;I i@[ @t 'i i, DR. EDMUND D. PELLEGRINO see Contemporaries page 18 ri 117 ti 73 money tz 146 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 c 0 v i@- iC A T I 0,@@ S @l t,@, n I o II i(, f @s @)i' Ai-izo3ii ()@l I -\,\"X. Ai- i(lkll --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. "lu- M a,@c, s I II,-,w b,-eed of doil-- ri,aki- a d f y c a I he Co. re A Or @i el ik@ "ly IT t 3,, r d '3v a i;e ',lilt hi,@,,, ill til(, @icink he wit' to sht-,o me 1 0 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.