.
                    conveniences   of   urban    practice    and   the   California   RMP,    was    launching     Their     training     program,     which
                    living.  There  are  few  physicians   will-   a  special   program   to   prepare   nurse   started  October  1,   1970,   was   inten-
                    irig  to  take  on  the  24-hour  day,   365   practitioners   for   just   such    needs,   sive  and  concentrated   for   the   first
                    da@,-per-year   responsibility   faced    by   and   agreed   to    accept    two    Idaho   three   months   with   clinical    experi-
                    the  rural  practitioner.  The  last   resi-   nurses in its  first  class  of  five.  The   ence  at  the   Stanford   Medical   Center
                    dent    physician    in    Cambridge    died   two   Council    physicians    agreed    to   and   nearby   clinics.     The      fourth
                                  nun    Fffr)rf@  fc)   renlace   enir)lov  the  nurses  and  to  help   with   month   was   spent   working   in    rural


                         Although the training period was essentially the same for both                                            meeting   was   held   with   representa-
                         practitioners, each has developed a unique position on the                                                tives  from  the  medical   and   nursing
                         health   care   team   in   her    community.                                                             associations   and   licensing    boards,
                                                                                                                                   the  Board  of   Pharmacy,   the   hospi-
                                                                                                                                   tal  association,  the  dental   associa-
                                                                                                                                   tion, schools of nursing  in  the  state,
                                                                                                                                   and   the   Regional   Medical   Program.
                         clinics,  in  California,   with   family              rates; normal deliveries; giving  well-            A  progress  report  was  given  by   the
                         physicians.   Content   and    experience              child care;  and  giving  routine  pre-            director   of   the   Stanford    program
                         were  geared   primarily   to   acquiring              natal and postnatal care.                          and the senior Council physician.
                         additional  skills  ordinarily  perceived                A    three-month,    six-month    and               The   numerous   speaking   tours   in
                         as  medical  with  the  assumption   that              one-year  evaluation  by  the   project            various   areas   of   the   state-Boise,
                         the   nursing   background   provided   a              director  in  the  home  setting  would            Twin   Falls,   Lewiston    and    McCall
                         sound   basis   on   which   to    build.              be an  integral  portion  of  the  pro-            -by  the  two  nurses  and  one  of   the
                         These  included  taking   and   recording              gram.   No   tuition   was    required.            physicians   have   been   an   effective
                         histories;   giving   complete   physical              Travel   and   living   expenses   were            means  of  providing  a  forum  for  dis-
                         examinations    (including     neurologic              paid  by   Mountain   States   Regional            cussion,  lessening  those   reservations
                         and  pelvic  with  Pap  smears);   sutur-              Medical Program.                                   and resistance that may exist.
                         ing  minor  lacerations   not   involving
                         tendons  or   nerves;   managing   chron-              Preparing the Community                            Practfcing In Council
                         ic   disease   problems;   managing    geri-             Sustained    involvement    and    infor-           Although   the   training    period    was
                         atric    patients;      treating          common       mation  sharing  not   only   among   local        essentially  the  same   for   both   practi-
                         infections   or   self-limiting   illnesses;           participants   but   among    all    health        tioners,  each   has   developed   a   unique
                         performing    and    interpreting    labora-           professionals   and    agencies    through-        position  on  the   health   care   team   in
                         tory  screening  tests,   such   as   C.B.C.           out  the  state  have  been   vital.   From        her   respective    community.    In    Coun-
                         and  differential,  Hgb.,  urinalysis,  sed.           the  beginning,  there  has  been  an   ex-        cil,  Ms.  Curtis  initially  worked   in   a
                         JOH-4  EDWARDS,  M.D.,  is  the  senior  physician     change    of    information    and    ideas        side-by-side   supervised    practice    with
                         a@,id  a  member  of  the  House  of  Repre-senta-     among   members   of   the   nursing    li-        the  two  physicians  in   the   clinic   and
                         tives and a  member  of  the  Health  and  Welfare     censing  board,  the   state   nurses   as-        in   the    hospital,    developing    compe-
                         Committee in the Idaho legislature  .Aside    from
                         membership  in  his  professional   organizations,     SOciation,    and    appropriate    commit-        tencies rapidly.
                         he is active in state and  local  health  planning                                                                                           r   by    mak-
                         groups  and  chairman  of  the  Idaho   board   of     tees  of  the  state  medical  association.           The day begins for he
                         health council on  mental  retardation.  A  gradu-     The   program   was   explained   in    de-        ing  morning   hospital   rounds   with   the
                         ate   of   the   George   Washington    University
                         School of Medicine, Washington, D     .C.,  he  has    tail  to  the   Joint   Liaison   Committee        physician   if   he   is   there   when   she
                         been a general  practitioner  in  Council,  Idaho,     of   the   Idaho    Medical    Association-        updates   progress    records.    Ms.    Cur-
                         for 25 years.                                          Idaho   Nurses   Association   which    has        tis   makes   rounds   for   the    physician
                         JA,I'F, A. CURTIS, who now signs her  name  "RiN8i     representation from all state areas.               if  he  is  unavailable.   At   the   clinic,
                         N.P,," graduated from St. Joseph's Schoo
                         Nursing in  Lewiston,  Idaho,  in  1952.  She  was       'I'he    Idaho    Nurses'     Association        she   screens    patients,    referring    to
                         serving  as  director  of  nursing  of   Council's     surveyed   all   nurses   in   the    state        the  physician   those   beyond   her   level
                         community  hospital  when  she  was  selected   to
                         he the nurse  practitioner  who  would  serve  the     (3,153)   shortly   after    the    program        of   competency.   She   sees   many    chil-
                         (@uncil  3rea.  She  is   deeply   impressed    by
                         the ease with which she    has  been  accepted  in     was   instituted   to   inform   them   and        dren,   treats   upper    respiratory    ail-
                         tier  new  role  not  only  by  patients  but   by     get  their  reactions.   The   Idaho   Med-        ments    and    ear,    nose    and    throat
                         crilleagocs, as well  as  by  the  great  interest     :,
                         others in the state show  in  her  work.  She  be-     ical  Association  sent  a   similar   sur-        problems,    and     gives     immunizations.
                         lieves there is a great  future  for  herself  and     vey  to  all  physicians  (525).   Of   the           An   important   activity   for   her   is
                         others in this role.
                         KA   ELIZABETH ORTMAN received             -S          respondents,  82  percent  of  the   nurses        patient   education.    The    patient    may
                                                              he' B
                         nurysLng at Michigan  State  University  in  l@68.     and   68   percent   of   the    physicians        be   too   bewildered   or   disoriented   to
                         She worked briefly  as  a  staff  nurse  in  Ohio,     indicated   that   they   saw   the   nurse        really  absorb   the   physician's   instruc-
                         then in  Council's  hospital  until  she  was  ap-
                         pointed mental  health  consultant  in  Cambridge.     practitioner   role   as   valid.   Thirty-        tions.  The   nurse   takes   the   time   to
                         As  the  nurse  practitioner  in  Cambridge,   she     three  percent  of  the  nurses   indicated        have   the   patient   tell   in   his    own
                         not only fulfils some  of  the  traditional  fa@ly     .1
                         physician functions,  but  @o  assists  the  local     tney  would  be  interested   in   pursuing        words    how    he    understands    instruc-
                         public   health   nurse   in   providing.community     such a  role;  32  percent  of  the  physi-        tions.  Often  patients  discuss   with   her
                         s@ices. "Three years ago" she s       ys,  "I  was
                         quite frustrated at the  '@ack  of  continuity  of     clans  said  they   would   be   interested        problems    with    which    they    hesitate
                         patient care. Today, I  aLm  actually  helping  to
                         change  that.  I  am  really  doing  something  to     in  employing  such  a  person   in   their        to trouble the busy physician.
                         fill the gaps in health care."                         own   practice.   There   was   some,   but           An    increasing    number    of     women
                         PIIC)EBE A. LINDSEY has been  staff  assistant  in     not   a    marked,    difference    between        request   that   the    nurse    practitioner
                         the  Idaho  office  of  the    Mountain     States     the  two  groups  as  to   what   functions        do    their    pelvic    exams    and     Pap
                         Regional Medical  Program  in  Boise  since  1970,
                         and has worked on several      of their  projects.     snould be performed.                               smears,  stating   that   they   dislike   to
                         She is  a  graduate  of  the  Boise  State  @lege,       Midway  in   the   first   four   months,        take  up  the   physician's   valuable   time
                         where  she  worked  in  the   registrar's   office
                         ,hhile earning her A,B. degree,                        while  the  nurses  were  at  Stanford,   a        when   "nothing   is    wrong    with    me."


                  The    mother    in    labor    seems    com-
                  forted  to    see   a    familiar    face-the
                  same one      she   saw   during   her   pre-
                  natal  care.   With   the   physician   pres-
                  ent,  the     nurse    has    delivered    23
                  babies    in    ten     nionths-a     healthy
                  record for    a town of 900!
                     Having     had extensive        experience
                  as  a  surgical  nurse,  as   well   as   the
                  training  it  Stanford,  this   nurse   PFTC-
                  titioner  has  sufficient  backgro   ind   to
                                                      L
                  function also  as  a  first  surgical  assis-
                  tai-it.   Her   other   activities    include
                  making  house   calls   to   shtit-iiis   and
                  invalids,     and     managing      emergenc@
                  roc)ria    problems.
                     Every third     ni-ht  she  takes   c@ill.
                  After  evaluating  the  paticiit's  st@itLi.@
                  she may take       care   of   the    problem
                  herself,  such     as   suturing   t    minor
                  laceration, or     ordering   essential   lab
                  work.   If   the   problem   requires   rned-
                  ical   consultation,   treatment    may    be
                  authorized    by    the     physician     via
                    hone   or   may   require   his   presence.
                  p
                  By-laws    approved    by    the     hospital
                  Board   of   Trustees   enable   the    nurse
                  practitioner   to   admit   patients,    ini-
                  tiate  lab   work   and   x-rays   and   pro-
                  vide emergency treatment.
                     The   physician    and    nurse    practi-
                  tioner    discuss    diagnosis    and    pro-
                  posed   treatment    of    patients.    Other
                  members   of   the   clinic   staff   include
                  a  lab  technician,   a   receptionist.   and
                  an   office   nurse.   An   intercom    teie-
                  phone   between   the    clinic    and    the   Lu
                  hospital,   which   is   one    mile    away,
                  keeps   the   staff   in   touch   with   the
                  progress   of   acute   hospital    patients.   One   of   Cambridge's   younger   residents   is all smiles as his responses are
                     For   Ms.   Curtis,   adjusting   to   the   checked  by   Dr.   John   Edvlards   and   Nurse Practitioner Ortman.
                  increased    responsibilities    took    some
                  time.    Previous     patterns     engendered
                  in  basic   education   and   20   years   of   only  other   full-time   staff   person   at   the  clinic   one   afternoon   a   week   to
                  experience  in  the   traditional   nursinc.,   the  clinic  although  the  services   of   a   see   patients   with    the    practitioner.
                  role   made   for    some    discomfort    in   local   licensed    practical    nurse    are   Three  days  a   week   patients   are   seen
                  working  as  a   close   associate   of   the   available  on   occasion.   The   clinic   is   only  by  her.  She  has   the   options   of
                  physician.   Learning    to    give    orders   situated   in   a    bLirned-oLit    building   taking   care   of   the   problem    without
                  rather   than   just   take   them   requires   which    was    purchased    and    renovated   any   medical   assistance,    calling    the
                  time.  She  found  that  the   most   difl'i-   into   a   modern   clinic   facility    with   physician  for  consultation,         sending
                  cult  part  of   mastering   the   new   role   funds  raised   entirely   by   the   conimu-   the   patient   to   Council   for    further
                  was staying in that role.                       nity  and  with  labor   donated   by   local   diagnostic   work-tip,   sending    him    to
                                                                  townspeople.    In    addition     to     the   the    physician    immediately,    or    re-
                  Practicing In Cambridge                         usual    examining    roonis,     laboratory,   scheduling  a  visit  on  the  day  a  physi-
                     The    nurse    practitioner    in     the   and   reception   areas,   space   is    pro-   cian wilt be there.
                  Cambridge       clinic    must       function   vided   for   a   dentist   and   optometrist      As  with   the   practitioner   in   Coun-
                  without  the  daily   on-site   presence   of   who make weekly visits.                         cil,  Nfs.   Ortman   takes   histories   and
                  a   physician.   A   receptionist   is    the      Each  of   the   physicians   travels   to   gives     complete     phvsical      examina-


                           The Idaho Nurse Practice Act was amended to allow the nurse                                          the   incidence   of   allergy   with   sinus
                           practitioners to diagnose and prescribe under certain rules.                                         problems   is   high,    necessitating    de-
                                                                                                                                sensitization    injections.    Ms.    Ortman
                                                                                                                                estimates  that  she   herself   can   handle
                                                                                                                                90   percent   of   all   upper   respiratory
                                                                                                                                tract infections.
                                                                              tiOnS,  rOLItirIC  preii@,@t@il  and  post-          She  finds  that  she  has  the  time   to
                                                                              ti@ital care,    ciiieii,,ciicy    treatment,     give  Supportive   therapy   to   the   large
                                                                              and  inini@inizati(@iis,  She  makes   fre-       number    of    women    presenting     meno-
                                                                              qllcnt   house    calls    to    homebolind       pzilisal   symptoms   and   receiving    hor-
                                                                              patients,    pLirti,:Lil,,tri@, to   geriatric    monal   treatment,   and,    in    well-child
                                                                              patients.                                         care,    to    discuss    development     and
                                                                                 A  typical  cl@i@- foi-   the    Cambridge     nutrition,   and   to   offer    anticipatory
                                                                                                     include    treating    a   guidance    and    reassurance    to    parents.
                                                                              practitioner
                                                                              43-@'ear-old   iiiiri %vith   chronic    otitis   She    is    often     able     to     determine
                                                                              media;    tdniinisteriiig     intramuscular       changes    in     cardiac     status,     making
                                                                              antibiotics     after    kscertaining        an   appropriate       changes      in       therapy.
                                                                              intolerance   for   tl)e   oral   drug;    con-   Pttients  with   aCLIte   illness,   with   pos-
                                                                              SLIlting   by   phone   with   the    physician   itive   lab    findings,     are       generally
                                                                              on    adjusting     medications       for     a   referred   to   the    physician    either    by
                                                                              patient   with      llii-kiiison's     disease;   phone   consultation   or   a   visit.    Refer-
                                                                              removing    sutures    from    a     5-year-old   rals  to   specialists   may   be   made   after
                                                                              child   who    had    a    cardiac    catheter-   consultation     by     phone      with      the
                                                                              ization  in   Se@ittle;   performing   a   pel-   Council   physician,    if    a    problem    is
                                                                              vic   exam   on   a    woman    with    chronic   acute.
                                                                              pelvic    inflamniatory     disease;     seeing      A   lab   technician   is    not    available
                                                                              a    patient    for     thyroid     regulation;   in  the  clinic   so   that   the   nurse   must
                                                                              removing    forcion     bodies     from     the   perform    her     own     laboratory     proce-
                                                                              surface   of   eves;   referring   a    patient   dures.   Feeling   a   need    for    additional
                                                                              with    a    suspected    fracture    from    a   training    in    this    area,    Ms.    Ortman
                                                                              logaing-niili   tccicleiit    for    diagnostic   spent   extra   time   perfecting   her    tech-
                                                                              x-rays;     performing     routine     physical   niques   with    the    hospital    lab    tech-
                           At the Council Community Hospital,                 examinations    on     pre-school     children,   nician in Council.
                           Ms. Curtis' day usually begins with                high-school    athletes,    ind    bus-drivers.      Because    the    nurse    is    the     only
                           hospital rounds, either with or                       Because    the    economy     is     largely   immediate   medical   resource,              she
                           without Dr. Edviards,                              agricultural       or       forestry-connected,   may   be    called    at    anytime-nights    as
                                                                                                                                well   as   weekends.    Three    quarters    of
                                                                                                                                these   problems    can    be    handled    over
                                                                                                                                the phone.
                                                                                                                                   Many     people     in     Cambridge      are
                                                                                                                                seeking    medical    attention    for     their
                                                                                                                                problems     Much     earlier     since      the
                                                                                                                                nurse   practitioner   is   in    the    commli-
                                                                                                                                nity,  and  they   do   not   have   to   travel
                                                                                                                                miles    for    medical     assistance.     More
                                                                                                                                than    ever,     patients     present     them-
                                                                                                                                selves    before    a    problem    becomes    a
                                                                                                                                crisis  and  it   is   possible   to   emphasize
                                                                                                                                the    value     of     preventive     medicine.
                                                                                                                                One     86-year-old      woman      came      to
                                                                                                                                the    Cambridge    Clinic     shortly     after
                                                                                                                                it    opened,    complaining     of     shoulder
                                                                                                                                pain   she   associated   with   a   fall   some
                                                                                                                                six     months     earlier.     Unwilling     to
                                                                                                                                travel   the   22   miles   to   Council,    the
                                                                                                                                woman   suffered   until    she    could    seek
                           House calls to homebound and geriatric patients are an important part                                the   services   of   the   new   nurse    prac-
                           of  @turse  Practitloner  Ortman's  practice.                                                        titioner,   She   ordered   an   x-ray,    con@-


                     firming   the    diagnosis    of    an    anterior                                      incl  t@tk-e.   Both   are   Stimulated   to   do
                     dislocation  of   the   shoulder,      and                                              further    Study.    Al]    of    the     medical
                     gave   much   needed    relief    to    a    grat-                                      COIISLI]t@tnts to   the           community,
                     ified patient.                                                                          itICILI(lill"    the    Idaho    Department    of
                       The    community    is    very     proud     of                                       Health      teanis, the      University      of
                     the   Cambridge    clinic    and    its    accei3-                                      Ore-on    Medical     School     Circuit     Rid-
                     taiice  is  excellent.  During  June     'f                                             ei-s,    and    the    Southwest    Idaho    Med-
                                                              0
                     1971,     the     second     month     of     full                                      ic@il   Society,    hive    helped    to    teach
                     operation    of    the    clinic,    352    visits                                      the   nurse    practitioners    how    to    ban-
                     were    recorded;    in    October,    302.     In                                      cile problem cases.
                     tl)e   first    five    and    one-half    months'                                        There   is   a   need    for    Such    edlica-
                     experience,     there     are      records      on                                      tioii  on  @i  formal   basis.   Idaho   his   no
                                                                                                             medical    school,    and.    to     date,     no
                     437    families    even    though     the     pop- @,A
                     tilation  of  Cambridge  is
                                                   less      thin                                                      for     the     nurse     practitioner
                     400.     Cambridge     Clinic      draws      from                                      exists    in    the    state,    although     two
                     the  surrounding     communities         of                                             schools   of   nursing    ire    exploring    the
                     Hell's       Canyon,       Brownlee,        Indian                                      development of such programs.
                     Valley,    and    Midvale.    In     that     same
                     period.   the   nurse   estimates    that    ph@,-                                      An Exciting Future
                     siciaii    consultation    or     referral     was                                        What   is    the    future    of    the    pro-
                     required   on    an    averaue    of    19    per-                                             Physicians   in    the    project    view
                                                                                                             grani ?
                     cent   of   the   patients   seen   in   a   given                                      it     with     increasing     enthusiasm      as
                     @veck.     Most     patients     have      learned                                      experience    grows.     Their     niorale     is
                     that    the    practitioner's     judgment     can                                      improved,     with      more      freedom      to
                     be   trusted    and    they    feel    comfortable                                      carry    Out    comnitinity    activities     and
                     %vith her,                                                                              spend   more    time    with    their    families
                                                                 Last minute  observations  are              without      throwing      additional      strain
                     Common Policies and Concerns                exchanged as Ms. Curtis and      Dr.        on   their   medical   associates.    In    addi-
                       Both     clinics     have     converted      to Edwards    scrub    for    surgery.    Ms. tion,   physician   time    is    released    for
                     problem-oriented     records,        permit- Curtis  has  the   experience   to   serve those     problems     requiring      a      high
                     ting     better     communication     with     the as first surgical assistant.         level  of   medical   skill.   With   this   kind
                     physician   and    allowing    a       much                                             of   doubling   of   the   health   care    team.
                     broader   approach    to    the    patient.    Alt                                      more         patien-is    can    be    cared    for
                     records   are    reviewed    by    a    physician. tLire   a   bill   to    tnieiid    the    Idaho Without    further    increasing     the     phy-
                     Prescriptions     written     by     the     nurse NLirse    Practice     Act,     which     passed sicians'     loads.
                     practitioners    are    countersigned     by     ain   Febrii@ii-@,.   This   permits   the   Pro- The    nurse practitioners    have
                     physician   when   he   is    at    the    clinic. fessionil   nurse   to    perform    tcts    "of found     more     professional      satisfaction
                       The   nurses   are   on   a    fixed    salary. medical    diagnosis    or    prescription    of thin   in    any    previous    experience    and
                     All     billings     are      handled      through therapeutic    or     cc)i-i-cctive     measures feel   thev   are   making    a    unique    con-
                     each   clinic's   office,   and   there   is    no . . . as t@iciy  bt,  ciittliot-izeil  by  Jules tribLItion   as   part   of   the   health   team
                     differentiation    in     charges     for     ser- aiiti   regitleitioti,y   Jointly    promulgated with   t   special   emphasis   on   "care"    to
                     @,ices    performed    by    the    nurse    prac- b@,  the  Iti(ilio board    of    iiied- the   patient.    They    realize    that    they
                     titioner.    In    addition     to     malpractice i(-itie aii(I the Idtilio  ho(it-(l  of  nursing ire    completing    their    first    year    of
                     insurance   carried   by    the      nurses         sli(ill  be  i)@iplei)ieiiteel  by   the such     practice     under     the      watchful
                     themselves,     the     physicians      pay      aIdaho  board  of        This    lib-  eyes   of   the   entire   state.   Other   rural
                     minimal    fee    for     additional     insurance eral   and   progressive   law    allows.    the communities with      similar      manpower
                     to cover the nurse practitioners.           nurse   practitioner    to    function    effec- problems   are    interested    in    instituting
                       Health      professionals      have      become tively    without    the    constraints    which this    concept    into    their    own    areas,
                     increasingly       concerned       about       the might   result   in other       legislation Certainly,    because    of    this    project,
                     legality  of    having    delegated      to licensing   physician's   assistants    or    by health    care    is    more    available     and
                     nurses      more      and      more      functions the   use   of   rigid   definitions   in    the more   accessible    to    a    greater    number
                     ordinarily     understood     to     be     within medical   or   nursing   practice    acts. of   Idahoans   in   this   segment   o    t    e
                     the   practice    of    medicine.    The    advent Continuing   education   is    as  vital state. And  the  project  seems  to  have
                     of  the  nurse  practitioner  caused  fur-  to  the  nurse  practitioner  as  to  any   proved  already  that  if   the   problem
                     ther  concern  in  Idaho.   Therefore,   a  other   health   professional.   The  reg-  of  medical  manpower  shortage   is   to
                     physician  (co-author  of  this   article)  ular  contact  with  the   physician  pro-  be @olved, the  use  of  nurses  in  such
                     and  a   nurse   legislator   had   intro-  vides    a  constant      teacher-student   expanded   roles   is    one    important
                     duced  into  the   1971   Idaho   legisla-  relationship   with   considerable   give   solution.

                     VOLUME 72, NUMBER 3                                                                                           MARCH 1972       465


                                                  3,fOUNTAIN STATES REGIONAL MI@DICAL PROGRAM

                                                           HELEN THOMSON
                                                        COORDINATOR OF INFORMATION

                                                                            P.O. BOX 5796
                                            TELEPHONE: (208) 342-4666       305 FEDERAL WAY
                                                                            BOISE, IDAHO 83705


                                                                                                                                                                                                  w                         TV

                                                                                                                                     MONDAY *'APRIL 161, 1973 0 10 CENTS

      973 bY Field EnterPrises Inc. 9mh year, Numbw  As Pages in A -@ctions

      pli@lit to suburbs
                                                                                                                             ijoctor e,.xodlis drops cit Is
                        ecor                                         exo                                us
                                                                                                                             per-capita count to netv low
                                                                                                                             Continued from Page I                  Underscoring     the     disparity,  Park,  a  suburb  of  similar   pol
                                                                                                                                                                  Dewey  said  the   10   most   impov.  ulation  two  miles  further   west
                                                                                                                             of  Kane  County,  and  more   live  erished      communities       within    Garfield   Park   changed    frot
             0                          oc -ors Here                                                                         in  Lincolnwood  than  in  all   of  the cit@y  dropped  in  the  last  20  2ero black  population  in  1950  1
                                                                                                                             McHenry County."                     years   from   about    one    doctor  96.8 per cent .black  in  1970.  Tt
                                                                                                                             Contrary   to   belief,   hospitals  @er  1,000  population  to  a  little  racial  ,,Iructure   of   Oak   Par
      y Arthur J'  Snider                  his  half  as   many   doctors   per   status  of   the   north,   northwest      move  to  where  the  doctors   are  more than one-fourth doctor.           (less  than  I   per   cent   blac@
      aily Nleivs Science  Editor          capita  as  it  had  in   the   19th   and west suburbs.                          rather   than   doctors   following    The  10   most   affluen-t   subur-  hardly   changed   in    the    sam
                                           Century.                               0 G  r  o  w  t  It  of  professional      hospitals, Dewey said.               ban   communities,    however,    in-  period,
      Chicago's   ratio   of   physicians    "Incredibly,"      the      report   buildings  in  the   regional   shop-      HE   CALLED    for    a     morato-  flated  their  ratio  from  1.78  per    in  1950,  there  viere  16I.Phys
                                                                                                                                                                                                         clans   in   West   Garfield    Par
       population  is   the   lowest   in  noted,    "metropolitan     Chi@ag@s   ping centers.                              rtum on    federal     construction  1,000  to  2.1  in  the  same   1950-
      ie  citv's  history  and   is   ex-                                                                                                                                                                but in  1970,  only  13.  Oak  Par]
                                           physician-populition    ratio     in   9  Changing   racial   structure   of      funds   and   other   public   sub-  1970 period.
      @cted  to  establish   new   record  1970 was  one-fifth  below  that  of                                                                                     Oak Park, Hinsdale an                on the other hand, had only
                                                                                  Chicago.                                   sidles "that   have   helped   subsi-                                       doctors  in  1950  but  the   numbt
      ws  every  year  for  the  next  20  the  average   for   the   natioli's                                              dize the    sul)urbanization     of                               d    Ev-
                                                                                  0   Physicians'   desire   to    rac.      .   .                     11         et-green Park made the         great-  rose to 276 by 1970.
      !ars.                                large metropolitan areas."                                          p             physicians and hospitals.            est  gains,   while   West   Garfield
      A    new    study,    "Where    the                                         tice near their homes.                                                                                                   West   Garfield   Park's   doctor
                                             THE    STUDY,     conducted     by                                               Instead,"      he       continued,  P   a   r   k   and    Auburn-Gresham
      octors    Have    Gone,"     showed                                           "More  physicians       live             'tliese  federal  funds  should  be                                         to-populaiion   ratio   fell   frot
                                           Dr   Donald    Dewey    of    DePaul   _                                      I                                        suffered the greatest losses.
      iat  the  outward  flight  is   in-     '.                                    vanston than in all    of    South-      diverted to  inner  city  hospitals                                         31/2  per  1,000   to   about   oni
                                           University    and    published    by
       asing  at  a  faster   rate   than                                         west     Cook     County."      Dewey      to be used  to  equip  and  operate .  HOW  THE  I   N   F   L   U   X   of fo
      e                                                          al     Medical
                                           tne  Illinois Region                                                                                                                                            urth  doctor  per   1,000,   whil
      ie shift  of  the   general   popu-                                           rites.  "More  live   in   Winnetka
                                                                                  w                                      :   outpatic                                                       xodus    of  Oak   Park   rose   from   1.15   1
      @tion.                               Program,  listed  these   key   fac-   than   in   all   of   Will   County.             nt     dephrtnients     that  blacks results in an e
                                           tors   as   responsible   for    the                                              Would   provide    primary    ambu-  doctors  is  pointed   up   in   com-  4.42, or from  one  doctor  for  ii
      While  still  the  nation's  med  -                                         More  live  in  Skokie  than  in  all      latory    care    in    communities  paring'West    Garfield    park    on  ery 870  people  to  one  for  ever
      Li  mecca   as   headquarters   for  trend:                     -economic   Turn  to  Back  Page,  this   sec@ion      lacking private physicians."         ChicAgo's   West   Side   with    Oak  225.
      edical    organizations,    Chicago  o The higher  socio


                                                       Medical Society, County of Erie/MGY,  1973

                                                        EXTERNSHIP PROGRAM
                                                          FOR RURAL AREAS
                                                   Over   100   applications   from    health
                                                science   students   around    the    country
                                                have  been   received   for   enrollment   in
                                                the Lakes Area R@ioiial -\I
                                                zra@i   Rur,                Pi-
                                                sumitier.
                                                   The program is designed     to     provide
                                                students A,itli  work-ina  and  living  expe-
                                                riences that  hopefully  will  interest  them
                                                in a rural health  career  after  they  @rad-
                                                uate. Students  are  placed  -,vitli  a  pre-
                                                ceptor or health  professional  in  assi,iied
                                                rural communities.
                                                   William  D.   Crage,   director   of   the
                                                Rural  Externshil)  Program,  said  "N@'hi  c
                                                only  4-0  students  can  be   accepted,   at
                                                least 70 will have  to  be  turned  away  be-
                                                cause of  the  lack  of  funds.  The  virgent
                                                need  for  professional  hea  t   manl)o@vei,
                                                in rural areas still exists; the  calling  is
                                                there, as are the students".
                                                   The   program,   funded   and    organized
                                                                                    .\fe(llcal
                                                                                it@,  contri-
                                                                                 70  in   re-
                                                sponse to  the  professional  health  i-nati-
                                                power  deficit  in  rural   areas   and   has
                                                placed 102 students thus far,
                                                   The   program   has   expanded   to    in-
                                                clude students in  the  fields  of  medicine,
                                                dentistry,  nursing,   nutrition,   pharmacy,
                                                physical    therapy,    medical    technology
                                                and  podiatry.  Each   student   receives   a
                                                ,A@eekly stipend  and  Nvorls  directly  with
                                                a health professional.


            Florida Regional Medical Program

                                Supplement

                To the Journal of the Florida Medical Association


                                                          Contents

                  Florida Regional Medical Program-An Overview
                      Granville W. Larimore, M.D., Gordon R. Engebretson, Ph.D. and  Coyle  E.  Moore,  Ph.D...  3

                  Emergency Medical Services Program in Florida
                      William T. Haeck, M.D. and Spero E. Moutsatsos, M.S    .   .............................   7

                  Regional Medical Program of Hospital Infection Surveillance
                      N. Joel Ehrenkranz, M.D .       ........................................................ 10

                  Florida Neonatal Intensive Care Program
                      Richard J. Boothby, M.D .       ........................................................ 12

                  Florida Renal Disease Program
                      William W. Pfaff, M.D., Ben A. VanderWerf, M.D. and Don Riedesel       ................. 17

                  Continuing Medical Education '
                      Michael J. Pickering, M.D .       ....................................................... 20

                  Comment
                      Robert P. Lawton  ........................   :    ...................................... 21

                  Coronary Care Unit Training Program
                      Louis Lemberg,  M.D.  and  Azucena  G.  Arcebal,  M.D .    ............................... 22

                  Intensive In-Service Education for Physicians
                      Arvey 1. Rogers, M.D. and Sidney Blumenthal, M.D   .    ................................ 25

                  New Scalar Computer EKG Program for On-Line EKG Processing
                      Lamar E. Crevasse, M.D. and Mario Ariet, Ph.D .     .................................... 28

                  Cervical Cytology Revisited
                      James E. Fulghum, M.D.  and  John  C.  Reagan,  M.P.H .    ............................... 31

                  RMP! - RIP?
                      H. Phillip Hampton, M.D  .       ....................................................... 36

                  2                                                                          VOLUME  60/NUMBER   5


                                    Florida Regional Medical Program
                                                                    An OverN,le,%N,

                                                                          -VI.D., GORDON R. ENGEBRETSON, Pji.D.,
                                         ('RANVILLE W. LARIMORE, i

                                                                AND COYLE E. illOORE, PH.D.

                             The  Florida  Regional  Medical   Pro-ram   is   one   other federally  funded  activities  in  the  health  field.
                                                                  t,
                     of   56   established   under   Public   Law   89-239.   The   These are:
                     law sets forth the purposes as:                                    1.    Local    decision-makin-:    Decisions     regard-
                                                                                                                     0
                             Through grants to encourage and assist in the devel-   inla,   the   assessment   of   need,    determination    of
                     opment of regional cooperative arrangements  ...  to  afford   T)riorities  and  allocation   of   funds   among   approved
                     the medical profession and the medical institutions  of  the   .
                     nation throu-h such cooperative arrangements, the         op   projects  are  all  made  within  the   re,,ion.   (In   the
                     portunity of making available to their patients  the  latest   Florida  Proaram,   the   "re-ion"   includes   the   entire
                     advances in diagnosis  and  treatment  ...  by  these  means                n               t5
                     to improve generally  the  health  manpower  and  facilities   state,  others  of  the  56  re,-,ions  are   made   up   of
                     available  to  the  nation  and  to  accomplish  these  ends   parts  of  a  state  or  combinations  of  states   or,   in
                     without interfering with the patterns,  or  the  method'  of           e  of  34  re-ions,  consist  of  a   single   state
                     financing, of  patient  care  or  professional  practice.  r   the c@               C,
                     with the administration of  hospitals,  and  in  cooperation   like  Florida).   In   each   region   provision   is   made
                     Nvith practicing physicians, medical center  officials,  h"-
                     pitat administrators and  representatives  from  appropriate   in    the    decision-makin-     process     for     maximum
                     voluntary health agencies.                                     participation   by   those    most    knowledgeable    about
                                                                                    the re-ion's health needs.
                             The  original  law  spoke  to  the  area  of  "heart
                     disease,   cancer,    stroke    and    related    diseases."       2.  Cooperative  arrangements:          Public       Law
                     Subsequent     amendments      (Public      Law      91-515)   89-239   calls   for    "regional    cooperative    arrange-
                     and   administrative   practice    broadened    the    scope   ment;-;"   and   one   of   the   accomplishments   of   the
                     of  the  Program  and   enabled   the   regions   to   oper-   Pro-ram  has  been  to   bring   to-ether   all   of   those
                     ate  in  other  areas  of  need   as   determined   by   the   concerned  with  health  services   in   the   interest   of
                     re-ions themselves.                                            developin-    the     cooperative     arrangements     which
                                                                                              Z3
                             The     Florida     Regional     Medical     Pro-ram   are  the  foundation  of  all   regional   medical   program
                     (FRMP) stated as its objective:                                activities.
                             "To raise the  levels  of  health  care  in  Florida       3.   Provider   orientation:   While   there   is   con-
                     by   assistin-   physicians,   allied    health    personnel   sumer    representation    on    the    Regional    Advisory
                     and   their   medical   institutions   in   providin,,   the   Group,   the   policy-making   body   for    the    Pro-ram,
                                                                          0                                                             t3
                     highest  quality  health  services   in   their   own   com-   it  and  all  of  the   expert   committees   involved   are
                     munities,   increase    accessibility    and    availability   dominated   by   health   care   providers.   Of   the   350
                     of  these  services  and  to   promote   the   most   modern   volunteers  who   provide   expertise   and   guidance   for
                     health   services   with   special   attention   to    heart   the   Florida   Regional   Medical   Program,    over    300
                     disease,  cancer,  stroke,  kidney   disease   and   related   are  physicians   or   other   health   professionals   with
                     diseases."                                                     physicians in by far the majority.
                                                                                        In  fact,  physicians  have  occupied  a  key  role   in
                                    Program  Characteristics                        the   Florida   Regional   Medical    Program    from    its
                             There  are  three   unique   characteristics   which   very  inception.  It   was   the   Florida   Medical   Asso-
                     tend  to  set   regional   medical   pro-rams   apart   from   ciation   acting   through   the   Florida   Medical   Foun-
                             Dr. Larimore is Director and Dr. Engebretson Deputy  Direc- dation  that  served  as  the   initial   fiscal   guarantor
                     tor       Fda Re  onal   ed Program.  -Dr.  Moore   is   Chairman
                                                                                    of  the   Pro-ram.   This   action   enabled   the   Program
                     of            g'          d      Grout).
                                                    y      P@"ided by Tit
                                             @"'sor
                             'Ori
                             h@Frid. Reg,.n. d b     nd@
                                                    u    Pr
                                                   f                    'e      of  to   get   under   way   after   some   months   of    uncer
                             hi. rk i.       re  Yfid n    nd conclusions
                             T-0             The                          re,,oled
                             Publ  .I
                                  . th   C,
                     the     i' H
                                          pr@.,
                     do      nt n@,5@.ril, -e n,  tl,@       f  the  Public   Health
                     Service;                                                       taintv.

                     J. FLORRDA M.A./MAY, 1973                                                                                                 3


                         In   the   Florida   Regional    Medical    Proaram,       resentatives  of  the  voluntary   and   public   health
                     the responsibility for plannin-  lies  with  the  Flor-        a-encies,   hospital   administrators   and   practicin-
                     ida   Re-ional   Advisory   Group.   Basic    to    its        physicians-likewise   has   an   opportunity   to   con-
                     plannin-  role,  the  FRAG  solicits  input,   informa-        tribute  to  the   FRAG's   planning   activity.   While
                     tion,  data,  opinions,  reports,  from  those  to   be        the  role  of  Board  members  is   confined   to   man-
                     served.  Such   input   comes   from   the   membership        a-erial  affairs  of  FRMP,  Inc.,  their   advice   and
                     of  the  Group   itself   amon-   whose   members   are        participation  is  solicited  by  the   Group.   Experts
                     providers of health care services.                             in their  own  ri-ht  in  various  health  problems  and
                         Health   and   educational   institutions,    agency       health   care   delivery   systems,   members   of   the
                     and   organization   representatives   on   the   Group        Board  have,  on  a  number  of  occasion2,,   suggested
                     likewise  provide  input  necessary  for  the  planning        solutions to some of Florida's health problems.
                     process.  The  State  Comprehensive   Health   Plannin-    b                           Evaluation
                     auency as well  as  local  health  plannino,  councils,
                     medical  association,  nurses   association,   hospital            The  Florida   Re-ional   Medical   Pro-ram   beoins
                                                                                                           Z3                     C)       t3
                     association,  representatives   of   voluntary   health        its evaluation process at  the  inception  of  a  project
                     organizations  and  others  are  examples   of   agency        idea.  Various  ideas  are  considered   in   li-ht   of
                     and   organization   participation.                            FRMP  objectives  and  are   weighed   for   their   po-
                         Plannin-  requirements  of  a   more   sophisticated       tential contribution  toward  reachin,,  the  objectives
                                  0                                                                                           ZD
                     scientific  and  technologic   nature   are   satisfied        of  the  Pro-ram.  If  project  ideas   are   determined
                     through  input  furnished  to   the   FRAG   from   its        to have merit, a staff  member  is  assigned  to  assist
                     special  advisory  Task  Forces,  Councils  and   Corn-        the  applicant  in  preparin-  his  formal   application
                     mittees.  Membership  on  these  groups   consists   of        materials.     Counsel   is   provided    the    applicant
                     eminent   Floridians   with   expert   knowledge    and        re-ardin,, clarification  of  his  objectives,  develop-
                                                                                      t)      Z3
                     experience  about  special  diseases  or  health   care        ment  of  methodologies  which  will   assist   him   in
                     problems.  These  experts  alon-  with  staff,   advise        reachin-  these  objectives,  and  elucidation   of   an
                     the FRAG of scientific and
                                                       ,@-hrlolo-ic   advances,     evaluation  procedure  which  will   provide   ways   of
                     innovative  approaches  to  the  delivery   of   health        measurin-  progress  toward  the   project   objectives.
                     care, new application of  existin-  knowledge,  or  the            In  some  instances,  FRMP   staff   have   assisted
                     need to  develop  new  or  to  use  more  eff  ectively        project directors  to  establish  standards  of  perfor-
                     existin- health manpower.                                      mance against which to measure pro-ress.                    -
                         The   Board  of  Directors  of   the   FRMP,   Inc.-       porting  systems  designed  to  aid  project   directors
                     made up of the  deans  of  the  medical  schools,  rep-        in assembling data  in  a  form  which  can  be  readily

                                                          PROJECT         PROPOSAL
                                                                 FUNDING
                         PROJECT TECHNICAL-.              RECOMMENDATIONS                       FRMP PROGRAM
                                 REVIEW                         DECISIONS                         MANAGEMENT
                            Task Force/Councils           Regional Advisory    Group        Board of Directors, FRMP, Inc.
                                FRMP    staff                                           FRMP Director
                         Regional Advisory Group          Planning   and   Evaluation    1. Receive,  administer   and   account
                         Planning and Evaluation                                            for funds
                                                          Committee                      2. Review affiliation  agreements  with
                         Committee, Si@e Team             Regional   Advisory   Group
                         Task  Force/Councils                                               respect to:
                         CHP a  or  b  agency                                               a.  FIigibflity for and  conformance
                                                                                                with  federal  funding  require-
                            Assess anticipated                Recommend                         ments
                            and real  success                 allocations of                b.  Capabilities of affiliates to
                                                              funds                             manage grant funds
                                                                                            c.  Fiscal and administrative
                         I. Determine   merit of new        Allocate funds                      procedures
                         .  proposal/contract                                               d.  Provisional and  final  indirect
                         2. Provide ongoing review                                              cost for affiliates
                         3. Recommended changes                                                 Manage FRMP funds in
                                                                                                accordance with federal
                                                                                                regulations.

                     J. FLORIDA M.A.@Y, 1973                                                                                                    5


                       analyzed  have  been  developed.  An  example  of   a      Decisions regarding  allocations  of  funds  among
                       data reporting  system  is  one  desi-ned  to  assist  continuin-  and  new  projects   are   made   by   the
                       in  the  analysis  of  various   medical   treatments  FRAG's  Priorities  and  Evaluation   Committee.   In-
                       rendered to patients in  and  out  of  coronary  care  put  to  this  decision-making  process  is  furnished
                       units to determine the most effective methods.         in the form of staff analyses of  project  activities,
                           Project  directors  are   required   to   furnish  reports   and   recommendations   from   the   various
                       monthly reports describing project  activities,  dif-  FRAG  task  forces,  councils  and  committees,   and,
                       ficulties  encountered,  pertinent  information   and  on occasion, when the technical  aspects  of  a  proj-
                       data and  an  analyses  of  findin-S.  These  reports  ect require special  expertise,  findings  and  recom-
                       are  summarized  for  the  FRAG  and  provide  it  an  mendations of technical site visit  teams  or  special
                       opportunity to redirect  ineffective  project  activ-  consultants. Those  projects  which  (1)  show  satis-
                       ities.  In  addition  to  written  reports,  numerous  factory  progress  toward  accomplishing   objectives,
                       telephone  conversations  between  project  directors  and  (2)  will  assist  the  Program  in  meeting  its
                       and  the  FRMP  staff  determine   interim   pro-ress  overall  objectives  are  recommended  for   continued
                       providin- opportunity for staff to render  assistance  fundina.   Fundin-   recommendations   are   forwarded
                       in solvin- problems of an uruent nature.               to  the  FRAG  who,  in  consultation  with  the  FRMP
                                t3                    In
                           Projects are site visited by FRMP staff at  least  Board  of  Directors,   may   approve   project   con-
                       semiannually,  sometimes   more   frequently.   These  tinuation, redirection, or discontinuance.
                       visits are cordial and are not viewed as  a  policin-      A  continuin-  concern  of  the  FRAG,  the   FRMP
                       action.  Honest  sharin-  of  information   and   ex-  staff and Board is that  project  directors  diligent-
                       chano,e of ideas have  led  to  innovative  modifica-  ly  work  toward  developing  new   fundin-,   sources
                       tions and  improvement  in  the  conduct  of  project  during the term of their project.  In  fulfillin-  its
                       activities.                                            catalytic  role,  the  FRMP  endeavors  to  see   that
                           Feedback  is  provided  to   the   various   FRAG  the activities initiated and refined durin- the  proj-
                       task forces, councils  and  committees  in  the  form  ect  period  be  continued  through  support  of   the
                       of semiannual pro-ress  reports  on  all  operational  affiliated institutions or other fundinc, sources.
                                          Z5
                       projects.  These  reports  are   prepared   by   FRMP      This  review  process   has   enabled   the   FRMP
                       staff and are  based  on  monthly  reports  filed  by  in the relatively short period  of  its  existence  to
                       the  project  directors,  site  visits  by  the  FRMP  address itself with considerable  success  to  a  wide
                       staff  and  correspondence  or  other   communication  variety of the state's health  needs.  Many  of  these
                       with the principals involved in the  conduct  of  the  activities are described in  this  special  supplement
                       project activities. On occasion,  a  particular  task  to the journal.  Space  does  not  permit  a  descrip-
                       force  may  request  a  project  director  to  appear  tion  of  all  37  of  FRMP's  current  projects   and
                       personally and report on  his  project.  This  oppor-  contracts.
                       tunity  is  also  provided  to  the  FRAG   and   the      Among the  major  activities  of  FRMP  are  those
                       FRMP  Board  of  Directors.  On  several   occasions,  directed  toward   such   important   health   service
                       the  FRAG  and  the  Board  have  elected  to  invite  areas as:
                       project directors to attend one of their meetinas  to      A    statewide    Emergency    Medical     Service
                       learn firsthand  of  the  impact  of  FRMP  pro,,rams  System.
                       on the health problems of Florida.                         A  coordinated   chronic   dialysis   and   kidney
                           Similar information and  data  are  furnished  to  transplant program.
                       the  FRAG  Planning   Committee   to   assist   their      An  intensive  care  program  for  newborns  aimed
                       appraisal of progress  in  solving  Florida's  health  at reducing the 1,800 annual infant deaths.
                       care  problems.  Such  information,  based   on   the      A  coronary  care  unit  nurse  training   program
                       solving  of  problems  and  changing  of  needs,   is  that has  prepared  more  than  500  nurses  to  serve
                       used to update and revise priority areas  of  concern
                                                                              in coronary care units.
                       to the FRMP.
                           The flow  of  information  is  then  directed  to      A  nurse-midwifery  program  aimed   at   reducing
                       the  FRAG  Priorities   and   Evaluation   Committee.  the 1,500 deliveries now done by lay midwives.
                       This Committee, which  reviewed  the  original  proj-      Consultation for family  physicians  in  the  care
                       ect application, has the  responsibility  of  judging  of children  with  cancer  (3,200  consultations  have
                       whether  the  objectives  originally   proposed   are  been provided for 400 children).
                       indeed  being  accomplished   through   the   project      Demonstration  programs   for   the   control   of
                       activities.                                            hospital-acquired infections.

                       6                                                                                     VOLUME 60/NUMBER  5


                         Out-reach,  "Health  Guides"  proarams  in   three  continuation  of   re-ional   medical   pro-rams   are
                                                          0                                      0                    zn
                     inner-city and a migrant labor area.                    now  pendin-  in  the  Con-ress  so   their   ultimate
                                                                                         0              b
                         FRMP  operates  with   a   small   staff   and   a  fate is at the moment in doubt.
                     minimum of  overhead.  All  of  the  37  projects  are     Without regard to  what  the  future  may  briii0a,
                     I)ein(y carried out at a total annual cost  equivalent  it is submitted that as a result  of  the  cooperation
                         0
                     to  approximately  25  cents  per  capita   based   on  and  support  of  the  physicians  of   Florida,   the
                     FRMP's   current   funding   level    and    Florida,s  Florida  Re-ional  Medical   Procrani   has   made   a
                                                                                         0                    0
                     population.                                             substantial  impact  on  many   major   health   prob-
                                                                             lems  and  throu-h  the   guidance   of   its   Board,
                         As this is  written  the  national  administration                   0
                     has declared its intention of  phasin.-  out  regional  Advisory  Group  and  expert  committees,   has   used
                                                                             its  funds  wisely  and  effectively  in  aidin-   the
                     medical  pro-rams  and  the  President  has   included
                                 n                                             lution of many of these problems.
                     no funds for the pro-rams in his  fiscal  1974  bud-et  so
                                         n                            0
                     year beainnin- July 1,  1973.  Bills  authorizin-  the  @  Dr.  Larimore,  I  Davis  Boulevard,  Tampa  33606.

                               Emergency -M-edical Services Program
                                                               In Florida

                                          WILLIAM T. HAECIC, M.D, AND SPERO E. MOUTSATSOS, M.S.

                         Florida lacks  a  comprehensive  system  for  pro-  lation on ambulance services  failed  in  the  1970-71
                          0     ergency   Medical   Services   (EMS).    In  and 1971-72 legislature.  Efforts  are  bein-  renewed
                     vidin,y Em                                                                                        C,
                     1970  nearly  1,800  people  died  in   Florida   from  for  the  current  (1973)  session.  The  present  law
                     automobile  accidents.,  During  1970,  of  the   more  calls  for  enforcement  of  the  ordinance   by   the
                     than 40,000  people  who  died  of  heart  disease  in  Florida  State  Division  of  Health  and  the  county
                     Florida, 65@c, died  within  the  first  hour  of  the  health departments.  No  state  funds,  however,  have
                     onset  of  SyMptoMS.2  From  national   data,'it   may  ever  been  appropriated  to  enforce  the  ordinance.
                     be  predicted  that  approximately  12,000  of   these      In 1969,  with  a  modest  allocation  of  federal
                     people might  have  been  saved  if  they  had  access  funds   from   the   Department   of    Transportation
                     to a good EMS System.3.4                                through  the   Governor's   Highway   Safety   Commis-
                         Florida lacks adequate  laws  for  the  regulation  sion, the Florida State Division  of  Health  formally
                     of EMS on a statewide basis.  State  statutes  require  established  a  Section  on  Emergency  Medical   Ser-
                     only 8!/2  hours  of  training  for  ambulance  atten-  vices.  The  budoet  for  the  Section   was   $43,000
                     dants.  It  is  legal  in  Florida  to  transport  the  during  the  1972  fiscal  year.  This  provided   for
                     critically ill and injured with no  attendant  in  the  -,ecretarial  staff,  two  EMS  field  representatives
                     ambulance. Efforts to  obtain  adequate  state  legis-  and  some  funds  for  education  and  traininc,.  The
                                                                             director of the Section was on loan  to  the  Division
                         Dr. Haeck is  Director  of  the  Emergency  Medical  Services
                     P oiect, Division                                       of   Health   from   the   Division    of    Emeroency
                       r            of Health. Tacksonville. and Mr. Moutsatsas  is                                         t)
                     Ass;sta@t Director for Plan@ing and  Ev@luation,'Florida  R@gion- Medical  Health  Services   of   the   United   States
                     at Medical Program, Tampa.

                     J. FLORIDA M.A./MAY, 1973


                     Public   Health    Service,    Department    of    Health,  March  1,   1972.   The   FRMP   also   provides   consul-
                     Education, and Welfare.                                     tation and other support when indicated.
                         In 1970 and 1971,      the   Section    conducted    a      The   Florida   Division   of   Health   maintains   a
                     county   by   county   survey   of   EMS   resources   in-  central  EMS  office  and  facilities  and  provides   the
                     cludin-   equipment   and    facilities    and    advising  usual managerial and administrative services.
                     counties  and  cities  on   the   development   of   local      The  central  office  functions  in   an   administra-
                     pro-rams.  The   1970-71   survey   revealed   that   com-  tive  and   leadership   capacity   directing   the   pro-
                     prehensive    EMS    proarams,    nationally    recognized  -ram 7s operations.  Seven  district  offices  staffed  by
                     for  their  excellence,  were  operational   in   Jackson-  FRMP  district   directors,   and   Division   of   Health
                     ville  and   Miami.   A   few   other   communities   were  EMS   representatives   are   charged   with    implement-
                     identified  as   havin-   promising   pro,-rams   underway  in.-, the EMS  plan  in  their  local  areas.  Implementa-
                     or  under  development.   However,   the   vast   majority  tion   includes   the    development    of    regionalized
                     of  the  counties  and  larger   cities   did   not   have  services  and  formation  of  state,  local  and  district
                     comprehensive      pro,-,rams,   lacked       satisfactory  emergency    medical    services    advisory     councils.
                     emergency   vehicles   and   equipment,   and   had    in-  These  councils  assist  the  staff  in  the   formulation
                     adequate   or   poorly   trained   ambulance    personnels  of  pro-ram  policies,  as  well  as   in   plannin-   and
                     Only  a  few  counties  and  larger   cities   had   plans  monitorin-   the    ongoin-    program.    In    addition,
                     on  paper  for  EMS  operations,   but   these   essential  some   expert   subcommittees   of   the   state   council
                     services were usually given low priority.                   have  been  established  in  such  areas  as  legislation,
                                                                                                                                b
                                        Statewide Plan                           finance,  training,   education,   regionalization,   com-
                                                                                 munications, and priorities.
                         In the summer of 1971, the       Florida      Regional      The  joint  program   plan   serves   as   the   guide
                     Medical     Pro-ram     (FRMP)      reviewed      priority  for  both  the  central  office  and  the  seven  district
                     health problems  in  Florida.  In  view  of  the  lack  of  offices.  A  general   administrative   manual   was   de-
                     a    comprehensive    statewide    EMS    program,    FRMP  veloped  which  includes  the  policies   and   procedures
                     accorded  the  EMS  problem   a   number   one   priority.  to  be  followed  by  all  personnel  of   the   project.7
                     informal   conferences   were   held   with    representa-  In  addition,  a  guide  for   the   evaluation   of   the
                     tives  of  the  State  Division  of  Health,  the  state's  implementation   of   the   project   and   its    related
                     medical    schools,    Florida    Medical     Association,  activities   was   developed   jointly    by    the    EMS
                     Florida   Hospital   Association,   and   the    existin,,  central office and the FRMP.
                     EMS   pro-rams   in    Jacksonville    and    Miami.    It
                     was   aareed   that   the   Florida    Regional    Medical              Goals and Accomplishments
                     Pro@ram  should  develop  a   statewide   plan   to   help      The  long-range  goal  of  the  Florida   EMS   state-
                     improve  emergency   medical   services   to   be   opera-  wide   project   is   to   reduce   mortality,   morbidity
                     tive  within  the  Division  of  Health  of  the   Depart-  and   disability   rates.   Accomplishments    thus    far
                     ment  of  Health  and  Rehabilitative  Services   of   the  have   stimulated   the   state   and   local   government
                     State of Florida.                                           and   the   voluntary   and   professional   organizations
                         FRMP  proceeded   durin-   the   fall   of   1971   to  to  become  involved  in  the  task  of  helping   improve
                                                    n
                     develop   this   plan.   The   medical   literature    was  EMS for Florida citizens.
                     extensively   reviewed;    national    authorities    were      A   state   EMS   council   has    been    rejuvenated
                     consulted  including  those  at   the   American   Medical  and  work  is  underway   to   provide   advice   to   the
                     Association  and  the  U.   S.   Department   of   Health,  project  in  all  phases   of   EMS.   The   council   has
                     Education,   and   Welfare;   successful    programs    in  also  provided  a  forum  of  discussion   and   coordina-
                     different  cities  and   counties   were   visited;   pre-  tion  for  the  many  agencies   with   an   interest   in
                     liminary  plans  were  reviewed  by  the   state   medical  EMS.    Among    organizations    represented    on    the
                     and   hospital   associations   and    the    FRMP    Com-  council are:
                     mittee  on   Health   Services.   The   final   plan   was  FMA     Committee     on     EMS;     Florida     Hospital
                     completed   February   1,   1972,    and    approved    as  Association;  Florida   Chapter,   American   College   of
                     a  cooperative  enterprise   between   the   Division   of  Emergency   Physicians;   Trauma    Committee    of    the
                     Health and the FRMP.6                                       Florida   Chapter,   American   College    of    Surgeons;
                         Under   this   arrangement,    the    FRMP    provides  Florida   Ambulance    Association;    Florida    Chapter,
                     initial.funds to  the  Division  of  Health  for  develop-  Emergency    Department    Nurses    Association;    State
                     ment   and   support   of   a   statewide   EMS    program  Legislators;   Florida   Association   of   County    Com-
                     for  a   period   of   up   to   three   years   beginnin-  missioners;   Division   of    Communications;    Division

                     8                                                                                            VOLUME 60          ER 5


                    of    Health;    Comprehensive    Health     Plannin-;  department  nurses   and   begin   proarams   to   meet
                    Division  of  Planning,  Department   of   Administra-  these needs.
                    tion, and individual EMS leaders.                           3.  Define the capabilities and   needs  of   emer-
                        The  cooperative  efforts  of   the   group   have  -ency departments in all areas of     the state.
                    helped  stimulate  the  Governor's  interest  in  EMS.      4.  Define  the   retrainin-   needs   of   Florida
                    He has stated that one of  the  goals  of  his  Admin-  EMT's  and  beain  pro-rams  to   meet   these   needs.
                    istration  is  the  improvement  of   EMS.   To   that      There is  no  accurate  tool  to  measure  the  im-
                    end,  a  multia,,ency  study   croup   Nvas   convened
                                   t5             0                         pact  of  an  effective  EMS  system.  The  project  is
                    and  has  prepared   a   preliminary   10-year   state  attempting  to  locate  the   expertise   and   fundin-
                    plan.8                                                                                                        ID
                        This  cooperative  effort  has  also  resulted  in  support  necessary  to  build  an   appropriate   tool.
                    the  preparation  of  companion   House   and   Senate  In  addition  to  measuring  the  impact  of  new   EMS
                    bills by  Senator  Poston  and  Representative  Hodes.  S@Stems, it is  hoped  the  tool  will  be  capable  of
                                                                 .  .       aeiineatin- objectively any  deficiencies  in  existin-
                    They  are  HB  124  and  SB  127.  If  passed,   these
                    bills would:                                            systems.
                                                                                An  accurate  tool  to  measure  the  effectiveness
                        1. Establish for the first time an official  -roup  of  EMS  trainin-  courses  and   to   identify   areas
                                                                   0                         0
                    within  state  government  whose  sole  responsibility  that need to be improved  is  also  needed.  This  tool
                    is EMS.                                                 will be developed when funds can be located.
                        2.  Establish   standard   trainin-   requirements      Accurate  and  easy  access  into  the  EMS  system
                                                        0
                    for Florida's EMT'S.                                    for  Florida  citizens  is  of  paramount   importance.
                        3.  Establish  recognized  standards   for   EINIS  Centralization of dispatch facilities and  use  of  the
                    vehicles and equipment.                                 the 911 System will  be  explored  in  more  detail  by
                                                                            project staff.
                        The  proposed  legislation  is  also  tied  to   a      Effective  telecommunications  to  link  all   ele-
                    budget  request  by  the   Department   of   HRS   for  ments  of   the   EMS   system   are   sorely   needed.
                    $1,000,000  to  improve   Florida   EMS.   Two   addi-  Efforts  to  detail  exact  needs  for  these  communi-
                    tional  bills  have  been  prefiled.  HB   447   would  cation links are underway.
                    establish conditions under  which  state  funds  could      Over  50  federal  programs   have   authority   to
                    be  allocated  to  community  EMS  systems.   SB   205  fund  EMS  activities.  The  project   hopes   to   see
                    would  allocate  funding  for   plannin-   EMS   corn-  that Florida receives its fair share  of  these  funds.
                    munication systems.                                     Present  cutbacks  in   federal   support   of   health
                        One outstanding   effect of project  activity  has  pro-rams are  not  clear  enough  at  this  writing  to
                    been to stimulate an  increase  in  EMT  training   in  delineate the effect on federal EMS activities.
                    the  state.  Over  1,000  EMT's   will   receive   the      As  local  EMS  systems  improve,  an  effort  will
                    standard 81-hour DOT course in 1973.                    be  made  to  identify  regional  health  areas.  Local
                        At the district level, activities have  been  con-  systems  will  be  encouraged   to   meld   to   effect
                    centrated  on  county  and  community   EMS   systems.  re,- onal EMS systems.
                    Many  EMS  councils   have   been   formed   and   are                       Summary
                    studying the needs of their  service  areas.  In  some
                    cases, these councils  have  proceeded  to  the  point      The FRMP has     funded,  and  given  priority  to,
                    of being able to  formulate  and  implement  effective  the development of   an  excellent   EMS   system   for
                    local  EMS  systems.  It  is  anticipated   that   the  the citizens of Florida.  The  project  has  helped  to
                    formation of local councils  will  continue  and  that  unify  the  fragmented  efforts  of  other  groups   in
                    eventually  the  entire  state  will  have   operative  Florida  in  the  EMS  arena.  Project  activities  are
                    local advisory councils.                                improving  both  local  EMS  systems  and  the   status
                                                                            of  EMS  at  the  state  level.  Earl   evaluation   of
                        The project has also initiated studies to:                                             y
                                                                            the project indicates that it will  significantly  help
                        1.  Define  the  educational  needs  of  emergency  to stimulate  Florida  out  of  the  EMS  "dark  ages."
                    department   physicians   and   begin   programs    to
                    meet these needs.                                         References are available from the authors upon request.
                        2.  Define  the  educational  needs  of  emergency  @  Dr.  Haeck,  P.  0.  Box  210,  Jacksonville  32201.

                    J. FLORIDA M.A./MAY, 1973                                                                                     9


                              Regional Medical Program of Hospital
                                                    Infection Surveillance

                                                                   JOEL EHRENKRANZ, '-\I.D.

                         Hospital-acquired   infection   is   a    continuin.-               Training and Responsibility
                                                                             I
                     problem  of   health   care   in   the   United   States,       The  administration  and  staff   of   a   oroup   of
                     which  is  likely  to  increase  as  new   and   sophisti                                                 n
                                                                             -   hospitals   in   Dade   and   Broward    Counties    have
                     cated   medical   techniques   are   employed   to   deal   made   commitments   for    ongoing    involvement    and
                     with  a  variety  of  life-threatenin-  diseases.  Effec-   ,                     0
                                                         0                       ;upport   of    the    pro-ram.    Nurse-epidemiologists,
                     tive  treatment  of  some  cancers,  heart   and   kidney   physicians,   administrators   and    other    interested
                     diseases   and    cerebrovascular      accidents      may   T)ersonnel  from  the  participatin-   hospitals   attend
                     paradoxically  increase  infection.   It   is   estimated   'weekly  classes  in  the  theory  and  practice  of  de-
                     that  SO,000  to  70,000  Americans   die   annually   as   tection of hozzpital-a;-;sociated infection and its  pre-
                     a  result   of   hospital-associated   infections-roughlv
                     the  same   number   as   die   from   automobile   acci-   vention.  Courze   work   includes   instruction   in   a
                                                                                 standard   approach   to   observin-    and    recordino-
                                                                                                                     zn                  11
                     dents. The  cost  of  hospital-associated  infections  is   rates   of   hospital-associated   infection   by   organ
                     estimated  to  exceed  $500  million  per   year.   Thus,   site, infectin.- organism,  geographic  place  of  infec-
                     this  is  clearly  an   important   problem   in   health   tion, professional service, patient  risk  factors,  etc.
                     care  which  has   not   disappeared   with   development   This   permits   appropriate   comparisons    within    a
                     of  new  antibiotics,  vaccines   and   therapeutic   de-   hospital   or   between    hospitals.    Formal    course
                     vices.  In  fact,  infections  at  times  have   occurred   work  covers  mechanism   of   acquisition   and   spread
                     as  a  direct  result  of  some  of   these   therapeutic   of   infection,   analysis   of   published    outbreaks,
                     efforts.   Moreover,   hospital    personnel    includin-
                                                                             0   various   strategies   of   prevention    and    measure-
                     physicians  and  nurses   may   be   exposed   to   other   ments  of  efficacv.  In  addition  to   regular   class-
                     infectious  diseases  such  as  tuberculosis  and   hepa-   work, there  is  a  weekly  visit  to  each  hospital  by
                     titis  in  the  hospital  settino,-in  some  cases  with-
                                                   0                             the  physician-epidemiologist   during   which   individ-
                     out  being  aware  of  the   risk   to   themselves   and   ual hospital  problems  are  analyzed,  including  a  re-
                     their  families.  The  dia-nosis   of   tuberculosis   or
                                                 C,                              view  of  procedures  which  are  in  force  for  preven-
                     hepatitis  may  not  be  readily  apparent  in   patients   tion  of  infection,  or   limiting   its   spread.   The
                     who are actively spreading infection.                       potential  for  acquisition  and  dissemination  of   in-
                         The   immediate   goals   of   this   Regional   Med-   fection  in  various  parts  of  the  hospital  is  exam-
                     ical   Program   of   Hospital   Infection   Surveillance   ined  in  great  detail.   The   physician-epidemiologist
                     (Program  #46)   are   the   following:   (a)   To   edu-   is  also  available  on  short  notice  for  on-the-scene
                     cate  nurses,   physicians,   administrative   and   sup-   investigation  of  outbreaks  or   review   of   episodes
                     port  personnel  in   criteria   of   hospital-associated   of  hospital  infection,  and  assistance   in   prepara-
                     infection and  its  recognition,  and  identification  of   tion  of  the  monthly   hospital   infection   committee
                     patients  and  personnel  at  risk  to  hospital   infec-   report.   He   attends   and   participates    @in    the
                     tion; (b)  To  examine  conditions  of  hospital  arc  '-   monthly  meeting   of   the   hospital   infection   com-
                     tecture,   patient   placement   and   use   of   various
                                                                                 mittee.
                     therapeutic  devices  that   promote   dissemination   or       A  number  of  specific  areas  has   been   examined
                     acquisition of infection.  The  long  range  goal  is  to   in  each  of  the  participating  hospitals.  These   in-
                     elevate the  standards  of  hospital  care  so  that  in-   clude  the  type,  cost   and   use   of   disinfectants;
                     fection is decreased or eliminated.                         means  and  techniques  for   isolating   infective   and
                        Dr. Ehrenkranz  is  Chief  of  Mediciiie,  Cedars  of  Lebanoii susceptible patients; flow  of  traffic  within  and  be-
                     Hospital,, @d tve, lvfiami. Aledicine,  University  of   Aliami               -h                                    -
                     School.    e,,,,Professor  of                               tween certain hi,     risk  areas;   types   of   environ

                     10                                                                                          VOLUME      60/NUMBER      5


                    mental  sanitation  and  ventilation-,  laboratory   ca-               Broad Education Program
                    pabilities  and  limitations;  employee   health   prac-      A further  function  is  a  broad  educational  pro-
                    tices and  awareness  of  types  of  hospital  infection  gram   addressed   to   the    community    of    health
                    exposure  of  employees;  type  of  infection  reportin-
                                                                           C, workers  who  are  interested  in  hospital   infection.
                    currently   in   use;   discrepancy   between   report@d  Health   ivorkers   including   personnel   from    aca-
                    and observed  rates;  use  of  various  therapeutic  de-  demic  centers  and  public  a-encies  are  invited   to
                    vices  known  to  be  associated  Nvith  spread  of  in-                                 0
                                                                              attend  the  weekly  classes  given   by   the   -\Iiami
                    fection and efforts  made  to  limit  this  to  what  is  based     physician-epidemiolouists-Dr.           George
                    necessary  for  -ood  patient   care;   responsibilities                                   0
                                    C,                                        Counts,  Dr.  Phineas  Hyams   and   myself,   and   our
                    of  the  hospital   infection   committee;   recommenda-  chief  infection  control  coordinator,  Leilani   Kick-
                    tions of this  committee  as  a  result  of  recognition  lighter, R.N.  In  addition,  all  are  welcome  at  our
                    of problems and examination of action taken.              annual  seminar  which  is  conducted   by   a   faculty
                       Physician-epidemiologists   each   serve   four    or  of  national  prominence.  In  the   seminar   concluded
                    five hospitals on  a  regular  basis.  They  review  the  in  January  1973  the  faculty  included:   Aliss   Su-
                    records  of  patients  considered  by   the   nurse-epi-  zanne  Leuace,  head   nurse-epidemiolo-ist   from   Ot-
                    demiologist  to  have   had   hospital-acquired   infec-            0                              0
                    tion to be sure the criteria  for  infection  have  been  tawa  General  Hospital,  Miss   Elsie   Buff   of   the
                                                                              Florida  State  Division  of  Health  and   Dr.   Geor-e
                    met.  They   review   the   results   of   environmental                                                        C,
                    surveillance studies and aid in selection  of  sites  to  Jackson  of  the  University  of  Illinois.   A   number
                                                                              of  topics  germane  to  hospital  infection  were   ex-
                    be  studied.  They   analyze   clusters   of   infection
                                                                              piored  in   depth.   These   included   techniques   of
                    to seek  a  possible  common  source  and  thus  try  to  ,
                    detect at  the  outset  an  outbreak-  of  infection  or  surveillance   of   hospital    infection,    laboratory
                    unusual   predilection   for   disseminating    microor-  methods in  detection  of  hepatitis,  drugs  and  N,ac-
                    @anisms.  They  participate  in  review  of   antibiotic  cines  in  influenza  prevention,  the  need  for  anti-
                    0                                                         biotic  restriction  and  methods  for   evaluation   of
                    usage, antiseptic administration and related       -sub:  environmental    contamination.    These     educational
                    stances.  They  make  rounds  in   the   hospital   seek  activities   plus   related   publications   have   been
                    in-  out  unreported  infections.  To  the  extent  pos-
                    0                                                         made possible  through  the  financial  support  of  the
                    sible,    physician-epidemiologists    render    unbi@ed
                                                                              Florida   Regional   Medical   Program   and   the   par
                    and  consistent  opinions.  Their  aims  inclucle  elim-  . -
                    ination  of  serious  hazards  which  may  promote   in-  ticipating hospitals.
                    fection. These they  seek  out  in  cooperation  with  a     Finally,  educational  activities  are  carried   out
                                   -epidemiologi                              on a one-to-one  basis  when  the  need  arises.  It  is
                    hospital's nurse              st   and   microbiologist.  .  .
                                                                              t)vlous  that  each  of  the  physician-epidemiolo,,ists
                                                                  onsibility  0                                                 c
                    Once such hazards are detected, the resp
                    of  the  pbysician-epidemiologist  is  to   advise   the  nas this  as  a  prime  role.  In  addition,  individual
                    hospital  infection  committee   and   the   administra-  consultation is  available  with  Mrs.  Kickli,-hter  in
                    tion of the full  implication  of  the  hazard,  so  the  matters  dealin-  with  nursing,  and  with  Dr.  George
                    committee   can   make   informed   decisions.   Report-  Counts  in  matters   related   to   laboratory   proce-
                    able   infections   of   broad   community    importance  dures.
                    are  at  times  detected,  and  the   physician-epidemi-     We  have  been  greatly   encouraged   by   the   en-
                    ologists   encourage   prompt    reporting    of    such  thusiasm of  the  staffs  of  the  participating  hospi-
                    infections to the county health department.               tals and  by  our  first  results  in  improving  condi-
                      A  computer  program  is   currently   being   written  tions Ieadino,  to  spread  of  hospital-associated  in-
                    for analysis  of  the  data  of  the  individual  hospi-  fection.  A  number  of  new  hospitals  wish  to   join
                    tals.  This  will  provide  each  hospital  with  a  de-  the  group.  We  hope  to  be  self-sustaining  in   an-
                    tailed summary of  its  own  rates  of  infection  on  a  other  year.  Our  limiting  factor  in   expansion   is
                    monthly  and   annual   basis,   alon-   with   compari-  being   able   to   provide    adequate    numbers    of
                    sons with the other participating     hospitals   in   a  trained professional personnel.
                    coded  rank  order,  in  order  to  preserve   confiden-    In  the  largest  sense,   the   program   should   be
                    tially.  Hospitals  that  show  significant   departures  seen  as  involving  more   than   infection.   A   con-
                    from  the  mean  infection  levels  of  the  group  will  sistently  low  rate  of  hospital-associated  infection
                    be investigated as to  cause,  with  a  full  report  to  can be taken  as  one  useful  measure  of  the  quality
                    the  Hospital   Infection   Committee,   including   ap-  of  health  care,  The  ability  to  measure   infection
                    propriate  recommendations   as   to   means   for   im-  occurring in  a  hospital,  in  a  reliable  and  repro-
                    pr(>vement.                                               ducible way,  and  to  decrease  the  episodes  of  hos-

                    J. FLORIDA M.A./MAY, 1973                                                                                       11


                      pital-acquired   infection   along   with   unnecessary   losis enter aeneral  hospitals  rather  than  sanitori-
                      expenses  for  health  care,  are   clearly   desirable   ums,  when  hepatitis  outbreaks  occur  repeatedly  in
                      endpoints. We also feel  these  are  attainable  goals.   hospitals,  when   ventilatory   assistance   machinery
                      Althou-h  hard  and  fast  rules  in  individual  cases   and  intravenous  fluids  infect  patients  during  the
                      may not always  be  applicable,  it  should  be  possi-   course of  therapy,  and  persons  with  various  life-
                      ble to define  the  actual  rates  of  wound  infection   threatenin-  diseases  such  as   lymphoma   or   renal
                      for  various  surgical  procedures,  pulmonary   super-   failure  are  effectively  treated  with  bone   marrow
                      infection  in  the  treatment   of   pneumonia,   post-   -,,uppressant@,  dialysis  or  organ  transplantations,
                      partum  infection  in  obstetric   conditions-to   name   yet   die   from   hospital-acquired   microbes-control
                      a   few   common   problems-and   reduce    these    by   of hospital infection must be a major concern.
                      improvement in  the  total  care  of  the  hospitalized   @  Dr.  Ehrenkranz,  University  of  Miami  School   of
                      patient.                                                   Medicine,    P.O.    Box    875,    Biscayne    Annex,
                          In an  era  when  patients  with  active  tubercli-    .\Iiami 33152.

                           Florida Neonatal Intensive -Care Program

                                                              RICHARD J. BOOTHBY,M.D.

                          The   postnatal   course   of    newborn    infants                  Operational Activities
                      varies  from  a   minimum   of   asymptomatic   adapta-       Four  major  components  are  necessary   to   pro-
                      tion  to  extrauterine  existence  requiring  only  ob-   duce an effective newborn care program:
                      servation  and  custodial  care   to   a   maximum   of       1. Identification  of  neonatal  nurseries  accord-
                      vital  functions  equivalent  to  the  intensive   care   in-  to  three  levels  of  capabilities  and  assurina
                      given a critically-ill  adult.  Thus,  organization  of    0
                      facilities, staff and ancillary services can be  divid-   that  they  are  properly  staffed  and   equipped   to
                      ed into  reasonably  distinct  groupings  according  to   meet  newborn  needs  occurring  in   that   particular
                                                                                nursery.
                      the care demands of the newborn population.
                          In  bringing  about  the  goal  of  promoting   the       2.  A communications system.
                      intact survival of all infants  (intact  in  this  con-       3.  A transportation system.
                      text  implies  that  the  infant  will  function  as  a       4.  An educational program.
                      complete  human  being,   both   physically   and   in-
                      tellectually) born in  Florida,  the  Florida  Neonatal   Details  of  Each  of   the   Four   Major   Components
                      Intensive  Care  Program  plans  to   demonstrate   the       Nurseries  will  be  classified  according  to  ca-
                      effectiveness   of   a    well-coordinated    statewide   pabilities and  patient  population  at  three  levels:
                      system  of  newborn  care  that  will   reduce   infant
                      mortality and morbidity.                                      1.  Basic Newborn Nurseries.
                                                                                    2.  Subregional Neonatal Centers.
                         Dr. Boothb  is Director, Florida Neonatal Intensive Care
                      Project, HopeyHaven Children 's Hospital, Jacksonville.       3.  Regional  Neonatal   Intensive   Care   Centers

                      12                                                                                       VOLUME 60/NUMBER  5


                         A  basic  newborn  nursery  is   one   located   in   the       2.   Infants   greater   than   32   weeks    gestation,
                     smaller   hospitals   with   capabilities    for    providing   %vei-hin-   more    than    1500    grams,    growing    and
                     effective  care   to   normal   newborns   and   for   stabi-   convalescent.
                     lizino,  the  newborn  in  distress  before  transfer  to   a       3.   Infants   less    than    32    weeks    gestation,
                     subregional   or   regional   center.   The   basic   newborn   @veighinu   less   than   1500   -rams    (until    stable),
                                                                                              0                       t3
                     nursery  will  care  for  infants   of   appropriate   gesta-   moderately  and  severely       ill    neonates,    neonatal
                     tional  age  greater  than  37   weeks   who   are   asympto-   suraer,.y, ventilatory support.
                     matic.  Table  1  lists  the   resources   and   capabilities
                     of a basic newborn nursery.
                                                                                     TABLE 2.-SUBREGIONAL CENTER.  RECOMMENDED
                            TABLE I.-BASIC NEWBORN NURSERY.                                     RESOURCES AND CAPABILITIES.
                                                                                     The    Nursery
                      RECOMMENDED RESOURCES AND CAPABILITIES.                            High-risk nursery  is  housed  separately  from  regular
                     The Nursery                                                            newborn nursery
                         Housed separately from general pediatric care unit          The Personnel
                     The Personnel                                                       A pediatrician specializing in the care of  newborns  is
                         A professional nurse is in charge of the nursery                   in charge of the high-risk nursery
                         Twenty-four  hour  coverage  is  furnished   by   profes-       A professional nurse is on duty at  all  times  and  may
                            sional nurses or qualified licensed  practical  nurses          be assisted by qualified licensed practical nurses
                         Physician: Pediatrician or general practitioner  on  call       Consultation  specialists  available  on  call  24-hours
                     The Services Provided                                                  a   day
                         Resuscitative measures                                             X-ray
                            Adequate airway                                                 Surgery
                            Adequate auctioning
                            Etc.                                                     The Services Provided
                         X-ray services                                                  All services available in a basic newborn nursery
                         Basic laboratory studies                                        Oxygen therapy with automated monitoring
                            Blood counts                                                 Automated monitoring of vital signs
                            Blood chemistry                                                 T.P.R.
                         Routine newborn care    procedures                                 B/P
                            Gavage                                                          Fluid and electrolytes
                            Lavage                                                       Procedures as
                            Phototherapy                                                    Intravenous therapy including venous cut-downs
                            Etc.                                                            Umbilical vessel (venous and  arterial)  catheteriza-
                     The Education Program                                                     tions
                         An  ongoing  planned   in-service   educational   program          Spinal taps
                                                                                            Inhalation therapy
                                                                                            Exchange blood transfusions
                                                                                            Mechanical ventilation
                         Subregional   neonatal   centers   will   properly   care       Additional laboratory studies
                     for   newborns    and    mothers    with    medical    and/or          Bilirubin concentrations
                                                                                            Blood gases
                     surgical    problems.    The    subregional    center    will          Blood cultures
                     care for the following types of babies:                         The Educational Program
                                                                                         An  ongoing  educational  pro.-ram  for  physicians  and
                         1.   Appropriate    gestational    age    greater    than          nurses
                     37 weeks, asymptomatic.
                         2.   Infants   greater   than    32    weeks    gestation       Tables  3  and  4   list   the   resources   and   capa-
                     and   weighing   more   than   1500   grams,   growing    and   bilities   of   the   regional   neonatal   intensive   care
                     convalescent.                                                   center.   The   only   major    difference    between    the
                         3.   Infants   greater   than   32    weeks    gestation,   Type  I  and  Type  II  center  is   the   presence   of   a
                     weighing   more   than   1500    grams,    moderately    ill.   full-time   neonatologist   at    the    Type    1.    These
                         Table  2  lists  the  resources  and  capabilities  of  a   centers   will   be   strategically    located    throughout
                     subregional center.                                             the  state  in  existing  facilities  in  Pensacola,   Jack-
                         Since  the  majority  of   neonatal   deaths   occur   in   sonville,   Gainesville,   Tampa   and   Miami.    Initially
                     premature     infants     from     high-risk     pregnancies,   the  centers   will   be   located   at   Jackson   Memorial
                                                                                     Hospital,    Miami;    University     Hospital,     Jackson-
                     regional   neonatal   intensive   care   centers   will    be   ville;   Sacred   Heart    Hospital,    Pensacola;    Shands
                     identified  to  provide   the   specialized   care   required   Teachinc,   Hospital,   Gainesville,    and    Tampa    Gen-
                     for  such  infants.  The  type  of  infant   cared   for   in            0
                     a  regional  intensive  care  center  will  be  as   follows:   cral   Hospital,   Tampa.   Additional   centers   may    be
                                                                                     designated    in    other    locations    where     adequate
                         1.  Appropriate   gestational   age   greater   than   37   personnel  and  facilities  now  exist  or   as   they   are
                     weeks, asymptomatic.                                            developed in the future.

                     J. FLORIDA M.A./MAY, 1973                                                                                                 13


                          TABLE 3.-TYPE 1-REGIONAL NEWBORN                                University  of  Florida,  and   it   is   our   plan   to   adapt
                          INTENSIVE CARE CENTER.  RECOMMENDED                             this for the other regional centers in the state.
                                  RESOURCES AND CAPABILITIES.                                The     communications     system     is     essential     in
                      The Nursery                                                         keepin-   parents    and    the    infant's    physician    aware
                                                                                                  0
                          An  intensive  care  nursery  separate  from  other   newborn   of  the  care  their  baby  is  receiving   and   his   progress.
                             nurseries                                                    If   parents   and   referring    physicians    are    not    in-
                      The     Personnel
                          Full-time pediatric staff                                       vol@,ed   and   do   not   have   direct   contact    with    the
                          Full-time neonatologist                                         re-ional   or   subregional   center,   a    concept    of    re-
                          Pediatric house-staff:  24-bour coverage                        .0
                                                                           the  ratio     110nalized care will most probably fail.
                          .Newborn intensive care professional nurse in                   t)
                             of one professional nurse to no more than    2  infants:        Efforts  will   be   made   to   tie   into   the   statewide
                             24-hour covera-e
                          Pediatric specialists in                                        emergency      medical      services      system       communica-
                             AnesthesiologN,
                             Cardiology                                                   tions   network   already   in    existence    to    avoid    un-
                             Radiology                                                    necessary    duplication    of    equipment,    personnel     and
                             Pathology                                                    expense.
                             Urology
                             Gene-.-al  surgery                                              Essential     to     facilitating     the      communications
                             Cardiac-thoracic surgery                                     referral   system   is   an   adequate   means    of    reporting
                             '\,eurosurgery
                          Specialists for consultation  and service in                    and    recording    information.    The    system    will    need
                             Neurology                                                    to   provide    standardized    information    and    data    re-
                             ,\Iephrology
                             Hema'ology                                                   (yarclin(y   the   status   of   a    newborn    upon    transfer
                                                                                          t3      zn
                             Orthopedics                                                  between     centers,     including     diagnosis,      treatment,
                             Infectious disease                                                                                 6
                             Endocrinology                                                patient    outcome,    follow-up    information    and    care
                             Genetics                                                     provided.
                             Plastic  surgery
                             Transplantation                                                                Transport System
                      The  Services   Provided
                          All services available in a                                        Safe,  efficient   transport   systems   will   be   estab-
                             Basic newborn nursery
                             Subregional center                                           lished including ground and air capabilities.
                          All services provided  by  physicians  listed  under   per-
                             sonnel
                          Critical care services of all types including                      TABLE 4.-TYPE 2-REGIONAL NEWBORN
                             Complicated fluid   and electrolytes                            INTENSIVE CARE CENTER.  RECOMMENDED
                             Complicated diagnostic problems
                             Cardiac   surgery                                                      RESOURCES AND CAPABILITIES.
                             Transplantation                                              The Nursery
                             Plastic  surgery                                                Same as Type I
                          Consultation services  to  subregional  and  basic  newborn     The Personnel
                             nursery physicians and nurses                                   Full-time pediatric staff
                      The Educational Program                                                A neonatologist
                          Provides  ongoing  in-service  education   for   physicians        Pediatric house-staff : 24-hour coverage
                          and nurses within its  facility  and  educational  programs        Newborn intensive care professional  nurses  in  the  ratio
                          for subregional and basic newborn nursery personnel                     of one professional nurse to no more than  2  infants:
                                                                                                  24-hour coverage
                                                                                             Physician specialists in pediatric
                                                                                                  Anesthesiology
                                      Communications  System                                      Cardiology
                                                                                                  Radiology
                          It   is   essential   that   a    communications    network             Pathology
                                                                                                  Urology
                      link   the   regional   intensive   care   centers   with   the             General surgery
                      subregional   centers    and    the    basic    newborn    nur-        Specialists for consultation and service in
                                                                                                  Neurology
                      series.   Information   essential    to    providing    optimum             Nephrology
                      care   for   each   newborn    must    be    communicated    by             Hematology
                                                                                                  Or'hopedics
                      the   referring   hospital   to   the    receiving    hospital.             Infectious diseases
                      Another   essential   service   is   the   need   to    provide     The.Services Provided '
                                                                                             All services available in a
                      consultant    and    guidance     service     to     requesting             Basic newborn nursery
                      physicians and nurses.                                                      Subregional center
                                                                                             All services  provided  by  physicians  listed  under  per-
                          A     communication     system     must     be     provided             sonnel
                                                                                             Critical care services of all types except
                      through    which    the    referring    physician    at     one             Cardiac surgery
                      nursery   can    easily    contact    the    regional    center             Transplantation
                                                                                                  Plastic surgery
                      for   rapid   initiation   of   patient   transfer.   We   hope        Consultation services  to  subregional  and  basic  newborn
                      to  accomplish  this   by   means   of   the   so-called   "Hot             nu.@-y physicians and nurses
                                                                                          The Educational Program
                      Line"  system.  This   is   already   in   operation   at   the        Same as Type I

                      14                                                                                                    VOLUME      60/NUMBER      5


                       The  level  of  medical  care  available  to   infants      2.  How  these  different   facilities   can   provide
                   enroute  should  not  increase  morbidity   or   mortality  the care the iie@vborn may need or does need.
                   as  a   result   of   the   transfer.   Experiences   with      3.  Situations  requirin,  intensive  care  and   why.
                   several   re-ional   newborn   systems   in   the   United
                              0                                                    Knowled-eable,   skilled   and   experienced    physi-
                   States  and  Canada  have   indicated   that   this   goal               0
                                                                               ciaii,,, nurses and  other  allied  health  personnel  are
                   is realistic  and  obtainable.  Modifications  wi  I  need  essential  to  the  success  of  any   regional   neonatal
                   to be  made  to  meet  the  care  needs  of  dis  re.-;sed                                        0
                   infants  such  as  the  addition  of  portable  incubators  care  system.  They  should  be  able  to  provide  levels
                                                                               of  care  consistent  with  their  resources  and  prompt-
                   to  existinc,   ambulance   equipment.   Other   serviceF.  ,
                             C,                                                iy   reco@nize   newborns    with    problems    requiring
                   of  the  Florida  Emergency   Medical   Services   Svsteni  transfer t@ to  more  sophisticated   centers   and   provide
                   can  and  will  be  utilized  in   transporting   infants.
                                                                0              adequate care prior to transport.
                       A  newborn  transport   system   can   be   structured      Eztal)lishin.-I  and   conductin.-   regional   educa-
                   either  as  an  autonomous  unit  based  in   a   hospital  tion  programs   for   physicians   and   nurses   is   an
                   or  it  can  be  affiliated  with  an  existing  ambulance  .        C5
                                                                               important  and   inteoral   component   of   the   pro-ram
                   system.  The  first  approach  is   exemplified   by   the                       C)                            tD
                   ambulance   service    presently    sponsored    by    the  io  reduce  neonatal   morbidity   and   mortality.   Pro-
                                                                               grams  must  be   desi,,ned   to   meet   the   needs   of
                   Pensacola    Educational    Pro,,ram.     Another     type                         C5
                                                   C)                          those   providin.-   care   to   the   newborn.   Programs
                   system  is  represented  by  the  one  operated   out   of                                     -    educational    re-
                   the  University  of  Florida   and   the   one   operating  developed  will  utilize  existin,
                                                                               sources  to  augment  the   expertise   presently   avail-
                   in   Tampa.   Jacksonville    utilizes    the    Emer-encv
                                                                     t,        able  in  existin-  intensive  care  nurseries.  Curricula
                   Squad   Ambulance    System.    In    Gainesville    these
                   services  include  charter   ambulance   aircraft,   while  already   available   from    the    aforementioned    re-
                   in Tampa it includes the capabilities of Mc                 -ional  neonatal  intensive  care  centers  will   consti-
                                                                        .@'ll  tute  a  basis  for  developing  the  standard   curricula
                   Air   Force   Base   Helicopter   Services.   In    either  ,
                                                                               ior all courses initiated in the pro,,ram.
                   system  the  essential   requirements   are   availability                                       C5
                   and  adaptability  to  the  specialized  needs   of   new-                 Program Organization
                   born  intensive  care.  The  transport  vehicle  must   be      Brin-ing  about   a   coordinated   neonatal   proaram
                   readily  available  at  all  times,  day  or  niaht,  with
                                                                 t,            to  solve   medical   and   surgical   problems   of   the
                   a  minimum   alert   period.   A   neonatolo,,ist   and/or
                   neonatology nurse-specialist should accompany        I  !he newborn required the appointment of          Ia    project
                   ambulance  to   pick   up   the   newborn   and   provicie  director   for   the   program   and   several    advisory
                                                                               committees.
                   care enroute.                                                   The  main   committee   for   the   program   is   the
                                   Educational Program                         Steerin-  Committee,  and  it   is   comprised   of   mem-
                                                                                       t'
                                                                               I)ers  of  the  Fetus  and  Newborn   Committee   of   the
                       Development  of   an   effective   newborn   intensive  Florida   Pediatric   Society.   Other   members   include
                   care  system   must   involve   the   education   Of   two  an  obstetrician,   hospital   administrator,   the   head
                   major   groups   of    individuals-health    professionals  nurses  of  the  intensive   care   nurseries   throughout
                   and  parents  of   high-risk   and   potential   hich-risk  the  ,tate  and  also   public   health   physicians   and
                   infants.    The    educational    program    for    health  nurses involved in newborn care.
                   professionals will include:                                     Four   basic   subcommittees   have   been   appointed
                       1.   Updating   the   knowledge    and    skills    of  by   the   Steerin,-   Committee:    Curriculum    Commit-
                   patient   care   provider   teams   (physicians,    nurse,  tee,  Records  and   Reports   Committee,   Policies   and
                   allied   health   personnel,   hospital    administrators)  Procedures   Committee,    and    Evaluation    Committee.
                   in all types of hospitals.                                      The  project  director  is  a   physician   on   25t7o
                                                                               time  with  expertise  in  neonatology  .   He   functions
                       2.   Developing   physician-nurse   teams   to   visit                                       oy
                                                                               as  overall  administrator  of   the   program   according
                   small  hospitals  to  assist   them   in   self-evaiuation
                   and   to   develop   appropriate   programs   for    their  to tne advice of the Steering Committee.
                   nursery staffs.                                                 The   nurse   associate   project   director   is    a
                                                                               nurse  on  1001/c  time   with   expertise   in   neonatal
                       Educational  pro-rams  for  parents   of   hign-ri--,K
                                         0                                     nursing.  She  assists  the  project  director  in  carry-
                   and potential high-risk infants will include:               ing  out  his  responsibilities.   The   nurse   associate
                       1.  Informing  parents  of  the  purpose   and   value  project  director  provides   the   leadership   and   co-
                   of different types of care facilities.                      ordination  for  the  educational  pro-ram   for   nurses,
                   J. FLORIDA M.A./MAY, 1973                                                                                            15


                     physicians and  allied  health  personnel.  She  ac-     Since the inception of  the  pro-ram,  there  have
                     tively participates in determining  learning  needs,  been  five  Steering  Committee  meetin-s   and   six
                     formulatin-  objectives,   selecting   content   and  such  meetin-s  are  planned  for  the  coming  year.
                     learnin- experiences, settin-  up  evaluation  tools  In  addition,  many  members  of  the  program   have
                     and restructuring the  educational  program  as  the  been meetid.- on a local level  in  order  to  imple-
                     need arises. She assists re-ional center  faculties,  ment the activities of the pro-ram.
                     organize and implement their pro-rams.
                                                       ID                        Goals for Remainder of This Year
                        A  full-time  secretary  provides  the   required      Our goals for the remainder of this  fiscal  year
                     secretarial support to the project director and  the
                                                                           include (1) conduct the course for  nurses  at  least
                     associate director.
                                                                           twice at  each  regional  center;  (2)  hold  one  or
                                      Progress So Far                      two-day  seminars  for  physicians  at  the  regional
                        Since the pro-ram became        a  reality,  both  centers; (3) have a  nurse-doctor  team  visit  basic
                     physically  and  financially  about  the  middle  of  newborn  nurseries  for  the  purpose  of  evaluating
                     September,   1972,   much   -roundwork   has    been  these nurseries and  conductin-  a  half-day  seminar
                     covered. The project  staff  was  appointed  and  an  at each  nursery;  (4)  identify  at  least  18  sub-
                     office established in Jacksonville.  Committee  mem-  regional centers by  the  end  of  August,  1973  and
                     bers  were  appointed  and  the  various  committees  identify at least  ten  basic  newborn  nurseries  by
                     were organized. It was  decided  it  would  be  more  the  same  time  with   communications   and   trans-
                     feasible to geographically locate the  various  sub-  POrtation systems established between  all  of  these
                     committees; thus people  who  are  in  proximity  to  hospitals and the regional centers.
                     each other every day  can  get  thin-S  done  a  lot                       Summary
                     better  than  particular  subcommittee  spread  over
                     the state. For  this  reason,  the  Curriculum  Com-      The Fetus and     Newborn   Committee   of    the
                     mittee  was  established  in  Gainesville.   Records  Florida  Pediatric   Society,   with   support   from
                                                              I            Florida  Re-ional  Medical  Prooram,  has   conducted
                     and  Reports  Committee  in  Tampa,   and   a   good             b                  0
                     percentage of the people involved  in  the  Policies  a study and is  developing  a  program  to  meet  the
                             ZD                                               eds of the high-risk infant in Florida.  The  pro-
                     and  Procedures  Committee  are  from  the  Jackson-  ne
                                                                           ,,ram is based on a  network  of  neonatal  intensive
                     ville area. It was clearly stated at the  beginning,  '
                     however, that this regionalization  of  the  subcom-  care centers  and  extends  through  cooperative  re-
                     mittees did not and should not preclude  feed-in  to  ferral  patterns  and  an  educational  program  into
                     these committees from all areas of the state.         each  community   hospital   nursery.   The   Florida
                         Once  the  committees  were  appointed  and  or-  Regional  Medical  Program  support  is  being   pro-
                     ,,anized,  the  Curriculum   Committee   began   its  vided through the  Florida'-Nledical  Foundation  for
                     work of formulating the first nurse's  course.  Dur-  tne implementation of the pro-,,ram  which  is  under
                     ing  November,  December  and   January   the   Com-  the  direction  of  a  project  director.  The   main
                     mittee worked diligently and  this  course  is  noiv  purpose of this programs as with others of  its  type
                     undenvay at the various regional centers.             throughout  the  United  States  and  Canada,  is  to
                       . The  Records  and  Reports  Committee  has  been  show that  a  reduction  in  neonatal  mortality  and
                     working equally  as  hard  and  has  organized  some  morbidity  can  be  accomplished  by  regionalization
                     of the statistical data that will be needed for  the  of newborn care.
                     program and also certain  forms  needed  to  collect  @Dr.  Boothby,   5720   Atlantic   Boulevard,   Jack-
                     data.                                                   sonville 32207.

                     16                                                                                  VOLUME 60/NTJMBER 5


                                    Florida Renal Disease Program

                               WILLIA,NI W. PFAFF, M.D., BEN A. VANDERWERF, M.D., AND DON RIEDESEL

                     A  number   of   community   and   university   hos-   mare.  In  the  main,  individuals  enter   a   medical
                  pitals  throughout  the  state  have  Ion-,,  had   the   system with a serious illness  and  are  either  cured,
                  capacity to take  the  first  step  in  the  definitive   ameliorated to  the  point  that  they  can  leave  the
                  management  of  renal  failure.  They   had   the   ma-   immediate  confines  of  the  system,  or  succumb   to
                  chines   and   knowled-,eable   physicians   to   lower   the disease.  An  individual  with  renal  failure  who
                  blood   concentrations   of   the   end   products   of   is to be mana-ed by  dialysis  in  a  hospital  setting
                  metabolism  and  to  reduce  circulatin-   blood   vol-   has a one year life  expectancy  of  85@o  and  a  five
                  ume  by   removing   water   and   electrolytes.   Yet,   year  life  expectancy  approaching  507o.  He  is  de-
                  until  1965,  this  approach  was   practiced   sporad-   pendent  upon  a  machine,  supplies   and   personnel,
                  ically, generally for  the  short-term  care  of  indi-   and  the  more  successful  the   therapy,   the   more
                  viduals with either acute renal  failure  or  in  prep-   rapidly must all  of  these  resources  be  multiplied.
                  aration to transfer to  a  medical  center  in  another      This   phenomenon   was   soon   apparent   at   the
                  area  of  the  country  where  dialysis  and/or  trans-   University of Florida to the point that no          new
                  plantation  were  being  developed  as   a   systematic   patients could  be  absorbed  into  the  dialysis  pro-
                  approach to the solution of irreversible urernia.         gram pending other disposition of patients          who
                     In  1965,  dialysis  pro-rams  were   organized   in   had been enlisted earlier. In early 1966, the      sole
                  Gainesville,  Miami  and  Tampa,  for  the   continuing   alternative  was  transplantation.  With  the  aid  and
                  care of patients  with  renal  failure.  With  the  co-   support  of  the  combined  clinical   departments   as
                  operation   of   uncertain   administrators,   machines   well as several basic  science  groups,  and  with  the
                  and  supplies  were  purchased  and   nursing   person-   cooperation  of  the  hospital   and   medical   school
                  nel trained to care for  patients  on  a  daily  basis,   administration,  a   small   transplant   program   was
                  assuming many  of  the  responsibilities  in  the  con-   begun.   Restrictions   on   the   number   of   trans-
                  duct of dialysis.                                         plants  to  be  performed  were  initially  created  by
                     As  predicted  by  the  nephrologists,  for   indeed   the  participants,  for  at  the  time  the  long  term
                  they   had   observed   the   phenomenon   many   times   results of  transplantation  were  uncertain,  the  fa-
                  in individuals with  reversible  renal  failure,  indi-   cilities available were limited,  and  the  expense  in
                  viduals  with   chronic   uremia   awoke   from   coma,   dollars  and  effort  were  sizeable  for  the  numbers
                  their  blood  pressure  became   manageable,   anabolic   of individual patients  to  be  benefited.   We   chose
                  functions returned  and,  in  some,  return  to  normal   to use cadaver donors,  feeling  that  this  should  be
                  occupation  became  possible.  By   this   success,   a   the ultimate approach   and   the   problems   attached
                  new  problem   was   created.   The   availability   of   to  this  route  needed  solving.   The   participating
                  dialysis to sustain life  in  patients  with  end-stage   personnel were untried  and  thus  a  potential  living
                  renal  disease  created  a  potential  logistic  night-   related  donor  should  not  be  asked  to   donate   a
                                                                            kidney  under  circumstances  that   were   not   truly
                    Dr. Pfaff  is  Professor  of  Surgery  and  Chairman,  Del)art- optimal for success,  both  because  of  the  state  of
                              er     ver ity of Floiida  Co  lege  of  Mediiine,
                  =.O@fil@UrAr.yilaYdneirWsert is Assistant Prolf@ssor  of  Surgery, knowledge  then  available  and  the  inexperience   of
                  University of Miami  School  of  Medicine  and  Chief.  Transplap-
                  tation Se-rvice, Mount Sinai  Hospital.  Miami.  Mr.-  Riede@l  is the  group.  Finally,  it  was   concluded   that   the
                  Kidney Program Project DirecO@     rtment  of  Health   and
                  Rehabilitative Services@ State of                         reported  experience  at  that  time   could   be   im-

                  J. FLORIDA M.A./MAY, 1973                                                                                      17


                         proved   upon   to   the   point   that   cadaver   or-an   I)ears  to  be  a  very  conservative  estimate  of   40
                         ,,raftin-, mi-ht  yield  results  similar  to  those  re-   patients  with  remedial   disease   p2r   one   million
                         ported with living related donors.                          population,  only  a  small   fraction   of   relatively
                            In  the  ensuing  four  years,  32  transplants   were   younf  adults  and  older   children   could   bz   man-
                         performed  at  the  University  of   Florida,   all   but   a,-,cd  at  the  existin-  facilities   in   Tampa   and
                         one  from   cadaver   donors.   Our   expectations   were   Gaincsville.  Further,  individuals   were   forced   to
                         not  entirely  met  however.  The  three  year   survival   travel  some  distance  from  other   major   population
                         of   transplants   was   31@o.   Patient   survival   was   centers for  twice  or  thrice  a  week  dialysis.  Once
                         40@o.  In   the   spring   of   1970,   reassessment   of   there, dialysis was limited to direct  care  in  a  hos-
                         means,    alternatives    and    new    options    seemed   pital  center.  Home  training  facilities  and  p2rson-
                         appropriate.                                                nel were  not  available.  To  digress  at  this  point,
                            In  the  interval,  scattered  transplants  bad   bcen   home  dialysis  was  b2ing  introduced  at  that   tim,2
                         performed  at  other  institutions  in  the   state.   In   and is a practical  means  of  reducing  the  costs  and
                                                                                     c       t,                                    0
                         1970,  a  more  formal   group   was   formed   at   th,2   xpandina  the  availability   of   patient   management.
                         University of  Miami  that  included  all  of  the  corn-   The  patient  and  a  responsible  relative  are  taught
                                                                                     the techniques of dialysis,  freein-  personnel  to  re-
                         ponents  that  might  be   ideally   required   for   the                                      0
                                                                                     p-at  this  task  with  succeedin-  patients  in  cycles
                         varied  and  vexing  problems  that  occur  with   trans-
                         plantation.   This    included    transplantation    sur-   of  approximately  six  weeks.  Ten  to   $20   thousand
                                                                                     savino's  can   be   appreciated   on   a   patient-year
                         geons  who  had  prior  experience  in   organ   graftin,   I   t' One of the major aims then
                         a  tissue  typing  laboratory  to  identify  ideal  pair"   ).aFis                                  of  the   physi-
                         in-  of  donors  and  recipients  for  both  livina   re-   cians  and  the  Regional  Medical  Prot-,ram   was   to
                          0                                                          create nz
                         lated  donor   transplantation   as   well   as   cadaver            w  dialysis  centers   in   Orlando,   Jackson-
                         transplantation,   consulting   services    to    provide   ville  and  Pensacola,  each  with  emphasis   on   home
                                                      t3
                         expertise  in  infectious  disease,  pharmacology,   spe-   traininl-.   In   addition,   home   training   programs
                                                                        0
                         cial  techniques  in  radiology,  and   the   cooperation   would   be   added   to   the   units   at   Tampa   and
                                                     0                                   esville.
                         of  nephrology  services  with   an   extensive   experi-   Gain
                         ence in several approaches to dialysis.                        A  second  critical  area  was  transplantation.   As
                                                                                     a  arant  request  was  bein-  organized,  written,  re-
                                      Kidney Disease Program                          n                         0
                                                                                     v7s2d and  discussed,  only  25  transplants  were  per-
                            In   1970,   the   Regional   Medical   Program   bill   formed  at  the  two  centers  in  the   calendar   year
                         was  altered  in  the  senate  by   an   amendment,   in-   1971.  At  the  University  of   Florida,   these   were
                         troduced   by    Senator    Yarborouah,    which    added   predominantly  living  related  donors   and   reflected
                         kidney  disease  to  the   previously   beni-hted   cate-   the  chan-e  in  direction  elected  in  mid-1970.   In-
                                                                    tl
                         gories  of  cancer,  heart  disease  and   stroke.   Pro-   deed,  the  survival  statistics  with  livino,  related
                                                                                                                                 0
                         grams  aimed  at  controlling  renal  failure  thus   be-   donors  are  more  encouraging.   Graft   survival   for
                         came  eligible  for  funding  under  this   federal   ap-   patients at risk for one  year  has  been  79,7c.  Using
                         proacb.                                                     world  registry  tables  for  comparison,   this   would
                             Interested  physicians  from   the   state   gathered   foretell  long  term   survival   in   the   50,lo-609'o
                         to  assess  existing  resources  and   deficiencies   and   ranae.
                         then,   gathering   under   the    umbrella    of    RMP,      At  the  University  of  Miami,   emphasis   at   the
                         sought  funds  to   correct   the   recognized   insuffi-   same  time  was   on   cadaver   transplantation.   When
                         ciencies.                                                   appropriate  and  available,   living   related   donors
                             The  strength  of  the  state's  resources   was   an   are  preferable  however  in  both   proorams,   consid-
                         ever-increasing  number   of   nephrologists   who   were   erino,  the  improved  survival   statistics,   expecta-
                         locating in most  of  the  major  cities  of  the  state,   tions, quality and duration of rehabilitation.
                         with   near   adequate   capability   for   dialysis   in      It  was  the  purpose  of  the  grant   to   increase
                         Miami  and  environs.  As  noted,   there   were   trans-   transplantation   numbers   by   subsidizing    whatever
                         plantation  programs  at  the   universities   in   Miami   ingredients  were  in  short  supply  to  deal  with   a
                         and  Gainesville.  Facilities  for  tissue  typing   w2re   larger  load.  This  included  faculty  support,   nurs-
                         identified in Gainesville, Tampa and Miami.                 ing  personnel,  technical   assistance   and   adminis-
                             The  principal  deficiencies  were  a  markedly   in-   tralive help to tie the diverse efforts together.
                         adequate  dialysis,capability   in   nothern   and   cen-      A  third  major  area  relates  to   organ   procure-
                         tral  portions  of  the  state.  Using   what   now   ap-   ment,  tissue   typing   and   organ   sharing.   Tissue
                         18                                                                                          VOLUME 60/NUMBER  5


                    typin- utilizes serolo,,ic  techniques  to  reco-nize   cluded  screening  programs,  physician  and  public
                    cell  membrane  antigens  that  are  one  determinant   education  and  the  production  of   antilymphocyte
                    of  graft  acceptance.  Within   a   family,   tissue   globulin,  an  immunosuppressive   agent   of   some
                    typin-, or histocompatibility correlates  exceedin,,-   significant potential use  in  transplantation.  The
                    ly  well  with  transplant  survival.  Amon,,  nonre-   disallowance of the latter was on the basis  of  its
                    lated individuals, the  logistics,  practicality  and   still experimental nature.
                    benefits of tissue typing  are  not  as  certain  but      Perhaps one of the more unique  features  of  the
                    remain to be  determined  by  continued  utilization.   RMP -rant  was  co-fundino,  of  the  administrative
                    It  was  and  remains  our   intent   to   transplant   apparatus with the State of Florida, relyino,  on  a
                    organs with the  most  favorable  anti@en  matchin-,.   legislative appropriation that created  the  Florida
                    In addition  to  identification  of  shared  antigens   Kidney  Disease  Board.   Responsibility   for   ad-
                    amona   potential   combinants,   the    immunologist   ministration  was  assigned  to  the  Department  of
                    who conducts  a  typing  laboratory  also  determines   Health  and  Rehabilitative  Services,  and  between
                    the presence  or  absence  of  antibodies  aaainst  a   the state  and  Florida  Regional  Medical  Procyram
                    potential donor, an  event  that  precludes  success-   administrations a  coordinator  was  hired  to  link
                    ful transplantation.                                    the activities  of  the  federally  financed  grant.
                       Tissue typing and  cross-matchino,  require  time.   Abetted  by  additional  financing  from  the  state
                    Often, the donor, recipient and  the  typing  labora-   legislature, the efforts of physicians,  scientists,
                    tory are in separate  areas.  To  preserve  the  kid-   nurses, technicians and volunteers in the state  and
                    neys until  all  ingredients  are  brought  together,   private universities,  community  hospitals,  county
                    the  RMP  grant  has  provided  for  organ  perfusion   hospitals  and  independent  dialysis   units   were
                    equipment,  which  allows  preservation  for  up   to   combined  to  solve  a  medical  problem  that   de-
                    72 hours.  This  has  the  added  advantage  in  pre-   manded effort, organization and funding.
                    dicting viability when the  nature  of  perfusion  in      Six  months  after  the  initiation  of  the  RMP
                    antecedent  terminal  illness  or  injury  may   have   grant,  the  initial  goals  have  been   met.   New
                    produced irremedial damage.                             dialysis units are in operation in  Or  ando,  ensa-
                       Perhaps  the  most  difficult  and   rate-limiting   cola and Jacksonville. The rate  of  transplantation
                    task  common  to  all  of  the  participants  in  the   nas roughly  tripled,  and  anticipated  transplants
                    state  program  is  the  identification  of  adequate   within the state in the  first  year  of  the  grant
                    numbers  of  cadaveric  kidney   donors.   Many   pa-   should total 60-75 grafts. The  typing  laboratories
                                                                            are  usino,  uniform  techniques.  Organ   preserva-
                    tients with end-stage renal  disease  simply  do  not           C,
                    have an appropriate livine,  related  donor  and  the   tion  equipment  has  been  used  and  found   work.
                                               C,                           able. Kidneys  have  been  transported  from  center
                    only potential alternative is thus  a  nonliving  un-   to center,  implanted  and  found  to  function.  In
                    related donor. Enlistment of the  aid  of  physicians   short,  the  purposes  for  which  we  gathered  are
                    throughout the state is sought to  give  notification   ,
                    when individuals,  particularly  with  mortal  neuro-   Deing met.
                    logic injury, might be used  as  kidney  donors.  The      When  a   statewide   program   was   envisioned,
                    participating   nephrologists   and   transplantation   only a fraction of the individuals with renal  fail-
                    groups have  repeatedly  stressed  their  willingness   ure were being recognized, a  smaller  fraction  had
                                                                   -        dialysis  and  transplantation  available  to  them.
                    to cooperate in clarifying the criteria  under  which
                                             0                              Physicians  conducting  such  programs   faced   the
                    a potential donor might be  used  and  the  steps  to   unwholesome  task  of  denyin-  or  postponing  pro-
                    be  followed  in  brin-ing  about  such  a  donation.                                0
                                         n                                   dures  that  would  give  both  comfort  and  life.
                    Recent  passage  of   the   Uniform   Anatomic   Gift   ce
                    Act by the Florida legislature will surely ease  this   The primary intent  of  the  Florida  Renal  Disease
                    task  over  the  years  as  larger  numbers  of   our   Program  was  to  ensure  care,   through   dialysis
                                                                            and/or transplantation to an       individual   with
                    population participate in an elective program.                                          y
                       A  number  of  other  activities   were   proposed   end-stage  renal  disease.  It  would   now   appear
                    within the grant  and  certainly  would  be  required   certain that the goal can be achieved.
                    to earn  the  adjective  "comprehensive"   that   was   @ Dr. Pfaff, Department of  Surgery,  University  of
                    initially used to designate the pro,-,ram.  This  in-    Florida College  of  Medicine,  Gainesville  32601.

                    J. FLORIDA M.A./MAY, 1973                                                                                  19


                                     Continuing Medical Education

                                                         -'\'IICI-IAEL J. PICKERING, M.D.

                        In  May  1972  the  House  of  Delegates   of   the  suspect  value  as  continuing  education  for   quite
                      Florida '.\'Iedical Association voted  to  require  a  some time.  Transferrin-  the  notes  of  the  speaker
                      minimum  of  30  hours  of  continuing  education  to  to the note pad of the listener  is  usually  a  prac-
                      become  effective   January   1974.   The   Committee  tice  in  speedwriting.  How  much  is  retained,   or
                      on  Continuing  '.,\,Iedical  Education  was  charg@d  more importantly, used, is unknown.
                      Nvith   developing   the   mechanism   to   implement     Self-evaluation tests  have  recently  been  touted
                      those  requirements.  The  final  drafting  has  been  as a rewarding endeavor.  At  least  the  student  has
                      done.                                                  to do  some  of  the  work  which,  according  to  Sir
                        In  the  process  of  developing   this   document,  George Pickering,  is  required  for  education.  Does
                      many  questions  arose.  What  type,  or  types,   of  the  successful  completion  of  such   work   provide
                      educational opportunities are  best  in  producing  a  the stimulant and  the  ability  to  alter  individual
                      chanae  in  the  behavior  of  the  recipients?  What  patient care?
                      educational needs are there in this state,  the  area     There is no  answer  to  the  question,  "What  are
                      or the  community?  How  best  is  quality  education  the  needs?"  We  have  not  had  the   mechanism   to
                      made available to  all  physicians?  There  are  many  determine the needs  at  the  point  of  contact  with
                      more such questions, but if  answers  to  just  these  the patient, and only through this data can        one
                      three could be found,  great  strides  in  continuing  find the remedy that is pertinent.
                      education  for  the  Florida   physician   could   be     Pondering the last query  leads  one  to  the  con-
                      taken.                                                 clusion  that  the  first  two   questions   must   be
                         Attempting to solve the  first  question  we  were  answered   to   provide   adequate   groundwork   upon
                      faced with little data. Internal evaluation of  medi-  which to make rational decisions.
                      cal education  is  of  rare  vintage.  Evaluation  of     It  is  with  these  thoughts  in  mind  that   the
                      continuing  education  opportunities  is  more  of  a  Committee  on   Continuing   Medical   Education   be-
                      rarity. Such statistics as  members  that  attend  or  oan  looking  for  available  mechanisms  to   provide
                      the number of  times  attended  are  of  no  help  in  the  opportunity  to  gather  the   necessary   facts.
                      determining  if  that  attendance  changed   or   up-  Ideally,  one  could  gather  the   proper   data   by
                      graded  the   practice   of   the   individual.   The  instituting  educational  opportunities   of   various
                      methods tried previously are each  stated  to  be  of  types based on established  data  of  needs,  contain-
                      value to some. Perusal  of  the  literature  has  be-  ing  intrinsic  internal  evaluation  that  would   be
                      come practically  prohibitive.  Which  of  the  volu-  uniform.  The  FRMP  with  its  functioning   district
                      minous articles are  fact,  fancy  or  fruitless?  To  offices, monies for  initiating  projects  and  expert
                      attempt to stay current in  a  subspecialty  in  this  advisors offers an excellent  chance  for  a  coopera-
                      manner  is  a  Herculean  task  often   -not   accom-  tive venture.  Preliminary  discussions  have  pointed
                      plished. Whether these change  the  practice  of  the  to  excellent  cooperation  and  an  exciting   chance
                      reader is unknown.                                     to gain real facts and  thereby  provide  the  patient
                         Didactic  seminars  and  meetings  have  been   of  proof that  the  physician  is  constantly  attempting
                                                                             to provide him excellence in medical care.
                                                                               Dr.  Pickering,  1600  Lakeland   Hills   Boulevardi
                        Dr@ Pickering is Chairman of the Committee on Continuing Lakeland 33801.
                      Medical Educatton, Florida Medical Association.
                      20                                                                                    VOLUME 60/NUMBER  5


                    Comment

                                                              ROBERT P. L.ANNTTON

                       Dr.  Pickering's  statement   accurately   raises  sicned for new programs,  should  have  major  input
                    the  specific  questions  and  problems  which  bear  from practitioners.
                    on  implemention  of  the  FMA's  proc,,ram   of   a     3. There should be  a.  major,  coordinated  seg-
                    required  minimum  30  hours  of  continuing  educa-  nient of program from  the  three  medical  schools,
                    tion.  The  Florida  Regional  Medical  Proaram   as  with appropriate compensation.
                    the capacity and  the  desire  to  assist  with  the     4. New  techniques  to  bring  continuing  educa-
                    answers  to  those  questions,  solution  of   those  tion to busy and/or isolated practitioners in  their
                    problems  and  general  implemention  of   the   FMA  own practice  settings  should  be  devised,  tested
                    continuing education program.                         and implemented.
                       PSRO,  peer   review,   quality   assurance   and     5. A  central  registry  of  accredited  programs
                    continuing education are all interrelated  and  have  should be maintained.
                    as  their  common  mission   continued   improvement     6.  There  should  be  a  central  data  bank  to
                    of the care of the patient through increases in  the  report the accumulated hourly totals  of  accredited
                    knowledge  and  skills  of   the   physicians.   The  continuing education for each FMA member.
                    selection of  the  seminar,  course,  conference  or     7.  There  is  widespread  agreement   that   the
                    article which will  be  of  greatest  relevance  and  cost of continuing  education  programs  for  physi-
                    value to the individual physician and hence  to  his  cians will be met by them.
                    patients will be  determined  by  constructive  peer     There should be  a  compact,  among  the  organi-
                    review of the effectiveness of care. As Dr.  Picker-  zations  and  institutions  concerned,  pledging   a
                    in- states, some assessment of the  impact  of  con-  concerted  effort  to  coordinate  and   rationalize
                    tinin- education on the physician's practice and  on  Florida's  future  system  of  continuing  education
                    the quality of care  received  by  his  patients  is  for physicians, to implement  the  principles  cited
                    necessary and the knowledge  that  it  brings  about  and,  in  effect,  make  positive  response  to  Dr.
                    demonstrable change for  the  better  is  essential.  Pickering's questions.
                    Further, it is crucial to the  preservation  of  the     FRINIP is  drafting  such  a  compact  for  co-n-
                    system of self-regulation by the profession.          sideration by the institutions and associations  in-
                       The  following  may  well  be  the  prime   prin-  volved.  If  it  continues  to  receive  operational
                    ciples of a program:                                  support, FRMP is prepared  also  to  be  responsible
                       1.  Continuing  education  programs   should   be  for the development  and  maintenance  of  a  total,
                    related to the major health problems of  the  people  long range program and  generally  to  work  in  the
                    of Florida.                                           closest concert with the FMA.
                       2. Selection  of  programs,  and  curriculum  de-
                                                                          @Alr.  Lawton,  3550  South  Tamiami  Trail,   Sirq-
                       Mr. Lawton is Associate Director for Manpower Dcvelopment sota 33579.
                    and Continuing Education, Florida Regional Medical Program.

                    J. FLORIDA M.A./MAY, 1973                                                                               21


                               Coronary Care Unit Training Program

                                                   Louis LEMBERG, M.D., AND AZUCENA G. ARCEBAL, M.D.

                          The   introduction    of    coronary    care    units                               Courses for Nurses
                      (CCU)   in   the   management   of    acute    myocardial                Throu-h   the   Florida   Heart   Association   (FHA)
                      infarction  has  been  recognized  as  one  of  the  most            and    the    Florida    Regional    Medical     Pro@ram
                      important   contributions   to   medical   progress    in            (FR,-%IP),  4-week  courses  were   started   in   March
                      the  last  decade.  Throu,,h  intensive   monitorin-   Of            1969.  The  immediate   and   long-term   results   were
                      the  patient  with  acute  myocardial   infarction,   the            juclaed  to  be   excellent.   Every   course   included
                      early  recognition  and  prompt  therapy  of   potential-            fundamentals  of   cardiac   nursing,   basic   sciences
                      ly   lethal   derangements   of   heart    rhythm    have            (anatomy   and   physiology   of   the    cardiovascular
                      -Significantly   and    favorably    altered    morbidity            system),      electrophysioloo,,y      and       electrocardi-
                        b
                      and  mortality.  Since  the  advent  of   coronary   care            oaraphy,  pharmacology  of  cardiac   dru-   ,   cardio-
                                                                                           0                                                 CIS
                      units   hospital   mortality   from   acute    myocardial            pulmonary  resuscitation  and  the  use  of  specialized
                      infarction  has  dropped  from  33,yo  to   as   low   as            electrical  equipment  for  monitoring   and   treatment
                      12@,.                                                                of cardiac emergencies.
                          Reports  indicate   that   the   number   of   deaths               The   Florida   Heart   Association's    Professional
                      from coronary heart  disease  in  the  State  of  Florida            Education  Committee  with   its   previous   two   year
                      continued  to  rise  from  1950  to  1966.   This   trend            experience  in  training  nurses   for   coronary   care
                      relates  to  the  increasing  number  of  Floridians   in            was able to expand  its  role  in  coordinating  courses
                      their  6th  and  7th  decade  of  life.  Although  a  few            of  instruction  in  coronary   care   and   provide   a
                      hospit  .al centers, mainly in the  cities,  had  initiated          4-week  course  with  the  help   and   cooperation   of
                      one  to  two-week  nurse  training   courses   in   coro-
                                                               3                           the  FRMP.  The  role  of  the   FRMP   in   this   com-
                      nary  care   and   established   coronary   care   units,            bined endeavor  was  significant  and  decisive  in  the
                      there were rural areas  of  the  state  Nvithout  facili-            success of the pro-ram.
                      ties for this  specialized  care  of  patients.  A  major               During the  three  year  operation  of  this  project
                      factor was  the  lack  of  trained  nurses,  as  well  as            31  courses  were  given  in  Florida  with  RIIIP  sup-
                      medica.1-personnel to man such units.                                port  and  coordinated  by   FHA.   Four   hundred   and
                          In  -the  hope  of  bringing  this  special  type   of           seventy-five  nurses  completed  the  courses,  In   ad-
                      medical,  care  to  the  people  in  the  smaller   corn-            dition  two  multicounty  courses  were  given  and   18
                      muniti  .es,  a  comprehensive   coronary   care   training          nurses  were  graduated.  As  was  done  in  the   other
                      program  was  conceived   for   four   teaching   medical            three   teaching   centers,   uniform   pretests    were
                      centers of the  state.  Since  the  keystone  of  success            given to each  student  at  the  onset  of  the  course,
                      is  a  well  trained  and  motivated  nursing  staff  the            with  the  objective  of  evaluatin.-   the   level   of
                      course  was  made  available  only  to                 qualified     knowledge  of  each  nurse  and  helpin-  identify   fu-
                      nurses.,                                                             ture needs of  the  program.  Besides  formal  lectures,
                                                                                           ECG practices  and  clinical  bedside  rounds  with  the
                                                                                           medical  staff  of   the   CCU,   an   examination   was
                         From the Depa;tment- of Medicin        University   of   Miami
                      School  of  Mediiine,  and  Coronary e6are  Unit    of    Jackson    given at the  end  of  each  week  in  'order.  to  test
                      Memorial-Hospital, Miami.
                         Dr. Lembirg is Professor of  Clinical  Cardiologyi  Univ@rsity    the  student's  ability   in   applying   the   material
                      of Nliami School  of  Medicine,  and  Director  of  the  Coronary
                      Care Unit, Jackson Memorial Hospital.                           '    Icarned   during   the   preceding   week   to   patient
                         Dr.  Aicibal is Instructor in Medicin  ,  University  of  M'am
                                                               e
                      School  of Medicine, and Director  of  the Coronary  Care   Unit,    situations.
                      Cedars of @banon Hospital, Miami.

                                                                                                                               VOLUME      60/NUMBER      5


                                                                               FIGURE    1

                           90

                                                                                                                                      LD

                           80.

                                          msm
                           70@

                                          DLV                                                                                         jp
                                          LD
                                          cwm                                                                                 41,9

                           60

                      w
                      0    50-
                      <                   HKM
                      cc
                      0
                      z
                      0

                                          MB
                      Z    40-4           is
                                          MO
                      x
                      ui

                                          TW
                           30-4

                                          ECJ

                           20-4

                           10@

                            0
                                          PRETEST           POST         0-3             4-6            7-9            10-12         13-15
                                                                         MON  THS        MONTHS         MONTHS         MONTHS       MONTHS
                                                                         POST            POST           POST           POST         POST
                            Graph illustrating pre and post-testing scores. These are compared to       the second post-test score given four
                        to 12 months after completion of the CCU course.
                        Note that two physicians showed an improved score in the last post-test.

                        J. FLORIDA M.A./MAY, 1973                                                                                           23


                         At the    completion of  each  course,  a  post-test   myocardial    infarction,    especially     arrhythmias,
                     was  given  in  order   to   evaluate   the   level   of   were emphasized  as  well  as  applied  electrocardioc,-
                                                                                                                                       0
                     knoivled-e    attained  and  how  this   knowledge   was   raphy,   electronic   monitoring,   and   CCU   planning
                     applied in    clinical situations.  This  was  not  con-   and administration.
                     sidered  to   guarantee   how   well   a   nurse   would      A  list  of  suggested  reading  material,   to-ether
                     function     in a CCU  but  did  serve  as  a  measure  of with  a  pretest   was   mailed   to   each   physician-
                     her newly acquired capabilities.                           student  accepted  into  the  program.  This  served  to
                         Followina  the  completion  of  the  course,   these   evaluate  the  level  of  knowledge  in   cardiovascular
                     nurses  were  either  employed  in   a   CCU,   partici-   medicine prior to the  course.  A  post-test  was  given
                     pated in, or  initiated  training  courses  in  coronary   on the last day  of  the  session.  The  main  objective
                     care  in  their  areas.  Many   were   instrumental   in   was  to  reemphasize  points  of   clinical   importance
                     establishin- coronary care  units  in  their  hospitals.   to  the  practicin-  physician.  During   the   16-month
                         As   an   outgrowth   of   this   program   of   CCU   program  20  courses   were   given   and   81   Florida
                     nurses trainin,-,, courses in other fields of  intensive   physicians were trained.
                     medical  and  surgical  care  have  emerged.  In   addi-                  Postgraduate Seminar
                     tion  a  number  of  manuscripts   have   been   written
                     by   CCU   nurses   graduatin-   from    this    program      Fourteen    months  after  the   first   course   was
                     and  these  have  been  published  in   national   jour-   aiven,  a  one-day   postgraduate   seminar   was   held
                     nals.   More   recently   a   textbook   in   programmed   at   Jackson   Memorial    Hospital,    Miami.    Twelve
                     instruction  in  coronary  care   has   been   published   physicians  who  had  completed  the  course   four   to
                     by  nurses   who   had   completed   the   prooram   and   12  months  earlier  attended.  At  the  onset  of   the
                     subsequently  became  instructors.  All  of  these   are   seminar  the  physicians  were   asked   to   take   the
                     evidence  of  the  stimulus  this  program  had  on  its   same post-test  that  had  been  given  to  them  during
                     participants.                                              their  CCU  training.  The  order   of   questions   was
                                   Courses for Physicians                       changed  in  order  to  eliminate  the  possibility   of
                                                                                rote  memory.  The  results   (Fig.   1)   showed   that
                         A    series of courses of instruction in    coronary   although  the  majority  obtained  more  or   less   the
                     care for the  practicing  physician  were  initiated  in   same  score  a  few  made  higher   grades.   This   was
                     September   1970.   The    program    was    designed.to   ,ratifyin- since it  was  apparent  that  the  retention
                     provide  close  teacher-student  relationship   to   in-   level  was  high  considering   the   length   of   time
                     sure  comprehensive  training  and  thus   the   courses   elapsed. A  number  of   physicians   were   responsible
                     were limited to  four  physicians  per  session.  Prior-   for settin- up  CCUs  in  their  local   hospitals   and
                     ity  was  given  to  the   general   practitioner   from   also  initiating  coronary  care  classes   for   nurses
                     small communities in Florida.                              and  other   physicians.   Some   have   arranged   pro-
                         The  physicians'  course  consisted  of   six   days   olrams for interesting  cases  or  ECGS.  All  of  these
                     of   comprehensive   lectures    and    coronary    care   added  dividends  of  this   trainin-   proaram   attest
                                                                                                                   6      tD
                     training  with  emphasis  upon  the  practical   aspects   to its success.
                     of diagnosis  and  care  of  patients  with  acute  myo-      Both  the   nurses   and   the   physicians   courses
                     cardial  infarction.  The   days   were   divided   into   initially  supported  by  FRMP   are   being   continued
                     ten  hours  of  instruction  which  included  two  hours   on a self-support basis. This  is  in  true  keeping  of
                     each  morning  of  clinical  bedside   rounds   in   the   RINIP  philosophy  which  was  to  help   initiate   and
                     CCU  and  14  hours  "on-call"  during  the  night   for   financially  support  local  programs   aimed   at   im-
                     problems  arising  in  the  CCU.  As   often   as   pos-   proving the  health  of  the  public  primarily  through
                     sible,  the  physician-student  was  exposed  to   prac-   physician  or  paramedical  education  and  these   pro-
                     tical  demonstrations  of  techniques   such   as   cut-   grams  if  successful   and   well   established   would
                     downs,   insertion   of    central    venous    pressure   subsequently  be  continued  on  a  local   self-support
                     catheters,  flow  diverted   pulmonary   artery   cathe-   basis.
                     ters  and  arterial  needles,  pacemakers   and   cardi-
                     oversion.  Current  concepts   in   the   treatment   of   @ Dr. Lemberg, 3180 Coral Way, Miami 33145.

                     24                                                                                        VOLUME  60/NUMBER  5


                    Intensive In - Service Education for  Physicians

                                           ARVEY I. ROGERS, M.D. AND SIDNEY BLU-%IENTHAL, M.D.

                       For  many  physicians,  a  highly  desirable  form  of Contiiiuinc,  Education  coordinated  all  adminis-
                    of  continuing  medical  education  is  an  activitN,  trative  arrangements  pertinent  to   the   trainee's
                    designed  to  fulfill  identifiable  needs,  oriented  use of medical center facilities  and  involvement  in
                    around specific, well-defined  objectives,  and  pre-  aspects of patient care. Total  cost  to  the  trainee
                    sented  intensively  in  an  educational  atmosphere,  included  travel  and  livin.-  expenses  as  well  as
                    preferably  removed  from  daily  work  responsibili-  those related to leavin- a  practice  for  1-2  weeks;
                    ties. These features formed the basis  for  the  "In-  no  tuition  was   char-ed.   With   rare   exception,
                    tensive   In-Service   Postgraduate   Education   for  trainees felt the experience  worth  the  expense  and
                    Physicians"  activity  which  has  taken   place   at  indicated a willingness to provide a tuition  if  this
                    the University  of  Miami  School  of  Medicine  over  became policy in the future.
                    the  past  tnvo  years.  The  pro-ram  was  sponsored      Tables  1-5  present  demographic   data   related
                    by the  Florida  Re-ional  Medical  Pro-ram  and  co-  to the 88  enrollments  (85  physicians)  in  the  in-
                                      o                   C5
                    ordinated through  the  Office  of  the  Division  of  tensive in-service activity. Slightly  less  than  one
                    Continuing  Education  at  the  medical  school.  The  half participated  in  pro.-rams  devoted  to  cardio-
                    following  information  is  provided   to   summarize  vascular  and  neurological  diseases.  Fifty-one   of
                    major aspects of this activity.                        the  registrants  represented  the  major  disciplines
                       Basically,  brochures  mailed   throughout   Flor-  of  family  practice,  internal  medicine  and   pedi-
                    ida  announced  the  program,  described  objectives,  atrics.  Physicians  tended  to  come  from  Dade  and
                    course offerings, and facilities.  Interested  appli-  Broward  Counties  (33  of  the  85),  but  17   total
                    cants  requested  (Ist  year  of  mailing)  or   com-  counties were represented. Of  the  72  physicians  in
                    pleted  (2nd  year  of  mailing)  an  application  in  which  a.-es  were  known,  42  were  between  41  and
                    which specific needs were solicited.  If  a  pro(yram  55 years  of  age.  Fifty-six  had  been  in  practice
                                                                   ZD
                    was available at the  medical  school,  an  appropri-  more  than  seven  years;  46  had   been   practicin-
                    ate faculty  member  was  selected,  the  application  more than ten years. This is  -ratifyin-  in  view  of
                                                                                                          tn       zn
                    discussed with him, and  the  request  made  that  he  the observation that the half-time  for  retention  of
                    review  the  application  with  a  view  toward  pos-  medical  knowledge  is   estimated   to   be   between
                    sibly accepting the  applicant.  Frequently,  person-  five and seven years. Of some interest is  the  appeal
                    al  phone  calls  between  preceptor  and   preceptee  the pro-ram  had  for  doctors  of  osteopathy;  while
                    ascertained more  specifically  preceptee  needs  and  less than 10,yo of  Florida's  physicians  are  repre-
                    preceptor capabilities at the time.  This  "personal"  sented by this group, 17 or 23,7o  of  the  88  physi-
                    approach  was  encouraged,  as  it  provided  an  op-  cians participating were D.O.'s.
                    portunity  for   meaningful   communication   between      A total of 233  applications  were  submitted  for
                    student and teacher at  an  early  stage  of  program  possible  course  enrollment.   For   a   variety   of
                    design.  If  agreement  was   reached,   arrangements  reasons, all  except  88  enrollments  were  not  com-
                    for specific time  period  were  made;  if  none  was  pleted.  The  usual  reasons  were  the  inability  to
                    reached,   another   faculty   member   was   sought.  accommodate  the  "broad"  requests   of   the   indi-
                    Processing  usually  took  4-6  weeks.  The  Division  vidual  seeking  the   educational   experience;   in-
                                                                           ability of the  individual  to  narrow  his  needs  to
                      Dr. Rogers is Associate Professor, Department of  Medi@in,, those which had the  greatest  chance  of  fulfillment
                    University of Miami School of Me&icine-.  and  Medical  School within  1-2  weeks;  program  not  being  offered   at
                    Rg.pre@elltative for the  Florida  Regionil  Medical  Program,
                     tam'.                                                 the  medical  school;  "personal"   reasons.   Further
                      Dr. Blumenthal is Professor  of  Pediatric  Cardiology  and
                    Associate Dean for Continuing Education, University  of  Miami comment on  several  of  these  is  appropriate.  Many
                    School of Medicine, Miami.
                       This work issupported in part by a grant from  the  Florida applicants expressed the  view  that  they  wanted  to
                    Regional Medica  Piogram entitled -Operational Project #40.

                    J. FWRMA M.Ai/MAY, 1973                                                                                    25


                                TABLE          I.-PHYSICIAN           ENROLLMENT.                     TABLE 4.-PRACTICE SPECIALTY                 OF
                                                                                                            ENROLLED PHYSICIANS.
                        Total Enrolled:  88 (represents  85  individual
                                                physicians; 3 re-enrolled)                            Angiolo-,y                                  1
                                M.D.        71                                                        Anesthesiology                              5
                                D.O.        17                                                        Cardiovascular  Disease                     3
                         Total Course Hours Completed:               4,351                            Dermatology                                 1
                         Age Distribution of Enrollees:                                               Family   Medicine                           5
                                25-30                                    1                            Emergency     Medicine                      2
                                30-35                                    6                            General  Practice                           18
                                36-40                                    12                           General   Surgery                           2
                                41-45                                    13                           Jnternal Medicine                           14
                                46-50                                    16                           Neurology                                   1
                                51-55                                    13                           Neurosurger),                               1
                                56-60                                    5                            Ophthalmology                               11
                                61-65                                    3                            Orthopedic     Surgery                      1
                              Over   65                                  3                            Otolaryngology                              I
                              Unknown                                    16                           Pediatrics                                  11
                                                                         -                            Physical Medicine    & Rehabilitation       1
                                                                         88                           Psychiatry                                  4
                                                                                                      Radiology                                   3
                                                                                                      Urology                                     4
                                                                                                      Unspecified                                 2

                                                                                                                                                  88

                                 TABLE     2.-LENGTI-I     OF     PRACTICE     OF
                                          ENROLLED             PHYSICIANS.

                              YEARS                       INUIIBER OF PHYSICLTNS
                                0-    1                                  3                     TABLE 5.-MEDICAL SPECIALTIES IN WHICH
                                I-    3                                  4
                                3-    5                               10                                PHYSICIANS          WERE          ENROLLED.
                                5-    7                                  4
                                7-10                                  10                              Anesthesiology                              6
                              10-15                                   11                              Cardiovascular  Disease                     24
                              15-20                                   13                              Dermatology                                 1
                                    20+                               22                              Endocrinology                               3
                              Unknown                                    9                            Family Medicine                             1
                                                                      -                               Gastroenterology                            1
                                                                      88                              Neurology                                   is
                                                                                                      Ob-Gyn                                      1
                                                                                                      Ophthalmology                               11
                                                                                                      Otolaryngology                              2
                                                                                                      Pediatrics                                  11
                                                                                                      Psychiatry                                  1
                                                                                                      Pulmonary      Disease                      3
                                                                                                      Radiology                                   3
                                                                                                      Renal     Disease                           1
                                                                                                      Urology                                     I
                                  TABLE 3-COUNTY DISTRIBUTIO@N OF                                                                                 -
                                           ENROLLED            PHYSICIANS.                                                                        88

                                      Broward                                  15
                                      Charlotte                                 I
                                      Dade                                     18
                                      Duval                                     3
                                      Escambia                                  3
                                      Hillsborough                              6
                                      Indian River                              2
                                      Lake                                      I
                                      Lee                                       3            get  the  most  for  the  time  and  money  spent;  this
                                      Monroe
                                      Okaloosa                                  1            was translated  to  mean  that  they  preferred  to  re-
                                      Orange                                    8            view  an  entire  specialty  rather  than   a   specific
                                      Palm Beach                                7
                                      Pinellas                                  5            area  of  that  specialty.  An  individual  who  desired
                                      Polk                                      4            to  learn  something  about   the   EKG   interpretation
                                      Sarasota                                  I
                                      Volusia                                                of  cardiac  arrhythtnias  was  more  likely   to   feel
                                                                                8
                                      Out-of-state                                           that  his  needs  were  met  by  program   design   than
                                                                                             the  individual  who  wanted  to  "review   cardiology."
                                                                                             Previous  experiences  in  this  approach  to   continu-

                          26                                                                                                      VOLUME     60/NUMBER      5


                   in@  education  had  emphasized  the   importance   of      Continuino,  medical  education   is   a   complex
                   reco,a,nizin- needs as the basis  for  realistic  pro-  process,  involvin-  teachin,,  and  learnin-.  It  is
                   o,ram  desian  which  offered  the  best   chance   to  complicated by the manN.      variables  relating   to
                   meet needs  within  the  week's  periol  of  intensive  methods   and   evaluation   parameters   applied   to
                   study set aside.  Every  effort  was  made  to  adhere  who  teaches  what,  to  whom,  when,  in  what  form,
                   to  this  educational  objective.  We  reco@nize  that  and  for  what  purpose(s).  The  very  complexity  of
                   there   are   certain   shortcominos   when   pro,,ram  the  process  has   encouraged   useful   experimenta-
                   desi-n is based on a  physician's  subjective  assess-  tion;  newer  methods  have  evolved.  Increasing  em-
                   ment of his needs; often, there   is no  parallel  be-  phasis on the  process  of  evaluation  has  forced  a
                   tNveen expressed  and  objectively  assessed  need;-;.  closer  look  at  overall  objectives,  methods,   and
                   The  objective  assessment  of  physicians'  needs  as  results.  The  truly  accurate  assessment   of   con-
                   they relate to patient care  is  difficult,  utilizin-  tinuino,,  medical  education  pro-ram   effectiveness
                                                                        0                                   ZD
                   tools presently  available  to  educators.  Aleanin(,-  depends to a areat  extent  on  the  ability  to  mea-
                   ful parameters for doin- so  will  ultimately  evolve.  sure its effect on  the  overall  objectives,  methods
                                           C,
                      The  pro.-ram  was   evaluated   by   questionnaire  and  results.  The  truly   accurate   assessment   of
                   which  attempted  to  elicit   and   compare   faculty  continuing  medical   education   program   effective-
                   (preceptor)  and  enrollee  (preceptee)  responses  to  ness depends to a  great  extent  on  the  ability  to
                   nearly  identical   questions.   Questions   concerned  measure its effect on the overall quality  of  patient
                   whether  coals  were   attained,   extent   to   which  care.  Sustained  high  qualitN.  or  improvement   in
                   needs were  met  educational  tools  utilized  in  the  the quality of patient  care  is  an  acceptable  goal
                               ount  of  time  devoted  to  specific  in-  of   the   continuing   medical   education   process;
                   process, am
                   struction as  compared  to  self-instruction,  whether  thou,h probably attained frequently, it  is  difficult
                                                                                                @cqualitv 11 and "pat ient   care"
                   the individuals would participate  in  similar  under-  to measure, since
                   takino,s in the future, etc. In  ceneral,  there  Nvas  are not easy to  define.  Evaluation  of  the  process
                   agreement  and  affirmation.   Major   problem   areas  of  continuin-  medical  education  must   await   the
                    0                                                                   in
                   related to difficulty in  determining  specific  needs  evolution of  an  equally  complex  process,  that  of
                   and desi-nino, "Personal" pro,,ranis  to  fulfill  the  the establishment  of  criteria  for  quality..patient
                   needs. The enrollees -,vere asked  whether  they  felt  care. The primacy of  activities  related.  to  estab-
                   the experience improved their  ability  to  take  care  lishing such criteria,  which  must  be  relevant  and
                   of patients; with rare  exception,  the  response  was  sensible, is obvious.
                   affirmative. Objective  evaluations  were  not  under-    Dr. Ro-ers,  1400  Northwe;-zt  10th  Avenue,  Suite
                   taken.                                                    11 P, Miami 33136.

                                                                                                                      I I
                    J-- FLORTIDA M.A./MAY, 1973                                                                                 27

     I   @@ic i


                                              New Scalar Computer EKG Program
                                              for On-Line Central EKG Processing

                                                                        LAMAR E. CREVASSE, M.D. AND @IARio ARIET, PH.D.

                                       When      one      considers      that      nearly       100       million    Florida.     The     total     system     consists     of      data      acquisi-
                                   electrocardiograms       are       processed       in       this       country    tion     carts,      data      transmission      phones,      and      a      se-
                                   each    year     the     problem     of     their     systematic     analysis,    quential       telephone       answering       interface        Nvhich        re-
                                   storage,      and      retrieval      is      of      considerable      magni-    ceives       both       local,       WATS        line        and        emer-ency
                                   tude.      The      ever-increasing      demands      on      the       health    calls    on     a     priority     basis     with     tape     recorder     back-
                                   care     system     for     efficiency,     cost     control,     and      re-    up  systems.  The  signals               are     received     by     a      tele-
                                   sponsiveness       make       computers       ideal        for        handling    phone     receiving     interface     and     fed      directly      into      an
                                   this     type     of     medical     data.      The      speed,      accuracy,    IBM       1800        computer        throu-h        an        analogue        to
                                   memory,     and     logic      of      the      computer      provides      an    digital        converter.        The        pro,-ram         analyzes         the
                                   excellent      system      for       EKG       analysis.       The       corn-    twelve-lead          electrocardiogram'          and          the           Frank
                                                                                                                                            2
                                   puter      furthermore      has      a      capability       of       handling    vector       system.       For       the       University       and       certain
                                   large       volumes       of       electrocardiograms        with        rapid    larger     hospitals     Frank     lead      vector      plots      are      made
                                   turn-around.                                                                      available on all abnormal EKG'S.
                                       A      computerized      EKG      center      must       provide       the         A             telecommunication             system             automatically
                                   necessary      service      for      outlying      hospitals      with       a    dials      the      sending      hospital's      teletype       and       returns
                                   responsive       turn-around       system       which        can        return    the    scalar    analysis    to     the     sendin-     hospital     within     a
                                   the      electrocardiogram      to      the      sending      site      within    three-minute      period.      The       analysis       time       for       both
                                   a     few     minutes.     The     responsiveness     of      this      system    the     scalar     and      vector      system      is      approximately      60
                                   is       essential       for       emergency        rooms,        preoperative    seconds.      We      are       currently       processing       EKG's       from
                                   evaluation,       and       many       other       situations.                    ten community hospitals, the University and
                                       it     is     now     possible     with     the     new      EKG      pro-    hospitals,       and       several       smaller        clinics        throughout
                                   grams      to      have      a      responsive      system      which       is    the state.
                                   5
                                   capable     of     acquiring,      analyzing,      and      returning      the                              Data Acquisition
                                   EKG     analysis     to      the      sending      site      within      three
                                   minutes     with     an     accuracy      that      is      comparable      to         Our       EKG        patient        transmitter        cartsO        acquire
                                   that     of     physicians     with     the     exception      of      compli-    all  of     the     standard     twelve     leads,     three     leads     simul-
                                   cated rhythm disturbances.                                                        taneously    for     six     seconds     each,     and     12     seconds     for
                                                                         Systems                                     the      Frank      XYZ      system.      In      dialing      the       computer
                                                                                                                     with       its       sequential        telephone        priority        answering
                                       The      regional      computer       EKG       system       as       out-    service     the     call     holds     until     the     technician      receives
                                   lined    here    is    located    at     the     University     of     Florida    an      answer      signal      from      the       computer.       The       EKG
                                   College       of       Medicine       in       Gainesville       and       was    identification     and      transmission      is      now      sent      directly
                                   funded        through        the        Florida        Regional        Medical    into our computer with analogue magnetic  tape
                                   Program.    It     is     designed     for     the     acquisition,     multi-    backup.     We     have      a      three-channel      direct      writer      in
                                   lead       transmission,       reception,       and        recording        of    the     computer      center      for      monitoring      all      EKG's      or
                                   electrocardiographic              signals           from            throughout    technical      problems.      In      addition,      a       technical       pro-
                                                                                                                     aram      for      noise,      missing      interrupts,      or       measurement
                                                                                                                     T
                                       From                           ,led     e and D          n  of   Comptiter    inconsistencies      teletype      back      the       failure       of       EKG
                                                                               n           ivisi" 0
                                   Scieurt                                                      i.@'   Gainesville:  acquisition      and      analysis.      In      addition,       it       signals
                                                                             ici
                                                                               e
                                                                     d       .1' _ff@  f     edic
                                                                         C                 i    .i
                                       D                                @art Stio.              o-  of    Cardiol
                                   o                                           dD   A    t      Director     Divi    the  sending  ca
                                                                       U   .                                                                  rt      with       three       audiovisual       signals
                                   sg,     Dep;                                           F    ,i
                                        of    I                          n     e                d.  Coll'ege   of
                                   Medicine.
                                       This   work   is   supported   by   Florida   Regional    'NedicAl    Pro.
                                   gram.Projeet #3.                                                                  (IDMarquette C-205
                                   28                                                                                                                               VOLUME         60/NUMBER         5


                         that the tracin- i@ unsatisfactory  and  to  repeat.                 Data  acquisition,  EKG  transmission,  and  com-
                         If  the  tracin-  is  satisfactory,  an  audiovisual              puter capability are  currently  functionin-  in  an
                         Si-nal so informs the technician.                                 efficient manner in a variety of settin-s.4 We  have
                                                                                           evaluated and refined this pro-ram  in  the  Univer-
                                                                                           sity and affiliated VA hospital system utilizin-  it
                                         Computer        Programs                                                                                   0
                                                                                           to service the needs of the re-ional  hospitals  and
                                                                                                                                 CD
                             A  variety  of  computer   pro-rams   are   avail-            clinics.  We  have  recentl  implemented   the           new
                                                                 0                                                           y
                         able and the major  deterrent  to  the  -Irowth  and              scalar  EKG  pro-ram  and  have  done   a   detailed
                         acceptability of  computer  EKG  analysis  has  been              test on a University hospital  population  of  1,000
                         the lack of an EKG  pro,,ram  with  the  reliability              consecutive  EKG's  with   clinical   interpretation
                         and   consistency   in   any   way   comparable   to              read by tnvo or  more  physicians  and  compared  in
                         physician analysis.                                               retrospect  with  the  computer  EKG  analysis.  The
                             The previous first versions  of  various  pro-rams            computer exhibits a bi,-Ih degree of  resolution  in
                         have been evaluated  by  a  variety  of  groups  and              bein- able to  differentiate  normal  from  abnormal
                         are not satisfactory for on-line  turn-around  with-              with 97(7o reliability. The overall computer contour
                         out over-read.3 The occurrence of a  hi-h  incidence              statement  accuracy  is  comparable  to  the   92'70
                         of both false positive and false  ne-atives  require              physician  accuracy  statements  correctly   stated.
                         constant  overview  by  a  cardiologist.  A  perfect              The false positives and  false  ne-atives  are  com-
                         EKG  pro-ram  is  obviously  unlikely   because   of              parable  and  are  related  primarily  to  physician
                         the  multiple  variables  related  to  transmission,              and computer  lo-ic  criteria  employed.  The  major
                         noise, faculty  pro-ram  lo-ic,  and  electrocardio-              flaw  in  our  computer  EKG  pro-rams  is  the  in-
                         graphic  variations.  However,  a  new  EKG  pro-ram              ability  to  analyze  complex  arrhythmias  such  as
                         and system with reasonable clinical  correlation  is              AN'  dissociation,   supraventricular   tachycardia,
                         now available for the routine analysis  of  electro-              varyin@ block, multiple ectopic foci, or other  com-
                         cardiograms.'                                                     plex  arrhythmias.  The  pro.-ram,  however,  states

                         IBM   EXPERIMENTAL   ELECTROCARDIOGRAM   ANALYSIS   PROGRAM
                         PATIENT   NUMBER   0942584     6192  DATE  02/07/72

                         SINUS  TACHYCARDIA,   RATE   110
                         ROBB  PLUS  LEFT  ANTERIOR   FASCICULAR   BLOCK   TBIFASCICULARI
                             ORS  ANGLE  IS  BETWEEN  -60  No  -120  DEGREES
                             ORS WIDTH IS GREATER  THAN  OR  EQUAL  TO  125  MS
                             THERE ARE NOTCHED  R  WAVES  IN  VI  OR  V2
                             INTRINSICDIO  DEFLECTION  IS  GREATER   THAN   50   MS IN VI AND  V2
                             S OR S  PRIME  WIDTH  IS  MORE  THAN  20  MS  IN  LEAD I (SINCE ORS ANGLE IS MORE  NEGATIVE  THAN  -45)  AND  MORE  THAN  30  MS
                             IN  LEAD  V5  OR  V6
                         CONSISTENT   WITH    ANTEROSEPTAL    INFARCTION
                             0  DURATION  IS  40  MS  OR  MORE  IN  LEAD  V2  ITYPE 1)
                             THERE IS ANY 9  IN  VI  OR  V2  PLUS  OS  IN  V3,  V4, OR  V5  (TYPE  1)

                         IKFARCTION    PROBAGLY     ACUTE
                             J IS ELEVATED  MORE  THAN  .2  MY  IN  Vl  AND  V2  OR V2  AND  V3,  WITH  ANTEROSEPTAL  INFARCTION
                              INTERVALS   IN   MS                                       FRONTAL  PLANE  ANGLES   lt4   DEGREES
                              P-R     QRS       0-T     I        p                      ORS       p      I i     QRST
                              60      144       345     201  119                        -74   i,4   98 NONE  -69
                                  ----  A14PLITUDES IN  TENTHS   OF A   MILLIVOLT ----              ------  TIME   IN    MILLISECONDS ------
                         LEAD                                                           ORS   R  WV                                 Sp  TNT     WPW ABN
                                      Q     R     s     RP       SP    i      p     7   AREA  NTCH       0     R      s      RP         DEF     IND S-T
                                  0.0    3.3    -0.5    0-0  0.0    0.1    0.8    -0.6     30     9      0     92   43       0      0     0       0       0
                         11       0.0    2.4    -12.9   0.0  0.0    0.6    1.9    3.6   -94       9      0     30   114      0      0     0       0       0
                         III      0.0    1.6    -16.3   0.0  0.0    0.4    1.3    4.2   -139      7      0     is   125      0      0     0       0       0
                         AYR      -2.0   4.7    0.0     0.0  0.0    -0.2   -1.3   -1.4     31     7      42    98     0      0      0     0       0       1
                         AVL      -0.6   9.8    0.0     0.0  0.0    0.0    0.5    -2 2     93     4      15  127      0      0      0     0       0       0
                         AVF      0.0    2.0    -14.5   0.0  0.0    0.5    1.6    3:7   -125      3      0     25   117      0      0     0       O'      0
                         VI       -4.4   4.0    0.0     0.0  0.0    1.5    -0.6   -1.9     -3     4      70    75     0      0      0   101       0       0
                         V2       -6.3   6.1    0.0     0.0  0.0    3.5    -0.5   -2.7     2      8      68    76     0      0      0   99        0       0
                         V3       -12.8  0.0    0.0     0.0  0.0    6.5    0.6    7.0   -68       8      1 3 3 0      0      0      0     0       0       0
                         V4       0.0    4.3    -14.9   0.0  0.0    4.8    0.9    4.8   -56       5      0     28   113      0      0   21        0       0
                         Vs       0.0    5.4    -11.8   0.0  0.0    2.0    0.9    2.0   -39       6      0     38   103      0      0   25        0       0
                         V6       0.0    5.3    -8.3    0.0  0.0    0.0    1.0    2.2   -30       2      0     48   93       0      0   35        0       0

                                                                                    FigurC    I

                         J.   FLORIDA   M.A./MAY,    1973                                                                                                 29


                         undetermined  rhythm,  and  these  rhythms  are  then                                         Summary
                         exarhined clinically at the center. We  believe  this                   A  re(,ional  computerized  EKG   processing   cen-
                                                                                                       t3                                            0
                         new  scalar  EKG  pro-ram  with   a   92,7o   overall                ter noNN, provides automated  efficien  y  for  on-line
                                                     0                                                                                      c
                         contour  statement   accuracy   performs   comparable                analysis of electrocardiograms  to  a  broad  spectrum
                                                                                                                           0
                         to physicians in contour analysis  in  routine  elec-                of  hospitals  and  clinics   throuohout   the   state
                         trocardio-rapbic dia-nosis. It has a  low  percentage                                                         tn
                                    0             b                                           initiated  by  the  Florida  Regional   Medical   Pro-
                         of false positive and false neaative  statements.  We                aram.  It  brin-  reas  nable  expertise  in  electro-
                                                                                                               tDs       0
                         are comfortable with its reliability  to  turn-around                Lcardiographic assisted  analysis  to  areas  with  and
                         a   reasonable   answer   for   community   hospitals                Nvitbou@t cardiologists. It assists  the  cardiologist
                                                                                                                   10                                    0
                         providin- an efficient economical  system  for  elec-                and  physicians   without   cardiovascular   expertise
                                   0
                         trocardio,-raphic analysis.                                          in  measurements  and  contour  suggestions.  It  pro-
                                                                                                                                       0
                             In  each  of  our  contour  statements  the  loaic               %,ides  an  educational   mechanism   for   physicians
                         criteria i.; printed to  indicate  how  the  computer                throuah statement  of  criteria  used  for  each  con-
                         arrived at that specific diagnosis. We feel  this  is                tour statement. Computer  assisted  analysis  at  this
                         an  important  quality  control  mechanism  as   well                time  provides  an  economic   and   rapid   mechanism
                         as an educational vehicle for  physicians  interested                for analysis  of  the  electrocardiogram  and  assists
                         in  electrocardiography.  A  selected  electrocardio-                the  physician  in   EKG   diagnosis.   However,   the
                         aram and printout is illustrated in Figures I and  2.                clinical jud-ment  of  a  physician  must  prevail  in
                                                                                              relatin-  the  computer  assisted  analysis   to   the
                                                                                                     n
                                                                                              proper clinical situation.
                         j                                                                                             References
                                                                           V.                 I .Boiiner, R. E.; Crevasse, L.; Ferrer. M. I.,  and  Greenfield,
                                                                                                 J. C.  Jr.:  New  Computer  Program  for  Analysis  of  Scalar
                                                                                                17lectrocardiograms, Comp. & Biomed. Rsch., Dec. 1972.
                                                                                              2. Smith, R. E. and  Hyd@,  C.Af.:  Computer  'System  for  Elec-
                                                                                                                                        ual Rock
                                                                                                                                             Co,ora@(,,Mountain
                                                                                                                                        of             Boulder,
                                                                                              3.                                         rauer, L.  E.;  Karsh,
                                                                                                                                        ity  of  Computer  Pro-
                                   v                                                                                                    a@s,  Am.  Ht.   Assoc.
                                                                                                                                          11 O@ .1 ,I Oct. 1972.
                                                                                              4.                                            S  r  ng   Computer
                                                                                                                                          gra ms (abstr),  Cir-

                                                                                               Dr. Crevasse, Department of            Medicine,    Univer-
                                                                                               sity of  Florida  College  of  Medicine,  Gainesville
                                                    Figure 2                                   32601.

                         30                                                                                                        VOLUME     60/NTJMBER      5


                                         Cervical Cy'tology Revisited
                                           .TA'.NlEs E. FULCHU-,I, M.D. AND JOI-l-, C. RI--ACAN, M.P.H.

                       Cervical cancer claimed the lives of an  esti-           Nvomeii a,,@leci 25-44 years, despite extensive cervical
                    mated  258   Florida   women   durin-   1972   and   an-    cvtolo-y screeiiina beina  carried  out  in  the  state.
                    other 220  died  from  cancer  of  other  parts  of  the    This  a-e  -roup  is  quite  valuable   to   the   corn-
                    uterus.  These  are,  for  the  most  part,  preventable    niunity and has  the  -reatest  responsibility  for  the
                    deaths. The  lives  of  many  are  bein-  saved  throu-h    care of manv children.
                    early  detection  by  the  Papanicolaou   (Pap)   te-qt,                    The ADC Project
                    a  hi-hly  accurate,  inexpensive  and   painless   test
                    for cancer of the uterine cervix.                              A    nioiio-raph,    "Cervical    Cancer    Detection
                                                                                throu-h  Cytolo-y,"  was  published  by   the   Division
                                          Mortality                             of  Health  as  mono-raph   number   11,   1967.1   This
                                                                                                   C,
                                                                                is a report of a study of 10, 1  74  Aid  to  Depen  ent
                       In  Florida,  as  in  the  nation,  early   detection    Children  (ADC)  reci  ients  durin-   the   period   of
                    and  adequate  treatment  have  been   responsible   for                           p             0
                    a  reduction  in  the   number   of   women   dyin-   of    1960-1963  carried  out  with  the  assistance  of   the
                                                                      n         U. S.  Public  Health  Service.  This  was  one  of  the
                    uterine cancer durin.-  the  past  two  decades.  Figure    first  times  that  a  pro-ram  of  this  ma-nitude  had
                    1  shows  the  death  rate   of   Florida   women   from                                             10
                                                                      I         been attempted within 18 colint;es of a state.
                    cervical  cancer  by  race  for  1960-1971.  This  snows       The  pro-ram  goal  was  to  screen  a   large   pro-
                    that  the  mortality  rate   can   be   and   has   been
                                                                                portion  of  an  indigent,  underprivileged  and   hioh-
                    favorably influenced.                                                                              0           t,
                                                                                risk -roup of   women.   Durina   the   period,   10,174
                       A sli-ht increase  in  the  death  rate  amon-  black        0                          0
                            n                                      0    .1 .    women  were   screened.   About   400   or   45/o   were
                    females is  noted  for  the  year  1971;  however,  tnis          I  to   tumor   clinics   because   of    abnormal
                    does not offset the general downward trend            of    referred
                                                                                cvtolo,-y-Pap  III,  IV  and  V.  This   underprivileged
                    total uterine cancer deaths.                                g.roup  was  biopsied  and  205  or   about   50,7o   were
                       The mortality rate for      both  white   and   total
                    has  shown  a  downward  trend  with  a  4851o   decline    positive  for  in  situ  or  invasive  cervical  cancer;
                    in the rate for  white  women  in  the  past  11  years.    most were treated by indicated methods.
                    Figure  2  shows  death   rate   for   cervical   cancer       This  project  did  much  to  raise  the   index   of
                    amon-  Florida  females  by  a-e  group  for  the  years    suspicion  as  to  cervical  cancer  in  Florida.   Much
                         C,                        C5                           valuable  information  was  -ained  as  to  the  natural
                    1960,  1965  and  1970.  There  has   been   a   remark-                                b
                    able decline in  all  age  -roups  for  the  years  1965    history  of  cervical  cancer  and  resulted'   in   the
                                              0                                 refinement  of  techniques  applicable  to  active  mass
                    and 1970, as compared with the year 1960         . T   e
                                                                                screening
                    aue group  of  65  and  over  has,  however,  shown  the            O'
                     0                                                             The   ADC    Cancer    Detection    Pro-ram,    whose
                    least amount of decline. Figure 3 shows the       y  er-    influences extended into all  sections  "of  the  state,
                    cent  distribution  of  deaths  of  Florida  women  trom    .
                                            0         t- 1960, 19               tias been a source  of  satisfaction  for  the  official
                    cervical cancer by ace durin,                  65    and    anci  voluntary  health   agencies   who   participated.
                    1970. This reveals that in 1970      over 4017,, of  the    Its  beneficial  aspects  have  continued  throu-h   the
                    deaths  from  cervical  cancer  were  in  the   65   and                                                    0
                    over   age   aroup.   Concentrated   effort   must    be    years  in  many  ways,  but  primarily  in   demonstrat-
                                0                                               ina  to  the  county  health  departments  that   perma-
                    applied  towards  the  detection  of   cervical   cancer      t,
                    in  women  over  age  55.  It  should  be  noted,   how-    nent  on,,oin-  cervical  cytology  programs   for   all
                                                                                in(liaent females  could  be  established  as  an  added
                    ever,  that  18.67o  of   the   deaths   from   cervical
                                                                                service  to  their  already  ongoina,  disease   control
                    cancer   in   Florida   durina   1970   occurred   amon-
                                                                                activities.
                                                                                   Since 1963, most directors       of   county   health
                                                                                departments  have  established  cervical   cancer   pro-
                                                                                arams as  a  part  of  their  county  health  department
                       Dr. Fulglium is Chief and iNIr. Reagan is Healtli  Ilrogram ;ervices.  This  has  been  accomplished  witb-financfal
                    S ecialist. Florida Division of Health, Jacksonville.  Dr.  Fulghum
                    ispalso Director of Project #39,  "Cervical  Cytology  for  Certain assistance  from  the  Division  of   Health,   American
                    Hospitals and Health Departments."

                    J. FL4DRIDA M.A./MAY, 1973


                                                                 FIGUR,E 1
                                                        CA.NCE,R OF CE-RVIX - DEATH RATE
                                                         Per loo,000 Females by Pace
                                                             Florida 1960-1971

                                  20                                                      Total
                                                                                          Black
                                                                                          hhite

                                   is

                                   10

                                     o
                                      1960 1961    1962   1963  1964  1965   1966  1967   1968  1969  1970   1971
                                                                         iw
                     Cancer Society, Florida Division, Inc., U. S.  Public  does not  include  the  many  thousands  of  examina-
                     Health Service,  and  in  recent  years-by  a  three-  tions performed by physicians  on  private  patients.
                     year  grant  from  the   Florida   Regional   Medical  Approximately  200  cases   of   previously   unknown
                     Program.                                               cervical  cancer  were  diagnosed  and   brought   to
                       In 1967,  the  American  Cancer  Societ  ,  Florida  treatment  durin-  1972  by  sponsored  cancer   pro-
                                                             y                             C5
                     Division, Inc., entered  into  the  cytology  program  drams.
                     with the Division  of  Health,  and  it  has  been  a               The FRMP Component
                     valuable colleague in aiding with  financial  support
                     in a number of Florida counties as  well  as  provid-     In 1967   and  1968,  the  U.  S.  Public   Health
                     ing excellent public education support  to  the  pro-  Service,  through   its   Cancer   Control   Program,
                     gram.  The   Florida   Division   of   the   American  funded several cytology projects directly to  certain
                     Cancer  Society  has  provided  its   assistance   to  hospitals in  the  state@  When  the  cancer  program
                     screen  the  underprivileged   high-risk   group   of  was sacrificed on  the  altar  of  economy  by  high-
                     women  through  certain  county  health  departments,  level decisions, this left the Public Health  Service
                     as  has  the  Division  of  Health.  In  1971,   some  sponsored activity without support.
                     63,000  medically  indigent   women   were   screened     In 1969, the Division of  Health,  on  the  strong
                     by county health departments  or  specially  selected  recommendation  of   the   Florida   Cancer   Council
                     outpatient hospital clinics. In 1972,  Pap  exarnina-  and  Cancer  Task  Force  of  the  Florida   Regional
                     tions  were  performed  on   about   97,000   Florida  Medical  Program,  made  application  to   FRMP   and
                     women through  the  combined  efforts  of  the  Divi-  a three-year project  grant  was  approved  to  oper-
                     sion of Health,  county  health  departments,  Ameri-  ate cervical cytology programs in  certain  hospitals
                     can Cancer Society, Florida Division, Inc., and -      and   health   departments.   This   is   known    as
                     Florida  Regional  Medical   Program.   This   figure  Project #39.
                     32                                                                                   VOLUME 60/NUMBER  5


                                                                     FIGURE 2

                                                     CERVICAL CANCER DEATII RATES PER 100,000
                                                               Fernales 'y 11'5"'U'1970
                                                           Florida   1960, 6  and

                                  30

                                  25

                                  20

                              co

                              C)
                              C)
                                  is
                              C3
                              C)

                              C)

                                  10

                                    0
                                             Under         25-44          4S-54         SS-64         65 and
                                              25                                                      Over

                                                                     Age Groups
                    Three centers were established  durin-  the  first employees, a public health nurse  (or  clinic  nurse)
                                                          0       Uni- and a clerk  or  secretary.  This  seems  to  be  the
                 year of the project's operation: Jacksonvilley
                 versity  Hospital  of   Jacksonville;   Miami,   Dade optimum  number  for  staffing   the   centers.   The
                 County  Department  of  Public  Health;  and   Tampa, average  workload  for  the  four  centers  is  about
                 Hillsborough   County   Health   Department.   During 2,400 persons screened per month.
                 the second  year  of  operation,  the  project  added     THE  COSTS-Cost  for   screening   to   follow-up
                 a fourth center, Pensacola located  in  the  Escambia to treatment has  been  just  under  $5  per  person.
                 County  Health  Department.  This   expansion   corn- Fifty-three cents  of  each  dollar  pays  laboratory
                 pleted a statewide network of  large  scale  cervical fees for slides processed. Each center has been  free
                 cytology  screening  centers.  The  Florida  Regional to negotiate with the  local  pathologist  on  a  fee
                 Medical  Program  grant  support  is   scheduled   to for service basis. Forty-two  cents  of  each  dollar
                 terminate in April, 1974.                             pays the salaries of the  eight  full-time  employees
                    ORGANIZATION-Under     the     project      direc- assigned to the four centers. The time to  the  proj-
                 tor, each center has a codirector who is  responsible ect director, the four codirectors and  other  county
                 for the program's  operation.  Each  center  has  two health   department   personnel   involved   in   the
                 J. FIA)RRDA M.A./MAY, 1973                                                                                33


                                                                      FIGURE   3
                                                       CERVICAL CANCER DEATIIS PER  CE,a  BY  ACES
                                                              Florida, 1960, 196S, 1970

                                                                                                                YO-7

                                     40

                                      30

                                                                                                            0
                                                                              22.1

                                                                   0
                                   41
                                   c:
                                      20                                                                    0

                                                                   0           0             0
                                                                   0           0             0
                                                                   0           0             0
                                                                   0           0             0              0
                                                                   0           0             0              0
                                                                   0                         0
                                       10                          0           0             0
                                                                               0             0
                                                                   0           0             0              0
                                                                               0             0              0
                                                                               1             0              0
                                                                   0           0             0              0
                                                                   0           0
                                                                   0           0
                                                                   0           0
                                                                   0           0

                                                  Undcr
                                                    Zs             Zs-44        4S-54          55 -64         65 and
                                                                                                               Ovcr

                                                                           Age Groups
                      follow-up and treatment of patients is not  paid            Annual short range objectives of    Project     #39
                      from nor charged to  the  project  grant.  Four  cents   are to screen approximately  12.69'o  (4,400)  of  the
                      of  each  dollar'goes  for  expendable  supplies  used   target population  in  Jacksonville;  11.5@o  (11,500)
                                               e  purchased  throuah   state   of the tar,,et  population  in  Miami;  8.6@o  (3,000)
                      by the centers. These ar                     0                    C,
                      contracts and result in considerable  savinas  to  the   of  the  tar(yet  population  in  Tampa  and   18.9t7o
                                                                   C,                    n
                      project. One  cent  of  each  dollar  -oes  for  staff   (3,000) of the tar,-et population in Pensacola.
                      travel expenses.                                                           Target Group
                                     Long Range Objective
                                                                                  From  its  inception  Project  #39   has   accepted
                         The long-range  objective  of  Project  #39  is  to   for testin- all females of sexual maturity  presenting
                      reduce  the  mortality  from  cervical  cancer   amona   themselves to the  screening  clinics.  All  of  these
                                                                           0
                      high-risk females,  i.e.,  those  from  low  socioeco-   programs  are  readily  accessible  -  to  the  target
                                                                       '\Iin-  p
                      nomic backgrounds and/or minority groups. i               opulation; i.e., medically indigent, high-risk,  pre-
                      ority  groups  include  Indian,  Spanish-American  and   dominately  minority  group  females.  Studies   indi-
                      Blacks.                                                  cate that 97@c of  the  females  served  by  the  four
                      34                                                                                      VOLUME  60/NUNMER-5


                                                                                                                                        40,368
                     projects  are  classified  a  I)ein,,  in  the  target  popu-        Total persons screened
                                                                                          Total suspicious and positive Pal)s              102
                     lation.                                                              Number referred                                  124
                       The   Tanipa   pro,,rani    utilize-;    another    Florida        Positive biopsies  for cancer                     54
                                            0                                             Number cancer cases treated                       53
                     Re,yional    ,Nledical    Pro-ram    Community    Interaction        Number cancer cases pending     treatment          1
                      n                      0
                     Project   which   employs   health   -uides   for   a   model        Other chronic conditions such   as
                                                         n                                   moderate to severe dysplasia and
                     iiei-hl)orhoocl   area   to   make   known   to   the   women           trichomonas                                   327
                     of  the  area  the  availability  of  the  center's   medical
                     services.  They  are  also   of   assistance   in   follow-up        The   Florida   Re(,,,ional   Medical    Pro,-,ram,    by
                     of    the    women    who    screened    positive.    Another    providing   financial   assistance   to   the   Division   of
                     center  utilizes   the   local   @'oluntary   Health   A-encY    Health,  has  been  most  helpful   at   a   time   when   it
                     to   provide   follow-up    services    and    transportation    appeared   that   some   cytolo.-   pro-rams    would    have
                                                                                                                      y     n
                     for  many  persons  who  require   assistance   to   get   to    to   be   discontinued.   The    Cervical    Cytology    Pro-
                     the  center.  In  other  instances,  the   assets   and   re-    cyram  has   continued   and   expanded   to   include   four
                     sources  of  the  community   Nvere   used   effectively   to    active  screenin-  centers   in   populous   areas   of   the
                     further  the  pro.-ram  at  no  expense   to   the   project.    state,  It  would  appear  at  this  time   that   the   pro-
                                                                                      -rams   in   the   four   individual   centers,   funded   in
                                             Findings                                 n
                                                                                      part  by  FRMP,  will   be   continued   when   the   project
                        Since  the  I)eginnin,  of   screenin-   in   June,   1971    is phased out.
                     some   40,368   persons   have   been   screened   for   cer-
                     vical  cancer   by   the   use   of   Papanicolaou   examina-                     Uterine Task Force
                     tion.  The  total  yield  of  positive  biopsies   for   this        The    Uterine    Task    Force    of    the     American
                     (,roup  is  54  cervical   cancers,   most   of   which   are
                     0                                                                Cancer  Society,  Florida   Division,   Inc.,   in   keepin.-
                     in  situ  lesions.  All  patients  have  been  referred   for    with   the   trends   of   the   American   Cancer   Society,
                     treatment   and   most   have    been    treated    or    are    has  as  its  goal  "to  insure  that  by  1976  a  Pap  test
                     awaitino,   treatment.   These    findings    are    somewhat    is  obtained  by  every  woman   over   19   years   of   age
                     above     the     number     of     previously     undetected    in   Florida,   including   those   women   under   19    who
                     cervical  cancer  that  we  expected   to   find   when   the    are  at  special  risk."  The   goal   is   2,400,000   women
                     program was planned.                                             to  be  tested  in  the  next  four   years.   Careful   con-
                        When  we   compare   the   rate   of   1.3   cancers   per    sideration   must   be   given   to   how    the    medically
                     thousand   females   tested   for   Project   #39   to    the    indigent    females    with    suspicious    and     positive
                     rate  of   20.4   per   thousand   found   durin-   the   ADC    findin,s  can   be   followed   to   diagnosis   and   treat-
                     Project,   one   might   be   somewhat   disappointed    with    ment.
                     the  yield  today.  It  should   be   remembered   that   the
                     ADC   group   had    never    been    screened    previously.                               Conclusion
                     The   findin-S   today   are   a   tribute   to   the    work        In conclusion, it  seems  timely  to   point   out   that
                                 In
                     previously  carried  out  in   the   state   from   1963   to    it  costs  about  $5  to  screen   a   woman   for   cervical
                     1971.   Samuel   Gunn,   M.D.,   of   the    Department    of    cancer.  It  costs  $17,500  to  treat   her   for   invasive
                     Pathology,   University   of   Aliami   School   of,    Medi-    carcinoma   of   the   cervix   and   then   she   may   very
                     cine,  often  refers  to  the  phrase  now  being   used   in    likely lose her life.
                     scientific  cytology   circles,   the   "Vanishing   Positive        Which  is   the   best   public   health   approach?   If
                     Smear.112  This  is   a   desirable   ooal   that   we   wish    one  fourth  of  the   money   now   spent   by   the   state
                     to   attain-no   more   deaths    from    cervical    cancer.    oil   medically   indigent   women   with   invasive   carci-
                     In   addition   to   the   suspicious   and   positive    Pap    noma  of  the  cervix   and   uterus   could   be   used   in
                     smears,   many   persons    were    found    with    moderate    an   examination   pro@ram   utilizing    the    Papanicolaou
                     to   severe   dysplasia,   inflammatory   changes,    tricho-    method,   society   would   gain    considerable    in    tax
                     monas   and   other   sources    of    chronic    infections.    dollars  spent,  not  to   mention   the   consideration   of
                     These  individuals   were   urged   to   seek   gynecological    lives   saved   and   happiness   of   the   individuals   at
                     care  in  the  hope  of  preventin-  in   situ   lesions   of    risk.
                     cervical cancers.                                                                       Ref    erences
                                              Summary
                                                                                      1. Fulghum, J. E.: Cervical Cancer Detection Through  Cytology,
                                                                                          Florida State Board of Health. Alonograph Number  11.  1967.
                        In summary,      the  findings   for   Project   #39   for    2.  Panel on Use of E .demiology, Americafi Societ of  Cytology
                                                                                          Annual Meeting, iVashingt.on, D. C., Novembeyr, 1971.
                     the  period,  June   1,   1971,   to   December   31,   1972,
                     are as follows:                                                      Dr.  Fulahum,   P.O.   Box   210,   Jacksonville   32201.

                     J. FLORIDA M.A./MAY, 1973                                                                                                   35


                                                             RMP!-RIP?

                                                            H. PHILLIP HA',IPTON,

                                                                                   rally financed influence on  cooperative  arrancr  -
                        The   Congress   enacted   Re@ional   Medical    Pro-   f ede                                             ,e
                                                    0
                       grams legislation in 1965 following  consideration  of   ments of health care providers,
                             C)
                       the report  of  a  Presidential  Commission  appointed      Many   of   the   initial   projects   were   campus
                       to study  national  health  problems.  The  Commission   oriented  and  hardly   apparent   to   the   community
                                                                    establish   physician  and   patient.   Others   were   outstandin-
                       recommended federal financial support to                                                                     ZD
                       regional systems for  health  care  delivery  centered   successes, such  as  aid  to  development  of  coronary
                       around medical school  affiliated  hospitals  to  pro-   care  units.  Some  of  the  projects  of  the  Florida
                       vide diagnosis  and  treatment  especially  for  heart   Reryional  Medical  Prouram  are  described   in   this
                       disease, cancer and stroke.                              special  supplement  to  the  journal  of  the  Florida
                        The  Conolress  rejected  this   proposal   but   en-   Medical Association.
                       acted  legislation   providing   federal   funds   to:      Gradually  RMP     re-ional    organizations     be-
                       11(i) assist in  the  establishment  of  reuional  co-   came  more  autonomous  and  oriented  to  their   par-
                       operative   arrangements   among   medical    schools,   ticular health  care  problems.  RMP's  were  at  their
                       research  institutions,  and  hospitals  for  research   best in the low key role  of  support  to  health  care
                       and  training,  includin-  continuin-  education,  for   and evaluation.
                       medical data exchan(,e, and   for   demonstrations   of     The  recent  decision  of  the   Administration   to
                       patient care in the fields of heart  disease,  cancer,   deny  continued  federal  financial  support  to  RMP's
                       stroke,  and  kidney  disease,   and   other   related   was founded  apparently  on  insufficient  evidence  of
                       diseases; (2) afford to  the  medical  profession  and   concrete  results  to  justify  the  money  spent   and
                       medical  institutions  the   opportunity   of   making   "because  the  regional  system  of  health   care   as
                       available to their patients  the  latest  advances  in   originally envisioned has not  in  fact  been  realized
                       the prevention,  dia-nosis,  treatment  and  rehabili-   in  the  seven  years  of  the  programs'   existence."
                       tation  of  persons  suffering  from  these  diseases;   The  RMP  lanv  as  enacted  by  the  Congress  forbids
                       (3)  provide  regional  linkages  amon-  health   care   the pro@ram  to  develop  regional  systems  of  health
                       institutions and providers in order     to     improve   care delivery and  the  action  of  a  catalyst  cannot
                       primary care and  the  relationship  between  special-   be readily measured.
                       ized and  primary  care;  and  (4)  improve  generally      Need  for  the  development   of   cooperative   ar-
                       the  quality  and  enhance  the  capacity  of   health   rangements   between   health   care   providers    and
                       manpower  and  facilities  and   to   improve   health   educational institutions  is  as  great  as  ever.  Now
                       services for persons residing in  areas  with  limited   that government  is  directly  financing  the  cost  of
                       health  services  and  to  accomplish   this   without   health care for  38,7o  of  the  population,  the  need
                       interferin- with  the  patterns,  or  the  methods  of   for  liaison  between  government   and   the   private
                               0
                       financing, of patient care  or  professional  practice   medical sector is greater than ever.
                       or  with  the  administration  of  hospitals,  and  in      The  recently  enacted   PSRO   law   gives   physi-
                       cooperation  with   practicing   physicians,   medical   cians and medical  societies  the  initial  opportunity
                       center officials, hospital  administrators,  and  rep-   to  formally  assume  enormous   responsibilities   for
                       resentatives from voluntary health agencies."*           the  evaluation   and   monitoring   of   health   care
                          Initial  development  of  Regional   Medical   Pro-   delivery.  They  need  expertise  and  technical   sup-
                       grams  Nvas  largely  dominated  by  the  faculty   of   port to fulfill the expectations.
                       5
                       medical  schools   who   often   were   not   entirely      RMP  was   beginning   to   develop   the   provider
                       disabused  of  the   original   Commission   proposal.   support to aid in  meeting  those  needs.  If  the  RMP
                       Practicing   physicians   generally   were   wary    o   organization is destroyed, what will  take  its  place?
                         Dr. Hami3ton is Cbairman of the Board of Directors of     Dr.  Hampton,  1   Davis   Boulevard,   Suite   507,
                       Florida Regi6nal Medical Progratns, Inc.                    Tampa 33606.
                       *From PI,89-239.
                       36                                                                                      VOLUME 60/NUM13ER  6


                                                                            r

                  A SIJRVEY ON
                                    How Ohio Physicians Feel About
                                                         Physician                  Assistants

                     HE    USE     OF     NONPHYSICIANS     as     assistants                 In  jantiar@?,  1971,  the  Ohio  Office  of  Compre-
                  Tlias  expanded  greatly  in   recent   years   with   the            hensl%-e   Health   Planning   published'a   report   pre-
                  introduction of  iienv  allied  health  professions.  This            pared  under  a  special  projects  grant   titled,   "The
                                                                                        Con   'bution   of   Non-Physician   Health   Workers   to
                  has   resulted   in   nenv   professional    organizations                  tri
                  which  have  certified  and   registered   the   graduates            the Dell%,ci,)@  of  Primary  Care,"  by  Amasa  B.  Ford,
                  of  programs  as  well  as  those  experienced  in   vari-            \I.D.,  and  David   P.   Ransohoff.   Included   in   the
                  ous  fields.  In  addition  to  being  recognized  by  new            text  of  the  summary  and  conclusions  were  the   fol-
                  or  existing  health  professional   organizations,   many            lo@@7ino-  statements:   "The   new   movement   has   the
                  of  these  disciplines  are  referred  to  as   "physician            potential   of   opening   up   more   rewarding   careers
                  assistant"  which  is  the  most  dominant  of   the   new            for  the   increasing   number   of   workers   who   have
                  types of health manpower.                                             been enteriiiy the health  care  field  in  recent  years.
                        Much  confusion   exists   regarding   the   purpose,           ----  Ti-ainiiia   programs   are   beginning   to   admit
                  definition  and  use  of  the  physician  assistant.   The            and attract iie@v  recruits  in  addition  to  the  nurses
                  variance  is  so  great  that  the  term  may  be  consid-            and   medical   corpsmen   with   which   many    started.
                  ered "generic"  rather  than  referring  to  a  "specific"            ----  Obstacles  to   the   extensive   participation   of
                  discipline.                                                           iioiiph@-s'ciai-i Nvorkers  in  primary  care  exist,  but
                        As  of  December  31,   1972,   Health   Careers   of           can  be   removed   if   the   need   is   great   enough.
                  Ohio  had  identified  161  different  types  of   "physi-            ------ \IeanNvhlle,  existing  physician   and   nurse   li-
                  cian   assistant"   programs   throughout   the   country.            censure  lanvs,  with  minor  modification,  can  be  used
                  Courses  of  study  range  in   length   from   12   weeks            to  protect  and   encourage   further   experimentation."
                  to  two  years  and   more.   In   Ohio,   nine   programs                  Follo@ving   this   report,   the   Committee   named
                  have  been  identified.   Others   have   been   reported.            Robert   J.   Atwell,   M.D.,   Frances   E.    Williamson
                        The   definitions   most   generally   accepted   are           and  -@\fonica  V.  Brown  to  study   surveys   conducted
                  those  introduced   in   May,   1970   by   the   National            in Ohio and other  states  on  this  subject.  An  instru-
                  Academy of Sciences which are:                                        ment -,%-as to  be  devised  for  use  in  Ohio  with  the
                            Type A. Assistant  has the      ability to  integrate       target  population  being  Ohio   physicians   -   Doctors
                        and interpret findings on  the  basis  of  general  medi-       ot  '.\Iedicine  and  Doctors  of  Osteopathic   Medicine.
                        cal kno@vledge and  to  exercise  a  degree  of  indepen-             In  1970,  the   Ohio   State   Medical   Association
                        dent judgment.                                                  conducted    an     "Opinion     Survey"     which     included
                            Tyi)e  B.  Assistant  possesses  exceptional   skills
                                                                                        amon, its questions: "Do
                        in one clinical specialty,  or,  more  commonly  in  cer-             0                          you   favor   the    employ-
                        tain procedures-within a specialty.                             iiient  of  trained   'physician   assistants'   to   work   in
                                                                                a       ph@   .' ' '  offices  performing  such   tasks   as,   (a)
                            Type C. Assistant  is capable of performing                       sicians    I
                        variety  of  tasks  over  the  whole  rang@  of   medical
                        care,  but  does  not  possess  the  medical   kno@vledge       preliminary   screening    for    illness;    (b)    .vell-baby
                        necessary to integrate and interpret the findings.              examinations; (c) family planning.
                                                                                              An  excellent   return   of   5,400   replies   was   re-
                  In     Ohio                                                           CeIX-E-Cl  on  that  survey,   representing   55   percent   of
                                                                                        fori-ns inalled.
                        Ohio   currently   has   no   provision    for    govern-             Of those responding, 46 percent said             cc   yes'
                  mental  licensing   or   registration   of   "Physicians'   As-       and  54  percent  "no"  on  (a)  ;   39   percent   "yes"   and
                  sistants,"   and    various    health    groups    have    been       61 percent   11 no"  on  (b)  ;  and   47   percent   "yes"   and
                  attempting   to   survey   Ohio   physicians    to    determine       ,-)3 percent "no" on (c) .
                  the  present  and  future  use   of   this   form   of   health             iNo  other   attempt   has   been   made   in   Ohio   to
                  professional.                                                         obtain     additional     and     comprehensive     information
                        In  1970,  the  physician  assistant   and   nenv   types       despite  concern   exhibited   by   all   involved   in   plan-
                  of   health   manpower   were    studied    by    the    Health       ning  for,  delivery  of  and   education   for   delivery   of
                  Manpower   Committee    of    the    State    Advisory    Coun-       healtl-i care.
                  cil,   Ohio    Office    of    Comprehensive    Health    Plan-             'I'lic  final  draft   of   the   Ohio   instrument   was
                  ning, Department of Health, State of Ohio.                            approved   in   May,   1972.    The    project    was    imple-

                  242   /   Y'he Ohio State Medical journal


                                                                                           Sreciati.,,l Service
                                                                                                                                        IN
                                                                                                                                      A
                                                                   PROFESSIONAL Li BILITY INSURANCE
                                                                                             @i  ct  4i9l@  I)ICtill@  0   cliiiilltclion

                                                                                    Professional                   Protection  Exclusively   since   1899

                                                                                                                              OHIO  OFFICES:
                                                                                 CINCINNATI:     Room     700,      3333      Vine      Street,      (513)      751-0657,      L.      A.      Flaherty
                                                                     CLEVELAND:  Suite  106,  23360  Chcigrin  Boulevard,  Beachwood  44122,  (216)  464-9950
                                                                                                               A.  C.  Spoth, Jr.,  R.  A. Zimmermann
                                                                                        COLUMBUS:      1989      West      5th      Ave.,       (614)       486-3939,       J.       E.       Hansel
                                                                               TOLEDO;     Suite     212,     4334     W.     Centrcil     Ave.,     (419)      531-4981,      R.      E.      Stall

                                                                                                                                                                                                   DESCRIPTION: r.!@thyltestosterone is 17i,'-Hydroxy.17.Nlethyland,.st4e,
                                                                                                                                                                                                   3-o@e.
                                                                                                                                                                                                   ACTIONS: t.l@t@)ltesto,tero@e is an oil soluble androgenic hormone.
                                                                                                                                                                                                   INDICATIDNS:  In  t,,e  @le:  1.  E@nuchoidism   and   eun@chism.   2.
                                                                                                                                                                                                   climacteric @y.;t-.s he, these are seconlary to androgen deficiency.
                                                                                                                                                                                                   3,,it.potence d,e to androgenic deficiency. 4. POs tpube,al    c,ypt@r-
                                                                                                                                                                                                   @ di,m with @@ide,ce of hypogonadis@.
                                                                                                                                                                                                   Cholestatic he,"titis with jaundice and Itered liver function teis, s,ch
                                                                                                                                                                                                   as increased BSP ete@ti.n and ri@e@ in SGOT le@ls, have been ep@,t@d
                                                                                                                                                                                                   after Methyt@st t@r an e.     These     changes     appear,0be  rela@d,   to
                                                                                                                                                                                                   dosage ol,t.,@ drug. Therefore, in the pre .. ce of any hage@  n  [,,e,
                                                                                                                                                                                                   for, ti n sts, drug sho@ld be dis@ontInued.
                                                                                                                                                                                                   PRECAUTIONS: P,@o@ged dosage of androgen .'y  resuit  in  sodium   and
                                                                                                                                                                                                   fluid reteThis  ay   Present   a   proble@@   especially   in   patients
                                                                                                                                                                                                   ,,ith co @pr..,ised cardiac reserve on renal disease. In treating  MI@@
                                                                                                                                                                                                   far sympt@ of climacteric, @@oid stimulation to the  p.int  of
                                                                                                                                                                                                   i,g Ihe he and  physical  activities  bey@d  tt,e  p@t  art   a
                                                                                                                                                                                                   cardiovascular capacity.
                                                                                                                                                                                                   CONTRAINDICATIONS: Cont,alndicated in persons  with  k@o.n  or
                                                                                                                                                                                                   pectad care o-,@a of the p,.@ate and in       carcinoma f the  @3le  b,e3,t.
                                                                                                                                                                                                   co ntraindicated in the presence cfsevere  liver   damage.
                                                                                                                                                                                                   WAR'[NGS: If or .theI@ig@s   of   e."Ssive   se@ual    stim@l@io'
                                                                                                                                                                                                   d@@ll. , dis,@,.ti,@ therapy, la the @.ale, prolonged adminis ratio, or
                                                                                                                                                                                                   ssp@,@  dosage  @y  cause inhibition of   te@tic@iarto ctti@,, itt,
                                                                                                                                                                                                   res@ltant and de                              me. Use        caA
                                                                                                                                                                                                   iously in y.,g b@y@ to @@oi                   sure           r pre
                                                                                                                                                     @,iUQE-:TS                                    co,i.0,P-nt.                                  c.@sti@      may
                                                                                                                                                                                                   p    @y
                                                                                                                                                     E3UCCAL7Tabs                                  occur rare y. BI   ,be  d                     ag.a@d,.g,    s.
                                                                                                                                                                                                   Hyp@r@alce.l@ @.@y p@                         f   ,
                                                                                                                                                                                                   breast If this cc@r                           ti@u@d.
                                                               n roic .
                                                                                                                                                                                                   ADVERSE REACTIONS: Cholestatic Jaundice - Oligospermia and  de
                                                                                                                                                                                                   creased ciac@iat.ri olu,,e. - Hyp@rcalcemia particularly in patients
                                                                                                                                                                                                   ,ithet,I@, I .... I ca,,ino,,. Tlil Usually inli at , 11 Ires,ion of
                                                                                                                                                                                                   bon@ Sodium  and  water  retention.  -  Priapi@@,  -   Virili-
                                                                                                                                                                                                                                             one ma @ti
                              Methyltestosterone N.F. - 5 mg.                                                                                                                                      ti@n in i-@ e patients - Hyper@e@siti@ity and gy@c e 0
                                                                                                                                                                                                   DOSAGE AND ADMI?IISTR@TION: Dosage must be st,i@ly i@di@id@@ii.,
                                                                                                                                                                                                   as Pa
                                                                                                                                                                                                   @ic id@ly   n   req   reme@ts.   Daily   requirements   are   b
                                                                                                                                                                                                   ast@,,, in decided d@es. The following cl,art is suggested as an
                                                                                                                                                                                                   erag@ daily dosage g@ide.
                                                                                                                                                                                                   INDICATION                                Average Daily Dosage
                                                                                                                                                                                                                                                 Tablets
                                                                                                                                                                                                   In the male.
                                                           n                      roi                                                                                                              Eunucholdi'n and e@nuchi@m                        10 to 40  ,g
                                                                                                                                                                                                   M@le symptoms and impotence
                                                                                                                                                                                                   due to androgen deficiency                        10   to   40 ,g@
                          Methyltestosterone N.F. -1 0 mg.                                                                                                                                         .stpuberal c,,jpt-rchism                                     30 @Z,
                                                                                                                                                                                                   HOW SUPPLIED: 5, 10, 25 .9. in b.ttles of 60, 250.

                                                                                                                                                                                                   Write for Literature and Samples              REFE-R        TO
                                                       n roi                                                                    of;                                                                                                              TDJR
                                                                                                                                                                                                   THE BROWN PHARMACEUTICAL CO., INC.
                      Methyltestosterone                                                                            I F. - 25 mg.                                                                  2500  West  6th  Street,   Los   Angeles,   California   90057

                                                                                                                                                                                                               April, 1973 /  241


                          i-nentecl     by     Health     Careers      of      Ohio      with      funds                   'J'al)le III. Possible Obstacles to Use of
                          provided       b@,        Northeast        Ohio        Re@ional        Medical                              Nonphysician             Personnel
                          Pro@ram@       Ohio       State       Regional        medical        Pro.-ram;         3. Do   You   regard   the    following    factors    as    major    obstacles
                                  N7 '                                                                              to    greater    uses    of    trained    nonphysician     personnel     in
                                     allen-      Regional      Medical       Program       and       the            medical practice?
                          I)el)artnien@      of      Health,      State      of      Ohio.      Endorse-                                                                    %
                          iiient     was     received     from     the      Ohio      State      Medical                Factors                                        YES
                          Association,      Ohio      Osteopathic       Association       of       Ph@--            Shortage of trained ,vorkers               ...     53.6           24.9
                          si     ians      @ind      Surgeons,      Ohio      Hospital      Association,            Patient           non-acceptance       .......     43.7           36.5
                                                                                                                    Impairment of Physician-
                          Ohio       Office       of       Compreheiisi%-e       Health       Plannino-,                Patient         relationship ........          42.5           37.8
                          Department      of      Health,      State      of       Ohio,       Northeast            Higher cost                  .................     33.8           45.2
                          Ohio        Regional        Medical        Prooram,        Ohio        Valle),            I-,',xcess time for supervision           ....     35.9           42.2
                          Regional       -@Medical       Program,       Northwest        Ohio        Re-            Legal   and    insurance    problems    .    .     69.0           13.5
                          gional       imedical        Program,        Ohio        State        Regional            Lack   of   office    space    ..........          29.4           48.4
                          Medical      Procram       and       Health       Careers       of       Ohio.            High       worker       turnover ........          27.5           43.6
                                             CD

                                        American  Medical Association
                                The       American       Medical       Association        has        ap-            'I'al)le IV. Future Considerations Regarding Use of
                          proved     guidelines     for     the     Assistant     to     the     Primary                              Nonpliysician            Personnel
                          Care      Physician.      Seventeen      procrams      have      been      ap-                                                         ith   a   view   to    employ-
                                                                                                                 @VoLtIcl you     consider     interviewing,      w
                                                                                                                 ing  the following graduates and            persons    with     other     spe-
                          proved.     National     Certification     of     Physician      s      Assis-         cifi"d training?
                          tants     by     Uniform     Examinations     is     now     under      study.                                                                  O/.
                                                                                                                 Graduates of -                                        YES            N%"
                                                                                                                    Four     year      programs    ..........          40.3           33.0
                                                                                                                    'I'hree      year       programs .........         35.5           35.5
                                                   Federal Support                                                  Two to three year programs                 ...     34.0           37.6
                                                                                                                    Two      year      programs    ..........          30.4           41.1
                                As  of  October,  1972,  more                 than      $6       million         Other    persons    with    specified    training
                          dollars     in     contracts     and     grants     had      been      awarded            Persons      with      extensive
                          to    institutions    in     26     states     and     the     District     of                on-the-job          training .........         41.4           30.3
                          Columbia       by       the       Bureau       of       Health        Manpower            Allied health professionals and
                                                                                                                        additional          training .........         39.6           30.4
                          Education,       National       Institutes       of       Health,       Public            Registered      nurses      with
                          Health      Service,      U.S.      Department      of      Health,       Edu-                additional          training .........         51.5           23.6
                          cation and Welfare.                                                                       Licensed practical nurses with
                                                                                                                        additional          training .........         42.1           31.0

                                 Table 1. House Calls and Physician Assistants
                          1.  Could a trained assistant-                         YES            NO                                            Legislation
                              (a)   replace you in any of your
                                    house calls              ..............      18.5           38.9                    Twenty-five     states     now     have     legislation     of     dif-
                                    L] DO NOT make house                                                         ferent     types      for      physician      assistants.      These      are:
                                        calls.  (19.5('/o)                                                       Alabama,        Alaska,         Arizona,         Arkansas,         California,
                              (b)   help you in any of your                                                      Colorado,        Connecticut,         Delaware,         Florida,         Geor-
                                    house calls              ..............      26.9           28.3             gia,       Idaho,       Iowa,        Kansas,        Maryland,        Michigan,
                              (c)   help in emergencies              ......      58.9           15.3             I\Iontina,        New        Hampshire,        New         York,         North
                                                                                                                 Carolina,          Oklahoma,          Oregon,          Utah,          Vermont,
                              (d)   help in minor surgery              ....      55.0           15.1             IVasliington     and     West     Virginia.     In     the     absence      of
                                                                                                                 legislation,    the    role     of     physician     assistants     is     de-
                                                                                                                 ten-iiined     by     custom      and      usage.

                                    'I'able II. How Physician Assistants Would
                                                      Affect       Practice
                          2.   Please   check   how   you   feel   greater   use   of    trained    non-                                               Terminology
                              physicians in your'practice would affect -
                              (@i)   its   quality   El   Increase   []   No   change    F-I    Decrease                In discussion        of    the    recognition     of     the     physi-
                                                         2 8.4 'Yo        40.3%             1 5.  2  "lo         cian   assistant,    and,    in    fact,    with    all    of    the    health
                              (b)   its   volume   D    Increase    E]    No    change    F]    Decrease         professions,       much       confusion       exists       regarding       the
                                                         52.9%            2 7.2 clo           3.5    ol,         definition     of     terms.     Following     is     a     glossary      com-

                                                                                                                                                                 April,     1973     /      243


                 iled     by     the     Department     of     Health,      Education        .,\I)otit  t%@'o-tliirds  of  replies  were  received   fro",
               i)
                                                                                                               and  roiiglil@,   one-third   from   pli@,-
               and    N%'elfare    @@71iich    defines     various     methods     of    solo practitioners,
                                                                                         s'(,.'ans  'II group  practice.     Replies     were     received
                ,iccel)taiicc.                                                           I I     I                                 elds    of    practice,
                                                                                         fi@oill I)li)@si(.,,],ins in 34 different fl
                                                      process   b),    @@-hicli    an                                'on   of   Ohio   pli),sicians   1)),
                          Accreditation  is  the                                         iicll(,,@iting ,t (@ross secti
                        agency or an organization    evaluates     and     recogniz@-    t@1)(@, Of J)r@t("tlcc as \%,ell a,.; gcoyrapliicall),.  E-cl.,  988
                        a  program  pf   study   or   an   institution   as   meeting                                         0
                        certain I)redcterininIed    clualifications    or    standards:                  i-ecei\@ed    from     general     practitioners,
                        Accreditation  sliall  appi  only   to   institutions    anti                                                       rnists,   etc.
                                                  y                                      333 from oclieral surgeons, 404 front inte
                        programs.                                                                    n
                           Certification   is   the   process   by   which   a   non-         i\lai-i@,  of  the   respondents   (38.9   percent)   N@,lio
                        go%-eriiriiental agency or association                  ogni-    IlllKc  house  calls  indicated   that   pli),sician   assistants
                                                                grants rec
                        tion to an  ind i@'i dual   who   has   met   certain   predeter- could  not  replace   them   on   the   house   call,   but   the
                        inined   qualifications   specified   by   that   agency   or
                        association.                                                     respondents   were   evenly   divided   on   the    sub'ect    of
                                                                                         helping  on  house  calls  (See  Table  1)  .   The   niaj'orit),
                           l,icensure   is   the   process   by   which   an   agency    (,)2.9   percent)   of   those    responding    felt    that    a
                        of Llo%7ernment  grants  permission  to  perso.n      ting                         tant   would    increase    the    number    of
                        Iredetermined                          g       s   nice
                                         ualifications  to  en   age   in   a   given    1)11N-siclaii assis
                                        q
                        occupation   and/or   to   use   a   particular   title,   or    patients  that  i   physician   could   see,   and   most   (68.7
                        grants  permission  to  institutions  to  perform   specified    I)er(,,eiit)  indicated   that   the   qualit@,   of   i-nedicin-
                        functions.
                                                                                         @%@otilcl   either   increase   or   not   change   (see    Table
                            Registration  is   the   process   by   which   qualified
                        indi@ridlials are listed on  an  official  roster  maintained
                        by   a   governmental   or   non-governmental   agency.                N\'Iicn    questioned     about     possible     obstacles,
                            Qualifying  examination   is   a   criterion   for   mea-    most   respondents    listed    legal    and    insurance    pro-
                        suring  an  individual's  ability   to   meet   a   predeter-    arlillis is the bio-cest obstacles (see Table 111) .
                        mined standard.                                                  ZD
                            Equivalency   testing   is   the   comprehensive    eval-
                        uation    of    knowledge    acquired    through    alternate
                        learning  experience  as   a   substitute   for   established
                        educational requirements.                                                                 Conclusions
                             Challenge    examination    is    equivalency    testing
                        which leads   to  academic  credit   or   advanced   standing           In   conclusion,   the    survey    ,vas    productive    in
                        in  lieu  of  course  enrollment  by  candidate.                   tliro@vin,,f  light  on  current  practices   in   the   use   of
                             Proficiency   testing   assesses    technical    kno.wl-      Pli),siciaii  assistants  in  the  broad  sense  of  that   term,
                        edge  and  skills  related  to   the   performance   require-      but is clouded as to future practices.
                        ments  of  a  ST)ecific  job;  such  knowledge   and   skills
                        may  have  bee@n  acquired   through   formal   or   informal           It    appears    that    Ohio    physicians    are     about
                        means.                                                             equally   divided   on   the   issues   of    employing    physi-
                         The    survey    @vas    conducted    by    mail     between      C'ian   assistants.   A\'ith   the    possible    exception    of
                   July   15   and   September    15,    1972.    The    number    of      Registered   Nurses,   the   respondents    -,vere    split    on
                                                                                               plo)-incr   graduates   of    ancillary    medical    person-
                   questionnaires    mailed    (less    those    undeliverable    and      cut
                   returned    blank)     was     12,908.     Of     that     number,      nel training programs (see Table IV).
                   3,472   responses   were   received,   for    a    27.0    percent            Perhaps,   if   the   legal   and    insurance    questions
                   return.   Of   Ohio's    88    counties,    replies    were    re-      are  solved  in  the  near   future,   and   if   trainina   pro-
                   ceived    from    86,    'Vinton    and    Wyandot    being    the      gi@aii-N  continue  to   grow   as   they   do   now,   the   use
                   only  counties   from   -,vhlch   no   replies   Nvere   received.      of noiipli@-siciai-is as assistants Nvill increase.
                                               Wolman Insurance Ageiftcy, Inc.
                                                         Specialists in Professional Liability
                                                  Providing Personal Service to Physicians and
                                                  Surgeons with Qualified Personnel Available
                                                  to    Discuss  Your         .     Insurance  Needs  in Your
                                                  Office.
                                                            WOLMAN  INSURANCE  AGENCY,  INC.
                                                                          PHONE 614/221-5471
                                                    38 JEFFERSON AVENUE, COLUMBUS, OHIO 43215

                        244     Y'he   Ohio   State   Vfedical   journal


                                                            ,@ lli'.L H,      i 6@  0:
                                                                                                m
                                                   I--7 S. High Stree't              -r r,
                                                   columbus, olaio 432-
                                                                         C'            -500
                                                                            irco 9.4
                                                                        AF,R      '7" .

                                                                I


                                                                                         r7   5u
                                                        e                 e            m
                                                N e       c     @,L
                                                                                  P7  @(;3

                                              i@y dos@ aid
                                            -V      by computer
                                            EAST     ORANGE,     N.J.-To     guai--
                                            antee safe, precise, and effective  ra-
                                            diation  doses,  22  hospitals  in  New
                                            Jersey  belong  to  a  statewide  tele-
                                            type  network  linked   to   the   Dose
                                            Distribution    Computation     Service
                                            at   New   York's   Memorial   Hospital
                                            for Cancer and Allied Diseases.
                                              Data on  patients  are  sent  to  Me-
                                            morial's  computer,   which   evaluates
                                            the   information   and    returns    a
                                            treatment  plan  to   the   originating
                                            hospital'
                                              The New Jersey                      i-
                                            c        am's (NJI                    n
                                            Automated  Dosimetry   in   its   first
                                            year  of  operation  has  upgraded  the
                                            treatment  of  9,500  of  the   state's
                                            annual  total  of  26,000  new   cancer
                                            patients, notes Dr.  Alvin  A.  Florin,
                                            NJRMP coordinator.
                                              Dr. Florin  says  the  project  "per-
                                            mits patients to be treated in  facili-
                                            ties  near  their  homes  and,  because
                                            the  project  can   compute   treatment
                                            plans in one fourth to  one  tenth  the
                                            time it took  in  the  past,  more  pa-
                                            tients can be treated."               4


                      Bold New Programs Fill'Country Doctor'Role
              Playing  hard   as   usual,   8-year-old   Juan    American   Medical   Association,    who    con-
            flailed  his  arms  in  a  diving  lunge  at  the    ceived the idea.
            thrown  football.  One  hand   came   down   hard      It is  to  these  new  approaches  that  rural
            against a rock hidden  in  the  grass,  and  Juan    America  must  look  for  health  care,   rather
            yelled  in  pain.  He  had  to  leave  the   game    than  waiting  and  hoping  for  a   doctor   to
            and go  home.  Soon  the  hand  began  to  swell,    settle in their midst, Dr. Snyder says.
            and  Juan's  parents  worried.  They   put   Juan
            in  the  car  and  took  him  into   the   nearby      Why?
            town   for   medical   attentions    town    that      "Because  it  is  obvious  that   many   small
            hasn't had a doctor in five years.                   communities  that  once  had  their  own  physi-
              The  town   happens   to   be   Estancia,   New    cian  will  never  again  have  one,"  he  said.
            Mexico,  where  a  new  kind  of   rural   health    "There  are  a  number  of  reasons  why:   Eco-
            care is being practiced.                             nomic conditions of  the  area,  isolation  from
              Juan's parents  drove  to  a  one-story  build-    professional  associates  and  cultural  activi-
            ing off the  main  street,  where  the  hand  was    ties, plus the demands put on  a  single  doctor
            x-ra  ed  and  found  to  be  broken.  The   lady    when.  he  has  to  serve  a   whole   community
                y                                                and the surrounding area."
            in  charge  sprinted  the   hand   and   directed
            iuan's parents to a  hospital  in  another  town,      It  is  not  that  young  physicians  are  not
            where a cast could be applied.                       dedicated-they  are,  and  that  very  fact  de-
                                                                 ters them  from  settling  in  a  country  town,
              The lady was not a doctor,      nor  a   nurse.      r. Snyder said.
            She was  a  nurse-practitioner,  a  new  type  of
            medical worker . . .                                   "These  young  doctors   have   been   brought
                                                                 up in an era of sophisticated medicine,  sophis-
              Far  to  the  east  of  Estancia,   a   minibus
            stopped  on  a  road  in  the  Maine   woods.   A    ticated  technology,  communication  and  trans-
            woman got in, for a  ride  to  the  Rural  Health    portation . .  .  all  of  which  can  sometimes
            Associates clinic, a "doctor's  office"  for  not    mean  the  difference  between  life  and  death
            just one  town,  but  a  couple  of  dozen  towns    for a patient,  and  they  are  aware  of  this.
                                                                 They  want  to  be  equipped  to  practice   the
            . . .                                                best medicine they can."
              In Salem, Mo., a heart  patient  got  an  elec-      How,  then,  can  the.  wants  of  both  rural
            trocardiogram.  Within  minutes,   a   specialist    residents and physicians be satisfied?
            at the University  of  Missouri  medical  center,
            130  miles  away,  was  analyzing  the  EKG   ...      One  answer  is  found  in  the  Rural  Health
              Those  are  three  examples  of   areas   where    Associates  in  Farmington,   Maine,   a   group
            totally new  methods  of  health  care  have  re-    practice  headed  by  Dr.  David  C.  Dixoni   a
            placed-or   augmented-the   traditional    "coun-    36-year-old  surgeon.  After  he  finished   his
            try doctor."                                         residency  a  few  years  ago,   he   says,   "I
                                                                 wouldn't go to a little town as  the  sole  phy-
              Another  new   approach   may   prove   to   be    sician.
            the most widely applicable  of  all  for  doctor-
            short areas-satellite  clinics  scattered  around      "The reason I and  other  doctors  don't  want
            a county  and  staffed  by  physicians  from  the    to do that is a great fear of intellectual  ste-
            county's  primary  city  or  town.  This   method    rility,  although  some  physicians   may   give
            is   being   inaugurated   in   Fresno    County,    other reasons-such  as  not  wanting  to  be  on
            Calif., home of  Dr  Leopold  J.  Snyder,  chair-    call 24 hours a  day.  It's  not  the  work-what
            man  of  the  Council  on  Rural  Health  of  the              (Continued on Page 787)

            782                                 JOURNAL   OF THE MEDICAL ASSOCIATION OF THE STATE OF  ALABAMA


                                                           PESTICIDE INTOXICATION
                 Treatment:              Atropine                                                               2-PAM
                                         12:30   a.   m.   4  mg     IV                               2:  00  a.   in.   1,000-   mg   IV
                                          1: 30  a.  in.   2  mg     IV
                                          2:30   a.  in.   2  mg     IV
                                          5:30  a.   in.   1  mg     IV
                                         10:00   a.   m.   .8 mg       oral
                                          2:00   p.   m.   .8 mg       oral
                                         Total:         10.6  mg
                 Later Course:           Fully   recovered.
                                                                                  described   for   Case   No.   1;   only    the    most
                 'All patients   exhibited    symptoms    similar    to     those
                 pronounced      symptoms        are mentioned for patients 2 through 9.
                                     Diwussion                                  this   type   of   poisoning   and    thereby    avoiding
                                                                                fatalities     through     prompt      diagnosis      and
                  The    patients     showed     marked     recovery     by     treatment.
                 .6  a.  m.,   March   10,   and   were   discharged   from
                 the  hospital  at  5:  10  p.  m.  that  day  to  the  Mt.                     Ref erences Cited
                 Meig's    Medical    Treatment    Center     for     pris-       1. Berstein, S.,  J.  H.   Gould,   and   A.   DePalma.
                 oners.   After   observation    at    the    Center    for     1968.  Parathion   poisoning   in   children:   Two   re-
                 two    days,    they    were    returned     to     Draper     coveries  and  one  @atality.  J.   Med.   Soc.   N.   J.
                 Prison   and   kept   in    the    infirmary    for    two     65(5):  199-203.
                 more days.                                                       2.   McLeod,   R.   A.,   1970.   An    epidemiological
                                                                                study  of  pesticide  poisoning  in   patients   admitted
                   Of  particular  interest   is   the   fact   that   only     to  Charity  Hospital,  New  Orleans.  La.   State   Med.
                 one   of   the   nine   prisoners   had   an    abnormally     Soc., 122(11) :337-343.
                 low   cholinesterase   level;   levels   in   the    other       3. Pietsch, R. L., J. F. Finklea,  J.  E.  Keil.  1968.
                 eight  were  low   but   still   in   the   normal   range     Pesticide  poisoning  in  South  Carolina.   J.   S.   C.
                 of   cholinesterase    values.    It    was    also    in-     Med. Assoc. 64(6):225-228.
                 teresting  to   note   that   all   nine   showed   higher       4.  Quinby,  G.  E.,  and  Clappison,   G.   B.   1961.
                 than    normal    levels    of    glucose.    Fortunately,     Parathion    poisoning.     Arch.     Environ.     Health
                                                                                3: 538-542.
                 none   of   the   victims   were   diabetic.    All    the
                 patients    recovered     quickly     and     were     re-       5.  Quinby,  G.   E.,   and   Lemmon,   A.   B.   1958.
                                                                                Parathion  residues  as   a   cause   of   poisoning   in
                 turned to normal duties at the prison.                         crop  workers.   J.   Amer.   Med.   Assoc.   166(7):740-
                                                                                746.
                   Although  the  prisoners  disclaimed                 any       6. Reich,  G.  A,  Gallaher,  G.  L.,  Wiseman,  J.  S.
                 knowledge that an insecticide had been                used     1968.  Character'istics   of   pesticide   poisoning   in
                 as    the    masking    agent,    they    admitted    this     South Texas.  Tex, Med. 64(9):56-58.
                 would    not    have    deterred    them    from    drink-
                 ing    the    homemade    brew     since     they     were       A    temporary,    artificial    vitreous    for    the
                 unaware   of   the    toxicity    of    insecticides    to
                                                                                eye  is  being   used   at   several   medical   research
                 humans.
                                                                                centers.   Vitreous   is   the   clear    gel    material
                                                                                inside   the   eye   which    gives    it    shape    and
                                       Conclusion
                                                                                helps   hold    its    parts    in    place.    Shrinking
                    The   inherent    dangers    of    pesticides    should     vitreous   is   a   major   cause   of   retina    cletac.I-
                 be   made   known   to   all   persons   who   may    come     ment,    which    affects    the    vision    of     many
                 in   contact   with    these    compounds.    The    inci-     Americans   every   year.   The    retina    lines    the
                 dent   described   in   this   paper    exemplifies    the     inner  wall  of  the   eye   and   transmits   light   to
                 importance   of    physicians    being    familiar    with     the brain via the optic nerve.

                 MAY,   1973-VOL.   42.   NO.   II


                                                     'COUNTRY DOCTOR'

                      (Continued from Page 782)                       The health  care  situation  there,  according
              they are really  saying  is  that  they  wouldn't    to a local  newspaper,  ranked  with  "the  worst
              be able to maintain their  skills  to  take  care    anywhere."
              of  patients  in  the  way  they  want  to   take       Fresno   County-bigger   than   Rhode   Island
              care of them.                                        and   Delaware    combined-is    farming    coun-
                "But if a man  is  involved  in  a  health  de-    try   ("half   the   cantaloupe   America    eats
              livery system like ours, it's a different  story.    comes  from  the  Mendota   area,"   Dr.   Snyder
              Our system is on call 24  hours  a  day,  but  an    said).    The     permanent     Firebaugh-Mendota
                                                                   population  of  15,000  is  doubled  by  seasonal
              individual  physician  is  only  on  call   eve.,    influxes of migrant workers.
              fifth night.  You  get  days  off.  And  you  can
              figure  on  taking  two  weeks  off  for  contin-       Only  three  badly  overworked  doctors   have
              uing medical education."                             been  available,  and  the  county   health   de-
                The  opportunity  for  consultation  with  oth-    partment  has  held   two   evening   clinics   a
              er  physicians-whether  in   a   group   practice    week in  Firebaugh,  one  a  general  clinic  and
              or with  other  solo  practitioners-also  is  im-    the  other  devoted  to  obstetrics,   gynecology
              portant, Dr. Dixon said.                             and  family  planning.  Each  session   &aws   80
                                                                   to  90  people.  Others  make  the   long   round
                "Medicine is  so  sophisticated  now  that  you    trip to Fresno for  treatment,  "but  since  many
              can take  the  brightest  doctor  in  the  world,    of them don't  have  transportation,  this  means
              and  if  he  doesn't  have   constant   interplay    that  many  of  them  don't  get   health   care,
              with  other  physicians,  and  a  chance  to  get    except in emergencies," Dr. Snyder said.
              back  to  academic   medicine   now   and   then,
              the quality  of  his  care  is  inevitably  going       The problem  was  obvious.  But  the  solution
              to decline."                                         was  decided  only  after  extensive   discussion
                                                                   with residents,  to  get  them  involved  in  the
                Dr.  Snyder  and  Dr,   Dixon   emphasize   tne    planning  and  make  sure  that   whatever   pro-
              importance   of   each   community    or    rural    gram  materialized   would   be   acceptable   to
              area designing  its  own  health  care  plan.  it    them.
              should  be  done  with  all  interested  parties-
              doctors,   business   and   civic   leaders   and       "All  health   programs   should   be   worked
              consumers-discussing    various     wants     and    out as we worked  this  one  out,  at  the  coun-
              needs, they say.                                     ty  level,  with  county  people,"   Dr.   Snyder
                "A  program  applicable  in   one   place   may    said.  People  like  Fidel  De  La  Cruz,   mayor
              not  be  applicable  in   another,"   Dr.   Dixon    of  Mendota,   and   John   Witworth,   who   has
              said. "And there  has  to  be  somebody  to  take    lived in the area  almost  30  years.  The  views
              the lead."                                           of   everyone-from   physicians   to    potential
                The  logical  leader,  added  Dr.  Snyder,   is    patients-were sought.
              the  local  medical  society,   as   in   Fresno,       The  rich,  the  poor,   the   middle   class;
              where  Dr.  Snyder  was  the  catalyst  for   ac-    whites,   blacks   and   Mexican-Americans.   All
              tion.                                                were  asked  what  was  needed.  And  their   re-
                After "playing  with  the  idea  for  15  years    ply  was:  Availability  of  more  physician  and
              and trying to sell it for  10  years,"  he  got'a    dental  services;  emergency  service  at  nights
              $10,000  grant  from   the   California   Medical    and  on   weekends;   transportation   to   local
              Association to get started.                          health facilities as  well as  to  facilities  in
                "We w                                              Fresno;  health  education,  especially  in   hy-
                       ent  out  to  two  adjoining   conununi-
              ties  in  northwest  Fresno   County,   Firebaugh    giene  and  nutrition;  social  and   rehabilita-
              and  Mendota,  about  40  miles   from   Fresno,"    tion  services,  and  payment  for  services   on
              he said.                                                        (Continued on Page 790)

              MAY, 1973-VOL. 42, No. II                                                                          787


       ecause ou
             0
             ice
         0 0
    ine icine in
       o .on a .e...


                                                  'COUNTRY DOCTOR'

                     (Continued from Page 787)                 one  should  receive  care  through  one  door,"
                                                               he said. (The same  philosophy  applies  at  the
            a sliding fee scal    ased on income.              Maine clinic).
              With  the  help  of  more  grant  money  from       "There won't be two  doors,  two  classes  of
            the  federal  Regional  Medical  Program,   the    service-only  one  class,  the   best   quality.
            California Medical Association,  and  the  com-    Those  who  can  pay  will  pay,  others  won't.
            munities,  a  comprehensive  health  care  cen-    This is the kind  of  thing  we  would  like  to
            ter will open this month (November).               see all over."
              It occupies a former  doctor's  office  which       Although "every area has  to  deal  with  its
            was   renovated   by   community   labor,   and    own problems," Dr.  Snyder  feels  that  a  pro-
            much  of  the  equipment   has   been   donated    gram  such  as   Fresno   County's   should   be
            by doctors  and  dentists.  Two  mobile  struc-
            tures, one a dental office and  the  other  ad-    widely applicable,  with  leadership  or  strong
            ministrati%7e headquarters, flank  the  center.    participation  by  the  local  medical   society
                                                               and other health  care  professionals.  (One  of
              The medical unit will provide  a  full  range    the leading  backers  of  the  project  was  Dr.
            of  care,  plus  immunizations,  health  educa-    Tal Carter, a dentist,  of  neighboring  Madera,
            tion and family planning information.              who  offered  equipment  and  staffing  services
              "We  have  close  to  100  doctors  from  the    for the dental unit).
            county  medical  society  who  have  said  they       "You can put all the funds  you  want  to  in
            will either help  regularly  staff  the  clinic    an  area,  and  if  the  health  care  providers
            (on a volunteer rotating basis) at  the  start,    don't assume  responsibility  for  the  project,
            or come out for specialty clinics," Dr.  Snyder    nothing is going to happen,"  Dr.  Snyder  said.
            said. However, he added, "we will  try  to  de-       "The  important  thing  to  me  is  that  our
            %,elop a permanent staff  of  doctors  for  the    medical  society  has  accepted  the  fact  that
            center, and rely  on  society  volunteers  only    it is responsible for the medical  care  of  the
            for back-up purposes.                              whole county. And  from  that  attitude  we  de-
              "We  are   arranging   with   the   community    veloped  this  program-to  give   everyone   ac-
            hospital in Fresno to provide  x-ray  and  lab-    cess to care."
            oratory services  and  we  also  are  arranging       Practicing physicians, he  added,  also  have
            what  is  probably  as  important  as  anything    an  obligation  to  young  doctors  in   helping
            else-transportation."                              to  solve  the  dilemma   mentioned   earlier-of
              Transportation  is  a  special  need  of  the    young  doctors  wanting  to  serve   rural   pa-
            rural poor, he  said.  "Usually  a  family  has    tients but not  wanting  to  be  stuck  in  some
            to wait until the father  gets  home  from  the    isolated  community.   Innovative   projectssuch
            fields with the  family  car,  late  at  night.    as  Firebaugh-Mendota  and  Rural   Health   As-
            Then they will come in with  a  child  who  has    sociates  in  Maine  provide  the  answer,   Dr.
            been  sick  all  day.  This  happens  over  and    Snyder said.
            over again."                                          "If we are  able  to  develop  systems  which
              Now, minibuses will  be  used  to  carry  pa-    will enable young people to fulfill  the  social
            tients to and from the health center  and  oth-    commitment  they  feel,  and  yet  remain   with
            er facilities,                                     their peers  and  maintain  their  skills,  then
              Dr. Snyder, a specialist  in  internal  medi-    they will be able to  settle  in  very  comfort-
            cine  who  expects  to  spend  one  evening   a    ably and carry on after us,"  Dr.  Snyder  said.
            week at the center, said it will  not  be  just    "The  young  person  hardly  has   the   knowhow
            for poor people, but for everyone.                 or the backing to  develop  suc  a  sys  em,  so
              "The  community  has   agreed   that   every-               (Continued on Page 798)

            790                               JOURNAL OF THE MEDICAL ASSOCIATION OF THE STATE OF  ALABAMA


               You carry one of the heaviest
               patient loads in the country.
               Since this may include
               a number of patients with
               gastritis and duodenitis...
               you should know
               more about LibraxOR

               Helps reduce                                                            Patient-oriented dosage - up to
               anxiety-related G.I. symptoms                                           8 capsules daily in divided doses
               A patient may blime his attacks of gastritis or                         For  optimal  response,  dosage   can   be   adjusted   to   suit
               duodenitis on "something he ate" but contribut-                         patient needs- I or 2 capsules, 3 or 4 times a day.
               ing factors may be his job,
               marital problems, financial                                             To hel-v relieve
               worries or some other unm
               tioned source of stress and                                             anxiet'y-linked
               excessive anxiety that                                                                                  0
               exacerbated the condition.                                              svmvtoms in  gastritis
               Whether it is "somethinc,
               he ate"or "somethinc, eating him," adjunctive                           and @duodeniti@s
               Librax  can  help.  Librax  offers  both   the   antianxiety                                      uncfive
               action  of   Librium-'@   (chlordiazepoxide   HCI),   that   can
               help  relieve  excessive   anxiety,   and   the   dependable
               anticholinergic   action   of   Quarzan@   (clidinium   Br),
               that  can   help   reduce   gastrointestinal   hypermotility               Each capsule contains 5 mg chlordiazepoxide HCI
               and hypersecretion.                                                        and 2.5 mg clidinium Br.

               Before prescribing,  please  consult  complete  product  information,      in treatment of anxiety  states  with  evidence  of  impending
               a summary of which follows:                                                depression; suicidal tendencies  may  be  present  and  protective
               Contraindications:  Patients  with  glaucoma;  prostatic  hyper-           measures necessary.  Variable  effects  on  blood  coagulation  have
               trophy  and  benign  bladder  neck   obstruction;   known   hypersen-      been reported very rarely in patients receiving the  drug  and  oral
               sitivity  to  chlordiazepoxide  hydrochloride  and/or  clidinium           anticoagulants;  causal  relationship  has  not  been  established
               bromide.                                                                   clinically.
               NVarnings: Caution  patients  about  possible  combined  effects           Adverse Reactions: No side  effects  or  manifestations  not  seen
               with alcohol  and  other  CNS  depressants.  As  with  all  CNS-           with  either  compound  alone  have  been  reported  with  Librax.
               acting drugs, caution  patients  against  hazardous  occupations           When chlordiazepoxide hydrochloride is used alone, drowsiness,
               requiring c )m,plete mental  alertness  (e.g.,  operating  machinery,      ataxia and confusion mayOCCLir,  especially  in  the  elderly  and
               driving).  T  iough  physical  and  psychological   dependence   have      debilitated. These are reversible  in  most  instances  by  proper
               rarely beei  reported  on  recommended  doses,  use  caution  in           dosage adjustment, but  are  also  occasionally  observed  at  the
               administer  ng  Librium  (chlordiazepoxide   hydrochloride)   to           lower dosage ranges. In  a  few  instances  syncope  has  been
               l,nown  addiction-prone  individuals  or  those  who  might  increase      reported. Also encountered  are  isolated  instances  of  skin
               dosage;  withdrawal  symptoms  (including   convulsions),   following      eruptions,  edema,  minor  menstrual  irregularities,  nausea  and
               discontinuation of the drug and  similar  to  those  seen  with  bar-      constipation, extrapyramidal symptoms, increased and
               biturates, have been reported. Use of  any  drug  in  pregnancy,           decreased libido-all  infrequent  and  generally  controlled  with
               lactation, or in women of childbearing  age  requires  that  its           dosage  reduction;  changes  in  EEG  patterns  (low-voltage  fast
               potential benefits be weighed against its possible  hazards.  As           activity) may appear during and after treatment; blood
               with all anticholinergic drugs, an  inhibiting  effect  on  lactation      dyscrasias  (including  agranulocytosis),  jaundice  and   hepatic
               may occur.                                                                 dysfunction  have  been  reported  occasionally  with   chlordiaz-
               Precautions: In elderly and debilitated,  limit  dosage  to  smallest      epoxide  hydrochloride,  making  periodic  blood  counts  and  liver
               effective  amount  to  preclude  development  of  ataxia,   overseda-      function  tests  advisable  during  protracted  therapy.   Adverse
               tion or confusion (not more than  two  capsules  per  day  initially;      effects reported with Librax are typical of anticholinergic agents,
               increase  gradually  as  needed  and  tolerated).  Though   generally      i.e., dryness of mouth, blurring of vision, urinary hesitancy  an,(l
               not  recommended,  if  combination   therapy   with   other   psycho-      constipation.  Constipation  has  occurred  most  often   when
               tropics  seems  indicated,  carefully  consider  individual   pharma-      Librax  therapy  is  combined  with  other   spasmolytics   and/or
               cologic effects, particularly in use of potentiating  drugs  such  as      low residue diets.
               MAO  inhibitors  and  phenothiazines,   Observe   usual   precautions
               in presence  of  impaired  renal  or  hepatic  function.  Paradoxical                    Roche Laboratories
               reactions (e.g., excitement, stimulation and  acute  rage)  have                         Division of Hoffmann -LaRoche Inc.
               been reported  in  psychiatric  patients.  Employ  usual  precautions                    Nutley, New Jersey 07110


                                                       'COUNTRY DOCTOR'

                        (Continued from Page 790)                    and  bruises,"  said  the  attractive  mother   of
                                                                     foui-, @,btit  that  slows  down  when  the  chil-
              that is  oui-  responsibility,  @e  responsibility     di-en go back to school."
              of organized medicine."
                 Some of those  systems  will  utilize  ph--vsi-       The  center   was   formerly   occupied   by   a
                                                                     ctoctor.  After  he  moved  away,   the   town   of
              cians fulltime  or  only  part  time,  and  others     800 could not  attract  a  replacement.  So,  with
              Will  utilize  physicians'  assistants  or  nurses     a  grant  from  the   federal   Regional   Medical
              only,  With  physicians  acting  as  advisors,  he     Program,   the   University    of    New    Mexico
              added.
                                                                     medical  school  trained   Mrs.   Schwebach,   the
                 Here  is  a  brief  look  at  some  other  pro-     nation's first  nurse-practitioner.  She   was   a
              grams:                                                 registered  nurse  living  in  Estancia  with  her
                 -RURAL            HEALTH            ASSOCIATES,     rancl@er-liusband.  Mrs.   Schwebach   got   seven
              FARIVIINGTON,    MAINE,    Organized    a     year     months  of  special  training   at   the   medical
              ago  by  Dr.  Dixon  and  four  other   physicians     school.  enabling  her  to  provide  "first  line"
              to provide care in  a  doctor-short  area  of  I,-     care   Such   as   suturing,   physical   examina-
              900-sqLtare  miles  and  29  towns  around   Farm-     tions, x-rays and splinting.
              ington,  Maine.  Physicians,  business  and  labor       She  does  not  diagnose  illness   but   "sorts
              leaders   and   consumers   reviewed   needs   be-     out  the  normal  from  the  abnormal,"   and   is
              fore  deciding  on   a   non-profit   corporation,     linked  by  special  telephone  to  physicians  at
              Vehicle  @vas  started  with  financial  aid  from     the medical  school.  Doctors  are  always  avail-
              the Office of Economic Opportunity.                    able to  her.  Two  physicians,  one  a  pediatri-
                 RHA  runs  a  central  clinic  in   Farmington,     cian, and a dentist also visit  the  center  week-
              and s@itellitc@ clinics have opened or  will  open     ly.   Each   Wednesday   morning,   Mrs.    Schwe-
              soon in Rayigel@,, Jay and  Kingfield.  All  clin-     bach is at the  medical  school,  conferring  with
              ic-,;      @i physician,  and  all  will  soon  be     doctors  and  collecting   reading   matter,   all
              linked  by   a   television   communication   sys-     part of her continuing education.
              tern, providing  instant  consultation.  Here,  as       As a  new  type  of  health  professional,  Mrs.
              ii-i  Fresno  County,  the  "one   door"   concept     Schwebach   has   met   with   enthusiastic    ac-
              applies  for  rich  and  poor  among  the   30,000     ceptance, although patients  still  are  a  little
              residents  served.  The  doctors  and   two   den-     unsure  of  what  to  call  her.  "Some  call   me
              tists  are  unaware  of  who  is  paying  and  who     nurse,  some  call   me   doctor-and   some   just
              isn't.                                                 call me Martha!" she laughed.
                 The  medical  staff  also  has  grown,  instead       -AUTOMATED     DEVICES.     In     the     Ozark
              of losing  doctors  as  is  usually  the  case  in     town of Salc-m,  Mo.,  Dr.  Billy  Jack  Bass  has
              rural areas. "The  thing  that  is  gratifying  to     a   unique   "medical    assistant"-a    computer-
              me,"  Dr.  Dixon  said,  "is  that  we  have   at-     telephone  linkup  with  the  University  of  Mis-
              ti@acted three  really  fine  physicians  in  just     souri  medical  school   130   miles   away.   The
              one year."                                             arrangement  helps  him  in   several   ways:   by
                 -NURSE-PRACTITIONER,                  ESTANCIA,     connecting  him  with  medical  specialists,   for
              NEW    MEXICO.    One    recent    morning     was     consultation (he used  to  have  to  refer  diffi-
              fairly  typical   for   Mrs.   Martha   Schwebach,     cult cases  to  St.  Louis  specialists  and  "the
              the  nurse-practitioner  at  Hope   Medical   Cen-     trip and  expenses  are  hard  for  people  living
              ter.  Besides  the  little  boy  with  the  broken     on  hard-scrabble  farms");   by   storing   medi-
              hand, she  saw  eight  other  patients,  including     cal records,  and  by  increasing  the  efficiency
              a  woman  with  tuberculosis  and  a   young   man     of his office.
              with flu,                                                The  equipment  enables   a   patient   to   get
                 "In summer I do a  lot  of  suturing,  of  cuts     a full battery of tests  in  less  than  3  hours,

              798                                  JOURNAL OF THE    MEDICAL ASSOCIATION OF THE STATE OF ALABAMA


                                              If he!s makin@ the
                                     rounds of San F@anc *Isco

                                                   (mecl*lz*lne
                                            .,.,or ver"

          Antivert"  (meclizine  HCI)  has   been   found                      CONTRAINDICATIONS.       Administration        of        Antivert
          useful in the  management  of  vertigo  associ,                      during  pregnancy  or  to   women   who   may   become   pregnant
                                                                                     traiiidicated in view of the  terato,7enic  effect  of  the
          ated with diseases aff ecting the vestibular sys-                    'd'r uco,'Ii n r a t s.
                                                                                  I
          tem. It is  available  as  Antivert  (12.5  mg.                        The  administration  of  meclizine  to  pregnant  rats   during
                                                                               the 12th-15t]i day of gestation  has  produced  cleft  palate  in
          meclizine  HCI)   and   Antivert/25   (25   mg.                      the offspring. Limited studies using  doses  of  over  100  mc,./
          meclizine  HCI)   scored   tabletsfor   conven'                      k,./day in rabbits  and  10  mg./kg./day  in  pics  and  monke@ys
          ience and flexibility  of  dosage.  Antivert/25                      did  not  show  cleft  palate.  Congeners   of   meclizine   have
          (25  mg.  meclizine   HCI)   Chewable   Tablets                      caused cleft palate in species other than the rat.
                     'lable for the  management  of  nausea,                     Mcclizine  HCI  is  contraindicated  in  individuals  who  have
          are aval                                                             shown a previous hypersensitivity to it.
          vomitinL:,. and dizziness associated  with  mo-
                                                                               WARNINGS.   Since   drowsiness   may,    on    occasion,    occur
          tion sickness.                                                       -,vith use of this drug, patients should be warned of  this  pos,
                                                                               sibility  and  cautioned  against  driving  a  car  or  operating
            *INDICATIONS.  Based  on  a   review   of   this   drug   by       dangerous machinery.
              the  National  Academy   of   Sciences-National   Research          Usage in Children: Clinical studies establishing,  safety  and
              Council  and/or  other  information,  FDA  has  classified       effectiveness  in  children  have  not  been   done;   thcreforep
              the indications as follows:                                      u;age is not recommended in the pediatric age group.
                Eff  ective:  Management  of  nausea  and  vomiting  and
              dizziness associated with motion sickness.                          Usage in Pregnancy: See "Contraindications."
               I  Possibly  E.ffective:  Management  of  vertigo   asso-       ADVERSE     REACTIONS.     Drowsiness,     dry     mouth     and3
              ciated with diseases affecting the vestibular system.
                Final classification of the less than effective  indica-       on rare occasions, blurred
              tions requires further investigation.                            vision have been reported.           RoeRIG(m
                                                                                                                   A division of Pfizer  Pharmaceuticals
                                                                                                                   New York, New York 1001 7

                MAY,  1973-VOL. 42,  NO.  II                                                                                           797


                                                        'COUNTRY DOCTOR'

               and  all  data  is  stored  on  the  computer  for     the  experiment  by  setting  up  a   no-physician
               quick  retrieval.  Formerly,   patients   had   to     satellite  clinic  30  miles  from  Salem,  linked
               travel  up  to  90  miles  for   comparable   ser-     by computer to the existing clinic.
               vices, and it  took  two  or  three  days  to  run       "These  few  models  represent  a  great   range
               the tests and get results.                             of situations, needs  and  action  to  meet  those
                 Another  machine  in  Dr.  Bass'   office   "in-     needs,"  Dr.  Snyder  said.  "And  this   is   be-
               terviews"  patients-through   audio   tape,   car-     cause there is  no  one  simplistic  solution  ap-
               toons  and  printed  questions-for   their   medi-     plical)le to all areas. Each  area  will  need  to
               cal histories. All  the  devices,  in  use  for  a     develop its own plan."
               year and  a  half,  have  proven  "100@(,  accept-       He  urged  interested   residents   of   doctor-
               able to patients," Dr. Bass said.                      short  areas  to  write  to  the  American   Medi-
                 The   equipment    was    developed    by    the     cal  Association's  Department  of  Rural   Health
               Missouri  Regional   Medical   Program   and   the     for  informational  guidelines   on   setting   up
               University7f-,M.l@s,o-u-r-i's schools of  medicine     health  care   systems.   (AMA,   535   N.   Dear-
               and engineering. The RMP       plans  to    extend     born, Chicago,   Ill. 60610).

                                                                                 -IC
                                                                               V   A63
                                                                      TA
                                                                        (J.
                                                    17
                                                            c-,@ r7     Aia       Cir3
                                                    l@onts

                                                                      Ni @Y


                                                                f  lt3
                                      y@. Sqte Tribune@@
                              Hosp*ltcls'Upgrade
      )tate
      .aboratory                                                Performance
        1)1,  I.(,(. [if-St      flit-ile(@(i II)I.             program.   Each   lab   has    about    a
      itivii ;I 1)1-0@i!l.illll %Vllt-ll lie joined             week    la    analyze    the    specimens
      lit('I]C;Illil (iL@pill-Illit-fil Nliilf  IiVt-           and    report    their    findings     to
      @'eiii-s ago.  I)tt(  l@ickt,(i  the  funds               Castle.   who   in   turn    sends    the
      lo stipix)l,l olliel. thin .1 iiiiiiiiiizil               results to Denver.
      leslitig program.                                         Test    results    from     all.     par-
        "A    clinical    laboratory     is     i               licipating   hospitals   in    the    two
                                                                states   are    scored    and    compared
      vital   t-olilIX)IIelit   oi         Colli-                                                    told
                                                                statistically, and each lab is
      iiiuiiitv's      iiiediciti       resources                                   with    all     other
                                                                now it compares
      I)eeau@e  of   [lie   importance   of   lab
                                                                labs  for  each  of  the  tests.
      tints   in    diagnosing    ilhiess,"    he
                                                                                                  testing
      said.  "But   to   really   be   effective,               "The   proficiency
                                                                component  of  our   project   tells   us
      a  lab   and   the   physiciatisit   serves
                                                                which   labs   needhelp   and   in   what
      must    know    that    the    (ests    are               areastliey    need    assis(ance,"    Dr.
      lone     properly     and     that      the
                                                                                               e      the
      results are accurate.                                       $,Ii,l:    ,This    is    wher
                                                                consultation        and        continuing
        "This   is    why    a    good    Jesting               education   aspects   of   the    project
      program       is       important,"       he               come in.
      continued.                                                                     lit,
        Dr.  Lee     explained      that      the                  have    I)CCII    able     to     Spot                  %%'Al.T       ('ASTI.F.               medical    1'. i.ee. laboratory      director      and
      ,'Wit'@NIP-stipported               project               llli)4)1-itiol-Y equipment  @vliicii  has                  (echnologisi       in       the       Wyoming    director     of     thi-      state-%vitl(,
      enables     Wyoming      hospitals      and                                                                          State       Health                 Department    Iii,o,fraiii to til)t!,rade  clinical  fit)
                                                                       il(lju.,illllt.lll,            Of'
      !Iinics  to   participate   in   a   highly               ev(-ti i-t-I)kict-iiieiit. Aiiti, in sotiit-               laboratory.    checks    a    test     sample    performance    in    the     state.     The
      Successful        laboratory        quality               ilisizilices.    we    leave    suggested                  of    a    chemical    unknown    prior    to    program   is    trained    by    a    grant
      !ontrof    program    which    has     been                                                                          sendiiig.vpecimens       toi        %Vvoniing    fro!ii      tl)p         I)eiivt-r-liast-tt
                                                                that   1;11)s    cil.-Iiigt,        their                  hospital         la  hi)ra   tories'      for    ('fiii)rad(i-%V%.o)ming         ltegioii@it
      Sponsored     for     several'yeai-s     by               techniques fol' Certain tests.
      he       Colorado       State       liealih                                                                          aiiil5  sis.  %%'atching  is  I)r.   I)onattl    Nletlical llro,,,raiii.
      )apartment.                                               "We   have    i-ec(iiiiiitLnide(i    that
                                                                some   labs   not   ;ilteinpi    lo    do                                                     iissulle(l-only   until   Dec.   31,   IIJ13@
        Each   foill'    lo    six    %vLeks    a               certain   test.   and   we   have    eii-    laboratories     asked     to     be     iii-    Dr.   Lee   is   hoping   for   state   fwids
      iuinber      of       laboratory       (est               courzig(-,d  others   to   expand   their    cluded.                                          to     take     over     project      support
      )reparations.        including        blood               services,"   he   pointed   out.               'rhe    project,     one     of     several    beginning in January, 1974.
      ;Cruins.     microscope     slides     iiid               "And      most      importantly,       we    sponsored       l')y       ('WitMil        in      All   hospital   labs    in    the    stale
      ,)acterial     specimens.     are      sent               have   noticed   a   definite    increase    ('()Ioradi)    and    Wyoming     to     ini-    are      participating          in        the
      rom       the        Colorado        health               in   laboratory   proficiency   in    the    1)rovethe    quality    and    delivery    of I  program.    with     the     exception     of
      li,parinient    in    Denver     to     Dr.               state   during   the   past   year,"   he    liciltli      care.      was       originally    those    in    -Clievenne,     Ctsper     and
      -ve's   lab   in   CliL-venne.   The   le$(               said.  "This  is   especially   true   in    programmed              to           continue    Slierid@iii.    where    the     labs     are
      ;nipples   are    identical    to    thosc,                                                                                                                           in      othei-      proficiency
                                                                the   cases   of    some    labs    which    through      1974       with       ('WItiNill    involved
      ;Llnt    lo    Colorido    hospitals    for               showed      only      -marginal      per-    funding     support.     11      wis      an-    programs.
      estirig   and   are   I%Ipical    of    the                                                                                                                Non-linspital          labs        pzi i- -
      ypes      of      specimens       routinely               formance     when      th(.,      project    licipii(ed   (li@it   state    funds    would
                                                                                                                                                        -1           -it  ing       include            tile
      inalyzed by clinical labs.                                began."                                      be able to I iike over full sul)poi              I icip.
        Wait      Castle,   a            inedicai               The     states      hospitals      appear    ol'th(-     lab      improvemen(      program    laboratory    of     Clinical     Aledicitic.
      echnologist   in   lhf!    Cheyenne    lab.               quite   pleased   with    the    program,    beginning in 1975.                               ('ody@    l,ailder    Nieciic@il    ('Iiiiic,
      @.xamines    samnies    of     [he     tfKt               which   was   originally   designed    to      -Ni)w.      howevei-,      with      (11(-'    let if d c i- @    Nledical              Arts
                                                                             ..  .       I                .                   nhqqt-.niii     oi     RIlPs    Aq,,nc-i;ition.       I,,irainic:        Wind


                                                                                                                                                                                 and            associate  director          o
                                                                                                                                                                                 L"$V II 11 P.
                                                                                         -y    (-V.Ilii;iti(oll
                                                                                                                                                                                    Afterl(-ssthatia      @-L-arof       actua
                                                                           li;it,tt-]-iollogy   Sl)(-Cilltt'lts   fill'                                     1)    tile           operation.    the     project     seems     I
                                                                                                                                                             y
                                                                           ,Iiiljlll(.Ilt tip %VV(Olilillg 114)Sl)itlls                II(.;Iltll                                be  %%-ell  on  its  Nvav   to   meeting   it
                                                                                                                                                                                 goal.          Twentv-lhree                 0
                                                                                                                                                                                 IV\oming's-l-.18         hospitals         ar
                                                                                                                                                                                 voluntarily.     participating     in     ill
                                                                                                                                                                                 program.     as     are      five      priva(
                                                                                               t@ko              ago.      I.      The     ultimate      goal      of      the   clin;cai labs in tht! state.
                                                                                                                                                                                    O@ficialiv  entitled  "\V%.
                                                                                                                                                                                                                         omill
                                                                                               public   ileikill,    official    -project     is      to      insure      [hat
                                                                                        I)t-tl%t-i,iiiici-obiologist      met    %"voming     patients,     through      their        i n i c a I       L a b a  r  a  t  o  r
                                                                                to             [II(-ii-  ilitilliil   concern    physicians.    have     access     to     the   improvement            Program,"            t
                                                                                                                                                                                 pr ,
                                                                                fol-   tilt-  (JUIllit     of        Clinical    be'st    possible     laboratory     services      olect     is     int-ended     to      hel
                                                                                lal)q)i-atut'v   set-\,ices   ill    1-ul-iii    throughout the state.                           I-,e)spitals      reach      and      maintai
                                                                                                                                                                                 hich           performance           standard
                                                                                %Vl%i)iiiijig hospitals.                           Headquartered                 at        the      2
                                                                                                                                 Wvoming             State        -     Health   through three mechanisms:
                                                                                           meeting.       ;iiid       several    Department            laboratorv           in      -A        proficiency               testin
                                                                                others.   led   to   the   estal)lishiii,-4it    Cheverne     iind     funded      @v      the   program   for    clinical    labs    in    th
                                                                                of    a    stale-%vide    laboratory    it''-    Den'ver-based                Colorado'-@%-vo-   state.
                                                                                proveiiieiii     project     which      [Oda@    niing        I,(-@gional         r%ledi'cal        -Professional       consultation        to
                                                                                is    bringing    about    continuous    aiia    Prograiii    i(",VR.NIP).    the    pi,ojilct
                                                                                                                                                                                 participating labs. and
                                                                                measurable     -      ii-nproveinents      in     .i,s              bv    Donald    T.    Lee,      --Continuing                     education
                                                                                the      quality        of            medical                                                    proarams      for       latoratory       per-
                                                                                                                                             (Itrectoi-    of    the     state
                                                                                la'uoratorv      work      in       hospitals    health    iiil)oi-alorv.    and     W.     C.   sor'nel-
                                                                                across the state.                                Nlorse.    I'li    1)..    a'iilicrobiologisi


                                   12       Sheridan    (Wyo.)     Press      Thursday,   May    3,    1973
                                      Improved patient care
                                     is goal of local                                                     nurses
                                                                                         t   being   recog- health   nurses   Mary   Jane   Lord
                                     A group of    Sheridan  nurses! and that it is jus
                                   im attending    a course of in.  i  nized  and  ways  are  being  sought and Esther McKenzie.
                                         on  designed  to  improve@ito   equip   the   nurse   with   addi-
                                                                                                            In  addition  to   those   persons
                                   @ir  professional  skills     and tional  skills.                      listed  in  an  article  last  week.
                                   ,make  them  better  able  to   eval- "We are not edu                     ers  helping  with   the   course
                                                                                           cating    doctor (yth
                                   4iate p a t I e  n  t  health-illness substitutes  -  this  is   not   the are  Pat   Carbone@   Jim   Louahery
                                                                       I                                                               t,
                                   satus.                              :  purpose  -  but  rather  we  hope and    Margaret    Berry,     @nver,
                                     Martha  Stoner,  senior  instruct  to  increase  the   competence   Of a  resource  person  assisting  Mrs.
                                   kr,  coordinator  for   rural   nurs- the  nursing  skills,"  Mrs.  Stoner Stoner.
                                       fMm  Colorado  University said.
                                   Nursing   School   continuing    edu- Mrs.  Stoner  said  she   believes
                                   gstion  services,  is  in  Sheridan  there  is  a  very  real  need  for
                                       week  conducting  the  court  I  continuing  education  for   nurses
                                        the  assistance  of  several;  and  in  some   states   there   -re
                                   area   physicians   and   the    hos- mandatory    programs    but    most
                                                                       states   have   voluntary   programs
                                            uMmate    goal    of    this of continuing education.
                                              is  improved   patientl   ..'Mis   program   is   unique   In
                                                                       i
                                   more," Mrs. Stoner said.            1 that it brings the courses to  the
                                   "She   said   the   program   ir,   aict@mmunity   where   nurses    can
                                   part  of   the   nurses'   continuing participate  without  leaving  their
                                   @tion.  The  instructions   will   job   or   tagni-ly,"   Mrs.   Stoner
                                   ftable  the  nurse  to  increase  her said.
                                   sidils and  lo  observe  the  patient Several   of   the   participants,
                                   inore,   accurately   and   in   turn taking tht- cour.4R or(!  al,-A)  ful.
                                   relate  gnore  accurat(@ly   to   the filling  their  j()b  reqllirfments.
                                   physician. Mrs. Stoner said.          fhe   program   is    funded    by
                                     she   has   given    the    coursel
                                                                       iC(,Ir)rado  and  Wyoming   regional
                                   three   times   in   Colorado   and:medical   program    and    although
                                   once   in   Wyoming,   in    Fremont'
                                                                       i, his  funds  have   been   curtailed,
                                   County.                                           said   cther   sources
                                                                       Mrs.   Stoner
                                                    is  the  first   one
                                     IlWs   course                     are being sought for funding.
                                           has    Included     hospitals
                                          nurses.   Generally   I   have Those  taking   the   course   are
                                                                                   x,    Virginia    Bowen,
                                   worked   with p u b I I  c-  health:i  Opal  Amou
                                   @es      and n  u  r  s  1  n  g  home!  Mary  Brayton,  Lucille  Byers,
                                   surs"," Mrs. Stoner said.           Vivian  Harris,  Mary   Lou   Kober,
                                   --She   said   she   believes   the,Barbam    Sales,    Nola    Wallace,
                                   imrstis@bleofdoingmoreland       Ellen       Hutt       and       public


                                    0
                        ec ica Progra                                                                              eceive
               The Coli)t-ado-Wyoming Re-  It  in  operation-though  with  a  said  the  grant  notice  came  in  aHealth, Education and Welf
             gional  M e d i c a I   Program reduced  staff-until     Feb.   14,   telegram   from    Dr.    Harold (IIEW).
             iCWRMP)   headquartered  in 1974.  ,                                Margulies,  director  of  the  Re-  Before  news  of  the  grant
             I)t@iiver hits received a $750,000  Dr.    Thomas        Nicholas,  gional   Medical   Programs   Ser- came, the CWRMP and 56 other
             phase-out grant which will keep C W R M P executive director,       vice of  the  U.S.  Department  of regional medical programs had


                                                                                 d
                                            **THII DENVE[I POST Sun ay,April2g,l
                         ase                              ut                       rusit
    been informed they  Rould  re-I  The  three  projects  to  be  ter-I  A  proposal  in  Congress  to  ex-
    ceive   no   further   funds   after minated June 30 include a rurall tend  the  Public  Health  Sci-viceq
    June  30,  because  of  the   termi- and urban genetic  counseling  I  Act  which  includes  the  regional
    nation  of  the  program  and   nine and  screening  program,  a   stij- medical    programs    and     nine
    other  health  Dr                  .dent   health   program   for   mi- other  health  programs     h as
                   .   ograms   as   n,' grants  and  rural   poor   and   ap@issed the  Senate  but  is  still
    result   of   President    Nixo    sprogram   to   provide    radiation a w a i t I n g  House  action.  if
    budget cuts.                       therapy  and  planning   by   time- pissed  and  not  vetoed   by   the
       FF       CUTS                   sharing computer.                 president, the  bill  would  extend
     A         CWRMP spokesman,       J.P. Smith said  the  decision  not  to the  Public  Health  Services   Act
    Smith,  said  the  grant  will  suP- fund  the  latter  three   programs through June 30, 1971, durin
                   e   projects   Okigi- was made in Washington, D.C.    which  time  the  act   would   beg
                   i  through   Dee..31, He  described  the   funding   a.,; rewritten.
                   10  contract  act'vi- "Phase-out"  money  "to  effect   aAmong  the  bill's  s   nsorq   In
                   letion.   But   about more   orderly    termination    of the  Senate   was.   Sepno.   Peter
                   ncy's  22   proi   s- projects."                      Dominick, R-Colo.
                                       e
    ona   staff    members,    including
                   s,  two  nurses   and
                   strators,   will   be
                   ginning   June    30,

                   e  six  projects   to
                   ugh   the   end   of;
                   ude     a     Wyoming
                   are    support    and
                   services        among
                   the  r   Wyom
            to     improve clini
                   third    Wyom
                   providing ph3
                   rsonnel, a Co
                   expanded         role
                   rses,   a    Colorado
                   are      practitioner
                   regional     pediat-@
                   ter  at   the   Uni-I
                   orado         Medical


               :tlie DEi'iVg@.R PO-ST
                       May 15, 19 73        21
                                                                          ev-ffs

               t4ORTHEAST COLORADO
                                                                                                                    -mraise
                                                                                               c3n Bar
                               nti tre                                              r
                                                                         p
                                                                                        4,500     grade-school     Supported   by   $I!,OM   in   grant    funds
                 STERLING, Colo.-An        extensive    strep- infections among the
                 emcus detection and      control      program children it serves.                                 from    the     Colorado-Wyoming     Regional
              @beglm  last   fall   in   Logan,   Morgan   and   More  important,  the   program   has   shown     Medical  Program  and  the   Colorado   Heart
             .'.Yima  Counties  by  the   Northeast   Colorado it can   be   effective   without    abnormally     Association,  the  program  has  two   goals-
             'Health  Department  here  has  resulted   in   a high costs, according  to  the  health  depart-     to reduce strep in  the  three  counties  and
               more  than  50  per  cent  reduction  in  strep ment.                                               to test its own effectiveness.
                                                                                                                   "Even  though   the   program   has   another
                                                                                                                   month  to  run,  preliminary  statistics  in-
                                                                                                                   dicate that our effort has been  highly  suc-
                                                                                                                   cessful  and  that  both  goals   are   being
                                                                                                                   met,"  said  Pat  W.   Freeburg,   laboratory
                                                                                                                   director for the health  department  and  co-
                                                                                                                   director of the strep program.
                                                                                                                   Strep is a highly contagious  bacterial
                                                                                                                   fection which generally manifests  itself  as
                                                                                                                   a  sore  throat.  The  rate  in  Colorado  is
                                                                                                                   among the highest in  the  nation,  especial-
                                                                                                                   ly during the winter months.
                                                                                                                   When detected early,       easily   can    be
                                                                                                                   treated with penicillin " other  antibiotics.
                                                                                                                   Untreated, it can lead  to  rheumatic  fever,
                                                                                                                   permanent   heart   "   kidney   damage   and
                                                                                                                   other  serious  conditions.  School  children
                                                                                                                   under 12 years of  age  are  especially  sus.
                                                                                                                   ceptible to strep and its complications.
                                                                                                                   Freeburg  said  the  best  method   for   de-
                                                                                                                   tecting strep is to perform  frequent  throat
                                                                                                                   cultures for  those  most  susceptible.  How-
                                                                                                                   ever, he said the cost of doing  this  is  p@
                                                                                                                   hibitive.
                                                                                                                   "We   wanted   to   discover   the    optimum
                                                                                                                   number of school children to culture  .  .  .
                                                                                                                   to have  the  best  possible  detection  pro-
                                                                                                                   gram at the  lowest  cost,"  he  said.  "And,
                                                                                                                   by   optimum,   we    mean    the    smallest
                                                                                                                   number that would  allow  us  to  effectively
                                                                                                                   monitor  the  prevalence  of  strep  in   the
                                                                                                                   schools."
                                                                                                                   Schools in the  three  counties  were  divid-
                                                                                                                   ed,into two test groups. In  one  group,  all
                                                                                                                   students  received  throat  cultures  once  a
                                                                                                                   month.  In  the  other  group,  only  16  per
                                                                                                                   cent were cultured. If a school in  which  16
                                                                                                                   per   cent   were    cultured    showed    an
                                                                                                                   unusually  'h  rate  of   strep,   then   all
                                                                                                                            big
                                                                                                                   students in that school  were   cultured.
                                                                                                                   In  the  schools  where  all  students   were
                                                                                                                   cultured  monthly,  the  average   percentage
                                                                                                                   of'positive  infections  declined  from  20.2
                                                                                                                   per cent in October to only. 6.4 per cent  in
                                                                                                                   March. In the schools in  which  16  per  cen
                                                                                                                   of the students were cultured,  the  positive
                                                                                                                   percentage  dropped  from  19  per  cent   in
                                                                                                                   October to 9.2 per cent in March.
                                                                                                                   Freeburg     said     the     program     cou
                                                                                                                   become  a  model  for  other  detection   and
                                                                                                                   control efforts across the country, - particu-
                                                                                                                   larly in areas of  high  -strep  rates  where
                                                                                                                   health   officials   are   sampling   large
                                                                                                                   numbers of students.
                                                                                                                   The   program   will   be   continued    next
                                                                                                                          Logan  County  with   fundipc.,   from
                                                                                                                   year in
                                                                                                                   the RE-1  Vallev  School  Board.  School  of-
                                                                                                                   ficials in-the other counties haven't r'Aacid-
                                                                                                                   ed whether to continue.