A \ @ I 'i @RC)CEEDIN(3S: VOLUME I I 'A im ..I mitio 9 I -- 4 I i PROCEEDINGS: conference- workshop on REGIONAL MEDICAL PROGRAMS VOLUME I Plenary Sessions o Panel and Discussion Groups* Related Background Information on Conference-Workshop (Appendices) VOLUME 11 15-Minute Papers on Regional Activities and Ideas JANUARY 17-19, 1968 0 WASHINGTON, D.C. NATIONAL INSTITUTES OF HEALTH PUBLIC HEALTH SERVICE U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Publication No. 1774 For 1).N, tli,, of I)ocii7iietits. la.'. (;ov(@rTiin(@iitr 1'ritititig OfY'ice @@'zi@IiiiigLoii, 1).(!. 20402 - Ilri(!(! $1.50 (I)ztl)cr (,,Over) The January 1968 Conference- Committee invited all regions to pre- At the time of the Conference- PREFACE Workshop on Regional Medical Pro- sent papers on regional activities and Workshop, many of the 54 existin, grams, the proceedings of which are ideas to submit exhibits which could reg' let'ng the' ions were comp i ir opera- reproduced in these two volumes, be viewed and demonstrated; and to tional proposals. The meeting served was significant in origin, content and participate actively in panel discus- as a catalyst, so that at the present purpose, and marked a milestone in sions. This invitation resulted in the time operational applications from the development of Regional Medi- presentation of 60 representative pa- a total of 24 of the reoions have eithei@ cal Proarams. pers and more than 40 exhibits. FLir- been approved or are under review. Growing out of a specific request thermore, virtually every invited The i-nenibet-s of the Stecrin<@ Coni- of the Program Coordinators at their speaker accepted the opportunity to inittee hav(, expressed their satisfac- meeting in June 1967, this meeting discuss the ma'or issues of the Con- tion that the meeting met the need.,,- was planned by the Steerin,, Corn- ference-Workshop. and purposes for which it was de- mittee of Coordinators under the The University of Mississippi Mccl- signed. From the Division standpoint. Chairmanship of Dr. Stanley W. 01- ical Center and the Stanford Univer- the Conference-NVorkshop was a son, Program Coordinator of the sity School of Medicine kindly grant- major source of substantive informa- Tennessee Mid-South Regional Med- ed leave to Dr. John A. Gronvall and tion concerning progress A@ithin the ical Program. Its purpose was to pro- Mr. Robert G. Lindee, respectively, programs which was invaluable as vide those directly involved in the to act as Conference-Workshop Co- testimony before the Subcommittee development of Regional Medical chairmen. These two men established on Health of the House Interstate and Programs the opportunity to ex- and directed the Conference Office Foreign Commerce Committee on change ideas and information which located in the Division of Regional March 26 and 27 in support of the would be of benefit in the further Medical Programs at the National bill to make necessary amendments implementation of their programs at Institutes of Health in the months and to extend Public Law 89-239. the regional level. The focus was on preceding the Conference-Workshop. Finally, and most important of all, is what Dr. Lowell T. Coggeshall in his Other outside consultants who con- the probability that this Conference- summary paper called "the emerging tributed richly to the success of the Workshop will emerge historically as substance" reflected in the on-going program were Mr. Greer Williams, the time when the definition of oals, activities in the regions, particularly who worked on the actual publica organizational arrangements and as they related to the key issues of tion of these Proceed'nas from the re- planninc, turned in the new direc- this program, the quality and avail- ceipt of the first abstract until publi- tion of initial operational activities ability of health care for heart clis- cation, and Mr. Greer Hermetet and in the regions. case, cancer, stroke, and related Mr. John Craner, who ,vorkcd with It is interesting to contrast these diseases. exhibitors and on Conference ai,- facts with those of the first Nationai Conference on Regional - 1 To achieve these goals the Steering rangements. %Ied'cal Pro- iii grams held a year earlier in January 1967. That meeting had been called by the Division of Regional Medical Programs to obtain information from a representative group of knowledge- able individuals, which could be used in preparation of the required Report on Regional Medical Programs to the President and the Congress (PHS Publication No. 1690), and further to provide an interchange of infor- mation on planning and on the goals of the program. Dedicated principally to the problems of definition and elaboration of the concepts of cooper- ative arrangements, local initiative and evaluation, that first meeting as reported in its Proceedings (PH Publication No. t682) did much to characterize the program in its early stages of development. To look back over the past 2 years and see how far we have come is to realize that Regional Medical Pro- grams are no longer a concept, but are becoming an increasingly impor- tant resource for improving the care of patients with heart disease, cancer.. and stroke. Robert Q. Marston, M.D. Associate Director, National Institutes of Health, tl??(l Dirt.,ctor, Diiii.vioit of I?e,,Z'oizal Mc(lic(il 1'rt),,riz?tzs March 31, 1968 iv IL Page SUMMARY OF CONFERENCE-@VORKST-TOP ON CONTENTS l@l-,"(,I()NAI, Ml,"I)I(@!Al, lll@()(;I@AMS ......... ........ Lowell T. Coggcsliall, M.D. QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO- SCIENCE AND SERVICE .......................... I 0 Carleton Chapman, M.D. REGIONALIZAT10N OF HEALTH SERVICE ....... 1 5 Lester Breslow, M.D. DEVELOPMENT OF PERSONAL HEALTH SERVICE ......................................... 19 Dwight L. Wilbur, M.D. THE POPULATION .............................. 24 Panel: Roger 0. Egeberg, M.D. (Chairman) Ray E. Trussell, M.D. Frank P. Lloyd, M.D. Amos Johnson, M.D. DIVISION OF REGIONAL MEDICAL PROGRAMS REPORTS ON- PROGRESS AND ISSUES .......................... 34 Robert Q. Marston, M.D. Karl D. Yordy A NEW EMPHASIS ................................ 38 Alexander M. Schmidt, M.D. Richard F. Manegold, M.D. OPERATIONS RESEARCH AND SYSTEMS ANALYSIS ......................................... 41 Robert Bucher, M.D. Jack Hall, M.D. Herbert P. Galliher, Jr., Ph. D. Maurice E. Odoroff vu Page Page A NATIONAL VIEW OF DEVELOPMENTS IN- REGIONALIZATION ............................... 105 HEART DISEASE .................................. 52 Discussants: Lester Breslow, M.D. (Moderator) Donald S. Fredrickson, M.D. Walter J. McNerney William R. Willard, M.D. CANCER .................................. ....... 55 URBAN I"IZOBT,EMS ........ Kenneth M. Endicott, M.D. I)isctissiiits: I'@itil W@ird (Mocl(@r;ttor) 106 STROKE ........................................... 59 Roger 0. Egeberg, M.D. Richard L. Masland, M.D. Frank Lloyd, M.D. Anne R. SorTiers PANEL DISCUSSIONS ON- Ray E. Trussell, M.D. HEART DISEASE ...... ............... I ........... 68 RELATED FEDERAL PROGRAMS.... ....... 108 Panel: Jesse Edwards, M.D. (Chairman) Discussants: Daniel Zwick (Moderator) Samuel M. Fox 111, M.D. James H. Cavanaugh, Ph. D. William Likoff, M.D. Donald Chadwick, M.D. Theodore Cooper, M.D. Carrutl-i Wagner, M.D. Campbell Moses, M.D. Eugene Veverka CANCER ........................................... 78 HEALTH SERVICES RESEARCH ............... 109 Panel: Sidney Farber, M.D. (Chairman) Discussants: Paul Sanazaro, M.D. (Moderator) Michael J. Brennan, M.D. Morris E. Collen, M.D. Juan del Regato, M.D. Caldwell B. Esselstyn, M.D. Kenneth M. Endicott, M.D. John Thompson Guy F. Robbins, M. . John Williamson, M.D. STROKE ....... ............................. ..... 90 CONTINUING EDUCATION AND TRAINING, FOR WHAT? ............................ ............... III Panel: Neinat Borhani, M.D. (Chairman) Discussants: Patrick B. Stor@,, M.D. (Moderator) Clark H. Millikan, M.D. Ltitlier Christman, Ph. D. James F. Toole, M.D. George E. Miller William A. Spencer, M.D. A. N. Taylor, Ph. D. Richard L. Masland, M.D. DATA COLLECTION ANI) REGISTRIES ........... 112 GROUP DISCUSSIONS ON- Discussants: Abraham M. Liliciife.Icl, M.D. (Moderator) James I,. Kiii(r, Jr. HEALTH MANPOWER-REVIEW Ol,- COMMIS- SION REPORT .................................... 104 Andrew Mayer, M.D. ,John E. Weiiiil)cr-, M.D. Discussants: James C. Cain, M.D. (Moderator) uiosi,i,rAI,S ........................................ 113 Leonard M.]). C. H. @Villi@iiii l@tilic, M.D. I)e@it-I l,'Islicr, l@.N. A. N. Taylor, Ph. 1). Jollll W. Dwight Wilb@ir, M.D. EciNvarcl I-[. Not,oi@iii viii ]'age COMMUNITY INVOLVEMENT .................... 114 I)isc@iss,ints: l@ol)(-rt M. (,'iinninghiiii,,fr. (Moderator) Aliti) (I. 1)@iv'ls [toward Eiiiies, M.1',Ii. l'ierre C. Fraley Marc J. Musser, M.D. OPERATIONAL PROGRAM DEVELOPMENT ....... 115 Disc@issants: Charles E. Lewis, M.D. (Moderator) C. Hiliiion Castle, M.D. '17. A. I)tAckwortla Albert E. Heustis, M.D. Donal R. Sparkmaii,M.D. A NONPROFESSIONAL LOOKS AT REGIONAL MEDICAL PROGRAMS ... .... ................... .. 118 Irving J. Lewis REMARKS ............ ..................................... 122 Honorable Melvin R. Laird APPENDICES I - CONFEI@ENCE--%VOI@KSHOJI I'l@()GRAM ........ 126 2. COORDINATORS' STEERING COMMITTEE .... 143 3. LISTING Ol,' REGISTEI@ED I'AL@TICIPANTS ... 143 4. REVIEW COMMITTEE AND NATIONAL ADVISORY COUNCIL . .. ..... ......... 158 @5. DIRECTORY OF DIVISION STAFF, ............. 159 6@ DIRECTORY OF REGIONAL MEDICAL PROGRAMS - - @ - @ @ . .... ... 161 7. PUBLIC LA@%'89-239.. ................ ..... 176 8@ l@EGITLA'FIONS... ...... I ............ 17@3 ix SUMMARY OF CONFERENCE-WORKSHOP Lowell T. Coggeshall, M.D. ON REGIONAL MEDICAL PROGRAMS SUMMARY OF Larson from the Mountain States Re- frame of reference for a reaction to reduce the costs of illness, and can it CONFERENCE-WORKSHOP ional Medical Program has so intelli- the Realonal Medical Pro-ram that I presci-%,e or restore the famllN,? ON REGIONAL 'gently pointed out: "Goals are essen- find I share a good man@, others. This pro-ram, I am del'- ted to I 1 1 i,h MEDICAL PROGRAMS tial to the success of any project It would be itia(,ctirate in the extreme find, prefers the experimental to tile one fyets @vliat lie wants to say that I (-am(, to sneer and stav(@ci exhortatory method of health pro,- because no Lowell T, Coggeshall, M.D. until he knows what he wants." to clieci-, but I did arrive at tl@iis con- ress. It is dividing its studN, popti- Vice President Emeritus ference in a state of igiioran(,e and I lation into three -roups. 6,ic N@-iii University of Chica(,o REGIONAL ACTIVITIES am (roirig a@%,av mu(@ii impressed -,%@itli deliver comprehensive care in a AND IDEAS what I have learned, and N@'Itli a great neighborhood health center plus deal of enthusiasm for the I)ro,,ram's multiphasic screening laboraton, ser-,,- The corpus of this conference is the outset of this meeting, future. I will trv to make this entliusi- ices to one group. It will aix-c onIN, the found in the 60 reports selected, I ARobert Marston spoke of the asiyi a little TI)OT-e, Sl)('.Cifi(@ later oil. scrcenlri,- laboratory, services to a sec- C, 11 understand, from 100 papers sub- emera,ing substance of the Re- Elam, in the introclti(,tlori to his re- end group. And it will save a third mitt(@ci. Tli(@se 60 have. been presented -Iona] Medical Pro,,rain. In so cloiii,, )ort, point,,; out that in (.orltl,.Ist to lrotil) for control, lca\@in,,, it to obtain to @,oii in tli(@ last 2 (lays @in(l, -,vicli its (.xl)lol.;It,(),, 01, (,@Ills(,s, ti-@@L(lit'lotiil itic!(Il(,al as best it he made r-nv surnrniii(,-Lil) task so ast(Irilsliirl(@ speed, III two TTIII(-IL tll(@ (.@tsiet- I)',, providing, III C)rl(l @111(i ti(@;itfil(,Tlt of, of ino(l(@st but apt little I)Iit-.is(-, tli(, k(@@,- bound volumes @in(I in @,otir AI I](. I "li@is li@LS (I(-- Cilairs, clav by dav and volume note for the entire proceedings. l@)y only i-ii(lim(,ntat,v r(,s(,ai@(I]i into lionv finecl here as (Compassionate, per- irl(@ tile )f It year af@ VO]I]rTl('. sori@i.1, (@oritiriiiiri(,, faizillv-c)r-'ent(-(], I will @tcl(iress my first fl(, 1 '(@tlllg "(!- i@(@latiri,, tli(@ patient to 011(@ Clo(:tOl- but vaguclv recognized the form of tile and Nvli(!tli(,i@ it riiakes iliticil program. Now, in addition to form, I narks to this body of reports (.@ntitled lien it is." I le points out -,%@liat so "' i %'I n,(,, film specialist ,roLip reinforce- 15-Minute Pape?@.@ on Re,lonal Ac- and a modern teclinolo-'cal iiicnt I find substance. i-nany of us knoN%,, but not all of us call In medical science and practice- tivities and Ideas. Since the total pro- make i@i-orousl@, clear -,@,heii we (go to backup. Further, the participating health care-the ultimate substance gram, both in its planning and initial the White Ilouse or Coii,,rcss' for the I-riembci-s of the coiiiiT-iunit@, will ha\@c operating I)Iiases, excltlsl%,c of a short is advancement of knowledge or moii(,v: "Yet," he sa%,s, "@ve have no a direct -,-oice in IDolicN@makiii- at the leadtime, is hardly i-nore than a year method that makes some %%,orth@vlille precise knowledge of N%,Iictlic,r corn- center. old, it is a little early to speak about This is but one example,, and per- difference in the II-,,es of people. 'I'hat results. So, quite logically, we find I)rchcnsive medical care (,oul)lcd N@@itli is, what we as members of the health modern tccliiiolo,v can be effective in hal)s more sophisticated than some, little about results in these reports. professions and the reat American improvin(, the health of our citizens." but is falrlv typical of manv other re- public look for is to be found under Rather, most of these reports run In this frame of mind, this %@oltin- 'ional efforts, I thin@-. The effort is much in the vein of the one from the the ton-nentln,,, unforgiving, one- tary proram, Yieadcluartei-ecl jointly sober, sensible, and devoid of ativ Tennessee Mid-South rc-ion, as pre- s at- claim or promise o%7ert-tinnin- tile word label: RESULTS. If we do not at Vanderbilt and Mefiai@t-v I senteci 1)@, Llovcl Elai-n from Melial-rN, 'denc(, lncr have in hand the kind of --ood results ternl)tlii,,@ to find out Nvhetlier cotii- e%,l - oi- dcf@ , i,calit@,. It is an c Medical Colle(@c. Let me ,-I%-e NIon reliensive, fam'ly-oriented health effort in N,,,hicli anv of Lis in clinical, we %vant, and this is certainly the cas p I in heart disease. ('ancer., and stroke, enou(,Ii of the sense of Elain's report care in a neighborhood health cen- academic, and scientific medicine then we are prone to speak in terms of to make inv point about crner(riti(r ter coordinated with air automated would be proud to tak(, part. Indeed. PI"ONIISE. I (lo not i-nean false substance and, in suni, I)ro\-icle a 1-nLiltiphasic screenin, laboratoi, Nvill I think it is an approach I'@'C lia%-e 1 promise in this instan(-(,. I mean rea- result in iiiil)ro\,ecl moi-talitN@. met'- been foi-. 'I'lie willingness to sonable liol)e, for cni-i(@liln,, as %%,ell as biclitv, health sci-%-I(,c utilization, and c,,p@riiiient, to ti,%, and risk n@atl\C 11 *7'lie 60 reports are az,(zilabl@! a, prolonging life. @\'Iiat arc, the deals lien(, ilill)O\'Cr'lsllccl results is a source of sheath in these I 11 of tire Conference-Wor'ks,@,,; health attitudes at I we seek to a(@(@oml)lisli" As l,aura (;. Proceedin,@. I)copl(@. I-'tit-ther, can this approach I)ro(,raTlIS. 2 t The program reports reflected the program of the Mountain States both a wide variety of plans and a Regional Medical Program, operated general sense of progress but, because by an organization called WICHE no one as yet has the recipe for in- (pronounced "Whichy")-the West- stant health, it was a progress of ex- ern Interstate Commission on Higher pectations rather than of realization Education. Here is a region covering in iyiost instances. In the time avail- all or part of four States-Idaho, a a le I can give only a few examples. Montana, Wyoming, and Nevada- s As Breslow pointed out, the grand- an area of 440,000 square miles with daddy of American regional medi- only 2,100 physicians, 15,000 other e cine is the Bingham Associates Fund health professionals, and no homing of the Tufts-New England Medical institution, that is, no university med- Center, which has been operating in ical center. Yet, I am told, this pro- the State of Maine since 1932. This gram has one of the most active and t program still flourishes, now under enthusiastic organizations and has Regional Medical Program auspices. found a cordial reception in the medi- e It is pleasing to find that 'nnovat' I ion cal centers serving it from outside of still flourishes, too. As reported by the Mountain States region. George Robertson, a guest resident Much emphasis has been placed on t program has been placed in opera- the need for innovation in the Re- on. Tufts sends residents and clini- ti gional Medical Programs, but it is cal fellows from Boston to work in not all innovation of course. Many selected small community hospitals of of the principles of good health care @i Maine. These postdoctoral students that do require innovation for wider e e go to Maine as teachers without and more effective delivery are deeply diplomas. They cannot be used for rooted in the traditions of medicine @i routine hospital work because their as well as community organization. nce is discontinuous. The local prese We find frequent reference to the doctors do not think of the guest resi- importance of "concern" and "in. s cients as teachers so much as channels volvement" and at one point Willard of information from the medical cen- y A. Krehl wraps the matter up by c ter. They seem happy to learn, stating: "The important objective is n through these young ii-ien, how the concerned involvement." 1, professors currently handle various I e problems. It seems that you can teach Speaking of the "educational pack- an old dog new tricks, provided you age," William G. Cooper says: "One know more than the do-. Put a nicer of the major overall objectives of 0 way, it always has been possible for Regional Medical Programs is to en- e the old to learn from the young. hance the learning of all members c We find another kind of innovation of the health care team in order that DR. COGGESHALL iiivolvln,- geography and logistics in they in turn will be able to provide 3 medical care for their citizenry. The sion, the telephone, and so on. The Vincent Larkin, from the New ISSUES RELATING TO 'learner' in this case may be the dc>c- medical and nursing professions are York Metropolitan Regional Medical QUALITY AND AVAILABILITY tor, the nurse, the medical technolo- capitulatin- quite brightly and grace- Program, a megalopolis constituting OF HEALTH CARE gist, the physiotherapist, other mem- fully, it appears, to the offerings of one of the largest regions in the Na- bers of the team or indeed the patient the visual and audio communications tion, diverts our attention from the Having felt mN, first responsibility himself." industries. Yet I am enchanted to limitations of the average practition- ,%,as to do Justice, however inadequate, The Albany l@egional Medical Pro- learn, although not from a formal er, about which ,ve hear so much, to to the Regional Medical Programs in action, I can no@@,, as the pro-ram for gram approaches continuing educa- paper, that a network of small rural those of the medical schools, so often tion by turning the tables on the hospitals in the southwestern area of assumed to be the ideal base for the opening session suggested, focus on the issues, in summar@, fashion. medical center, as Frank M. Woolsey North Carolina called the "State of regional medicine: implies. If the mountain, that is, the Franklin" plans to resort to carrier "On closer inspection we can see The first three speakers were ex- practicing physician in the commu- pigeons to transport laboratory speci- that the medical school falls far short tremely ,%,ell chosen for a diversity of nity, will not come to Albany Medical mens back and forth. The pigeons of being able to play this central role viewpoint and as con-,,ersel@@ it turned College for further training, Mahom- can carry the load. But for transplant- effectively. Institutions which have out for the general harmony of their I I assiirn(@, it will be ti;tls, I think, th(,r(, (,t, that is, tli(@ iTie(l'cal c(@,i)ter, will able li(@arts, focused on tli(@ tr@@tiniii,,, of r(@ryiarks. On (@ssen 'IO to tli(! ii!ountain. 'I'he strategy is necessary to employ falcons. Actually, students are asked to fo(-tis oii tli(! 1)@t- not discord but ,(,neral a(,i-(@(, iii(,nt, @-t N%'OTI(](,r to inc(, coniniunltv I)osl)ltal learning cen- a pigeon homing on a hospital lab- )iit(@iiil)lat(! s' ti(jit; faculties wlil(@li have been cl(,- ters" and the instrument is a so-called oratory serving smaller institutions, to voted to the eclu(-ation Of Tnedi(@al stu- they I)ro'ecteci the disparate inia(rcs medical 'uke box, now in its develop- me, expresses the very essence of dents, interns, residents, and fellows of medical clean, public health official, i mental stage. This J'uke box plays rec- regionalization. are asked to instruct practitioners, and medical politician. I grant that ords and pr 'ects pictures of whatever But Luther Christman, Dean of high walls which were erected to pro' each represents a -i-cat deal more Oi the School of Nursing at Vanderbilt, a n these one-dim"' ion profiles as the medical center is pushing, educa- tect the standards of the ivory towers tha ens anyone Nvho knows Carleton Cliap- tionally speaking. The basic machine sociologist, sounds a warnin, that I are to be demolished without assur- n is actually a commercial j'uke box, can appreciate, from a career lifetime ance that the standards will not be man, Lester Breslow, and-most tly-Dw'ght Wilbur might and the new jargon is wonderful: in internal medicine: Be- lowered and the ivory towers sullied; pert,nen I "Dial access carousel projectors have cause messages about care must filter I speak of this professor of in short, the racing car is to be har- protest. been added," through many people, the messages nessed to the plow." medicine as a medical politician only We find a great deal about auto- may become garbled or not reach Therein lies one of the less obvious because I doubt that anyone can rise mated multiphasic screening at the their target at all. Much time must be but more difficult problems in our to become president-elect of the American Medical Association with- rate of 60 tests a minute in the pro- spent scurrying around . . . to in- heaven - and - earthmovincr project, out engaging in the politics of orga- gram reports, and a heavy emphasis sure that everyone is infon-ned about otherwise known as regional med'- nl,,d medicine. on the familiar subject of continuing the necessary care measures for,each cine. I can speak with the authority Because the Regional Medical Pro- medical education. I am pleased to patient. Under this set of conditions of a retired dean who has had many rams now seem to be developin- find Margaret Sovic from Syracuse tli(@re is likelihood of many errors of t-irics to Tyiov(,. his fa(-tiltv in the, clii-e(,- explicitly or implicitly, as a reason- reporting on continuing education in omission. . . . Thus, patients may able and acceptable idea, ancl do tion of desirable change, soi-netirnes nursing, using the teaching facilities be placed in some 'copardy by the the American i finding that havin, moved these I-s- have the approval of 1 of a university hospital nursina serv- very system set up for their care." It tinguished men he has to move them Medical Association.. I am sure the ice. Again, as throughout the pro- warms my heart to find a sociologist a(rain at a later time and over tile Realonal Medical Prouram's coun- aram, @ve find a resort to electronic preaching this essential point of first- a ... e (,,round. cils and staff would as leave for-et communications techn;-Iues, televi- class clinical i-neclicine. the i)ro(@ram's rather opportunistic 4 conception and bizarre gestation, l@tit was that research is serv' Chapniai@i denied that medical shared this skepticism until the last 1 ice, even as I I I I 1 Our @%ritli @t of history Fiji(] patient care ;ti,(! set,v- has I';Ill(,Cl to tli(@ fruits three days. tfi@it s(-,h(ilars can hardly abandon 1(:Cs. There is r(@@illy no CILIirrel here, of I)Ioiiieclic2il i-es(-,at,(:Ii to tll(,@ I)a- NNIlIbLir, however, was more San- %v Lilolit iiij);I-I.Ill(@lit of their Of 'Ill(l his IS ;I ]II('(' NV@ly Of' 1)1'011]Otlll@' tli@it tti(- (I(,- tl)otiL Our (-al)acity foi- social free inquiry, (@oulci not leave genesis of the conflict resLilLlii(l, from IIV('I-y Of these fruits Iran b(@(,ii spotty. @t(-.tioii and I)t-o@l,i-css by common con- (Itilt(,, alone. tti(,- ov(@renii)lias's on riicd'cal re- 1-1(.- also justly coiiti-@tcl'ctecl the coill- sent. He recalled that "De Tocquc- Chapman t-(-inark(@(I that Lli(@ (,na- S@.Ll-(@li at the exl)cns(., of reaching and iiioii cliar,tl,c of it 1)(@tNvecii lal)oi-a- @rillc identified this uiilqti,c American bling legislation was I)c)x-n "aini(.1 talk patient service. toi-y discovery and ,tl)l)llcaLloii in ability to become associated A!ith oth- of crisis in medicine," and added, Chapman speculated that Federal rnedi(@al practice, suggesting that if the crs to plan and operate pro,rams in "There has been so much talk about participation in the creation of a cli- biomedical researcher has aiiv fault, the absence of central Governmental the crisis in medicine that we are mate favorable to research is trace- it is that "he rushes into print and direction and control." beginning to consider all the shout- able to the career officers of the Pub- sometimes onto the television screen Here, beyond a doubt, is the key to in,,,- -with suspicion instead of alarm." lic Health Service; in this, I should inu(@h too readily and uncritically" the future success or failure of a Re- Wilbur, reflecting on oricin a I 1 1 1 1 1 1 Is I nd in- differ with him by amplifying those w th find'n,@ described as break- tonal Medical Pro-ram that has the tent, aareed that "in many respects responsible to include not only cru- tliroughs. So, "it is small Nvonder that singular characteristic of bein- im- this act is quite extraordinary." Cer- sading Public Health Service officers both physicians and laymen become posed not from the top down but the tanly none of us who had the oppor- but health-minded politicians and re- bewildered when so many break- bottom up and therefore leaves the tunity to read the DeBakey report search-minded physicians from the tliroughs are either forgotten or distinct impression of having no from an objective position can ex- medical schools and research insti- proved wrong a year or two later." strong and inspired leadership. The press anything but pleasant surprise tutions. As a matter of fact, the first This speaker conceived the prob- potential genius of the Division of that the heart disease, cancer, and sizable medical research grants to lein to be one of equal access to l@c,,Ional Medical Programs is that it nonl)rof institutions and their in- health services On the part of all peo- insists that the ideas and the 'nitia- stroke I)ro,,ram has turned out so it I 1 Whatever ground the infant lost vestigators (@amc from private ph'- ple, and concluded that tli(, l@egional tive, the organization and the stimu- in qi-icstionable percentage or diffi- lanthrop@,, followed by national Medical Pro@ams is a moderate, evo- lus, come from the grassroots, so to cult delivery, it has been made ul) voluntary health organizations. The lutionary measure designed to carry speak. There are some students of hrou their fellow man and his motivat' t gh skillful legislation and admin- Federal Government embraced such out the prophecy that public dollars ions istration, as well as being demon- support after World War 11 and spent for research (,an bi-iii,,, us better who regard all this as too good to be strated in the emerging substance I greatly augmented it. true, yet as far as the arrangements mentioned. Due in part to the infor- Chapman further speculated that health. in 54 different re 'onal programs 'I'hose who believe that social bm I'D mat'on overkill on heart disease, the "politics of the research cli@atc," have ,one it is true. groul3s with lon@,-cstablished and cancer, and stroke and in part to the have "ke])t us from developing a WilbLir praised Dr. Marston and \well-defined self-iiiterests are al)t to It's staff for "the creation of a local slml)](., fact that planning and organ- rnc(-.hanisrri (@al)abl(@ of looking at , I 1 t)e riion,cd only by threats oi, by I)rO"I- and regional climate which en@en- 'ke the public as dull, the the health problem for what ac- 1/.ation stri it l@e,,,]<)nal Medical Pro,,rarris until ttially is: A tightly interrelated, ,,es have been i-naclc skeptical of the dcrs voluntary cooperative action to no%%@ have not had much of a story to enormously complicated, and over- OLITCOITIC of @t I)i-o(,i,aiii which de- iiiipi-o\,e the health care or--aniza- 'D tell. Sl)cak'ng perhaps Yratultously whelmin,,,Iy important unity." I-le I)cnds, by direction of Con(,ress, on tional patterns and delivery svstem foi- regional medicine, I would say pointed out that we as yet do not voluntary cooperation of pi-acticiii,,, N,,,,Iilcli currently exist," and latei@ the story is ,ettin- better all the time. have al'i organizational pattern that doctors, academic i-necliciiac, public added, "in a sense, the program corn- I airi much impressed with it. is stron(, enough to foster balanced authorities, and a variety of others bines the better features of the liberal -Under the title, "Science and Serv- development of research, teaching, not wholly distiii'Llished for their and conservative approaches to a ere- ice," Chapman's primary messacc and practice. compatibility'. I must admit to havin@ ative societv." 5 At the same time, Wilbur spelled also mentioned runaway costs: "The HoNv you persuade doctors to come to ity of care theN, are I%@ln,a, the effi- ou,t the position of organized medi- tremendous costs involved in apply- and stay in small towns. One (,ood clency of their Tllethods, the validity cine's cooperation in unmistakable in, 'ust one set of advances in medi- way is to be-in with a coi-nmunitn, at- of "felt needs," or the number If @ j terms. It is well known, I should note, cal science, namelv, organ transplan- tractive to the doctor's wife. AnN.- persons not -etting adequate health that physicians and hospitals have tation, are causinff tol) bud,et officials thin<,, that makes life tolerable for tile care. credentials and qualifications by in Federal and State governments to doctor also licll)s. Johnson deinon- The suuestion that the IZe,lonal which they attempt to assure them- burn the midnight oil. Ilow fast strated himself to be cluite (@ornfort- Medical Pro,rams offered an extra- selves of each other's competency and should we develol) these iie%v I)roce- able @@,itti tlic,, idea of til-),,radiri,l@ the ordinary opportunity to pin down hope to insure their patients of a hi,rh dures and lioA, can economv be quality of the practitioner's services. some of the variables in mectinc, man- quality of medical care. Since a poor maintained?" power demands and thus make a be- quality of care is sometimes worse We must hurry on without answer- DISCUSSION GROUPS ginnina toward solution obtained than none at all, it is natural for in- in', these questions. ready acceptance. In mv own opinion, telligent patients or their group rep- Ro-er 0. EgebergA,Ishecl to give no A kind of i-ougli and readv @'alid'a- the organization, distribution, and resentatives-such as organized labor (rrounci on tYi(,- need for excell(-n(@e, tion of tli(, choice of issues and points more effective utilization of the serv- or welfare a-enc' pursue(] by tlic@ program speakers ices of health professionals is equally ies-to apply the but pleaded that availability of serv- I I I came out of the discussion -roui.)s. In profession's own standards to obtain ices was e-,,erv bit as important as 0 as important as, if it does not have the "best medical care." There is, of some instances, discussants stated their quality. higher priority over, large increases course, no -Uarantee. their problems and their opinions . n Ray E. Trussell conceded that the n the production of doctors, nurses, Wilbur warned: If R TTIOI'(, forcefully tll@ITI tli(, sl)(-al@ers. ' MP I)tjrsi.ilt of cltiility (@@ir(, %vts 'I'lils %%!as tli(- Ias(@ in tli(- ,t-otil) that and otil(@rs. becomes an instrument for tli(! (,stab- (@oiisuiriir)g irici costly, 2Lri(.1 supported lishment of national standards with Will)Llr's position against national I)oncl(,r(@(I Lli@I)ail 2trid related I)rc)i)- AT)NIINIS'I'l@i\'I'ION OF the coercive compliance compelled by standards in regional medical care, ](,ms. 'I'lieli- (@on(@ei-ii tiicl to do @vitli REGIONAL MEDICAL such standards, it will arouse nation- 0 the difficulties of I)roinotin(r corn- yet he held that at his level (the city . . PROGRAMS munity involvement and organizing wide resistance from physicians, insti- of New York) it is necessary to limit tutions, and allied health profes- public funds to medical and hospital re(,ional programs in metropolitan Presentation of the Re ional Medi- 9 sionals. What can be ained by coop- ,,rvi(,es that i-n(!et riiiniinuiyi stand_ areas contaiiiin', a @vicl(- var'et@, of cal Pro-rams through the eyes of Bob ('r@-ttioil ilicl or. M@it-stoll III,, vt;lfl' 1)1,()Vi(l(.(] ;III ov(", will I)(. ]<)St if tli@. us(, of to (',LI'(' to I)I'iV@tt(@ 1);Lti(!Ilts ti(@IIS :Lll(l S('Ilo()IS, (I(@illoilstl-:Ittoll of tll(, (li%,I- ,,M li(,@Litli and for tile moment li(-S (lot-- will not satisfy tli(@ intent of I' 1) fare ageri(,les, or tii(@ like. I listened, Siol .is genius for di-a@@,in(,-- attention not mant in Public Law 89-239, becomes lie said. "There has to be an improve- tself but to its regions, whence all its dominant characteristic.',' and heard lively discussion but no to I ment in service . . . ." thin-s come and ivhere all things hap- This @vas practical advice on how Frank P. Lloyd explored the tecl-l- answers. In these discussions, no one ques- pen, according to the la@v. In all to avoid conjuring up old devils, such niques of involvement by which the bability, tho as the fear of "socialized medicine." cli,ialitN, of ni(,dic@al care can be tioned the existence of a health iyian- pro se listeners who con- e, nor did anyone quite that the stafrei-s of this cli@,l- Breslo@v touched on other kinds of r'a'seci-for example, by persuading 1)owei- shoi-ta,, problems in the regionalization of know what to do about it. Particl- sion of the National Institutes of practitioners to give routine Pal)ani- health, such as the fact that those (-olaou smears. Amos Johnson, the pants appeared to agree that no one Health were a lot less interesting tl-ian interested in environmental health articulate encral practitioner from a knows for sure how many doctors the people from the field A,ere merely control and those planning patient rural North Carolina (Community at- and other health professionals the uncompreliendina of the devotion of care services "have remained almost tacked the issues of quality and avail- country needs, inasmuch as there is Bob and his stafT to the concept that entirely oblivious of each other," he ability from still another standpoint: presently no way to measure the qual- leadership must come fi@om the corn- 6 munity or region and not from Wash- administering the Regional Medical tem, and the educational imperfec- ington bureaucracy. Programs, will strive to preserve tions are the fabric of oui- health care It was a lii@hli,ht of the confer- existing centers of excellence in scl- crisis. The new emphasis being crice, from iri@, standpoint, to find that ence, education, and service, @vhlle, placed on these major issues by Re- the members of both the division and at the same time, working with State gional Medical Programs is being re- the staffs of the programs themselves and local forces, evolve a system that flected by the developing resources were, at every level, persons of appar- @vill make available to the bulk of the and energies of the prorrams." ent high caliber. 'I-he observation ex- population medical services that are It is significant that the staffers tends to the many bright, youn, peo- excellent in quality and adequate in speak of not one program but of ple I met. The analogy of the cluantity-at least in a major segment "programs" in the plural. In other Linl%,,ersity came to mind; the institu- of the diseases that plague us all." words, Nve have borne witness in these tion is precisely as strong or as weak I have little doubt that his ap- three days to the emerging substance as its faciiltv. 'J'al(-nt plainly %,Isl- I-)roach N@,oulcl have I)cc@n extremely of 54 "happenings," that is, 54 Re- i)](. in til(@ (li@-l'iloll stiff ;in(] telex I-(.- ])Iizzlltl", to .,oil)(! of tli(, pro- gloii-,tt l'i-ogi-ains now in existence. In lo[) @l I(@oor.(I III; ;I11( I t II(-i I'St; II ;II Of LI)(! Old @Lll,'Ilogy Of the ff tli's unusual policy ol leader- rc- I fohn iit of the I"Iockcfeller Llir(@e-legged stool of Leaching, shil)-someone called it "creative Foundation or Joe Mountain of the search, and service to patients, I anarchy"-sun,lves its inherent dis- Public Health Service, as it may also should like to introduce a new one to advantages, such as the apparent lack perplex some of the advanced stu- fit the' occasion. I see the Federal of aggressiveness and articulateness, it dents of social systems and processes. Government as the hub of a wheel will (@onstitLit(@ one of tli(@ ,r(,at totir,; litit if we regard tli(@ program is in in wlil(,Ii the sl)okes are reaching, rc- (I(. form(,(. ;fl (11(@ History of ;t(l- iii@ly ;1,1'.,O ('Otl(@(!iV(! It S(@l-Vi(@(', ;III(] tll(' run I)in(l- . . ( , If] I ftiiriistl,@iLloll. I I o I' (.,I I 1-y' sL@ii-tliiig innovation. It '11,g them togctlici- is l@eg'oiial Medi- ,g (jut as a I I the effective organization and opera- has the great virtue of keeping the cal Programs. tion of a program based on the neces- enterprise well removed from that sity of voluntary cooperation and im- battlefield where we can still see the plemented by letting leadership come unburied boncs of many a social from the outside in and the bottom I)Ianner and social reformcr-that is up is difficult to get used to, I con- the battlefield of socialized medicine. cede, Once one appreciates what is Alexander M. Schmidt, chief of the happening, however, he is not dis- Continuinc,, Education and Training I)osed to change it, but becomes rather 13ranch, stims up the situation in this intrigued with how it will come out. articulate fashion: The division staff otlienvise gives "The challenges faced bv Re,lonal (!\,e@, (@%,idencc of bcin- extremely Vedical Pro-rams are no@v readily able. 'T'here seems to be method in apparent and, while great in size and their madness. scope, are rnatched by the potential .%Iarston (iiiot(,(l his chief, James foi- solution offered bv the programs. @li;tillloll: t(,I@(.1 iliziii@, di (-@rse geographic l'isill" (!Osts of (:are, the shortages, the and social cir(7LIiristances, NIH, in impersonalized and disjointed sys- 292-414 0-@18---2 7 QUALITY AND AVAILABILITY OF HEALTH CARE FOR HEART DISEASE, CANCER, STROKE, AND RELATED DISEASES IN THE FUTURE AS RELATED TO. . . . SCIENCE AND SERVICE Carleton Chapman, M.D. REGIONALIZATION OF HEALTH SERVICE Lester Breslow, M.D. DEVELOPMENT OF PERSONAL HEALTH SERVICE Dwight L. Wilbur, M.D. THE POPULATION Panel: Roger 0. Egeberg, M.D. Ray E. Trussell, M.D. Frank P. Lloyd, M.D. Amos Johnson, M.D. QUALITY AND one of the others for special-usually aspirations. The term "research in the How does society produce its Curies, AVAILABILITY OF defensive-purposes but the preser- service of mankind" has very funda- the Floreys ancl Flemings, the Enders HEALTH CARE vation of independence has still been mental meaning despite the fact that and Salks; the Eiiisteiiis, the 13ohrs, FOR HEART DISEASE, paramount. This, contrary to the it has become so hackneyed and its and the Ferinis? It is not, in our own CANCER, STROKE, views of some roups, has not always context so restricted that it rubs many bewildering and complex day, an ac- AND RELATED been a bad thing. On the contrary, of us the wrong way. The basic re- curate answer to say that outstanding-r DISEASES IN THE it has for generations been a reason- searcher, no less than the conscien- and giftecl men -,vlll rise to promi- FUTURE able modus vivendi tinder which a tious schoolteacher or medical prac- nenCC no matter where they happen to AS RELATED TO- great deal has been accomplished if titioner, is en-aged in rendering a be born and live out their lives. We we persuade ourselves to take the long service to the public. He may succeed, know, of course, that a man like NVil- SCIENCE AND SERVICE view of it. But it has, at the same time, within the confines of his laboratory, liam Witherin, Imade his methodical Carleton Clia[)tiiati, M.]). a] Solved tli(-. problem- we must now in iriipt-ovirig the lot of ryiillions; or c)l)s(@r%,atioris A,hll(- he wis engag(,(] in solve to (I(@V(@iol). We (7.11illot llo%v (,o met,(, likely li(! will @i(@(7oiiil)lisli a @.L busy ;tn(.1 fit-. did it Dean, Dartrnouth Medical Scliool "I Hanover, N.H. our separate, independent ways and less (Iranian(-, ol-)J'ective. But be is en- Without @t sl)rccl Of CtICOLir@gcriient that, to my mind, is one of the chief gaged in public service all the same. from His MajestN's Government or things the Regional Medical Program Unfortunately, the more unobtru- from a universitv. Such men will un- law is all about. sively he works and the more remote qliestionablv appear from time to -E)egional Medical Programs is a his research area from immediately time even though the climate of their concept that was concerned, SCIENCE IS SERVICE discernible need, the more likely he is time is one of indifference to investi- and is now being implemented, amid to be regarded as a supernumerary, gative effort. But it happens ex- talk of crisis in medicine. My topic-Science and Service-is a parasite, on the social body. Or it traordinarily rarelv. NN'c kno@v also I There is so much talk today about a very appropriate one by iTieans of may be assumed that if he works part that phenomena ilke Leonardo de the crisis in medicine that we are be- which to approach today's problems, time at some task that is visibly and Vinci have sprung up from time to ginning to consider all the shouting although I know in advance that -L immediately useful he may be al- time in what seems superficially to ,,vith suspicion instead of alarm. We run the risk of being too diffuse IoNved, more or less grudgingly, the be the most unpromising settlnos. are becoming so used to talk of crises coming at it from this angle. But 1 right to do basic research on a lim- Leonardo, at the start, had little more and dire predictions that @ve are get- should say at the outset that if we ited basis. In other situations, ' the than a proud father to urge him on. ting a little bored with the whole don't approach the problem dif- investigator is viewed with tolerance But we tend to forget that he had his thing. fusely-or at least in general terms- 0 because he is obviously capable; but patrons in his formative years@ men But there is a crisis in medicine, we will fail to reach above the special he is at the same time considered to like Lorenso di Medici, who made it misdefined but real, one which has privileges, functions, and obligations be so impractical that someone in au- possible for him to Nvork independ- been gradually gathering force for a our individual professional callings thority must tell him what work he cntly for something like 15 years. long time. All three aspects of our impose on us. And we will fail to per- can and cannot undertake. Whenever extraordinary talent has profession-research, practice, and ceive the elements of nobilitv that are flourished, the ambient society has al- education-are caught up in it and inherent in the taxing and gruelling THE CREATIVE CLIMATE most al@vavs had a hand in it by ere- there obviously is no easy resolution. efTort that lies before us. ating, one wav or another, a favorable In this connection I sfiould like to All these The three components have coexisted views arc, in their un- climate. to now, each leading a relatively inde- persuade vou that science is service, diluted forms, i-ossly wrona and are Today, the patrons of rescai-cl-i are pendent existence despite overlaps that hoxvcver basic and specialized it in themselves a public disservice. The malnlv the @reat foundations and the here and there. Each component has, may be, its relation, immediate or dis- question no one, the scientist in- Federal Government, acting through from time to time, teamed up with tant, is to human need, hopes, and eluded, is really willing to face is: the universities. Quite carIN@ in the life 10 of the American republic, our univer- cial forces, as well as about science, sities attempted on their own to pro- had to point out the need for such 'de a limited climate for research a climate and had, at the same time, vi (@1'e@itivity @is it was then understood. to be able to make ti-ic concept politi- Our (,ovcrniiieiit at first liid its cally acceptable. It was and remains hands full with other matters and a subtle and tedious process; and the took no direct action to support re- key to success was and is a convincing search but in Britain the identity of presentation to the public and to leg- research and service was compre- islators of the fact that 'in the short liended relatively early. Victoria had term and in the Ion-, research is serv- been on the throne little more than a ice and must not be defined too decade when the Parliai-nent ave sci- narrowly. ientific creativity a boost, using tax- In the United States, Federal par- payer's money for the purpose. It ticipation in the creation of a climate did it by setting up a system of grants- favorable to research in the health iii-aid to individual scientific investi- field seems to have come not from gators, to be administered by the our great research societies-not di- Royal Society. The Society itself was rectly from the most renowned of our a bit suspicious of the governmcnt's scientists-but from an arm of the intent but the system was accepted Federal Government itself: The U.S. and the first grants were made in Public Health Service. The effort be- 1850. Socially and politically, it was gan about the turn of the century and a monumental event in the En-lisli the most significant step was taken in speaking world; yet one can sc@arch 1937, when the National Cancer Act all the standard authorities on Vic- not only set up the National Can- torian Britain and find hardly a men- cer Institute but also gave the Public tion of it. The scientists themselves Health Service authority to anvard failed to comprehend the social im- rants-in-aid and fellowships to in- portance of what was happening. dependent investigators worl,-ina out- They may, possibly, have been a bit side Federal institutions. The subse- ashamed of it and they grumbled quent evolution of the system, and about threats to their independence; the fundamental features which have but, even so, they accepted the funds made the National Institutes as we and went to work. No one, least of all know them todiy so extraordinarily the scientists seemed to understand successful were the work of percep- that the creation of a healthv climate tive and dedicated career Public for that form of public service we Health Service officers. call research is in important ineas- The importance of all this is, I be- Lit,c a i)oiitical i-riatter with all that very fundamental indeed. The that entails. Someone who is kno",I- politics of the research climate is a DR.CHAPMAN' cdgeable about politics and other so- I)oorlv understood and badlv ne- I I t glected academic topic. I should hope fee 'ng ground is and the present situation so blatantly be described as breakthroughs. And tive common meet that before very long an enlightened quickly established, our actions in the bad, that only revolution will suffice. is small .@,onder that both physicians scientist, perhaps working with other immediate future mav do nothing But these -entlemen, I believe, fail to and laymen become be@@,ildere@ when men from other disciplines, will study more than to create a new type of understand that revolution is a process so manv breakthroughs are either for- the matter exhaustively and that, in imbalance, fully as unfortunate as Nvliich injects an element of violence or proved @vrong gottcn a vear or t@vo so doing, he and his colleagues will the ),-(,serlt one, in wlilcfi the resear(@li @iti(i disorder I I into a Progressive riiove- later. Sor-ne of them unfortunately put all these forces-political, scien- climate is attenuated while one or ment that is already under@vay. And reach the bedside almost immediately tific, @ial-into proper perspective. both of the other elements is built up. fully as often as not, the end result is and produce results of which, under- Such a study has not, to date, seemed This, some of my colleagues in the a destructive one and an obscuring standablv, -,,erv little is subsequently very important. Had it been other- academic woricl are saying, is f)r(-- of nol)lf- @tricl n(,(@(@ss@ii-v ,,,oils @viii(@li 'I'o f@) t' I irii@tt(" "is tll(@ flr(@-si- @vise, and bid the very ter-rii "re- (@isc,ly @vliat is litl)l)criiii,, aiicl tli(@y iriay have tli(@iiiselves @lll-(,@icly;tr's(@n by evo- (I(,iit's Coriirnission ozi lfeart I)jsease, search climate" been viewed realis- be rigfit. The danger of creating a new lutiozi. But the least we in the aca- Cancer and Stroke did in late 1964, tically instead of as a justification for imbalance is a very real one. The un'- demic world face, as ive go about re- that the researcher is revealing his emulating across the board the ex- fyiniz force of the future, as the Re- designing our methods and tailoring findings only to other members of his ample and method of the medieval gional Medical Program law recog- or expanding our total product to own particular research brotherhood university we might be much further nizes, will probably be the emerging meet the Nat@ion's needs, is a degree is, I think, to avoid the major issue. along. It would, I believe, have led us medical center, an agglomerate of of internal dislocation and redistribu- There is no conspiracy of secrecy in- to create an orderly technique for hospitals, medical and health train- tion of emphases. The Regional Mecil- volved. But it is quite another matter self-examination and broad projec- ing facilities, community health cen- cal Program law, the cynics notwith- to point out, as the Commission also tion. ters and programs, 'and varying standing, is designed to minimize the did, the undeniable fact that equal Z, But the influences and currents that amounts of input from parent uni- disturbing effects. access to full and effectz've Izealth have tended to keep the biomedical versities. This may not be ideal. But, servz'ces is not available to all our peo- researcher, the educator and the since our system has developed no THE PROBLEM ITSELF ple. And it is a diversion to engage practitioner on his own narrow path other unifying force, it is comina to I debate on whether adequate health have by the same token kept us 0 There are those who ask: What 11 - from developing a mechanism capa be the fact. Paul Sanazaro recently ldroblem? What crisis? services are a privilege or a right. defined the "broad outlines of aca- However the statutes read, the strong The problem has been defined, in I ble for looking at the health problem demic, scientific, and social adapta- T)roiDability is that our electorate @vhat I think to be unfortunate terms, for what it actually is: A tightly, in- tions in our medical (centers)." lie ' comes closer to regarding these bless- terrelated, enormously complicated, cites a redefinition of goals to include as the failure of the fruits of biomedi n(,s as a right than as a privilege. cal research to reach the, bedside. The and overwhelming important unity- broad community involvement and fact is that they are indeed reaching Our country has been sold on the We have not developed an organiza- restructuring of the medical schools, @e, proposition that if we use public funds the bedside-but very spottily. If t tional pattern that is strong and re- administratively and curriculumwise. to enhance the development of a sourceful enough to foster simulta- His hope and apparent expectation biomedical researcher has a fault it is Climate favorable to biomedical re- certainly not that lie locks up his find- neous and appropriate development is that all this can be done so judi- . search, the country's health will be ngs in his files. On the contrary, he of all three main components. And ciously that none of the -ood in the 1 the better for it. This I)rol)ositioti is now that the ii-ribalance is aljl)arent 11) I, svs I't]Sli(@s into print iii(I sorii(-titri(,s onto t,@ -es(,tlt, acirti'tt(,(Ilv otityrio(l(,( (,,I (,ot,l,(,(,t is far ts it qo(.S; but it at tll a cotinterreaction has set in t(,Ill will 1)(, lost. 'I'llis may I)ossll)lv 1)(@ tll(, television S(.I-(.(.Il iiiii(@li too l@(,a(li v s not (,oyiil)](,t(@ in itself. It his tal@(@ii tends at times to tli(, tli(@ (,.is(- if tli(, 1)i,o(-(@ss is an oi.(l,(!I@ly ;had @LTI(I tlil! LIS 0111Y part of the way toward the imbalance and to set the stage for and evolutionary one. There are practicing physician (@oijie all too realization of the public expectation remedial action ,vhich may turn out those, on the other hand, %vlio feel (Itjl(7k]y to be apprised of resear(@ll and, I believe, of the intent of the to be less than optimal. -Unl(@ss an ef- that the goals are so I)atei@itly (-]ear, fliiclirl(,s TTIC)st of which are llkelv to Con ress. Regional Medical Proorarm 9 12 is a i-nod(,.rate, evolutionary measure stratum is the most abstract; the low- of modem diagnostic and therapeu- never before actually pooled their designed to take in the rest of the est strata are those items which deal tic methods are much too expensive resources to the extent that the mag- with such mundane matters as corn- to be installed and staffed in every nitude of the problem unquestion- munity structure, the distribution of town and village in the country. And ably requires, to do so now? TI-IE REST OF TFIE PACKAGE health personnel, emergency and the lack of access to such methods is Very frankly, I doubt that anyone screening mechanisms, and the like. one reason physicians decline to set can say. The law will not of itself To complete the job so well begun, Our research societies have accepted, up shop in small communities. Medi- fundamentally change the goals of complementary steps are obviously not implausibly, the upper strata as cal school researchers have devised the basic researcher and the service he necessary and we begin to run into their proper baillwicks and have, in most of these advanced methods and renders, Items which are in them- conflicts of interest and philosophies. effect, continued down the years to have, therefore, indirectly partici- selves justifiable and necessary to so- This stacfe, as I have already in- 0 create valuable and indispensable pated in the maldistribution of phy- clety. The law will not overnight timateci, might have been avoided forums for their members. But most sicians. Should we therefore now de- transform the desperation many of had @ve developed a unifying plan- of theiTi have shown no great interest stroy these tools and dismantle the our physicians feel as they battle to ning mechanism as we proceeded in in the lower strata and have at times, system that produced them so that, as carry their service loads; nor will it the development of a very necessary in fact, unofficially reacted against in the early 19th century, our great necessarily convince all our physi- climate favorable to research. But proposals to attack such problems in medical centers will have no more to cians, or for that matter the entire this has not happened and it is rea- depth. There has been an unhappy offer than one man carrying the tra- public, that our traditional system of sonable to ask why it has not. resistance to the fact that the strata ditional doctor's bag of instruments? health service needs updating. And as Should the researcher, public serv- are interdependent and, indeed, con- No one today seriously argues that for the consumer, the law provides ant that he undeniably is, have done tinuous. we should take such a course al- him with new avenues of participa- it? Should the medical schools have Nor have the medical schools been though one occasionally sees nostalgic t'on in planning but it will not neces- taken' t'he lead in it? Or should the notably successful, as a group, in statements that have somewhat the sarily educate him in distinguishing practicing physician, busy man that creating some sort of planning mech- same effect. Obviously, what is between what is reasonable and he is, have brought it about? The anism that would have prepared us needed is an effective link between professionally Justifiable, on the one I obvious answer is that for various and better for what we must now under- the patient, wherever he is, the physi- hand, and what is not only medically complex reasons no one of the three take. Many of our schools have cian, the investigator, and the medi- indefensible but also extravagant and -irrn,s of oiii- profession hLs been able inaiji-,tjrat(,(l or participated in efforts (,.a] (-enter. 'riie. R(,gloii@il Medical wasteful, on the other. The back- to c)l)(@i-at(@ above the 1)t-lri(ill)le of in- to sliorc ul) the educational process Program law was designed to develop @,round against which the law is be- dependent coexistence. itself and to assist in correcting the such a linkage and to improve those ginning to operate is not, in itself, The researcher, accustomed as he maldistribution of physicians by set- that already exist. And it puts the especially favorable. We are passing is to logical and methodical ap- tin@ up programs designed to en- primary responsibility on regions. in all aspects of our national life from proaches to biomedical problems, courage young graduates to tackle The medical schools and their in- a period of spacious, eager, and re- might have helped by broadening his eneral practice in relatively large vestigators, along with the consumer sourceful projection to one in which definition of research to include some areas. These efforts have failed. The and the physician, are inevitabl Our attitudes are much more anxiety as ects of the distribution of health schools cannot by their own efforts specified by law as participants. y ridden and our outlooks much more p I services. This could probably have counter the forces that are produc- constricted than Nvas the case a fe@v best been undertaken through the re- ing ma'or shifts not only of physicians CAN IT SUCCEED? years aao. search societies; but it has not and other professionals but also of But can the law really succeed in A sequel, in Secretary Gardner's @iapl)cri(@cl, The tendency, (in the con- the population at large. Nor have accomplishing such a goal? Will 'it words, is ". . . the bitterness and trar%,, has been to establish a strati- they any way of undoin,,, the simple really succeed in indLicin,,, relevant all,@er toward our institutions that fi(-d attitude toward resear(@li; the top fact that many of tile most effective but disparate elements, which have wells up when high hopes turn sour. 13 No observer . . . has failed to note Initial cooperative efforts have, for that are neither justifiable on health CONCLUSION the prevalent cynicism concerning all the most part been encouraging. The grounds nor within the means of the leaders, all social institutions. That basic goal so far, and it is indeed Nation, rich thou-h we still are. If My assignment was science and cvnicism is continually fed and re- basic, is to help the physician and all this should transpire, it will be service. Altering the title sliahtlv, I @e@ved by the rage of people who ex- other health workers outside our great clear that the course of evolution and have stressed the point that research, pected too much and got too little centers provide more adequately for moderation is not appropriate, that however rarified, is service. I have soaring hope follonved by rude the needs of their patients. The focus stronaer medicine is required. The plead for the preservation of a disappointment is a formula for is on the physician and gives him full differences between the three conipo- favorable climate for research and trouble." It is a dan(,erous time in voice in, if not total control over, the nents of our profession will appear to have .tried to indicate that the de- the life of the Nation, and one in plannin, process. It does not, per se, the layinan to be irreconcilable and strtiction of the present climate in the @vhlch -,ve are all too likely to fall tamper Nvith the all-important cli- his natural tendency will be to assume hope of accomplishing the broad and into the paradox of t)]aTliln,r the very iiiate for r(,seLr-(,.Ii I)t.it it does strori(,Iy that we cin riitke no (-oritt-ll)t.it'o-- riece-,sarv ,(-)als-in solving the crisis if ']I you wi --will have no sucii effect. accomplishments of our recent past indicate the need for new types of othei, than purely te("Illllcll, to ti c for the dilemma we now face. But research and research training. So solution of the health problem. And On the negative side, I have iii- none of this actuallv changes the prob- far, it is indeed moving us toward a we will be in no position to preserve dicated that researchers and their or- ganizations have I I lem at hand. It 'will not simply go more complete, or balanced, view of the valuable and the oood that has ven little evidence away because -,ve are frightened by the health problem. been so painfully built up in the past; of understandin- what is involved in national and international events that One can predict, I believe, that the way will then be: Out with the the genesis, the care, and the mainte lie outside the field of health alto- firm directions will emerge from the old and in with the new. Ilut-and nancc of the research climate. The gether. It is fortunate indeed, in my planning, that inadequately defined this is the key question-who will ay i-nedical schools have tried to be view, that the Regional Medical Pro- regions will restructure themselves what the new is to be? even'thing to all men, They have gram concept emerged Nvhcn it did. alon- lines that make sense, and that A moment of truth in health plan- made ingenious but ineffectual efforts It was basically a late product of that the peripheral physician -,vill begin to ning is at hand and the processes to build a world for the researcher period of eager, resourceful pro'ec- get the help he needs. The essential of polarization have already beaun. and to discharge an incredible arraN, tion but must now be implemented in service the researcher must render is The (,onccpt of lZc<,Ional Medical of service and educational obligations a very different setting. I have heard in helpina to design planning experi- Prouram in this troubled environ is as @vell. The service, research, and the law ref6rred to as the worst, most ments and in evaluating results. If the concept of reason and good sense. educational elements have not ),et ill-conceived piece of health legisla- his own field of training and interest There is nothinc, else that hol@s found the common ground, the uni- tion ever passed by Congress. But, im- make it inappropriate for him to serious I)roii-iise of doin, the 'cb et- i lying instrument they need in order -h it undoubtedly is, it render this service, he must at least fectively and 'Lid'c'otisly. And perfect thou 0 j I I i t is to Drina the total health establish- is potentially the most important and comprehend the need for research- heartening indeed that it seer-ns to be "I its basic concept the most enlight- er-, who can. All this is beginnin, to @vorkin,, in its initial phases of im- ment to the level of development the ened. Politics aside-as much as one happen. So far, so @ood. I)Iezyicntation@ that as a result of the situation now requires. can set it aside-the law does great But the future, dependin, r of the concept disparate ele- If the Re,ional Medical Program ,, in some powe credit to the Congress that passed it. measure on circumstances outside the merits arc becoiiiin, less disparate; law is not a perfect mechanism for ring instrument, it -I'he reason is simplv that it provides health fielcl, may bring a time Nvlien that effective inquiring and sensible creating that unifN' a common xN,ork--,Iiop in -,@,hl(,Ii the the researcher and soi-ne of our incdi- I)Ianiiin(,, (,ettln,ff t,iticl(,i- way. It Is tli(, closest approximation on the components of our profession (!,,in (-al schools 1)(@(,otiie so dlsliitei,est(@d (lo(@s not ltistll-(, tll(' ti-itiltil)ll of iiit(@l- ciii-i-(@tit s(,ciie. And @vlill(, the, (@ai-ly no",, with consumer participation, be- and iticlifterent as to clisen(@age them- ll,,,(.@nc(- and moderation but it clo(.,,s i@c.-sults of it,.; 'ml)leri-)(@litation are not ,@in to liar-nryier out the system our selves. Practitioners may follow suit. metric(, us to e.\aiii'iie the 1)i-obal.@le alto,etlier orclerlv and uniform, tliev bLzr(-@eoninz Nation needs. The consumer may make demands effects of doctrinaire extremism. are in stim encotira(rincr 14 QUALITY AND cilities, To some extent, they have for Heart Disease, Cancer, and ship to surrounding suburban and AVAILABILITY OF also undertaken cooperative en- Stroke. All of us here are generally rural areas from that experienced by HEALTH CARE deavors in health manpower devel- familiar with the legislative history many of us in childhood, This new FOR HEART DISEASE, opment, patient care such as labora- and intent of the program and its set of living circumstances is inducing CANCER, STROKE, tory services, administrative services, present state. many changes, particularly in the AND RELATED and other aspects of health care. The other extensive endeavor that service industries such as transporta- DISEASES IN THE To safeguard our environment in is concerned with regionalization tion, education-and now health. We FUTURE the interest of health, as well as aes- undertaken recently by the Federal can no longer plan in this country AS RELATED TO- thetic considerations, water pollution Government in partnership with solely on the basis of the small com- and air pollution control districts are State and other agencies is compre- munity; we must also plan for the big REGIONALIZATION , - OF HEALTH SERVICES oeing established in many parts of hensive health planning. The latter community-the region. the country. Similar efforts will soon seeks to organize comprehensive Another force toward the regional be underway with respect to solid planning for health through State concept is growing public belief that Lester Breslow, M.D. waste, and possibly noise. The new governmental action and the forma- health care costs must be held down Professor of Health Services environmental control agencies tend tion of areawide or regional bodies somehow, perhaps by greater atten- Administration to lie somewhere between State and within and between States. The scope tion to organization. The Congress, School of Public Health local government, both functionally embraces both environmental and reflecting that belief, has called for University of California and geographically. Prodding by the personal health services, as well as de- more efficiency in the health indus- at Los Angeles Federal Government is playing a big velopment of health facilities and try. The tremendous costs involved in role 'in their evolution. Those con- personnel. It seems clear that the applying just one set of advances in cerned with regional planning of pa- Congress intends comprehensive medical science, namely organ trans- o those concerned with the im- tient care services and those in the health planning to be a global effort, plantation, are causing tol) budget of- Tprovement of health care in this environmental field have remained bringing together what is done in the ficials in Federal and State Govern- country, regionalization has become. almost entirely oblivious of one an- environmental health field, in the Re- ments to burn the midnight oil. How the ordei, of the day. The regionaliza- other. This is unfortunate, because gional Medical Progi-airi, and in fast should we develop these new pro- tion idea is growing both rapidly and both have the goal of protecting and health facility and manpower plan- cedures and how can economy be in a variety of forms. improving health, and each could ning-with an emphasis throughout maintained? Furtheniiore, Congress For example, recently covering learn from the other's experiences on regional considerations. has expressed a public feeling that most of the populated areas in the with many similar problems with re- Why this rather sudden emphasis the benefits of medical science are United States is a network of several spect to regionalization. Groups re.- on regionalization? not being applied uniformly enough score regional voluntary health fa- sponsible for environmental measures Probably it derives principally to all segments of the population. (,,Ility planning bodies. They are us- and those responsible for patient care from our Nation's coming to grips This latter point has been well docu- ually based on metropolitan areas services-to advance healtli-Ilave with the changed character of our mented during the past decade or so and extend beyond local govern- more in common than they usually life, especially the trend toward met- in the case of new immunizing agents mental Jurisdiction over geographic realize. ropolitanization. Migration from rLl- despite the fact that their application The Congress has recently estab- ral areas and small towns of the was organized by local health an- areas with Populations of several thousand to several million. Initiated lished two iiia'or programs involv- United States to the cities in recent thorities and the medical profes- largely by hospital groups, these iiig rationalization of health sei@\,ices. (:Iccades has not only expanded cities sion.' Reflection on the much agencies vary in streii-th and scope One of these is the ob'ect of our but has brought acl'acerit cities into slower and uneven spread of the cy- i i of effort. They have been principally concern in this Confet-eticc-lVork- large metropolitan complexes. The tologic test for cancer 2 and other concerned with I)Iaiiiiiii- hospital fa- shop, the Re-lorial Medical Pro-ram latter have a quite different relation- well-known medical advances, where 15 I I relatively little systematic effort has throughout Maine and part of Massa- A potentially big boost to regional- represented the principal nat'onivide been undertaken, will indicate fur- chusetts, in connection with Tufts ization of health services came with movement toward re-lonalization in ther justification for the public feel- Medical School and the Pratt Diag- the passage of the Hill-Burton Act in the health field. ing that improved organization, per- nostic Hospital in Boston, with see- 1946. Two years earlier, Thomas In other Countries, some prooress haps on a regional basis, would lead ondar-y centers at Lewiston and Parran, then Surgeon General of the has been made toward re-lonaliza- to better as well as less costly health Bangor, Maine.-' The services in- Public Health Service, had proposed tioii and, as in the United States, care. eluded complete diagnosis and sur- regionalization of hospitals as a principally with respect to hospitals.7 Regionalization also arises from ger-y in Boston for patients selected means of raising the level of medical For example, in 1946, the National growing recognition within the health by participating physicians in the sur- care in a community. When Con,ress Health Service in England created a field that the present complexity and rounding areas; consultation in lab- apl)ropriat(,,c] funds for assistance in ,vst(@iii of l@e,,Ional Hospital l')oaz@(Is specialization of health care requires oratory diagnosis, radiolo- and clec- hospital survey and construction, re- 1-CSI)OnsilDle for both hospital coii- @y exploration of new patterns of trocardiography; and postgraduate gionalization was incorporated into struction and operation. Under tli(, oilganization. education through teaching clinics at the prouram design. However, even aLlthorltv of the Ministry of Health. Hence, the trend toward metro- several hospitals and courses at the with the subsequent authorization of the regional boards cultivate s@,s- politanization, public concern about medical center. The medical school specific funds through the Hill- tematic and cooperative relationships the cost and use of health care, and thus entered into direct support of Burton mechanism for studies and with respect to purchasing supplies, professional response to the now individual practitioners, with the arm demonstrations, little was done to re(@rtiltment and training of person- highly specialized nature of health of iml)rovin(,, tli(@ quality of medical I)rortiot(,. regionall@ition until tfi(! n(!], consultant services and otli(@r care-all these and possibly other in- practice. 1960's. There was a 15 to 20 yeai- 21si)('(@ts of iri@inagement artiori,, ill tll(@ fluences are focusing attention on the Around Rochester, N.Y., with sup- in national action. During that time hospitals in their areas. The medical possible advantages of regionalization port from the Commonwealth Fund, progress was being made only by oc- schools with their large teachin- hos- in health care. the Council of Rochester Regional casional voluntary, privately sup- pitals, however, report separately to A,, with all such social phenomena, Hospitals w,-t-, organized in 19@6 to i-)ort@ecl (-fTort,, @,@icii is In l@o(Ji(!stf@r tti(@ Mirilstrv riot tliroti(,Ii tii(- r(,- one and for I)r-ovl(](,: rot' :111(i li;tll()Il:ll I,ioIl:ll 1)();It,(Is. f)tjf.l)oS(-',' (@f' llosl)lt@ll S(.I-vl(,(" l[Ig SI)OIII(I, flit' Into all ol 11(@:lltll III ;11, - S ' ) Iiist,or-y. What we now see is the sud- visor-y service in (@Iiiii(@al in(@dicinc Vince opposition ,Ill SOIII(@ (ILI-,Il't(@r's toward S@ve(l(@,n has been divided into seven den flowering of an idea that has hospital @Ldiiiinistration, joint hospit@il Governmental participation in tfi(@ eg'ons each consisting of 3 or 4 coun- roots in other times and places. services on a regional basis, and stand- planning and organization of health ties. At the heart of each reion is a In 1920, the Dawson Report to the ards for hospital operation .5 The (,,are. Widespread advance be(ran in lii.-hlv developed medical center, in Ministry of Health of Great Britain Rochester University Hospital and the early I 960's @vhen the Public, I five of the seven re,ions a medical projected a network of primary and other large hospitals in Rochester Health Service gave grants-in-aid to I scnool. A tv secondary hospitals, affiliated with served as the base for this effort. the locally organized, regional vclun- pical countv in the region teaching hospitals, as a pattern for Other medical schools, Including tary health facilities plannin- bodies. will have one general hospital with These have rown in number from achieving effective integration of hos- those of the University of Virginia rclatl%,elv specialized services and Lis- pital services throughout the coun- and Tulane University, from time to one in 1945 to a handful in 1960, ually some smaller general and cot- try,' Over the years, this has time have sou-lit to establish closer to about 80 at the present time. As ta-C. hospitals. served as a model for regionalization working relationships with physicians noted above, these bodies have pro- l,'ollo%vin,'@ this brief review of the in various countries. and hospitals in the areas around the vided diverse ranaes of service -tiid I-)a(,k,@i-otirid, it may now be al)proI)ri- Beginnino- in 1931, the Bingham medical centers.'; This effort has lia%,(@ acl-ilev(,cl vai-vln,ff degrees of (@f- at(, to (consider a definition of reg' I loll- Associates Fund inaugurated a re- taken the fot-iyi mainly of I)ost(rra(ILI- @t(l,,,(,nt of tti(, @iliz@itioii, aTI(I Son)(' Of III(, is- c@ional system of health services ate education. it. Regional Medical I't-oc@rain, the@@ S@IES Surrounding 16 cated in the following list taken from praisal of services rendered sential to maximum advance in the the same source as the definition: and costs of medical care. current situation. In essence, a range of desirable (6) Development of programs of One major issue in implementing goals for developing regional sys- research specific to area or regionalization thus is: What shall tcms of health services would regional interests and prob- be the scope of any particular include: lems; opportunities "to learn component? (1) Continuous opportunities for the truth about matters which Shall one element, for example, be postgraduate education for all otherwise must be accepted on limited to the placement and size of levels of health personnel. faith, and to stimulate cor- hospitals? Shall it also consider spe- (2) Participation of the regional rective action." cific facilities such as for laboratory organization in planning and (7) Continuous study of medical work and radiation therapy? Further, expanding of systems of under- care given outside the hos- shall it include educational, advisory, graduate education conducive pital toward improvement of and consultation service on clinical to attracting and maintaining office and home services, as matters to physicians in the particl- an adequate flow of health well as recommendations of pating institutions? Shall it provide workers from every health dis- new forms of health services for the actual transfer of patients, for the region. when deemed appropriate medic- cipline into service. (3) Advisory services to small in- (8) Creation of a program of ally, from one hospital to another? stitutions and agencies unable health education related to Shall it endeavor to link up services to attract and support the full all aspects of the regionaliza- within a health facility to those avail- DR. BRESLOW range of medical, technical, tion system for the general able outside in the community? Shall and administrative specialists. public. administrative, rather than clinical, While several definitions have been (4) Development of systematic (9) Encouragement of participa- services in health facilities be the set forth, it seems most useful to use utilization and sharing of tion in regional health pro- focus? Shall effort be devoted to a broad definition such as: equipment and personnel grams of the physicians with standardization of procedures and Regionalization is the organiza- within the region based on only home and office practice, records for purposes of evaluation? tion and coordination of all the distribution and availability the dentist, the pharmacist, This brief listing of potential scope health resources and services with- as related to adequacy of and the nurse, medical records in hospital regionalization implies two in a defined area, for the purpose health services, such as: librarian, and all other tech- sets of questions for those involved in of maintaining the highest possible (a) hospital beds and services, nical and administrative per- Regional Medical Programs: (1) level of medical care, and of adapt- (b) laboratory facilities, sonnel throughout the region.' What shall be the scope of activity in ing a comprehensive health pro- (c) public health and visiting With regionalization viewed thus a particular regional medical pro- gram to the characteristics and nurses., broadly, it becomes clear that both gram? and, (2) how shall this relate needs of the area.' (d) blood bank operations, regional planning of hospital facili- to regional development of hospital If the latter part of this definition is (e) purchasing of clinic and ties and Regional Medical Programs facilities and to comprehensive health taken to include environmental health hospital supplies. for Heart Disease, Cancer, and planning in the region? services and health education of the (5) Uniform methods of report- Stroke are important components of Rather than struggling over 'uris- 1-)tiblic (as I believe it should) , then ing financial, professional, and it. Uticierstaiidirl- this relationship of diction with others engaged in region- it encompasses all activities directed all other service activities to Re-ional Medical Programs and al health care planning and develop- toward the impro@@eiiieiit of health. make possible continuous coiii- other coiriponents to regiorialization iiient, those responsible, for Regional The scope is more sl)e(@ifically indi- parative and evaluative ap- of health care in its totality is es- Medical Programs might do better to 17 important contr h I 1 1 1 corn- determine the most ' i- throu@- out the country. In defining tions vary from one-half to 10 rii'l- to appreciate the motivation and bution they can make to the improve- and ainin(r acceptance of a proper lion, and distribution from center to pctence of these a,eiicies. both the ment of health care, which now ap- role, it will be essential not only to periphery mi-lit vary from 25 to 250 @vell-estal)llshecl and the ojies, pears destined to be planned on the specify the particular scol)c of func@- developments as well as consideration their potential for health de,,-elol)- basis of refflonalization. That contri- tions to be undertaken by the Re(,lon- or more miles"." In developin-- Re- iiient, and their ultimate coinniunitn- bution mav be, on the one hand, to al Medical Proff rams, but also to work gional Medical Procyrams, as in other of interest @vitli Rcional Nledical extend the excellence of the medical out their relationship to other health aspects of health care re-loiializa- Proai@ams. Eventually, the se%-cral center in handling heart disease, can- care developments which are based tion, the primary focus should be ina.ioz- aencics sponsol,iii,@- i-e,,ion-,ii cer, and stroke, amon, the re,lon's on a regional concept. Study of the on function; area considerations are health activities must entei@ into con- hospitals and physicians; and, on the historv and current status of the other secondary. NNIliat to do and the re- structive relationships A@itli one an- other hand, reflect back to the medi- developments, as well as consideration sources necessary to do it should de- other. This could be accelerated b@@ cal center the substantial obstacles to of the main strength of the Regional tcrmine the boundaries of tll(- his- ttit-oti,,iiout a i-c- tli(, enterprise. tc),-'C..tl role tjicl ctirr-(,jit i-(!@,ioiial Medical f't-ogi-arris--iiieclic@il (,x(,c,]- gion, such as isolation of individual lence-will be helpful in workin- out Again, it would seem desirable that health acti\,itics of the %,ar' IOLIS physicians and inadequate planning the i-cjationship. Regional Medical Pi-o.-ram leaders agencies. -1 of facilities. Regional Medical Pro- What to do, in the sense of scope of study carefully the as- Coiisid(,i@ for a iiiorn(@nt the pl'(,Iit (rrams arc clearly intended to become fLin(-tioii, may seem a sliffi(@iently large 1)c,,ct,; of otfi(,r i-c,,'ori lic@iltli i al of the Stii, (@on Geiier-@il In i,(@,,arcl. a two-way street; and some believe issue foi- consideration today. 13LIt ol)ments. Understanding their his- He must ultimately respond to the that those in the medical centers have perhaps brief attention can be given torical, functional, and philosophic sc\-eral rcaional health endeavors as much to learn as those elsewhere in to two other issues in re-ionalization bases will be extremely useful in ar- which the Public Healti-i Service is the region. of health care: Ge@,raphy and spon- riving at mutually acceptable clcfiiil- now spoii,;oz-in-: Regional -.%,I(,cllcal An approach by Re-ional Medical sorsliip. tions of roles. Pt-o(,rarns, liosl)it@il development and Program leaders, based on such a The question of size and clistribli- For l@e-lonal Medical Pro,,raii)s, coii)l)rehcnsiv(,, health I)Ianninc,T. I-le concept of their relationship to other tioii for Re,lonal Medical Programs initiatirig sponsorship has come large- @volild surel@, be ,rateful for field solu- current re-ional developments, may is, of course, largely determined by ly from the medical centers, as one tions to the problem of interrelation- be useful. Certainly, Regional Medi- the availability of medical centers might expect. Participatin- and ad- ship among these programs. cal Program personnel are encounter- for participation. More (,encrally, visory elements come from the re(@ion In sui-nina@,, the Re "onal '-%Iecllcal ing in their realons, States and the with i,esIDect to re(@loi)alization of generally. In the case of other p,,),, rain "I I for Heart Disc,,as(,, (,2inc(,i-, country, persons who call themselves health "the ftiri(laiyiental ,c- rent re,lorial @icaltli (leveloprll(,Iits, Z, @ti)(I Strok-(,@ is one important (-Ollll)o- hospital planners, comprehensive quireincrits @is to @lzc! al)l)eat- to be: such as hospital I)Iarinin,,, and corn- ticnt in the rapid development of health planners, and the like. Even (1) Each re@,ion should be larue I')rehenslvc health planning, sponsor- health care on an area@@,ide oi- rc,@oioii- thou-h initially startled by the en- enouch to include (or warrant the ship has come from hospital rotips al basis in this countn@. To fulfill its counter and reactin- momentarily on inclusion of) such an amount and va- and State health authorities. Other particular mission, those responsible the falrlv low blosocial level of "my rietv of resources for health services affencies in wide -,-ariety no@@- are be- @'ill have to define' Scope of function, jurisdiction," perhaps Regional Med- that, when tliev arc I)i,ol)er]N, i'nt(,- (,Ortlirlg Involved in tr(,a%vl(l(@ @tii(I (@o ancl ,pc)iisoi-- I 11 i(@ ('OV ical Program leaders can move enei,- @,ratecl, the re,,Ioii will be s(@ll'-stiffl- r(!.qlorial health slill) all in relation to otti(@r i-c,(,Ional geticallv into the negotiations neces- clent for most I)ui@I)os(,@,;; (2) i-(,- So('I('tl('S, ('OLIII(-Il',, local and li(@.iltli activities ai-(, also ,ettiII(, sarv to establish an al-)propriat(! role ',loll slio(lici be sii)all enoLi(,Ii to make i-(-gloiial (,o\,@c-riiiiierital I-)oclies, iticlt,- iiiidc,rNva%,. In clarlf\,ln,u these i,cla- for their programs in the complex, the administrative center or any pendent (@oriiinissions and CoLin("Ils. tiotishll)s, it ma-,! be useful for those fast-paced progress that is oc(,urrinu other unique feature ac(@@sll)le to all ;tj)cl otli(@t's. Ag2LIii, it 1)(@ I iTill)ol,t@tilt tocl;in to @idol)t @i broad con- in health care rc,,ionalization parts of tli(@ t-e(,Iozi. JZ(@c,'onal I)ol)tila- foi, lzeglorial Medical Program leaders (-(,I)t of i-egionalizatl(-)n in lif-altii af- 1 8 fairs, specify the particular activities (8) Building America's Health. Report QUALITY AND many misunderstandings and an un- which Regional Medical Programs of the President's Commission on AVAILABILITY OF certain but hopefully great future. will undertake, become sensitive to the Health Needs of the Nation. HEALTH CARE The zeal and enthusiasm of the men Vol. 2. Superintendent of Docu- the other major agencies and pro- ments, U.S. Government Printing FOR HEART DISEASE, and women including numerous grams involved in regionalization, Office, Washington, D.C. 1952. CANCER, STROKE, medical leaders-reflect the dramatic and ultimately achieve a complete (9) McNERNEY, W. J. and RIFDEL, D. C.: AND RELATEI) appeal that it has for many individu- pattern varied in different parts of Regionalization and Rural Health DISEASES IN THE als of good will and high hopes. The the country according to circum- Care. University of Michigan, Ann FUTURE @,a-uely defined authority of the act Arbor, 1962. stances, in which Regional Medical AS RELATED TO- seems to many inadequate to bring Programs can make their maximum about the innovation and organiza- contribution to the improvement of DEVELOPMENT OF tional changes they seek. health care for, the American people. PERSONAL To Battistella,' the act's promise HEALTH SERVICE is to facilitate- References ". . . the planning, organization, (I ) MERRILL, M. II., et al.: Amer. J. Dwight L. Wilbur, M.D. and delivery of health services Pul,)Iic Health 48; 146 (February) Palo Alto, California within a fiinctionally-based re- 1958. President-Elect gional framework, capable of cir- (2) BRESLOW, L. and HocHSTIM, J.: cumventing State-local political Sociocultural Aspects of Cervical Anierican Medical Association boundaries and orthodox health Cytology in Alameda County, Calif. channels. Additional excitement Pub. H. Rep. 79: 107 (February) 1964. his Conference-Workshop pro- centered on the possibility that, Interim Report on the Future Pro- Tvides an excellent opportunity to once launched and successfully vision of Medical and Allied Serv- demonstrated, the application of ices. Consultative Council on consider the potential impact of the regionalism might spread to en- Medical and Allied Services, Regional Medical Programs author- coiyipass a number of other prob- Ministry of Health of Great Brit- ized under Public Law 89-239 on the ain. London: HMSO, Parliament lems pressing in on the health fielcl, Command Paper 693,11920. development of personal health serv- ancl might lead eventually to a (4) GART,AND, An Experiment in ices. It is especially fitting that those J. E.: complete reorganization of health Medicine: A History of the First most active in conducting this com- services." 20 Years of the Pratt Clinic and plex and potentially highly beneficial the New England Center Hospital In another portion of his recent activity be brought together at this of Boston. Cambridge: Riverside aper, Battistella has this to say: time to review planning efforts of the p " 1 Press, 1960. last 2 years and consider their transla- . . . to have insisted upon a more (5) RoSENFEi,i), L. S. and MAKOVER, comprehensive and idealistic vcr- H. B.: The Rochester Regional tion into operational implementation. Sion would have been politically Hospital Council. Harvard Uriiv. In many resl)e(@ts this act is quite ex- Press (Commonwealth F ii ii d ti-aordinary. Its geiiesis and promo- naive arid would have precluded C.irnl)ridge, 1956. the passa,e of any legislation at all. (6) ROFNIER, M. 1. and tion as described in the recent article To this %'@ MORRIS, R. C.: vav of tliirikin,,, a slice of Hospital Regiorializatiori in Per- in the Atlantic Monthly are ititt,igil- pie is better than no pie at all. Some spcc,tive. Pub. H. Rep. 74 (10): ing, to say the least. 'I'he diverse in- of the 1)'II'S Supporters take an 916-922 (October) 1959. tei,pi,(,tations among \various C)I)S(@t-v(@i-s evoltitioiiarn, point of arid (7) RoF,'IIER, M. I.: Personal (-Oiriiiiii- rii(,atiori. of its loll"-t(,I-Ill objectives @ll'),,Ycst sit .... est that a (combination of es- calating problems in the delivery in the qualit@@ of diagnostic and of health services and rising expec- treatment capabilities available to tations for better and more eco- different patients within this Na- nomical care, will inevitably trig- tion, in the area of heart disease, ger an expansion of the program. cancer-, stroke, and related diseases, Eventually, they see the seeds (2) That tlaroucli the mecha- planted by the Heart Disease, nism of re-Iona] cooperative ar- Cancer and Stroke Act leading to raiigenierits of the people, liastitu- a complete reorganization of all tions, organizations and agencies health services ,vithin a reional iii\,olv(-d in li(@altli in that re(,ion framework." these differences can be lessened." The article by Clark' also pro- According to Maver, this program poses a national blueprint and sug- is designed to strengthen existing in- gests various models Nvhlch might be stltiitions rather than to create new follo,A,ccl in estaljllsliiii(, this nation- ones. Ile stresses the point that tfils is ivide program. Any impartial phy- not a national pro-ram but a regional sician @vho studied the Clark-Battis- one, and he underscores that word tella thesis, as presented in their "cooperative." He points out further papers, would reach the conclusion that- that RMP was in fact designed to it is important to under- provide an instrument by which the stand that the Regional Medical organization and delivery of health Proorams are not simply another care of the American people could be kind of mechanism of funding in- changed in a revolutionary manner. dividual projects. It does represent These articles are well written and a new kind of conceptualization in have the commendable characteris- the approach to health care and tics of unequivocation and candor. education. Whether it is capable of Although one might disagree with serving this function onl@, tir-ne will the conclusions, one cannot impugn tell." the authors' motivations. The fact re- I applaud this point of view and mains, however, that the issues as the emphasis -iven to these aspects of presented by this school of thought DR. WILBUR the program bv the division of Re- are not designed to stimulate strong alonal Medical Programs. If the pro- physician support of these programs. mate which engenders voluntary co- on local initiative, flexibility, and de- ffram in fact is clearlv one clesianed to Dr. Marston and his staff, on the operative action to improve the health (@isionrnakin,'@; and the reason for the catalyze and to facilitate the dc@@elol)- other hand, and manv of vou who care organizational patterns and de- pro,ram is the relationship bet@veen ment of better programs that now are active in the proaram, have livery systems which currently exist. science and service." exist to serve Patients and tl-ieir phvsi- sought through talks, articles, and As Marston has so \vell expressed it in The tivo key assumptions On which cians, it will undoubtedly receive ell- actions to promote a different basic several addresses: "The focus is on the purposes Of Public Law 89-239 tliuslastic cooperation from the medi- concept of the program, that is, the the patient; the inechaniSTYI is coop- rest, according to Mayer,' are: (@al profession and related i-oLips. @@7e creation of a local and regional cli- crative arrangements; the emphasis is "(1 'I'liat there are differences krio@%, that the law and its legislative 20 I 1 histor@, stress the %@oluntar@, coopera- rent emphasis on the working to- compel changes, some of which may cult to disagree with this statement ti%,c nature of t@ie pro,ram and that gether of regional groups, it will ful- be favorable and some undesirable. from the Report on Regional Medical .1 interference ,@'ith existing patterns is fill its purpose of improving the RMP is in a strategic position to Programs to The President and The 'f'(@allv I)rohibit(@cl. As Dr. M@ti-s- quality, ;.L(:c(@s'bil@tv and availability bring about changes acceptable both Coti,ress ' of June 1967- sl)(.,cl I to., r, said in a recent talk-- of li(@altli care, pfi),s,cian and institti- to physicians and their patients every persoi-i whose life and "'I'li(,se i-)rograrris face the cli,,tl- tic)nal performance, and consumer that will improve performance and well-being may be in 'eopardy i lenge of influencing the quality of satisfaction. On the other hand, if patient satisfaction without under- from one of these diseases should @icalth services without exercising RMP becomes an instrument for the mining patterns of behavior that are have the full strength of modem Federal or State governmental con- establishment of national standards traditional, and, more significant, I I medical science available to him trol over current patterns of health with the coercive compliance corn- considered by the medical profes- through the cooperative efforts of the medical and related resources a(@tivities." pellcd by such standards, it will sion essential to the preservation of ldc resistance from high cluality care. Public statements of tills tyl)(@ are arouse nationw of the region in which he lives. 'tris, 'Fll(,, sensitivity of medicine to the These are the goals to Nvhlch Re- (@ri(@ouraging of tl I(! I)hysi(@i, institutions, and allied standing by those r(@sl)onsibl(., for cli- @icaltfi professionals. What can be possible establishment of national -ional Medical Programs are gained by cooperation and meaning- standards under RMP for the treat- dedicated." recting this program of the pro- founcilv complex problems and social ful participation will surely be lost if ment of certain diseases was demon- This utopian ideal, however, will and coiiimunltv interrelationships the use of coercive power, @vhich for strated recently when it appeared that be realized in varying degrees depend- that confront al,I those who be the moment lies dormant in Public IZMP might be moving toward such ing on the ability of the medical pro- participating. The innate difficulties Law 89-239, becoi-nes its dominant a development. I have been assured fession and the health care industry of achieving a consensus among a characteristic. by Dr. Marston that no proposals for to make available such services and large number of disparate local acfen- I have dwelt on these basic issues such national standardization have facilities, and upon the patient popu- cies, all traditionally striving to main- at some length because one cannot received any sympathetic hearing and lat'on to utilize resources as they be- tain their independence and special discuss this sub'ect from the perspec- that, on the contrary, it is his feeling come available. I am deeply impressed by a recent prerogatives, arc well known. tive of personal health services with- that such proposals run counter to out first considering the basic issues the spirit of the legislation and the article by Lahav ' on "Methodologic Rational decisionrnaking i)y ind(@.- . ivatc (@n ' ' I I I I I Problems in Health Manpower Re- pendent public and pr' t t ('s nvolved in the dcvclol)i@iietit of the in@triner in which it is being adinin- I i i , I f)rogram on a voluntary basis, hoA,ever, is an as a whole. Change is ex- 'stered. I applaud this attitude, and search." His observations are espe- objective that is worth pursuing. -Un- Pected by the vast majority of think- I urge that it become a part of the cially gen-nane as you develop meth- like many other countries, our Na- ing persons-, and the medical profes- fabric of your thinking as you con- odology for effective implementation tion has reached its preeminence in s on, like others, is changing its tech- duct these regional programs. of this law. He identifies some of the many areas of activity because of tll-s niclues and operational I)ro(-.(!cl@ir(,s Another aspect of the currently countless variables that make health unique combination of multiple inde- constantly. Sometimes these changes evolving RMP program that deserves economic research so difficult and pendent focal points of activity co- are forced by external environmental commendation is its scientific spirit- facile conclusions and recommenda- operating on a voluntary basis to factors which lead to improved pre- that is, its willingness to depend upon tions so perilous. He notes, for ex- v(,ntion, diagnosis, and therapy of observation and experimentation be- ample, that Government sponsored achi(n,c a commonly desired goal. De identified this Liniclue (liscas(!. At other tliTies, (lian,@es are, forc reaching firm conclusions. The I)ro,rams can contribute to a more American ability to become as'so- forced which are unacceptable to danger of national blueprints or rational distribution of medical and i-nodels is their usual inflexibility. other health facilities but that their elated %@@lt@i others to plan and op- physicians and their patients. The crate programs in the absence of current health manpower shortages Your objectives arc laudable, and they ability to effect a comparably rational cc,@i-itral ,o%,ernmental direction and and escalating health care costs are require implementation which per- distribution of health personnel is control. If l@MP riiaintains its (@ur- examples of external pressures that i-nits ready change. It would be diffi- relatively small because, in a free so- 21 ciety, distribution of professional placement in an efficient, rationally Continuin, education. The problems recent Presidential Commission on manpower is predominantly a func- organized, and economically con- of medical care and contini-ting medi- Health --%Ianpo@,,,er on @vhicia I had tion of personal decisions made by in- ducted system may be even more cal education are inseparable. In fact, the of serving. You re- dividual practitioners. important. continuing medical education offers call that one of its rather contro-,,Cr- In discussing rural health centers In this connection, the recent (,,om- the greitest potential for rapid wide- ,ial recommendations ,@@as tl@i,-tt rell- in rural northern Michigan, -,where ments by I-)r. Marston' when he sl)i-(@ad Solution of the identified pi-ob- censtire of physicians be considered McNerney and Riedel ' found that talked to a group in Illinois are es- leiiis or difficulties in the eneral at-ea as one means of stimlilatin-, pli@@si- their producti%@ltv was lo@v in terms peciallv appropriate- of patient care. In the planniri", and cians to continuousl@- to re%@' I ic@v new of unit cost and that they had cliffi- "As one views the current health early operational IZMP programs, it information, l@'hate,,@er technique is i culties in attractiii,, and iiiaint@iiiiinc, scene, L seems inevitable that, as plays t iiitiot- i-ol(.@,. AMA is used to assure a I)Ii@s'c',Ln's Lil)-to- qualified professional and administra- an increasing proportion of our na- 1)cciallv anxious that this asl)e.(@t of dateiiess, the I)ro%Fis'oii of continitin, tive personnel, Laliav noted that the tional wealth is devoted to health the evolvin,, program 1)(., emf)liaslzccl. education throti,li tli(, cle@-elol)ln(--nt difficulties in this situation could not and as the expectation for health Marston and Mayer,!' in their article of core curricula and other tech- be modified easily under conditions services continues to rise, there will on "The Interdependence of Re- niques, and the utilization of corti- of "nonsocialized medicine" where be marked pressures for the most gloiial Medical Programs and Con- inunications technology now i-apidIN practicing physicians had a large cfTective allocation of health rc- tinuing Education," in(licat(,- becomin- available, must be pursued measure of independence. The keen sources. These pressures will exert "The following two points con- Vigorously. observation that decisionmaking on influ(!nccs in such critical areas as cerning the development of contin- The RMP program has stimulated a voluntary basis may tend to frus- the distribution of resources be- uing education activities within a widely favorable reaction from the trate the impatient administrator with tween short and long goals, that given Re-ional Medical Program medical profession. As a whole, the innina limited authority clearly applies to s, between biomedical research, are of prime importance. First, the Iiiedical profession at the be@,' ' "I RMP. I urge a frank discussion of for example, and the immediate de- Division of Re,ional Medical Pro- of the year 1968 is prol)abl@ more this question and your resolution of livcry of service. Within service it- grams can make grants for two I)iir- deeply involved in the plannin- proc- I to determine the natu,re of the Re- the problem in favor of voluntarism, self, there will be pressures for the poses only (a) to plan or (1)) to css for the gains that you will make in distribi-ition of effort between im- establish Rc,ional Medical Pro- c,loiial -.%Iedical Pro@rams than it has terms of flexibility and physician sup- I)rovements in cluality on -th(, one grams. It cannot riiakc grants for been in the plannin, of any port will far more than offset any hand and cxt(!nsion,, of t(-c(@ss to the estal)]iS]IITI('Ilt of continuing (,cl- Oil-" l,'ecleral T)roaram. %fan@, of our, losses you may incur. licalt@i care on the c)tl)er; tli(@ @illo- ti(,,atiori i)ro,,rirns." most (listin,rUiSll(@(I nl(@CI'C.@ leaders Another important point made by cation of resources for general pur- Understandin,r the preclusion of are participating full oi- part-time in the Re-ional Prc),rams. Lahav is his emphasis on the coordi- poses as opposed to targetive ob- support of re-loiial continuin- edii- z:l nation of scarce resources rather than n "I Many State and cotintn, medical the mere creation of ne@v ones. It may je(,,tivcs; exploration of mechanisms cation prograi-ns alone, we hope that .ties are cooperating aIctively or to alleviate the actite shortage of special ei-npliasis will be given to this 'Ocl well be, as we strive touether to create in an advisory capacit@, and have ex- all health talent; and the need to aspect of a re-ional prorari-i, since the best possible health care system explore the division of resl)oiisi- to a sl,,,tilficant de(rrce the (,ap that pressed their enthusiastic support. for our nation, that the (@ml)liasis is of billtv bet%@,ecii those health rcsl)oii- may exist between sciences and se,-%.,cc Dr. (;Lillatt,,"' for example, in the RMP on cooperation, coordination, sibiliti(@s carried out through the can be minimized by such continuing Oklahoma State infeclical .,Association and regional plannin,, will turn out (rovei,nrnental sector and the re- education. Incidentally, this I-)i-ol)lciii Jour?zal for @kpril 196/@ said: to be far more productive than pro- sponsibilities of the voluntary in- of (,ontitit,iiii,,, the education of I)IINs'- "The Re-lonal -.%Ied'cal Pro- urams dc@sineci simply to increase the stitutions and organizations." cian,s and otliei- health professionals (@raiii has the potential of inakin@ output of health professionals. Cer- I N@,ayit now to turn to another sub- in a rapidly chairman scientific cli- remarkable impingements in the tli(- litter is ii(,(,(,ssai,y@ but tll(-]I- i(@('t of to ;It I)%, ti)(@ (,otitirilliti", of cians, an objective to which we "There is no question of the pro- existing facilities; rural medical man- conservative also can feel reasonably @ia-,@e al@@!avs been dedicated." fcssion's ability to do the job. The power is under study; a number of comfortable in the context of this pro- North Carolina prepared a special important step is to direct our total hospitals have opened their records gram because it is not intended to be issue " devoted to RMP in May talent and energy to it. The 'ob- for review of current handling of pa- a rcvolutionar), substitute or a na- i 1967. In an editorial in that issue, the @vell done-will reassert and secure tients with heart disease, stroke, and tional blueprint for existing patterns following comment is made: our leadership in health affairs and cancer; communications among hos- of behavior. "In the months and years ahead, assure an ever improving state of I)Itals within a region are being ap- Rather, it builds upon the past and these early times of the program national health." praised; interconnecting color tele- the present, adding new features, 'II no doubt be re(,arded as the In Georgia, Dr. Battey," a mem- vision among these hospitals is being changing old ones, as local demands Nvi critical period, @vhen the shape of her of the steering committee for the considered, as well as the educational and resources make possible. Its flex- things to come became apparent. pro,ram, said: television network; the transporta- ibility, pragmatism, and acknowledg- Thus far the \Icdical Societv has it is the intent and sincere tion of laboratory specimens to central ment of regional variations, particu- pla@@cd a creative role and, our desire of the members of the areas is under study; the use of heli- larly appeal to me as wise emphases. Georgia Regional Medical Pro- col)tcrs for transport of the sick and, This program can make a real con- State's progrwn is out ahead of gram advisory group that this ap- perhaps, physicians, is a possibility, tribution to personal health services inanv others because of this atti- proach, during the planning phase, and an extensive library project is if it continues to pursue what appears tude. 'I'lic only scrisible course is to will seek out and find those in- already underway. The strong sup- to be its main thrust today-to serve continue to act intelligently and tcrested individuals all over the port of the County Medical Society is as a catalyst for and to facilitate those coilstructi@rcly." State who will be anxious to take implicit. This same attitude of study, winds of change Arhich blow in the Dr. Frank, jones,'2 the president of part in what ii:iay Nvell be our great- inquiry, and active implementation right direction. If your zeal and en- the Medical Society of the State of est opportunity to achieve the best exists in many other medical groups thusiasm are tempered with a sym- North Carolina at that time, said: of medical care for all patients in the country- pathetic understanding of the tradi- cl, . . the medical society repre- utilizing the regional and the truly Clearly, RMP has stimulated a tions and basic motivations of those healthy atmosphere of voluntary co- s(-,nting the physicians of North cooperative approach." who now render health care, I pre- Carolina is involved in the Re- In Missouri, a physician who ini- operative review of current health dict that they @vill cooperate willingly p gional Medical Program. It was tially had serious misgivings about i-)rograms and a refreshing @villing- with you, and that in this cooperation this pro-ram is now conducting a ness to express self-criticism of a con- you will have the basic ingredient for involved in a somewhat similar @D valuable regional pro'ect on the man- structive type. In a sense, the program success. Basically, we all have the pI-<)C,rarn before Heart, Stroke, and i agement of cardiac emergencies. combines the better features of the same desire: To help the American Cancer was birtlied, and it will Under his direction, certain defi- liberal and conservative approaches physician to provide the best quality continue to be involved, working clencics have been identified and to a creative society. The traditional of care to the American people, in the @vit@i the i-cl)r(!sentatives of the many individuals and facilities are liberal dependence on the Federal American tradition. public and the other deliverers of cooperating enthusiastically to rem- Governi-nent as a means of solving all health care and the involved State c@y these deficiencies. problems is mitigated and redirected References I am imf)ressed also by I into a new type of program sponsored, (I) BATTISTELLA, R. M.: The Course governmental agencies in a con- an art cle . of Regional Health Planning: Re- tiniiing f)i-o@,r@im directed toward 'In tli(, Oiiozi(i@t,,a (county M(,(Il(,@il So- it is by tli(! Govei-tini(-t)t view and Assessincnt of Receiit (ILialit), care at all levels." N(.,.@N, York rc- ]-)Lit emphasizing the use of local as Federal Legislation. Aled. Care In the sairic .Tournal, Dr. Musser,':' (OL]ntliig tli(@ specific I)ro'ccts being x%,(,Il as Federal funds and dcl)e d iig 5: 149-161 (May-June) 1967. execut'v(@ director of the association (-ons'(Ierc-(l under their l@a'onal upon local regional decis'onmaking (2) CLARX, H. T., Jr.: The Challenge of the Regional Medical Pro- established to conduct this program, Medical Programs. All available rec- and si(,nificaiit participation by the Legislation. 1. Med. Educ. 0 grams said: oi-cls are being analyzed to evaluate private nongovernmental sector. The 41: 344-361 (April) 1966. @114 0 23 ------- - -- (3) MAYER, W. D.: Regional Medical (10) GULLATT, E. M.: President's Page. QUALITY AND cellence for the last 8 or 9 years. I Programs-A Progress Report. J. of Okla, State Med. Assn. AVAILABILITY OF do not @vant to lessen m@@ feeling J. of Med. Assn. of Georgia 56: (April) 1967. HEALTH CARE about excellence or an-,,bodv the 143-147 (April) 1967. (Presented (11) N. Carolina Med. J. Vol. 28 (May) at the Second Georgia Conference 1967. FOR HEART DISEASE, impression I am not in favor of ex- on Medical Education, Mar. 4, (12) JONES, F. W.: The Medical Society CANCER, STROKE, cellence as fai- as @ve can brina ex- 1967, Callaway Gardens, Pine and the Regional Medical Pro- AND RELATED cellence, but Nve need to think of Mountain, Ga.) gram in North Carolina. N. Caro- DISEASES IN TITI', avi'labil'ty from the point of %,I(I%@, (4) MARSTON, R. (2. and ScirNtir),r, lin(i Me(l. J. 28: 17'3-175 (May) F U'I'U I-' , E that excellence is fine, but if it is not A. M.: Regional Medical Pro- 1967. grams: A View from the Federal AS RELATED TO- available it really isn't verv helpful (113) MUSSER, M. J.: North Carolina Level. (An address delivered to Regional Medical Program. N. THE POPULATION to any particular patient. the Continuing @Medical Educa- Carolina Med. J. 28: 176-182 And I thought I would go back to tion Section of the Association of (May) 1967. an experience I had in the war. Mr. American Medical Colleges, Fri- day, Oct. 27, 1967.) BATTEY L. L.: Georgia Regional Panel: (Stephen) Ackerman told me this Medical Program. J. of Med. d (5) Report on Regional Programs to the Assn. of Georgia 56: 141-142 Roger 0. Egebe@g, M.D. mornlna that I ha sed this once President and the Congress. Sub- (April) 1967. (Chairman) before, but I hope it was a different mitted by William H. Stewart, Dean, School of Medicine "roup or smaller group, because as I M.D., Surgeon General, Public Health Service, U.S. Dept. of U?zz'vcrsz'ty of Southern California came cast on the plane vesterdaN7 I Health, Education, and Welfare. Los Aneles, Calif. thou-ht, "There is the basis of N@@@at U.S. Government Printing Office I -,vant to say." (June) 1967. Ray E. Trussell, M.D. I was at Western Reserve at the (6) LAHAV, E.: Methodologic Problems Director, School of Public Health beginnin- of the war and helped form in Health Manpower Research. and Administrative Medicine The New Eng. J. of Med. 277: the fourth general hospital there: and Columbia Universitv 959-962 (November) 1967. we were commissioned. The iinmar- (7) MeNFRNrY, W. J. and RIFDFL, D. New York, N.i. ried men became lieutenants, those C.: Regionalization and Rural Frank P. Lloyd, M.D. who were married became captains, Health Care: An experiment in three communities. Ann Arbor, Director, Medical Research and if 'vou had a number of children Mich.: Univ. of i%licliigan Press, Methodist Hospital You might make major. Well, I had 1962, p. 175. Indianapolis, Ind. four children so I became a major, (8) MARSTON, R. Q. University Hour and that Nvas the way it was done in sponsored by Alpha Omega Amos Johnson, M.D. that outfit; possibly for the same rea- Alpha, University of Illinois, Garland, N.C. son, I was the assistant chief of the Oct. 4, 1967, unpublished. medical service. (9) MARSTON, R. Q. and MAYER, W. D.: The Interdependence of Re- This @vas a talented group, as the gional Medical Programs and This transcript has been reviewed encral hospitals affiliated -,vith uni- Continuing Education. J. Afed. and approved by the participating versities were, in the sense that they Fduc. 42: 119-125 (February) had assistant and associate and other 1967. (Presented to the Section professors and clinical professors in on Continuing Medical F,(Iti(:a- R. Ecl--BF.RC. Noxv, we are talk- the various specialties. There was a tion at the 77th Annual Meeting D iTig about excellence or qLialit@, talent in deptfi here. of the Association of American Nfedical C(,Il(@ and Lvailahilit@, of And We in Mi,ll)ot.ii-ti(, @tiici set San Fi-;tTi(-is(!(,, I I Oc@t. 21, 1966.) 1 lia\,e I)e(@ii I)eatliig the (]rLIT11S for ex- Lil). Soozi I \@'as @isst,,,ii(-cl to tli(@ Iol) of 2.@t setting ul) a venereal disease hospital they should do the best they can with corner." And a little further question- patients, or of them to care, becomes because that seemed a little more im- the work that comes to them. And ing showed the slab was to lay them a vital part of any pro,-ram that is portant than a general hospital at now, with the advances in medicine on while they are waiting for the am- going to succeed in this Regional that f)olnt in our flistory. But, after that have occurred in the past two or or the licai'se. And further Nledical Program. a while, I managed to feel that there three cle(@ad(,s, it perhaps becomes questions brought Out that this was 'Flie transportation of care, the 1 @ @,vas i,ornari(@(@ in New (;uiri(@a or sortie- necessary fc)r some representatives of tli(- concept tti(-y had of medicine. availability of care, is just as inil)or- I)rjdv needed me there and I managed those doctors to go out and seek the And I am sui-c this applies in large tant as the excellence of care. We I to et there. It was the experience work for themselves or for others. areas of our country to certain parts must think of these thin,s as a coor- 9 0 1 had in Ne%v Guinea-the fact that There are 30 million people in the of our Population. dinated plan where we use, insofar as I got through it-that has driven me United States who hardly know what Now, to take Los Angeles as an ex- Nve can, the people who are already into the things I am interested in no@v. medical care is. As some of you know, ample again, I have long been asso- working in the areas, and bring peo- In the front lines one could find -,N!(- have started a project in the Watts (,rated with the Los Angeles County ple into those areas @vhere they have 'L lieutenant who had recently gradu- area of Los Angeles, and @v(- are work- ,It ilos I I-losl)lt@il, which is .11, ex(-,cll(. not chosen to work because there ated or. if one were visitin,, the Aus- iiig with a group of people there hol)- 1)ltal. And for those who are acutely wasn't much reward of the kind they trallans, a sergeant who did not have ing that we can turn the project over ill and for those less ill it -ives very, really had to have. a medical education except as taught to them when it gets going well. very good care. But it is about 13 So just to begin, I Nvould like to by the doctors, but who was avail- When we first got this group to- miles from Watts. And it is 13 miles make 'the plea that availability in our able to the people when they were gether, we asked them what they from many other areas of Los Angeles case s every bit as ' I 1 important as %%,ounded or when they were first ill thought they needed most in Watts- where people also get sick and can- excellence. \@'ith malaria or when they first had finally, a worri@iii got Lil) and said, not on the A,hole afford private Dr. TRUSSELL. I would like to talk the @)eginnin,, of an emotional break. "@@lhat we need is a slab on every Physicians. to the issues of availability and qualitv He was available to stem things I think we should picture a N%,omai-i and the opportunities for and chaf- Just as they started, and he handled, I cas who has a lenges to our RMP from some urban in one of those ar would say, probably 80 percent of the child who is sick. I have seen these experiences which I have had, from cases that came to him. infants and small children come in some New York State experiences, It was my considered opinion after moribund who should have been in and from some frustrations I have being tlic@i-c for about a year that prob- a couple of days earlier. Even if a had beina a member of HIBAC, cl 'I that establishes ,tblv more ,oo A,as done in the thea- mother Nvith a family of two or three @%,Iilcli is the counci ter and iriore help was given the sol- or six children knows that one of her policy for medicare subject to the al)- dictrs by t@ic d(--,ctc)rs or corpsmen who (,Iiil(.Ireti is sick and that she should 1)i@oval of the Secretary of Health, were available at the time help was take it to a physician, a hospital or a Education, and Welfare. needed than by those who might have clinic it may be impossible because of Each Regional Medical Program been better trained in narrower spe- the distance. For her 13 miles is prob- operates in a different climate. There cialities, but who were t@vo or three ably a greater distance than 50 or 60 are different precedents, different hospitals anvav. miles is in a rural area. She may not t]-iinlas going on, different understand- problem exists in I think the sarri(. even bay(,, the money for bus fare in(,@s, different cle,@recs of -,@rillingiicss society at the present time. Doctors which 1.9 almost $2 a round trip. She to face ul) to the realities. And Re- %%ho fla,,-(@ been in practice have been can't ii-npose on her neighbors be- (,Ional Medical Programs may be the tau,ht foi- -,.ears, for encrations, per- cause there aren't that i-fiany cars in leaders. I have described RMP legis- hal).@ siric(, Hippocrates, that -:h(@v the areas we are talkin, about. And lation as the first legislation in this Shouldn't @o out and look foi- DR. EGEBER(; the transportation of care to such country that ever gave the scientific 25 - . .... @, @-- -- - - -@, @ I . -- 1. - - - community a chance to get together minimum. This is what medicare is even more minimum standard. As a study made of what kind of care I and tell the public what it needed faced with. Congress enjoined us to national instrument, medicare con- ivas payln,- for in %@oluntan, hospitals and how they would like to do it. see to it that any hospital which had tributes nothing to raising standards in Ne@v York City. It that time, I 'lization committee and was ac- of care in most hospitals of any size was author'z'n, about $60 or $70 Re(rional Medical Proo-rams may a uti 1 1 1 1 be the leader and innovator, or IZMP, credited by the joint Commission on and importance. 'I'here are absolutely million of care fol- poor people in the as is true in some urban areas, has to Accreditation of Hospitals must be no controls on the quality of the med- voluntary s@Istem, in addition to find a way to fit itself into what is certified as a provider, if it also com- ical care or on the utilization of the spendin-, a couple of $100 i-nillion ill already (,oin- on in order to achieve plied with Title VI. That is a mini- care outside of hospitals except as the municipal system. its ooals and make the kind of addi- mum standard. carriers may draw attention to excess @Ve found that 85 percent of the ti%,e contribution to which Dr. Bres- There were a lot of hospitals which utilization which, as a result of fee care ,@,cre purchasln,- from the lo@v addressed himself so well this were not accredited. So we took the review, may appear to them to have voluntary s%lstem ,@!as in approved morninc, joint Commission standards, and o(@cLirred. teacliin(, pi-o,,rarns, and I ,%@otild skis- I think that i-nany in this room modified them and said if the liosl)i- So (,a(,Ii R(,,@iont] Medical pro- f)cct that, as a national @(,ol,c, that is @@IoLil(I do to think sci-lotisl@, a]-)otit tils ''let note @tri(I ]'Hill zt utilization ,i,aiii ofl,(.I@s -,I iii@li-vt,lotls il)str,lllll(,rlt (100(l. f@tit 15 of that Dr. l@reslo@v's iiiessa(,c because it was coirlriilttc(, @in(I (Compiled with 'I'Itl(' to ftii,tli(@r stljiitilat(, an interest in and care was in hospitals that were il)- the voice of experience. If you look VI, they could be certified. That is an furtherance of standards. It has an proved for nothing. The@ didn't have at the studies of duality of care in this opf)orttinity to draw on the I)rof(,s- interns. 'fhev might lia@re had I- or country-and thev are time consum- sional talent in the re,-']on (and there. 2-vear approvals in a couple of spe- in- and cxl-)ensive-yoti find a wide is t lot of talent in every part of this cialties. These hospitals tll(-- range of excellence in care. Almost country) and let that professional same hospitals that turn up in reed' invariably, the highest scores are climate develop which one finds in cal audits with lo@@, scores, in health achieved in the medical centers with centers of excellence which we all department inspections with low teaching programs and the lowest strive for and realize we will never scores, in laboratory, testings with low scores in the small proprietary and have completely. But let RMP be the scores. voluntary hospitals. I don't think professional leader to the extent that And so, through the auspices of there is any reason to argue that there is possible. Let RMP speak out for the Interdepartmental Health Coi-in- are not differences in quality of care 'I, which %vas started bv Commis- the person who is aett' cl in a given City or in this country. ing poor care ioner Leona Baurii(TartneIr when she and in favor of that per-son ettinz There are exceptions to the rules that better, care. But this is voluntary, and was Commissioner of Health in '.\'ei&, I have mentioned. I can think of sev- it does require courage. @'ork City, we set up some standards cral excellent small hospitals, and I which wre a-reed to b-,r all the citN, I would point Out that we are can think of several poor large hospi- a(,encics-bv the citN, controller N@,lio now in a ri-itich lar,r(!r ball -aiiie than tals. Nevertheless, the Generalization disbursed "I we were at the turn of the centur),. th" money.. by the Board of emerges from the studies that have There are many oi-aanized ap- Hospitals Nvho established policv for been done in this direction. the Department of Hospitals,, and proaches to the deliverv of care, and I bv the Inter-Departmental Health One thinks about remedies to un- these offer excellent opportunities I even quality of care. One immediately I Council. And we foi- dealiri@,@ with the subject of qu just set out some itv. 1 1 1 supports Dr. Wilbur's view that there There are administrative deci- simple little Guidelines. shouldn't be a national standard be- sions that can be made and have been First, we announced @lie @N'OLlld not cause, as somebodv pointed out, a na- Iiiade in certain settinas, pav for care in a @'oluiita@, hospital tional standard %%'OLIICI @iak-e to be a DR. 'I'RUSSELL F, or example, tt one tiriie, I had a which was not accredited. 26 Secondly, we prohibited payment tary hospital codes. For example, the its money and its policy in that di- by the Governor, then approval by 1 1 1 1 for care of children on pediatric sci-v- code prohibits ina'or surgery by men rection. the State Commissioner of Health. ices which were not approved for who are not trained to do major And finally, in some parts of this Whatever Regional Medical Pro- residency training. surgery. country, i@caionwide planning has -rams is going to achieve in the way Third, we required that adults eith- This code has now been upheld gone far ahead of this recent RMP of major program changes and facil- er be cared for on a service approved throu h the Federal Supreme Court, pro,,raxn. In New York State, we ity changes in New York State will 9 11 for residency training or be taken care thereby determining the right of gov- have a System of seven councils cov- have to be done through this pre- of by clualified specialists. ernment to protect all patients in in- ering the entire State. There can be existing network of mandatory corn- We set up some other standards stitutions which have been licensed no building, no modification of a muiiity planning. By some people, t h r o u g h the Interdepartmental rather than 'ust patients who are paid building, no establishment of a build- this has been viewed as the end of Health Council, using expert advice for by public funds. This code has ing, without approval of this local voluntarism, by others the beginning from outside of ,o@,ernment, on %vliat now been adopted essentially for all refflonal council Nvhlcli is a localy of a control of excess costs through kinds of services amputees needed. hospitals in New York State. elected rroul) broadly representative ing unnecessary 1 prevent building and The city then offered all the institu- We now have a code in New York of the community, then the approval of rational planning for health serv- tions in the citv an opportunity to be State wliic@h affects all hospitals and of a State Council which is again ices. certified as am Iputee centers. And 14 which establishes a minimum which broadly representative, but aldpointed Dr. LLOYD. Health is a major re- out of the vast array of health facill- is far bevond the requirements of the source of a community and a nation, ties in New York City qualified. The joint Commission. In fact, one of the and it should spend its money to cltv then adopted a policy of paying requirements is that every hospital protect its health. I do not believe for services to ariiputees only in those must become accredited. I once re- that spending monev for research 14 centers. (juired every proprietary hospital in and continuing education compro- With the help of a groLil) of outside New York City to become accredited, inises the delivery of health care serv- experts, 11 nongovernmental @%,Itfi the and 33 became accredited compared ices. And the country need not delete funds from research and from educa- exception of one who happened to he to 1 3 that fiad already been. When it comes to av 1 a cancer expert in the Cit@, Health De- a'lability of tion to finance the delivery of medical I)artnient, A,c established some stand- service, there have to be some very care. ards to guide the paN@ment for the care large-scale public decisions made. I The delivery of medical care is of patients with cancer and limited am all for continuing education. We spotty and the quality varies within J)avments to the hospitals that met have one of the lar,est continuing the country. Regional Medical Pro- those standards. education programs in my school grams can work in a variety of ways These were administrative decl- [Columbia] of any School of Public in our communities. One of the best sions which were made about the use Health in the country, but training ways that it can function is by devel- of public funds, but called on expert brl.(,,Iit practitioners to (@ive better care opin', in areas that do not have corn- advice outside of -overnment to to private patients will not satisfy prehensive health care planning and them. the intent of l@e(,I()nal Medical Pro- undertaking the development of corn- li;i(i to (.ofrl(, to solllf'- ll.)S to 1)(@ III ilill)l-()V(I- I)i-eliciisiv(- I)t-o(,i-aiiis that will clclivel, itilrif-I that 11, 1101@ Ill this ('011TItt'@l: lli(,llt, III III(, s(@i@vl,(.(, Nvlil(@li is (Itiality lic@iltli care to the I-)ol)tilation. @Ol't Of 1-t@l-ILIlatOl-V ill Lill),Ill settings Lo people We do not believe that there is an nisrn@s. A hospital (-ode was developed who are entitled to free care. And unusual rising expectation for un- Birth the rich) of an expert committee Re,,-Ionai Medical Prorams has to usual medical care. I believe that the C)f @tboLlt (",O to @-IOVCrn I)roprl(,.- i-nakc i conscious decision to allocate DR.LLOYD legitimate expectations of the citizens 27 of this country regarding medical house sales technique, and we sent know how remote I am and back to community does not need a physician, I c small care have not been really fulfilled and into the private practitioner's of-fice what fundamental basis of primary And I be.1'.eve that nian@, of th' that this country has paid for the individuals with a sjyiall, 3-rninute iriedical care I go, I practice in mv communities in this country who now delivery of medical care that has not movie that showed how a Pap smear village where I was born and I have have physicians will no longer have been rendered under the systems that should be done. We left samples of been practicing there 34 years. When them when the ones -,vho are there we now have. twenty Pap smear kits and paid for I went back to practice in my village, now pass on. I am sure my commu- If the country was receiving ade- them, to be read and returned. This it had 642 people in it. But after nity will not have another one when quate medical care and the delivery has increased the use of the Pap World War 11, we had a population I am gone. And I don't think tlae@, was good and the quality was good, smear in the community in which we explosion and we have got 700 people need one. there would be no real reason for have been working some 200 percent. now. When I came there,, people who the Regional Medical Program. The I believe that the Regional Medi- It is my contention that people Nvho lived 5 miles from my community mere fact that we are here means cal Programs should be a mechanism live in, Dr. Egeberg, the Watts dis- were over 30 minutes away from mv that in some way the volunteer sys- for further experimentation in the trict of Los Angeles oi-, Dr. Tr-ussell, office. Now, we have paved road, tem has failed in delivering quality delivery of medical care. Now, we the Harlem district of New York, are running in every direction, a hospi- medical care to its population. must go outside of the medical pro- perhaps more remote from the stand- tal 17 miles on each side of us'. where- I believe also that we need to re- fession for help in the delivery of point of having adequate available as we had a hospital 45 miles a@vav evaluate the delivery of medical care; medical care. I do not believe that health care for them than are most @vhen I started there. And by auto- and I feel that the private practi- we can depend totally upon the uni- of the people who live in rural corn- mobile or ambulance, a person can be tioner may not be able to be available vcrsities oi@ the public health depart- rnun't'es throughout the United in c@ither- one of these hospitals with- for all of the services that he has been ments for the delivery of care. It is States. There has come to be in my in 15 or 20 minutes if thev are in a available for before and that we community involvement, and it must thinkin, another dimension of what big enouah hurry. should look much more into provid- be a community involvement, that constitutes adequate health care co-,,- So that I think it is axioriiatic that ing that first line of medical care with will make health care much more erage. And that dimension relates to any community that cannot support other personnel. In continuing edu- available to the population and time. And I firmly believe that any at least two physicians, a measure of cation, I believe that the programs, also have some control over the person who is within 30 minutes of -roup practice., can ]II expect to re- althou h extensive in the country, quality of care that is rendered to thea 9 dequate health care facilities avail- ta'n one. And I think that the prob- have failed in -etting into the physi- population. able is adequately covered for the lem that @ve are goin,, to have to face cian's office. I believe that the Regional Med- matter of health care. in this countrv and it is -oing to have We have been concerned with one ical Program can serve this purpose. Now, we realize, those of us who to be faced at a community level, per- small program and having physicians, If it serves the purpose only of per- come from small communities and haps ivith some measure of stimula- private practitioners, do Pap smears petuating the type of care that we are rural communities, that every cross- t'On from regional programs and in their office. now giv'n@ it will be 'ust another road in every community wants aOther approaches to the provision of We held several meetings in which line of frustrations for those who are doctor just like they want a preacher health care for people, is to stimulate all practitioners in the community looking to the Government for the and sometimes need an undertaker. these small communities to combine were invited. And then, we checked provision of adequate and quality And in my village, the man wanted into a lailger community,. the laboratories to see if the number medical care. to be convenient so lie built directly In nianv instances, it is entlt-cln- of Pap smears increased; the Pap Dr. 01-INSON. I guess I was chosen @icrogs the street from iii(, But tliit possible to'ta@-(- fotii- or fl\@(, siiiall(@Ii, smear statistics did not show a large to tilk to you here today to I)rin,, to s a little bit too close, and that stilliti- rural COMT-nUllit]CS, where each of the increase. you a message about remote areas latcci me to iij)(@rade my cluality of (,orriiiitinities is within a measure of So we did a different thin-. We and the provision of health care in care. 20 or 30 miles of another commiinitn,. took a pa-C out of the pharmaceutical these areas. And in order that you I firmly believe that evez-v small and someavliere in the center 'denti 28 And I don't think I would do this week. The same thing with weekends. medical students will not identify @i(,aill. Oii(@ physician can cover zLI] of the Nvith it arid %vill not go into it. I'@kit if we by W()[-]- planning priority. clearly and precisely in English or Credit for the mathematical meth- graphic illustration and assist in find- odology for this problem is,due to Mr. ing the most suitable units of meas- Leonard Krystynak, a graduate stu- urement. The operations researcher dent working with Dr. Galliher. He can then formulate the mathematical has derived the initial solution and is statements which summarize, in un- currently subjecting the model to ambiguous specification, the exact further testing. We are now prepar- facts and principles of the problem. in@ real-life data for insertion into the From here, he can identify the specific model. However, it is not our purpose type of mathematical process-es to be to exaxnine this specific model, and utilized in identifying the optimal TIME EXPENDED IN TEACHING x further discussion on it will await strategy. SLIDE 6 have the partnership of someone strategy by selectively searching familiar with the system and one who among the totality of all feasible corn- can assist in obtaining the most ap- binations and permutations of al- 57 qii Xii(t) - zi(t-l propriate methods of measurement. locating time expenditure for each of As was stated, this particular problem the capability types in each time pc- has been cl(-fined as a multitime pe- r'od to each type of care and to the iod linear program. Without en- teaching of each specific type of stu- OTAL AMOUNT OF CAPABILITY EX]' dea@7ot-in, to explain A,Iiat a linear dent in each time period. This partic- pro-,ram is, I %@,oi-ild only state that it ular model with the hypothetical four THE AMOUNT OF CAPABILITY WHICH EXISTED AT PREVI US TIME is one @vhic@i has been used for many types of care and personnel results III purposes, and computer programs a linc!ai- program problem consisting THE AMOUNT OF CAPABILITY PRODUCED BY A UNIT OF TEACHING exist to enable tl)e solving of those of I 10 formulas and 200 variables. @@-hich are complicated and extensive Once the data has been iiiserted, a THE AMOUNT OF TEACHING TIME EXPENDED (e.g., In the autoi-nobile industry a man using a calculator could solve linear pro@,-rain on the assembly ol-)- the 1)roblei-n in several weeks. The THE ATTRITION WHICH OCCURRED DURING THE PREVIOUS TIME c cration is rkin each night). In brief, (-()ml)utcr, ho@vev(@r, can solve it in sev- ;t the metlicidolo@, picks the optimal eral minutes. Of course, this is a s' 1 A(') im- OBJECTIVE---MINIMIZE @y 47 SLIDE 7 a mathematical model has been de- 4. Reoional economic problems in veloped and is being validated. A industry related to location of plants, stochastic model is being attempted warehouses, and sales re(rions have n CONSTRAINTS with the ob'ect've of d(-termiti'n been ass'stecl by anotlici- set of i-nathc- lioi%, many coronary care units should be iriatical processes ,N@tilcli give promise Pi mi (t) provided in each locality. If success- in approaches to regional economics' @TOTAL OF CAPA ful, the model may be useful for each in health care. The group has ex- region. amined this and some preliminary MI NIMUM- LEVEL 2. The methods of approaching work has been done. production scheduling problems in in- 5. The study of patient traj'ec- dustry may be applicable to a host of tories has also been instituted. The medical problems. The example cited methodologies in this problem are re- 2 pij ( t ) + xxii(t) <- Ni(t) today is one of these. Another on lated to those which have been de- which work is progressing is that of veloped and used in marketing coronary care capability programing, research and consumer behavior. AMOUNT OF CAPABILITY DEVOTED TO CARE This represents a miiltitime period It is our conviction that we arc capability programing of coronary 'ust entering upon the threshold of AMOUNT OF CAPABILITY DEVOTED TO TEACHING care modalities and of manl)ow(.,r a new scientific devcl<)pmci-it in nied- TOTAL AMOUNT OF CAPABILITY EXISTING provision. The objective would be to ical care. Hopefully, -,ve may leave determine as accurately as possible two major points with you at this how the division and the regions time. The last slide (8) illustrates the a number of problems to which the should allocate their funds and other First, health operational research process and, in addition, indicates the group has directed its attc@titiori. A r(.,sotirc(,s in the establishment of coro- will be successful oniv a,, there is full magnitude of input ii(,(!cl(,c] at ca(@li ina'or portion of out- activity has 1)(-eii nary care units and rTianl)o@vcr-. 'I'lic teajri%vork between the Operations re- stage by operations res(.,ar(,Iicrs and bv cxpeiacied in reviewing the acc,,,om- time clynaml(.s in this problem ti-c searcher and medical people. Full medical people familiar with the svs- plishments of OR-SA in other areas comparable to those shown in the ex- time commitment of significant i-ned- tem and capable of making value and assessing possibilities of relating aiiaple. ical manpower is essential. judgments. One can see that the bulk these accomplishments to health 3. A rheumatic heart disease con- Second, Regional '-%Iedical Pro- of the effort in all but two of the problems. A few specific examples are trol model, which includes a multi- -rams represents an operational ex- staaes must be contributed by medical cited: I stage model of the disease and con- pertinent. Operations research is the people. The actual solution is purely 1. Within industry and the mili- tains both cl)idemiolo-ic and I)t-of(.-s- science of operational experimenta- mathematical and the model testin- tary services, OR-SA has developed phase is often heavily mathematical. theories and methodologies related to sional training components , is I)eiiia tion. Thus, those of us here assembled The particular methodology used the prediction of demands for prod- develol3ed. This utilizes decision- have one of the best opportunities for in the example given (linear pro- ucts and services. One example of a theoretic niethodolo(ries -,vlilch have a leadership contribution in the o,ramina) is only one of many which health problem to which these may be been developed foi- process and qlial- development of its application to are available, and this is but one of applied is that of coronary care, and ity control, and military surveillance. health. 48 SLIDE 8 @S FORMULATE PROBLEM CONSTRUCT MODEL DERIVE SOLUTION y ------- ------------ - - - - - - - - - - - -- -------------- ------------ ------------ ------------ - - - - - - - - - - - --- - - - - - - - - - - - - ------------ - - - - - - - - - - - - -- M D ------------- D- - - - - - - - - - - - - ------------- ------------ - - - - - - - - - - - -- - - -- - - - - - - - -- OR ----------- ----------- ------------ OR 0 R )f - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - --- - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - -MD - - - - - -- - - - - - - - - - - --- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - -@--7-=M D ------------- FA b - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -10 OR D APPLY SOLUTION ESTABLISH CONTROLS TEST MODEL 49 A NATIONAL VIEW OF DEVELOPMENTS IN. . . . HEART DISEASE Donald S. Fredrickson, M.D. CANCER Kenneth M. Endicott, M.D. STROKE Richard L. Masland, M.D. 51 A NATIONAL VIEW division of labor as we all move to- of three or four major types. The first sic'an time by tak'n, over tasks in OF DEVELOPMENTS IN- gether to meet the Nation's needs concerns training of individuals in the intensive care units, hyperbaric cham- HEART DISEASE for better health care. techniques of cardiovascular research, bers, emergency rooms., hemodialysis, Our mutual involvement in this diagnosis, and care. Our trainina pro- and other functions. The Institute has common endeavor obviously is Corn- grams have several ainis of impor- looked upon such an effort as re- Donald S. Fredrickson, M.D. ple-@ and our roles are not so clearly tance to regional activities. Currently search, for all discoveries of ' 1 11 1 impor- Director, National Heart Institute divided, for discovery and application we have as fello,,vs or trainees I)rl- tance are not molecular in nature. 1 1 National Institutes of Health are not casilv separated. Society-not marily learning how to do research, The broader application of successful unreasonably-supports all of our ac- nearly 1,800 individuals. Since its in- portions of such prototype exper,- tivities because it expects something ception, more than I 1,000 scientists ments is not within the resources of better for itself. It gains when dis- have been trained under the training the Institute and is distant from the ome time ago I would have con- ips program. center of its mission. It is mu S sidered this morning's program covery is applied. In this sense, dis- grants and fellowsh' ch closer best defined as an "interfaith meet- cover-y may only become real when it Some of these men are now leading to Regional Medical Programs. becomes practical and safe and and participating in aspects of l@e- ing." My judgment and pronuncia- I 1 1 A second program of direct impoi-- clearly beneficial, and when it be- gional Medical Programs, and more tance to Re-ional Medical Programs tion have improved alike. I now 'lable to those who need it. will follow. is the development of cardiovascular know that this is better described as comes rival 1 an "interface meeting." Defining the Thus, the Heart Institute has its Of more direct relevance is a rela- research and training centers. These surfaces at which the programs of stake in delivery of such gains it may tively new program of clinical train- are units Ienvisoned in the President's achieve through research. And RMP ing -rants. Begun in 1966, 35 of these Commission for Heart, Cancer, and the categorical institutes and the Re- has its stake in applying the mecha- grants are currently being supported Stroke and for which plannin@ funds gional Medical Program mutually nisms of discovery. For how shall you by the Institute. The ob'ective here were first awarded ' interact is a difficult exercise, but i in fiscal year t966. essential to perform. know, 'save by applying the best of is to train physicians who understand With respect to the Cardiovascular experimental methods, how to solve enough of research to make it easier Reseach and Training Centers pro- I In organizational language the the problems of application, to deter- for them to apply new developments oram, I should begin by stating that mission of the National Heart Insti- min valuate the and to teach them to others. They are c the needs, and to e no centers are presently in existence. tute is to develop new knowledge that worth of interventions? And how an essential "hybrid" ingredient Of At least one is ready for fundin- and will lead to both a reduction in the shall new techniques be taught and the plans to ii[)gracle the I)rict'ce of IO arc now in the plannina stage, but rate at which healthy individuals de- disseminated most widely except by cardiovascular medicine. 'I'licy will the first specific operational grants velop cardiovascular diseases and those who have acquaintance with not all remain in 1-iniversltv centers under the center concept are expected improved care of those who have the method of their discovery. and most are not expected to pursue in 1969. Thereafter, -iven available such diseases. We have common purposes, then, research as a major means of the' ir funds to support the operation of such The major mission of Regional and must be prepared to blend and livelihood. Their contributions should centers, the NHI timetable calls for Medical Programs would seem to be cxhange our eflorts, expertise, and have a major impact on the success of two to become operational in 1969; a to promote the application of that resources at many points of contact. Regional Medical Pr@,-rams. total of five in 1970; seven in 1971: nter- knowledge and to see that its benefits As we see the programs in the rc- 'I'he Heart Institute is also i are available to the greatest number. training 10 in 1972; and t2 in 1973. gions unfold, there are several inter- ested in some aspects of the I This separation of the concepts of faces between these programs and of special paramedical skills. On an What -,vill these centers be? We discovery and delivery seems splen- those of the Heart Institute that are experimental basis, we have been sup- hope they will represent true car- didly convenient. It is also not very particularly identifiable at this point porting, for example, the Duke Uni- diovascular "centers of excell nce" c helpful Ln(I cotil(i be wrong in tilli(@. @,(@rsit.y (,fl'or-ti to tf'.'Iirl I)IIysi(@l;ttl tll(- Pt-(,-,](If,llt,s if interpreted as 21 I)L'I-f(@(@tly WOI'l@@Ll)](' litstittit(, @l(@t'tv'[tl(!S ;LI,(, ;Ls.@lst;tiits. 'I'll(!S(,. iii(liv,(Itl;llss:tv(@ I)IIY- 52 While the center will be conducting pect them to be foci of activities rele- vascular rather than cerebral in a broad range of studies, it will also vant to Regional Medical Programs. origin. be involved in research directly rele- We expect to increase the number A third kind of program of interest vant to the solution of clinical prob- of planning -rants to 20 or 30. This to our discussion this morning is lems posed by the cardiovascular will provide a competitive basis for coordinated research. Much of it is diseases. selecting the 10 to 12 that will qualify funded by contracts and aimed at Thus it will provide, or else be eventiaally for full operational sup- solving specific problems of general closely allied with, personnel and fa- port. The criteria of excellence that interest and judged to be especially ciliti(@s essential to the conduct of ad- we have set for these centers are ad- important. Generally these deal with vanc(-@d diagnostic and therapeutic inittcdly hi,-h. Given the continued accelerating developmental research procedures, 'I'lic operational grant availability Of funds for this program, or testing out on a large scale the will provide funds for the care of re- we expect that enough institutions efficacy of possible interventions. search patients both on an inpatient will -radually develop the capabilities Both are the inevitable byproducts and outpatient basis. The center will needed to qualify for an equitable of more basic research. All tend to be a clinical rcsource.for referral of geographical distribution of centers to be expensive, complicated, and patients requiring highly sophisti- be achieved. highly demanding, both of Institute catcd diagnostic or therapeutic pro- Meanwhile, there are many units, and community resources. They are cedures not generally available in the smaller than the centers envisioned also essential for advancement of average community hospital or clinic. above, which are now being funded means for managing cardiovascular The center will provide a training as program projects. They, too, pro- disease. DR. FREDRICKSON resource for equipping scientists and vide a combined attack on cardio- The first of these is our Artificial physicians with tli(-, sl@ills and tech- vascular diseases by multidisciplinary Heai-t-Myocardial Itifarction pro- As we are now planning for them, niques of modern biomedical re- support. The Institute was a pioneer gram. This program is combining each center will be an organizational search. Throu-h its clinical training in creating such programs and be- bioenginecring and biomedical ap- s, it should be a focus for cf- lieves they have significantly enriched preaches to the problem of heart unit, existing within the framework program of a i.iiilversity or similar institution, f(,@ctive dissemination of the fruiti of the clinical capabilities in major lios- disease in general and the actite heart arch to the region which it 1)'t@ils, both Lin'@,ers'ty and tinaffil- attack in particular. for the purpose of attacking a broad its r@,@e I I 1 1 1 1 1 range of cardiovascular disease serves. The activities of the center lated. Again, the basis for fundin- is The bioengineering attack on this 0 problems. will be national or even international primarily research productivity. The enormous health problem is being ideally,, the center would be orga- in scope but it @vill exert its strongest cluality of the diagnosis and treat- carried out by the Artificial Heart II; (Ii- on cardiovascular research i-netit in these institiations, ho@vcvcr, branch. It is presently concentrating lz(,c] a sit I I gl(, outstanding rectoi-. It would be staffed with a 2,,id clinical care in the region where has invariably gone up hand in hand on the development and refinement of corps of scientists and clinicians rep- it is located. with research. devices to provide pumping assistance resenting not only the clinical disci- It is axiomatic that a good clinical I expect that Dr. Masland will deal to damaged or failing hearts. There is plines, but also the physical, engineer- research program in a hospital has with activities relative to stroke reason to believe that temporary car- ing, and social sciences. a way of improving the medical care centers, for his Institute has a far diac, assistance can salvage patients iits lar - share than otirs in such a pro- -ary loss of sufficient so,(, I - for il by tfi(,, regular warcl I)at'(, of a teriil)oi l'i-(-)vis'on will I-)(- ir)a(l(, to work in stifllcj(!iitly (@lo,;c in tli@it lio.,il)ltal. In -the case of tli(@ We pleased to I)(,- able to (,,ji,(I'ac I)tiiiil)iii,@ reserve. We i-ice(I proximity to encourage free exchange center, we hope that it will serve as participate in j.oint council activities better devices and more investigation of information, ideas, and construe- a standard of excellence for hospitals concerning this ffering to prove their capabilities as well as pro-ram, o n tive criticism. in its sphere of influence. We also ex- such program help as is primarily their limitations. Within the present 53 constraints, we are also supporting re- to determine what drugs or other the problem of sudden death, that susceptibility to atherosclerosis and search aimed at solving certain vital measures miaht be used to minimize lar-C segment of infarctions or other coronary heart disease. It thus seems problems of materials, pumps, en- heart-muscle damage resulting from coronary deaths which do not reach reasonable to suppose that elevated ergy, and controls necessary for the attack. the hospital. blood lipids also advei@l@, afTect sur- development of a permanently im- They will seek to understand better 'I'he Myocardial Infarctioii pro- %,lv-al among patients who have sus- plantable device to replace the heart. the development of arrhvthmias, car- grain will seek to coordinate the ac- tained heart attacks bv increasing It is presumed-and I think cor- diogenic shock, and other potentially cumulation of knowledge Of man), their susceptibility to recurrent heart rectly-that such a device will be lethal complications of the acute at- aspects of its specific concerns. Its co- attacks and related complications of feasible. It will only be desirable if tack and means for more rational operating research units need not be preexisting coronary heart disease. it permits complete rehabilitation of management. restricted to 10 or 12 large operations. We hope to establish that long-tenri a productive individual. We proceed They will evaluate, more precisely Ways are being considered now of reduction of blood lipid levels will on this premise. In this regard it and thoroughly than has previously how the facilities of the Regional Pro- confer some protection against these should be noted that heart transplan- been possible, both accepted methods gram might be utilized and joined iii complications and thus improve lon-- tation and artificial devices are not of treatment and promising new ones, this effort. temi survival amoncy these patients. mutually exclusive. Indeed, develop- including assisted-circulation techni- Of direct importance to the Re- We hope that one or more of the ment of both possibilities-as a total ques and devices. gional Programs is an example of lipid-lowering drugs being tested will problem of "cardiac replacement" The units themselves will be well coordinated res(-@ti,cli to try out the reduce the 5-year mortality rate by 25 to ;Ill(l ;Irl(l (.ffl(.;I(.y of ;I, I() I)II'Vi'lit of, error,(,. Of more ])Cl,tlllerlce to Ite- I.01. iiif;ti-(@tioii. 'I'lils is tli(, 'I'lie drugs 1)('illg C%',Lltt@tLcc[ Coll- gional Medical Proc,rams is the co- and patientcare. An aim is to attract Coronary Drug pi-oject-a secondary 'ugated equine estrogens, d-tllyroxine, ordinated program to improve all to this neglected problem those who prevention trail. nicotinic acid, and chlofibrate. All phases of medical management of the have felt infarction to be too hopeless Mortality from first heart attacks are known to reduce blood lipids and acute heart attack. This is the primary or complex for application of their is about 30 percent; but with each to be free of serious toxicity, and all goal of the Myocardial Infarction special skills. recurrent heart attack the patient's are currently available to tile branch of the Artificial Heart-Myo- The MIRU's will be training chances of survival decrease sharply. practicing physician. cardial Infarction program. grounds for medical and paramedical Most heart attack deaths are due to The study involves 55 clinics Presently it is supporting the estab- people needed to extend acute coro- recurrent attacks; and, with each re- throughout the continental United lishment of Myocardial Infarction nary care to as much of our popula- currence, the likelihood increases that States, Hawaii, and Puerto Rico. Research Units, or MIRU'S, at five tion as possible. The ultimate effec- death will be sudden or else occur so Eventually, it will involve a total of university medical centers. Even- tiveness of the MIRU program is swiftly that hospitalization proves 8,500 patients, more than 1,200 of tually, 10 to 12 will be established. dependent upon the development and impossible. which are already enrolled. The clini- Each of these units will be espe- clisset-niiiation of new knonviedge and The oal of the Coi-oniry DRLI@ cal phase will be coi-npleted in 1974. 9 cially equipped and staffed to conduct techniques that can be applied when- project is to see if lipid-lowerin(l, drugs Aiiion- the clinics particll)atin- are intensive research on acute heart at- ever and wherever heart attack cases can improve long-term survival some involved in Re@ional Medical tacks and their complications while start. amony heart attack patients by re- Prourams. Here is an example of how providing unexcelled medical care to The Myocardial Infarction pro- clueing the incidence of recurrent Realonal Pro,rams with its coordina- heart attack patients. aram will do more than develop heart attacks and other complications tion, access to large number of These units will attempt to learn MIRU'S. It will actively support a of preexisting coronary heart disease. and special expertise in patients as much as possible about the pres- program to develop animal models of Elevated blood lipids, especially patient management may find op- ently unpredictable clinical course of infarction, study contracts to close blood cholesterol, have been found portunity for important research. acute heart attacks. They will attempt gaps in knowledge, and to examine consistently associated with increased Field trials arc indispensable for 54 determinin- applicability of research these products be met without serious components of blood that occur A NATIONAL VIEW and findin(,s. 'I'lirougli R.MP the "field" strains on existing blood resources. through outdating in storage. This OF DEVELOPMENTS IN- seems vatcd is now better organized and can be 'I'hc clinical demand for specific includes the study of chemical addi- CANCER t sur- more helpful than ever before. blood components such as red cells, tives as well as the storage of cellular There are other NHI field trials, platelets, or specific protein fractions components at very low tempera- sus- such as effect of relief of extracranial has increased rapidly during recent tures. Present freezing techniques, Kenneth M. Endicott, NI.D. !asing occlusions on incidence of strokes, of years. It will probably increase far which are expensive and rather Directoi-, National Cancer Institute heart the value of renovascular repair or of more rapidly in the near future, for cumbersome, need to be streamlined National Institutes of Health ns of treating 1)@lelonephritis, or hyperten- the use of whole blood where some and, where possible, automated if 3e. sion, of gamma IobuJins in prevent- sl)c(@ific blood component is called for their full potential is to be exploited. -term I I will inly hepatitis after open heart surgery, is being increasingly considered un- The National Cancer Institute, like- -Decent and important develop- to name a few. A-ain, some partici- desirable and wasteful. The list of wise, has a considerable program re- -L@ ments in the field of cancer at these p,tnts in RMP units are already such components is increasing, and lated to blood products, particular the moment are not in its treatment long- involved. includes frozen cells, as well as pro- platelets and other formed elements. and diagnosis, but its prevention. The nts. Finally, there is one more new co- teins latelets, and leukocytes. It is planned that the National pace of discovery in the relationship f the I p I will ordinated program that deals with The use of the specific blood corn- Blood Resources program will also of viruses in the production of cancer Dy 25 p 'roblems of great national and re- I)onent to correct a specific deficit study the feasibility of better corn- is indeed rapid. I personally regard gional concern, the availability of yields superior clinical results while puter-based inventory systems for it as certain that viruses play an im- con- blood and blood fractions. diminishing the risk of transfusion blood and blood products than are portant role in causation of human This is the National Blood Re- reactions. At the same time, it makes now available on a regional basis. cancer and I entertain some optimism xine, source program, now in its second it possible for a single unit of blood These, then, are some of the that we may, indeed, discover an ap- . All year of operation. Althoii,,Ii head- lood I)roach in that direction in the pro- ,tt Nill, this to S(!I,V(, ill(- ll(.(,(Is of iii@iiiy 1)i-(@(,nt @oils of the Nit'oiial B it'oii of this disease. 'I'li's has il- ill(. ilo@lis of' the V(ll I l I ready been @iccoiiil)llsliecl -,vitli re,,ai-(l N;itloti;tl l')Ioo(I Is o;tl, of (-,otii,s(-, is to iiisiti,(.,. tliit all n of Institt.it(,,s @Aricl (livisioi)s of to certain cancer ill experimental ani- NIH, other l,ederal a(,encies, and to il]SLII-C an adequate supply of blood @icle(ILi@itc supply of whole blood, inics . . 'D fractions to meet clinical and re- plasma, or specific blood fractions is mals and I do not think man is all fired jion-Fccl(-ral organizations such as search needs. With contract support always available whenever and wher- that different. That is the only hope the American Red Cross and Amerl- at the moment for any general @i(@o, from this program, the American ever it is needed. see a] of (-all Asso(-]@Ltioll of I'@100(i 1))@itik,;. National l@ed Cross ii @vc)rkiiig oil an T-low some or all of these programs solution of the I)robleirl. participants share a coi@rimon interest: 'II specifically interlock with re- No\v we are certainly not lackitig 0 of All are concerned in some way @vith ritegratcd blood fractionation system \v '1onal activities is to be resolved. causes for cancer. There are at least ,Ilni- the acquisition, processing, stora-e, for the large-scale production of gi hemicals that 974. specific blood components. Your presence will be of the greatest a thousand different c distribution, usaffe, or study of blood I'D importance in i-nakin(y our own pro- can produce the disease in animals' are and blood products. When perfected, such a systei-n now how many of them lical The major goal of the program is could be installed in large, strategi- grams more meaningful. We're glad We do not k how to improve all phases of technology cally located blood banks around the you're here. We will do our best to have something to do with human %vork ivith ),on and for you in everv cancer. Several fori-ns of radiation lina- related to the handling of blood and country to serve regional needs for produce cancer. Various hereditary of blood products. Oniv through more blood and plasma fractions. way we can. factors seem to operate from time to in efficient production, stora(,e, and dis- Other major concerns of the pro- time; endocrine imbalance and, in the op- @rch. tribution of blood products can a gram are research on ways to reduce light of some recent studies, probably for steadily accelerating demand for the losses of whole blood and cellular arrangements of the immune mech- 292-414 0-68-5 55 m anisms have something to do with it. and its preparation for loans to phy- of the medical schools have qualified able to make available sometlllncr There are so many causes of cancer sicians and hospitals around the colin- and are being funded Linder this pro- much better than N!oLi have no@@, fol, that to eliminate them all would be trv. '17tiat program is still in existence (,i'aiii. I iiil"-Iit iii(ll(-atc that oLir i(]- Iii,,Ii %,olt@i(,(@ tlici@al)\.. Oi@(-, of tli(@ ,i-cztt a superhuman task. But the virus al)- but as @'OLI call well @tl)l)reciate, the visol's halt (-V(@1-y (.fl,ol-t sliol'tl,,es, we believe, so fai- as the proach, I think, offers liol)e. (]eV(-Ioj)lll('Ilts III ill(' field of l@@icli@-I(Ioti Slioill(i 1)(' to this ti(@@v 1)1-01)(,I- of Now, that is not to say tl)at siti(-e I!)'i7 liziv(-@ soiiic%vli@it cliiiiiiii,,Iic(l I)i@o,,i-aill, III YOLII' tCI'IIIS, tl(@Ilts is (Concerned, is the sl)(.)i-ta,,c of are not advances in the diagnosis and the importance of ra(IlLim use. 'I'hc noiiiinational or interfaith," so we radiation therapists. At the risk of treatment of cancer. There is slow, second was a -rant to Di-. E. 0. Law- cnco@tra,,ccl the medical schools I)cln,,r shot down by sor-n@, of niN@ col- steady proaress in sur-ical mana-e- rencc in California for cxaminlnl- the to lll%'OIVC 11ILiltiple departments and lca"LleS ill the audience who are acii- ment and impro%@ei-nents in radiation potential of the cyclotron for the establish t 1)z-o-i@aiii ,vliicli does not cral radiologists, I would like to rc- therapy. Of particular interest to me, treatment of human cancer. become a captive of a single depart- port that we have been adn@isecl and because of my background, has been The institute was very small and merit. @ve a(rree that the trainino- aeneralIN7 progress in chemical treatment of can- consisted larcely of an intramural In the late 1940's, radiation was a -iven in therapeutic radiolo,@, in the cer so it is now possible to say that basic research proram until 1946 field of intense interest, and the ra- Course of preparation for general some forms of human cancet- can be %vli(-n tlic@ present i-)Ii(,iioii)crlal growth (]lo](),,.ists Nv(,I-(.' very tilti(.Il interested I',I(Ilolog@F Is quite lrll(le(filate. About cLii-ccl with drugs. That is an iml)or- of Nltl 1)(,(,ati. Shortly after that a in ]indicate. I'm litl)l)y to say that 6 ,ears a,,o we launched a I)ro-raiii tant development, even tliouh the number of new pro,,rams were estab- they still are. One of the nc@v pro- to inil)ro%-e and increase the trainin, field of application at the present time lishcd by the National Cancer Insti- grams at that time, Nvlilch has a real of therapeutic radiologists. It was is quite limited. Chemotherapy, in the ttitc which were aimed at the problem relevance here, was the clevcloj)i)icnt stai-tlln(, to cl's(-n-,@er tl)at 'II 1 960 there better centers, has come to represent of the provision of services. The first and installation of a series of incga- @,,,ei-e some 15 therapeutic racliolo,ists an important therapeutic device for of these pi-o-i'ams was a teaching volta,Te instruments for exploration of in training in the United States, of palliating advanced and disseminated grant to medical schools and dental their therapeutic possibilities. From @@,hicli eilit @vei-c forel,,,zi nationals. cancer. Its skillful use can keel) many, schools for improving the unclergrad- this has come the present Generation After 6 of intensive effort in this many people reasonably comfortable uate education in the diagnosis and of linear accelerators and betatrons field, the ntii-nber of Ai@iierican na- and productively engaged until vir- treatment of cancer. That pro,ram and the like. This program has 'ust tiolials in ti-ainin, has (@ ne from se-,-- i @o tuallv the end of their disease. was discontinued about 2 years ago been brOU-Ilt Out and dusted off and en to 70. There is quite a little em- We have lon@ been concerned at and replaced with a nenv one which lvcn a new start @vitlilii the past year phasis given to radiation bioloc, and ny the Cancer Institute with the problem has a much broader tar-et. It is called or two. The radiologists aclvlsln(,r Lis radiation research in the course of of the provision of services. The Na- the Cancer Clinical Training Grant believe that the present -eneration of ti-aiiiin-. About 15 oi- 16 are bein- tional Cancer Institute, which is the pro,ram and is aimed at improving hire ener-v sources is outmoded ancl trained each ,@ear. Thev are bein- oldest institute, was char@d by the the educational environment in the that it is possible to ci@eate a neav snapped Lip in the medical centers and Congress, with the total job of bring- medical schools and university-teach- generation of radiation sources, pai@- schools and we could place i-nanv ing the disease under control. The in- hospitals to enhance the edlica- ticlilarly lincai- a(@celei-ator's and clec- more than we leave. We are continu- Cancer Institute, created in 1937, had tional c.-Ill"" I)OLI) @Lil(i ('@Ll'(@1110111as treat- \\'OLIICI be. too brief to clis(@o\,ci, a iiliiii- i,iurses, et (@etcra, without @@'IIICII one radiotherapy slii(,@c \vc do not have, iiient. her of early cancers of the breasts and cannot think about having an ade- nor can expect to have, in the near fu- It is not because it is early that it is have someone do a simple mastec- quate center for radiotherapy. turc a Sufficient amount of radio- easier to treat it. In fact, it requires tomy on them. This is the time to Now, it is olivious that there arc therapists. We need easily eight to 10 a -reater skill sometimes to do the do really adequate surgery, and this certain in(II(@@itioris of r@tcl'lotli(,i-al)\, ti@iies as many as Nv(@ have at the pi-es- 'ob even though the patient is early. is the thin- that I think is worth that 1)4, t@il@(@ri ol' %@,itliotit (,tit And tli(, of men in same tliiii@,- applies to sLi(-Ii things ciiil)liasizill(Il'. all of that, but tli(! point that %%,(! ai,c@ the training of radiology as ('aii(@ei- of tile breast. Nvllctllcr the Dr. FARBER. The third speaker is tlilii]@in,,- about is a c@eritei, that is rc- is ratlici- reduced. It is of the order of clia,,nosis is done in every doctor's of- responsible for the lar(rest pro(Tram III sponsible for.. respondent to, all of 50 to 60 in the entire Nation. That fice, as it should be, or whether it is the world today-the National Can- the needs with which we might be yields, at most, some 20 new radio- done in special cancer centers like our cer Institute. presented, all of the possibilities, not therapists per year. This is really a own, a great number of earl), cancers Dr. ENDICOTT. I thought today I a selected "roul). The selectivity might very small amount of new radlother- of the breast can be found, and they might talk a little bit about some come at the secondary centers level apists for such a large country with can be found by young physicians who of the problems of operating a can- where the people in charge might de- such great needs. are specially trained to palpate thor- cer center because- we have sort of cide to take up onlv certain problems This presents, I am certain-and oughly the breasts of all women in a cancer center. Perhaps it is a little that can be managed at this level and I am not trying to make it worse, but followup examinations. on the long-haired side because it then transfei- the others to the major rather ii-iake it evident-a very'scri- We have a large clinical followup is primarily research oriented, but counters. That is a cluestioii of lo-istics otis problem to envisaffe. It isn't easily examination of thousands of patients it comprises many of the features of in @@,@ilch I cannot nor am I coiii- solved, but it is Ol-)V,IOLIS that tile SO- that were treated for minor things so-called excellence which I think petent to -0. ]Lltlon of the problem is not neces- like basal cell carcinomas of the tip medical schools and university-based My emphasis has to be upon the sai7llv to buy the equipment or to will of the nose whom we have follcnvecl cancer centers would want. It is part fact that @%,hene%Ti, )rou (!ontemplatc this no Ion-er a problem. It is a now for periods of 15 to 20 years. All of a more general facility in @vhich radiotherapy. as Dr. Endicott alread), problem and will continue to be a patients are properly examii-ied an- many diseases are studied. So it is not indicated @-cstci-day in his brilliant ad- problem. nually @viien they come for their fol- really a cancer hospital, although clr(,Ss, I)F-ol)@II)IY too No\@,, from otii, point of view, out- lo\v(ii) c\aininatioii this yields a N%rc have separate %vards. Most of the many Cobalt units ill Lll(@ (@OLilitiy -1 side of tll(.- field of i-acliotlici@al3y, we considerable iiutiibei- of cancers of tile specialities that ml,,,-lit be conceri-icd 81 with the treatment and diagnosis of and only a portion of these are re- the Memorial Hospital for Cancer down there, this woman said, "And a cancer are represented and most of search beds. and Allied Diseases in New York City. little child shall lead them." them have separate wards of their The beds are expensive. They are Di-. ROBBINS. I have found that But, you knonv, you do have to take own. It is concerned primarily with much too expensive for patients who working in the vineyards which are some sort of an approach to all of treatment and research on therapy of are ambulatory. And we have Iona being irrigated and nurtured by the these things and look for techniques advanced disease, but it also includes since developed arrangements with Regional Medical Pro,ram is really and for ,vays of communicatina that substantial leavening of studies of the local motels for patients who are one of the most stimulating activities will present your objective. And as abnormal physiology and biochemis- taken care of in the outpatient fa- that I have been involved in. I found you know, with many of Blllv Sun- try of the disease and something cility and live in motels. This is es- carly-I am trying to speak as a sur- clay's converts, they stopped near the which I regard as very important- pecially helpful in dealing with chil- geon-tliat one of the greatest thin@s local bar to celebrate their salvation we insist on the right of our physi- dren, especially children Nvith acute that one had to do was to take the oil the @vay home and that was it. cians to admit patients with other leukemia. We have beds enough to Billy Grtham approach, not the Billy But I think that from what I have diseases and to carry out studies in bi-lri,- them in when they really re- Sunday approach. seen, the team tliit his been (I(@v(-.1- otli(@r- areas. ))Lit fOl' til(@ IIIOS(, Nf y w;ls;t M(@tlio(I ],,,L minister, ()I)('([ IS t;ll@ltll-l ill(' frilly ( ;T'@Lli@1111 No@v, I think this is soiiictliiii,, very ])art, they @Ll-C C@ll-CCI fOl' ill the Out- down in southern Iticilaii@i. We used And this is @t tou(,Ii thing important in keepin(r first-rate men patient facility. to have these men and women come foi, surcons to do because, you know, working in the management of ad- To do this adequately, obviously, in to save souls. This basically was the we are pretty egotistical, and most of vanced cancer. They have to have rccluires more than the ordinary out- utilization of a tccliiilqli(- which us, I think, really shy a little clear of Some Outlet some I)sycliolo-ical out- patient facilities. One has to analyze WOLTICI -et SotilS Out of the. l@@,ll)tiSL and caii(@r- because somehow or anotli(@i, let, especially the younger@ones, or the kind of' Itlilng that is going to be Christian Church into the Methodist it is woven into our philosophy that they simpl@, can't take it. They can't done in this facility and prepare for it. Church. And I remember as a small you do soiilctliln,," like a hernia, and face those patients, especially chi]- No@v, I am convinced that many of boy one of these characters cominla to it gets all done, and that's fine. But dren, day in, day out, unless they have the medical schools, medical centers, town and taking me out to et a soda. if you take care of a cancer patient some variety in the diet. that are aoing to be involved in this Right a@vay, I was suspicious because, and there is a recurrence and there Our group requires ,%,hat many program over a period of years can havin(r dealt with a lot of ministers, are all these famllv problems and would consider to be excessive sup- attract and keep the kind of men you they usually didn't give very much everythiii," else, you sort of look at it I as a defeat of your own. To trN, and port in terms of laboratory facilities. are going to need to do the educa- away. So I said to Mrs. Barr-first, Part of these laboratory facilities are tional job, the consultation job, the drank the soda-"Why did you do develop amon(r sLir--cons and those directly related to what they are do- central referral job, if you will provide workin(T with surgeons an intradis- this?" ing in patients, but even more is re- research beds, some laboratories, and ciplinary approach to look at the quired to do the research they @vant a good ambulatory care arrangement She said, "Guy, I am here to help a -,vhole, a person, this is your father. Now, sometimes durin(r patient as to do which is not directly patient re- of some sort. . 0 toLi h. my first evening, things don't go just 9 lated. And I am sure that it is nec- Mike Brennan has talked about one But there are more and more peo- essary to provide this if you are goin- right, and I want you to get one of e that are doin, this. And certainly, possibility. I have mentioned the use . . I)l your friends, and when I am givin(y 'D to get first-rate men and keep them of motels. Perhaps we might @et Dr. it falls within the philosophy of the on the job. n my plea, if things don't --o right, I will way of life that I think can be clearly Farber to mention how he handles We have 250 beds. Of those, 150 this same problem, especially with give you a sign, and you come on defined as Americanism. are in the clinical center in Bethesda, children. down the aisle." I have been vcrv fortunate to ha%,c and they are all research beds. We Dr. FARBER. The final formal prcs- And I will nevei, for,@ot to my dY- been involved wit@ the Cancer Corn- have another 100 beds in the Public entation will be given by Dr. Guy in,- day as I pulled this other little mission of the Colle-C of Surgeons for Health Service Hospital in Baltimore, Robbins, the Director of Planning at ragamuffin out into the aisle and Nvent a number of yeai@s, and ivith Murray 82 mission to get this intradisciplinary activity on the road. We have repre- sentatives from general practice, pathology, radiology, radiation ther- apy, and general medicine. We also have entwined in this practicing sur- geons all over the country and are succeeding in getting them to look at this problem-the way of helping people get along, utilize what we have, throw away some of the things that are bad. But we have found there ery few things that are bad; it is just the way that they are used. I am sure that you will find extra man- power if you will utilize these men that are all over the country now. There are 200 of them. Many of them are in the program now, but there are some that would like to be part and parcel of @s. We have found that our tumor registries are a good way of evaluating how things are going. However, we have found one thing that we were terribly lacking in. We have had all kinds of support at the local level and certainly at the national level from Mary Switzer and her group in voca- tional rehabilitation. It is great to diagnose a patient. It is great to treat him right. But the trouble is so often that that is where our treatment has Copeland and Lee Clark and many Many of you may or may not know 6 years ago. We found out a lot of stopped. of the other people I see here in the about our regionalization program. things that you are finding-things All of us in this room believe that room I am part of a team that is We had a tumor registry program. that we thought were all right. you should do everything to get a working with the regional medical It has been going for a long time. Well, instead of shaking a nasty person back into the socioeconomic group. And I can tell you we are 100 And under John Klein, Lee Clark, finger and saying, "It is no good; get swing of things, but what are you do- percent behind the program, and we and Murray Copeland, we decided rid of it," we got together to try to do ing about it? There are ways. We are not too far behind, either. We to do an audit on this just to see how something about it. The first thing we used to say, "Well, the laws are no are right in there with it. good it was. This started about 5 or did was to broaden our cancer corn- good; we can't help a cancer patient 83 until five years." There are ways to I don't think near enough of us are- grams, I think, to which you might be sho%v them. He- has told the whole take care of that. and that is finding the time to help in alludino-. One is the tumor registry stoi@l, and I think it is up to you fel- I wish you could see the way New the lay education program. There are protram which has been goin, on for IoNvs to do a self-analysis and find jersey's DVA works with the State, arts of this country now where pa- 30 years. We believe that if you are what is wron,. Is it vour followup or p n the Federal people, and with the pa- tients come in, and they are too far going to evaluate how a patient is is it that a lot of vou are doing slil)- tients in the hospitals. They are doing advanced even to consider as possibly doing or has done or how you as a sliod operations a@d modified simple a great job. New York is coming being a cure. There are parts of this physician are working, there should inastectomies?" along, too. This takes a lot of Billy country where everybody has a radio, be some records kept. I didn't know if I were goin- to Graham approach, though. You 70 percent of them have televisions, Now, just to take the names and et out of the room or not, but t@vo can't do this overnight. but in the local newspapers there is numbers and ace and site and stage or three people came up to me and One of the most interesting and en- nothing on health. And on the tele- and so on, that's great. But if you said, "This is what we have needed lightenino, meetings I ever went to vision and in the radio programs, just put that in a repository and never for a lon- time." And then I found was one that Dr. Smith down in Jer- there is nothing on health. I think we utilize it, it doesn't make any sense. there had been two or three people sey fielded. They had 500 practicing need some comic books and things of And we have found administrations Nvlio had been tryin(Y to do this. TheN7 physicians in the middle of the week this type. Because if people can be don't like to spend money on some- had put this particular hospital on listening to the problems involved sold, if you can sell a population cig- thing that their staff doesn't use. notice that if thev didn't -et a clinical with getting the aid that is available arettes, why can't you sell health pre- One of our main efforts throu-h pro,,ram alonx with their tumor rear- at the community level, and it was vention aaainst these diseases? the regionalization program has been istry, we weren't -oin,u to okay their great. And there are going to be more We have worked hard, and a lot of to try to get these records used in tumor i-c-'str@,. We feel keepinu rec- of those meetings. money has been spent. But there cer- teaching exercises and in self-evallia- oi-ds and not usinff them is not ao0d. They Nvere a little surprised, as a tainly must be something more we tion. I was asked to go to a 500-bed The second part is the study that matter of fact, how good a turnout it can do. And I have found that if you hospital in Westchester and give a we have been designated to do on was. But they had spent a lot of time put a surgeon on his guard to try to talk on breast cancer. And I said I lookina into a number of hospital ac- disseminating information about this, get him motivated, if you get this fel- would love doing it, but I wouldn't tivities to see if we can -et ideas as utilizing the many, many forms of low goin,, lie is almost as big a terror go unless they had one of their men to how they are clolnl- tlilno,-s in the communication. These are the things in this sort of thing as he is in the give their experience in Nvhat has been inana,ement of cancer patients. @'Ve that we have got to do. We have got opcratin(r room. done and then I would be glad to dis- will have a larffe bulk of information to get the people that may even be Dr. ANDREWS. Neil Andrews, Ohio cuss things. that can be passed on. considered by some as just too busy State University. When I was in Tuc- Well, one of their men went into That is the Warren Cole Commit- making a living, but if vou give them son at the AMA meeting, I had the the tumor re,isti-y, and he found, al- tee that is doin, this work in con- just the slightest notion that you Nvant opportunity to talk to Clif Mount and thou-h they had had several hundred 'unction with all the specialists, in- their ideas and you Nvant them to hell) Bradiaan about a program that is be- breast cancers, primary cases, out- cluclin,y those in the Acadamv of Gen- get this thing on the road, it works. ing done-and I think you alluded patients that tlicv had operated, they cral Practice. In no N%@av are And, of course, this is the heart of the to this just a moment ago, by a num- didn't have a siti,le one that had lived cliai-,,ed to set ul) staTidarlis. We are whole Re ional Medical Program. her of organizations, including the 5 years. And this man ave the 5-@,cai- finclin, out a lot of thiti,s that are 9 9 And it is a sermon th,@it ev@oric is Colle-C of Surgeons, the American survivals at the national level k,,,Itli most iiitci,estin(,,-. In one hospital, xvc, preachin,- that is %vorkin- in this Cancci, Society, Colle,@c of Cli(@st tioc](@s tticl positive iioci(@s. former tli(@y liax-(- @%,oiicfei-ftil lioz-1- SLII"ICOIIS @iiid otlicrs-iii (-cancer i-eg- @VI]CII I ',I)Ol@(@ f tll(' tISLI@ll Cl('I'- Y.Ofit@ll (@otililltlil]Clt]OIIS, but the so(-I@il There is another tl)ing I think that istries if I i-enici-nber correctly. Could iiiition of a sl)e(,Iallst. Then I said, %%,oi-kei- had ncvei- met tlic,. mail is awfully important foi, stir-cons to You ,ive us a 1)1-0(rl-CSS I,(.,])Ol,t oil that? 11-(. illy slicl(,S; f @ilit not (,Oill(, \N@ll() %vts ill tll(. I)]-o- 'I'lict,c are two pro- to use them. I iiii not going to foi- that hospital. And the social do, and some of us are doing it, but Dr. ROBBINS. 84 service worker had 16 mastcr's degree that the Surgeon General shall estab- College of Radiology, the American lines. TiicN, arc iio@A,, testing them as to social service workers Nvorking with lish and maintain a list or lists of mcd- College of Pathologists, and others. their feasibility in actual visits to her. This particular chief of the social ical facilities in the country staffed 'And we have negotiated a contract various types of hospitals around the 'c(@ de I 1 1 1 with tli(- American Collc,e of Stir- country. And if this works well and -I)Lii-tin(,nt had 1)(@eii in this and to 1)i-ov'cl(,. the latest hospital siiict, 1952. advances in the diagnosis @iii(i treat- geolis to coiisi(Ic',- this field, to coil- productively in the field of cancer, We also found that, although they iiicnt of heart disease, caii(.-ci-, and si(ler N@,liat SIIOLIICI really ]-)c present ill we propose to undertake similar ac- didn't 1-ia@,e a rehabilitation program stroke, and to serve as training situa- a medical facility which is ,@oizig to do tivities in the field of heart disease and that the social service Nvorkers tions in these diseases. the kind of job Nve would all like to and stroke. didn't actually know anything about It further says that the Surgeon see in the diagnosis and treatment of Dr. COLLINS: Collins from North- what they A,ere doing, the orthopods General, in carrying out this activity, cancer. western Ohio. I happen to be a path- i When these criteria, as we arc call- olo-ist in a conim ' I were doing a fantastically good 'ob. shall from time to time turn to ap- unity hospital pro- Those on medicine and those in propriate national professional or- ing them, oi- guidelines are available viding service in pathology to several the nurslii,,, area and those in the so- ganizations in the country. in the field of cancer, wl-licli we ex- small community hosl)ltals-let's say The division, in trying to deter- cial service department said, "gee, we pcct A,Ill happen sometime next sum- from 50 beds up. I have been im- had better Nvork to,ether; we look mine how to respond to this part of mer, we propose to make them avall- pressed with the fact that in the sort of silly." All horizontal communi- the legislation, decided that as an in- able to hospitals all over the country smaller community hospitals, cer- cations, no vertical communications. itial step, it would be appropriate to for their own internal guidance and tainly in my area, there has been no Now, coming up -,vith data of this consult with the national professional to program coordinators and mem- long-term follo%vup of cancer pa- type is not going to change the way organizations of the country. We arc bers of their staffs in the Regional tients. Perhaps in a sur-eon's owi-i medicine is practiced, but I think that thoroughly appreciative of the great Medical Programs. personal experience, he has followed it will make people utilize @vhat they sensitivity of the medical profession Through the availability of these them, but to my knowledge, there has have. We have found that there are toward federally imposed standards, guidelines, we hope it Nvill be easier been no collective experience. These some hospitals who do not have an and we do not propose to develop to identify the gal)s in the diagnosis cases may move from community to X-ray therapy department. But they federally imposed standards through and treatment of cancer, in the capa- community. have a regional arrangement so that this activity. bility of a region to carry out good With this background in my, let's their patients are getting excellent Knowing that the American Col- cancer diagnosis and treatment. This say, puzzlement about how to work care. And certainly, we wouldn't say lege of Surgeons had already estab- Nvill be a guideline, both to hospitals out a proper followup situation, I this was bad. lished the Cancer Commission, which in their development as better 111- \wonder if a regionwide tumor re(,is- Dr. FAR13F-,R. At this time, I would included in its membership rcprc- stitutions for the future and a guide to try isn't the answer. Most hospital like to call on Dr. Margaret Sloan to ,ntatives of all the professional Or- Regional Medical Prograii-is in try- tumor registries I have been familiar say sorriethin,, more about the Amer- a;,nizations in the country most ing to develop regionally the calda- th have been as Dr. Robbins has hip ican College of Sur,,eons' relations cynosis and bility they Nvill need to perform ade- 0 - closely involved in the dia, already cited-dead. The material with the division of Regional Medical treatment of cancer, we turned to the quately in this area. goesinto .a file and nobody ever looks Programs. American Collec of Sur,cons and I believe that we have been very n at it. Dr. SLOAN. I would like to com- asked their help in this undertaking. fortunate in persuading Dr. Warren And I am very much disillusioned ment a little bit on what Dr. Robbins The Cancer Commission includes Cole, who is known to all of you and has 'ust said and to set in proper tli the hospital tumor beds. I -,vas i representatives of the American Col- has the respect of all of you, to chair wl perspective this activity which is le,e of Surgeons, the American Med- the comi-nittce, representing all these very much impressed with Dr. now known as the Warren Cole ical Association, the American professional or,,aiiizatiois, which is Smart's presentation on the Salt Lake Committee. Academy of General Practice, all the struggling with this problem. Thcv City, and I think it might be the an- Section 907 of our legislation says surgical specialties, the American have developed a list of such -uide- swer. I don't know. 85 Dr. ROBBINS. You are a -reat her of variables, lots of different kinds for a checkup? We feel that it is ini- (@'ii'a. I can't help but coml)are, as straiahtman for Dr. Smart, and I am of cancer, all different types of exist- I-)ortant that you do so. And if you I listen here, the heart i)ro(,i-am and another of his strai-htmen and so is ence as far as survival is concerned, are unhappy @vitli him, let's find an- tli(, cancer I)i-o,@ram. They run into Andy Mayer of the Colleo-e of Sur- and yet, the secretary is not a statis- other one." difficulty in that in the heart pro- creons and so is Murray Copeland. We tician, she is not a physician, and And I am aii\lous to see the Ameri- grain, there is a carcliolo(,Ist %Vlio is think this man has come closer to a even the physician is not a statistician can Collee of Sur,cons in particular the captain of the team: in t e cancer and is unable to deal with the tre workable sort of a re,ional tumor - try not only to establish these cancci- i)ro,,Tam, there isn't anv cal)ta n of registry than anyone else that we mendous number of facets. rcaistries, but in sonic way to see if the team. Manv specialists are inter- know. And this is primarily because How can the American College of we can't develol) a mechanism by ested in cancer. of one thin,: He is doin,- quality con- Surgeons or the Recional Medical which we can give them an individual When it comes to -Cttiria adequate trols and really A,orking with the local Program or any other program sim- hospital automated followup. examination for cancer of the lar@e hospital and it,-, staff and givina them plify this tremendous number of I think for about $50 a ycai- that 1)0%%rel, I think one of the troubles is prestige and also givin, them a prod- facets? I think a meaningful corn- most community hospital registries that the iiiternist, the surgeon, the Lict that they can use and understand. putcr pro(,ram can actually service a I I)roctolo-ist, the I)atholo-ist, the (,en- could ,et a report of the. SLIT-viva Mr. Chairman, maybe Dr. Smart ,reat number of hospitals as individ- curves On all their patients, listiii-l-s of et'al practitioner,. are interested, but might want to comment. ual hospitals and yet correlate the all their patients, and a listen', to each "Obodv has the %%-Iiole interest. The Dr. SMART: I believe that one of statistics that come from the health inclividi-ial physician of the patients public health person is interested. the most important things that we departments. It can account for all that he has been following for that I\la\-be this is a shot from the blue, can do in improving the quality of the deaths and immediately update year. I think it could be done cheaply. but -we have specialties that deal witl-i 0 cancer care at the present time is to all the registries simultaneously. It I think it could be clone effectively. a verv narrow part of medicine. Per- follow the lead of the American Can- can pick up the patient that moves And I think that these tumor rea- hal)s plastic surcrerv is one example. ican College from one hospital to another or from istries which they have been ptisliliio' There is no specialty board for on- cer Society and the Amer' of Surgeons in trying to make these one doctor to another. It can simul- could actually be made to be a very colog@7 or tumors, for cancer. Perhaps hospital tumor registries really effec- tancously, then, update the registry effective tool in education and in re- there should be such as we have for Si carcliolon,. tive. which will send out automated letters search, as well as in saving patient A tremendous amount of work has to doctors to remind them, at 6-month lives through folloN@,up. I -,vonder what the panel gone into the gathering of this data. intervals,. of - certain patients. And, Dr. ANDRI,-,-VVS. Dr. Farber, if I think of that. I kno%@, it is sort of per- And if we can induce physicians to not only that, I believe that it is im- may j'tist comment to my colleague haps a ne%v idea. followup their patients regularly . . . portant also to be able to have some from Lima, the department of health D I-. BRI-,NNAN: The American So- By "regularly," I mean every 6 kind of action arm so that, if the of Ohio State did until about 3 ciet\ for Clinical Oncoloav was lan, we formed ap I months, preferably. I think it depends patient is lost to that physic' years ago maintain a central cancer prox matel\ 3 or 4 veai-s a little bit upon the type of malig- have some ethical way of approach- registry. Unfortunately, th' - a-0. One of the problems -which im- is was un nancy they have,. but they need to be ing that patient. available as rc,,ards follo,,%@up mate- raiediately came up following tl-ie or- r followed. And in our particular area, we rials. So it was disbanded, and we at -anization of that societN, -,Vllose No@v I think a tumor reffistry must have tried to devclol) an action arm Ohio State now are attcml)tln(,@ to membership consisted lai-,elv of men have a mechanism for relicving the tlll-OLI,,h the public health depart- put to(,@cthcr an automated I)i-o(@raiii N%,Iio had been active in clinical re- tremendous amount of secretarial nierit @%,Iiei-e we c@in ittilize tli(@ public sti(li as Dr. Smart has stated so that s(@ar(-Ii @is opposed I)urel@7 to the ('are of -,vork. The problem at the present health nurs@ actually to visit the I)a- we can i-nake this available tliroti(,-Ii- ('aii(-er patients. was an impetus on time in the community hospital tu- tient,,vith the permission of the I)Iiysi- out out, I-(.",ioti -,I-, we have developed tti(, 1)2irt of the i-oi,il) toward tti(@ mor registry is this: A tremendous cian and say, "How is it that You it. formation of a subspecialty, board ]II number of patients, tremendous num- haven't I,)(@cn golii(l, to your physician 1)1-. WII,IIAIZ. N\Iilf)ai-, West V'r- ori(-olo(,@ 86 Well, I have found myself opposed medical needs. Actually, there are I would like to point out to all of ultimate salvage rate, in cancer by to this idea. As a hematologist, I only personal needs-nceds of indi- you the fact that there is a different using optimally the available detec- never found it necessary. The Amerl- vidual persons who are part of a social approach which we undertook 20 tion facilities, not by 450, but by can Society for Hematology suc- matrix the entire integrity of which years ago, and that now is being closer to 1,000 a year in the Detroit ceeded in doing all that we wanted is disrupted when the personal needs adopted in certain other areas than metropolitan area. My point Nvas that it to do for us or we wanted to do of individual members are not met. ours. It is the small cancer hospital if we brought up the level of accessi- for hematologists without going the In chronic illness, it is very obvious in association with a large general bility of care and the quality of care route of the subspecialty board. and clear that we have to respond hospital, the cancer hospital utilizing for the indigent to that which holds However, this does not detract in an altogether different way than all of the advantages of the special presently for the nonindio-ent popula- from the fact that there must be a we have before. We have to go out- institution and nevertheless utilizing tion in America today, we would save captain of the team in every institu- side the ranks of medicine as such to the talents and facilities that are only 450. tion. He should be, I suppose, in an do this. These are not simply medical already there. Now, I don't believe that the pri- old Latin way of expressing it, problems; they are also problems that This is worthy of consideration in vate profession is utilizing detection Primus inter pares, the chairman or require the skills of socioloists and practically any city in the United iiietliodolo," in an optimal way. And head of a group of equals, who con- social workers, the whole rai-i-c of States of any size because you already I a,,,-rce with you, we need to look to sultatively deal with the management helping professions. And we @nced have talents there tl-iat can be used detection and find intelligent xvays of problem of the patient. As we know captains for these teams, but I don't and do not need to be displaced in doing this. from all human affairs, there must think that we can identify them in order to start a unit of cancer ap- We have experience with a can- exist a last place of responsibility and terms of their medical specialities. We proach that will involve all of the cer detection clinic which is 20 years decision. Now, who that man should can't identify them in terms of where skills that are necessary in pathology old and which examines approxi- be will depend upon the staff of tli(@ tli(@y from ]'II training. We can as well as in radiotherapy, clielilo- iiiately 8,000 I:oat'ciits a yeir. And %vc I institution 'Itself. III some cases, lt,%vill only identify them in terms of where therapy, et cctcra. kiio", -,,cry well %%Iliat the yield of be a surgeon who has a long and they stand in coml)ctericc, in interest Dr. DAVIES: Dr. I)avi(!s, N4cllll)llls. these eliminations can be. But out- wide-based interest in cancer man- and in concern at a particular time. I would like to address this question has to think in -terms of priorities, I agement. In others, it will be a radi- Dr. DEL RFGATO. I would like to to Dr. Brennan. In making an appeal believe, too. And the overwhelming ologist. We have the Penrose Hospital introduce a consideration in which I for an extended care facility, you and crushing problem that is in front captain sitting right next to us here. think all of you will have an interest. pointed out that there are sonic 6,000 of us today is that, because we insist In other places, it will be an internist. It is a fact that you would have easily deaths from cancer in Detroit a year semantically in separating out social Our problem is that we don't real- confirmed that this country has a and that only 450 lives could be saved and medical needs and writing insur- ize the degree to which American lesser number of cancer hospitals if you went the route of early detec- ance pro-rams for one and not for medical institutions, the whole ap- today than it had 30 years ago. And tion and increased facilities for early the other, we are ending up with a paratus, has been around the problem the reason is that the concept of a diagnosis. wastage of hospital facilities, a de- of acute illness. And vet, we now are n and I cancer hospital in this country has Doing a little arithmetic, since you moralization of the professio tying in stroke and cancer (I exclude been a total, full-time staff type of said that the deaths come to about the discouragement and despair of heart from this problem) to deal with approach to the treatment of cancer, one out of 50 deaths in the country, I many patients and their families 1 1 chronic illness in this acute care with which the American medical get a figure 'of some 7,000 people, simply because -,ve can't make the in I 1 fra ework. And the whole apparatus profession as aA,hole doesn't go along lives, that could be saved in the colin- sociorned'cal product we need for ha.,; to be changed to fit chronic very well. So this has been limited for try, which I think is a fairly sizable chronically 'II people in acute care illness. tli(- itiost part to the treatment of iii- iiiiiiib(-j-. Institutions. We have hurt ourselves @vitti the digents or to outstanding research Dr. BRI-"NNAN. I believe that you Let us try to understand, for ex- idea that there are social needs and institutions. could increase the salvage rate, the ample, why a doctor keeps his patient 292-414 0-68-7 87 in the hospital when he isn't actively this is impossible; you would never be beginning with January 1966, up to problems of cancer in the Regional treating him any more. Why have so able to get the health care system at the present time. We did get as close Program. I think it is quite clear to many of us over-used the Blue Cross? several levels at which it functions to as we could, but we still didn't ao to vou that all of us will leave this room It is not because we are careless about cooperate in such a program. the practicing physician's office. IomeNvhat dissatisfied because there the Blue Cross; it is because, in many Dr. SMART. Dr. Baylor of the Na- This was a very efficient method, are so manv probleriis that we would instances, we recognize that the hos- tional Cancer Institute is presently and we were able to survey in a pe- like to have discussed. If -,ve can con- pital is the only existing acceptable undertaking, again, beginning in riod of 8 weeks 4t hospitals in the vcA, this to Dr. Marston, perhaps we facility in which, in the totality of this January 1969, a 3-'ear study of ten State of Utah and 36 hospitals in the can have another session in the not y patient's situation, we can reasonably cities and of two States to try to de- State of Wyoming with ei,ht medical too distant future @vitli much more say he should stay. This is a great te=ine the incidence by having every students in a period of 8 weeks. That time allotted for the discussion of problem. physician pick up every single case is one way of -ettln,- at this thing. i-nariy other problem,, which are con- Dr. S'I'ORI-"%'. Storey, %vitillil their ii) tli(- I A,otilct likt@ to @LSI@ a ([Lit'.';tlOll tii@tL is Now, flow IIILICII tll(! Is to (10 1)1'0@L(711. 'I'll(@y Said, "W)ILL %V(@ Otil@lit related to the discussion t@iat has 'List that in all areas of the country, I am to do is it t law." And they just I I i @i few points I %vc)tilcl I'k(! gone on, but I would specifically like uncertain. But I would say that in passed the law in Wyoming that all to make here because I think thev are to ask it of Dr. Smart. Specifically, it Utah and also in Montana and also in pathologists must send a duplicate of some importance to our work is whether or not you consider it Idaho, it is a reportable disease, and report of the histology of every case wlii(@ii will go on bt@foi-c tli(, next practical to make cancer a reportable they are getting reporting of about IO of malignancy to the Stite health (-otif(,r(-nc@(@. disease in any given region. What I percent of the cases. And the reason c](@I)artriierit. And in the last :3 Mc,nLion was made bv Dr. Breiiii@iii have in mind with that is that @ve that they are getting reporting of months, even though it has been a of that important segi-nent of the don't have too much difficulty getting only 10 percent of the cases is be- reportable disease by physicians for population which is less favored than information on mortality and we are cause they aren't giving anythin- several years, in the last 3 oi- 4 others. Of course, we are all deeplv able to get morbidity statistics back to the physician. They are re- months, they have picked up more concerned in seeing to it that even, through tumor registries of hospitals questing more and more work of him, cancer cases than they have in the man, woman, and child in the coun- which have tumor registries, but we but they are giving nothing back in entire 3 years previous. And that is a try has access to as fine methods of have great difficulty in finding out return. pretty efficient way of doing it. cancer diagnosis detection and dia@-- what the true incidence of any form And the answer is that the reports Dr. FARBI-',R. If you will permit me nosis and then treatriient, and finallv of cancer is and what the prevalence have simply been filed on a desk in to make a few concILiding remarks. rehabilitation, as anv other man, of the disease is. And we also have the health department and nothing First, I do want to acknowledge woman, and child in tile COLintn. great difficulty in finding out what has ever been done with them. The the distinguished leadership which But I would emphasize that if N@,e the stage of cancer is in any given only incidence figures they have ever Dr. Robert Marston has given to his did no more than carrv on the kind community at the time that it is come out with are the incidence fig- staff and to the country in this very of cancer diagnosis and treatment diagnosed. ures that have come from the Cancer great and important program. It is available todav to patients -,vho are It seems to me this is critical in- Society where they say 285 patients one of the most important moves, I in the favored group able to pa@r, we formation, and we have got to be per 100,000 are doing to develop a believe, in the historv of i-fieclicine in N,,,otild not be dome Our job. There able to get this. And we have dis- malignancy. this country. We arc grateful to him are two more 'ohs to be done. cussed the possibility of the mech- We took the approach of hiring and to the splendid staff that he has The first is to see to it that evenr- anism of making cancer a reportable eight medical students and sending brought to work with him in this one,, inc]Lidin, the private patient, disease as being a way of getting at them out so survey all of the hospitals important program. recci ,vcs everything that medicine, sur- this kind of information, but the gen- of the State. We went into every re(@- We arc grateful to our panelists and laboratory science has to a eral feeling among our people is that ord room; we pulled every record, here for their contributions to the off(@r todav for their prolong tion of 88 life and hopefully for their cure. I is a much abused term. I have used the disciplines of biochemistry or in- Programs were created for. We must lia%@e figured and I am willing to de- another term-the conception of ternal medicine or surgery or pathol- not be content Nvith years and years fend these statistics, that if we applied total care of the patient which brings ogy. It should detract from none of of application to the base upon everything that is known today to in everyone, every discipline, that them, but brin-- additional strength which we are goin- to build because every Patient in the country, includ- might be of aid to the patient. I was to every one of these disciplines. there is so much that is known today incl, those in favorable economic cir- pleased with this question about who If we do that in every medical that we can use for the benefit (> cumstances and those who have no is the leader of the team. The leader school, we will turn out doctors who those who do not have what is known private doctors at all, we could save could be any one of the specialists are already accustomed to an inter- to those who are most expert in this 100,000 patients this year of the mentioned and one more. disciplinary approach no matter field. I would hope that we will have 300,000 who are going to die of There is one speciality that could what field the new doctor may enter. in the near future another confer- cancer. be added, Dr. Brennan. There was a I would say one final word here. ence of those interested in the prob- I think this should be our imme- man named James Ewing, and there We have -one through a period of lems of cancer related to the Regional diate goal in the Realonal Programs. was a man named Dusty Rhoads; discussion of continuing education, a Medical Programs, and that we will We must be certain that when we both of them were pathologists, and matter of tremendous importance. talk about more specific programs initiate these programs, Nvc must not they were leaders. What is important We have also -one through a period which can be instituted today and pen-nit Gresham's law of economics is that in this interdisciplinary ap- of data collection, plannlnl-, and which hopefully will have been in- to operate. We must not have poor proach to the entire problem of can- study. There is no question that this stituted by those of us wh are here I 0 work pushing out good work in an cer treatment and cancer research, is a field of great importance. But today to report on at the next confer- attempt to spread this to everyone. there must be someone who is highly these are supporting structures of the ence. We must raise the standard for pri- skilled -in his own discipline, who by program that will lead us to the final vate patients as well as for those wfio his nature and interests has a broad goal of these Re--ional Medical Pro- are less favored. view of the field of canc@er, and grairls. That is the care of the patient. I think there ai-(.- a few delusions awat,(,ii(,ss of what it ii@ictns to achieve We must get to the patient as i-al)icllv under which @v(,- have ol)(@,r@it(!(l in tli(- goals of I)i@(@v(@iition and goals of cure. as possible \without waltiii,@ for 5 oi- past. One is that every doctoi"s office That man can come froi-n any dis- 10 years of study and planning. is a cancer detection center. That is cipline. We must not permit any of We Must hell) them and we must impossible. We must not impose that the rules of craft unionism or the spe- help the continuing education peo- load upon a eneral practitioner, who cialty boards to determine who will ple. But -,vith knowled@e and re- is not equipl-)cd by training or with be tfic Icaclei- of a ,roul) interested in sources of medicine in this countiT tfic proper instritment@ttlc)n or with tli(,, 1)@iti(,iit with c,-Ln(@cr. today, we call apl-)Iy w)i.-it is known by tlif-- I)t-ol)(@i- hospital to W(@ li;lv(@ to 'go ]lot only to those Who illol.(" (Ixl)('I't, illol'(, (,N- the responsibility of telling a given tl)c hospital, but to the medical periciiced, in caiicet- than those who person that he has or has not evi- school to bring into the medical have not worked in the field, to every dence of cancer. school the word "oncoloa i ,,y" as an patient of every doctor n the country To follo@v this along, I am glad that honorable temi, rcprescntinc, a pur- and to every person who is sick with this A7as brought out by Dr. Robbins suit that brings in people from every cancer, whether he has a doctor or that no one doctor can take care of discipline represented on the faculty not. any one patient with cancer. There of the medical school. And such a I would fire that we push ahead never was a time when any one doctor division of oncology in a medical with I)Iannin,,- which leads to the care could do that. school must be so created that it will of the patient. That's the goal, and This team approach is essential. It not interfere with the development of that's what the Re--ional Medical 89 PANEL DISCUSSION ON- (ICD 330-334), rank third among States and the lowest rates are in the Unfortunately, not enough infor- STROKE leading causes of death in the United Southwestern and Mountain States. mation is available on incidence of States; they are outranked only by It should be noted that the geo- cerebrovascular disease in -,encral arteriosclerotic heart disease and graphic clustering of cerebrovascular populations. Those data which are Panel: malignant neoplasms. disease mortality in the United States available are difficult to compare. Nemat Borhani, M.D. (Chairman) In 1965, a total of 201,057 persons does not, in general, conform to geo- The Middlesex County, Conn., Professor of Internal Medicine and died of cerebrovascular diseases, a graphic distribution of mortality study reported an annual incidence Chairman, Department of rate of 104 per 100,000 population. from arteriosclerotic heart disease. rate of 2.3 per 1,000 population of all Community Health The age-specific death rate increases The findings of the recently con- ages. This incidence rate increased University of California School with age, from 15.4 per 100,000 in ducted National Cooperative Study tremendously with age, from 4.1 per of Medicine the age group 35 to 44 to 430 per on Mortality from Cerebrovascular 1,000 in the age group 55 to 64 to 50 Davis, Calif . 100,000 in the age group 65 to 74 Disease indicate that the observed per 1,000 in the age group 85 and Clark H. Millikan, M.D. and 1322.2 per 100,000 in the age geographic variations in mortality are over. Consultant in Neurology group 75 to 84. Death rates also vary real and not due to statistical arti- In Framingham, Mass., among Mayo Clinic among the races and between the two facts. 5,106 men and women aged 30 to 62 Rochester, Minn. sexes, 96.3 for white males, 108 for More specifically, analysis of the years who were found to be free of white females, 113.5 for nonwhite death ccrtificttes foi- wl)lte iiial(@,s arid both coronary heart disease arid (7cre- James F. Toole, M.D. males and 115.9 for nonwhite females, age 45 to 69, from nine areas I)rovasculai- disease during the initial Professor and Chairman females. of the United States, representing examination, there occurred 90 cases Department of Neurology Cerebrovascular diseases impose a high, intermediate, and low reported of cerebrovascular diseases in 12 years Bowman Gray School of Medicine multibillion dollar burden on the Na- cerebrovascular disease death rates, of observation, an incidence rate of Winston-Salem, N.C. tion's economy each year. The most showed that the difference in rates do less than 2 per 1,000 per year. In recent data from the National Center not seem to be due to: . Framingham, thrombotic brain in- William A. Spencer, M.D. for Health Statistics indicate that in 1. Coding differences in selec- farction was by far the most common Director, Texas Institute for 1962 the loss from the labor force tion of the underlying cause of type of cerebrovascular disease, ac- Rehabilitation and Research reached 177,700 man-years at a cost death on certificates that list cere- countin@ for 63 percent of all such Houston, Tex. of $701.8 million. The direct and in- brovascular disease diagnosis, events. Hemorrhage into the brain Richard L. Masland, M.D. direct estimated cost of stroke in 1962 2. Differences in certification was the least common (4 percent), Director, National Institute of amounted to $1,147 million. practices by coroners or medical but most lethal type of cerebrovascu- Neurological Diseases and Blindness Nearly 50 percent of the direct cost examiners, lar disease. National Instt'tutes of Health of $211.6 million was for hospital 3. Use Of Vague terminology, As far as prevalence of cerebro- care; more than half of the indirect and vascular disease is concerned, the cost or $468 million was associated 4. Large number of deaths at- 'lable data leave much to be de- R. BORHANI. The first item that with morbidity from cerebrovascular tributed to cerebrovascular disease aval Dwe will cover this morning is diseases. in nursing homes and outside of sired. By and large it is believed that the epidemiology and early detection The analysis of mortality data re- hospitals. total prevalence of this disease in the of cerebrovascular diseases in the veals that there exists a marked The findings of this study bring to United States is between I and 2 United States. clustering in mortality from cerebro- focus the need for a comprehensive million. It should be emphasized that Disorders of the cerebral circula- vascular diseases within the United morbidity study to further explore the accurate data on prevalence of tion, grouped together under the States. The highest rates are found in reasons for the geographic differences cerebrovascular disease are not avail- category of Cerebrovascular Diseases the South Central and South Atlantic in mortality. able and are much needed. 90 In summary, the available data 3. Ascertain the true incidence tent have current advances in the called the RMP approach to the suggest that there is no appreciable and prevalence as well as the field become known to the practicing stroke program. sex differential in cerebrovascular magnitude of disability resulting physician? What rehabilitation serv- So we start also with the presump- disease, that Negroes experience more from each type, and ices arc available, are they adequate, tion that for a given region there will cerebral and subarachnold hemor- 4. Accurately assess existing and how are they being utilized? be centers of excellence, or a center of rhage than Caucasians, that increas- therapeutic and rehabilitative re- It is evident that there is a great excellence, which must interrelate in ing age and blood pressure are sources and measures, as they may need for b@isic reliable information to terms of the original law to all por- (@l(@@irly to Lll(-. (I(-v(-Iol)ii)(-rit of :Ilt(!I- tll(. natural history of v@ll-lot"; 'I'lits must 1)(' (]one 1)(@- tiotis in(i all (-oniiyiiiiilties tiid all (lisca.S(.-, tll;tt liyl)(,.I-- tyl)(--S of tl)is clisc,as(-, in the (,orit- foi-c any meaningful I)i,cveiltiv(l 01' persons of the region. I am going to cholesteroicinia is associated with munity. control ii-icasure could be applied. To start with the theoretically optimum the risk of developing this disease Once cerebrovascular disease has me, these questions pretty well chart center setting to demonstrate the only in the age group 30 to 49, and become manifest, its treatment is es- the way for the activities of the Rc- complexity of the problem we are not thereafter and that there is some sentially limited to either surgical gional Medical Programs throughout talking about, what kinds of persons evidence relating cigarette smoking to procedures, or acute supportive medi- the country. or disciplines should be represented cerebrovascular disease. cations. Also with modern medicine, I think we can leave the epidemiol- a, far as the center is concerned. Major deficits in our knowledge of many patients anticipating cercbro- ogy at this point and hear from our Now, the word "should" was used the occurrence and the nature of vascular disease can be treated cffcc- distinguished panel. The first mem- advisedly. This is in a sense a theoreti- cerebrovascular disease are evident. tively to avert catastrophe; and, ber of the panel who is going to dis- cal concept, and you will see not Many aspects of the epidemiology of among those who have suffered severe cuss the subject of various aspects of many fulfill the criteria as the criteria cerebrovascular disease need urgent attack, treatment can reduce or pre- management of the acute phase of are elaborated. Here is a list: tudies. Furthermore, as vent chronic disability. It is commonly cerebrovascular disease is Dr. Clark- One, Neurology. Now, neurology systematic s was reported by the President's Com- believed that all new and modern Millikan. might handle EEG, brain scans, and mission on Heart Disease, Cancer, techniques of therapy and rehabilita- Dr. MILLIKAN. If we start with the encephalography in a given setting, and Stroke, many fundamental prob- tion could, and indeed would, pro- presumption that the Regional Medi- but often different personnel Nvill be lems of physiology, pathology, neurol- vide benefit to the patient, when in- ' involved with some of those items. cal Program is going to attempt to ogy, neuropathology, circulatory dy- telligently applied. What is not do something about stroke patients, Two, Neuroradiolo,@y, for contrast namics, and blood clotting, to name known, however, is information re- it seems wise at least to discuss the studies. In some instances this in- only a few, need to be studied with volves scanning, or they handle echo, garding utilization of current knowl- matrix into which we may mold the respect to development of cerebro- edge in the medical community and stroke setting. or may not, of course. vascular diseases. how judiciously these measures are I am going to begin in terms of Three, Medicine, including Cardi- If intelligent programs aiming at being applied to the cerebrovascular personnel and facilities because, after ology, the inspection, diagnosis, and the prevention and control of cerebro- disease patient population as a whole- all, the core issue has to do with the therapy of hypertension, and hema- vascular disease are-to be established, Indeed, questions arise as to how to tology in reference to blood constitu- it is vital to: effectively the medical community is kinds of people that are going ents. Now we have the business of the 1. Be able to distinguish be- utilizing the information already address themselves to the individual high hemoglobin raising its head, and care of individual stroke patients, or Nvhat the meaning of this is going to tween various types of cerebrovas- available with respect to ccrebrovas- 1 cular disease and their precursors, cular diseases. Are the high risk in- the prevention of stroke in individ- be remains to be seen; obviously the 2. Know accurately the mor- dividuals being identified and to what uals, plus facilities, meaning all of the diagnosis and long-tenti care of tality and case fatality of the extent the risk being altered? Are ade- physical components, the two molded diabetes. various types of untreated cerebro- quate diagnostic procedures and fa- together into an organizational com- Four, Su@,,ery, vascular and neuro- vascular disease, cilities being utilized? To what ex- plex which might in this instance be surgery. Although there has been verv- persons involved in the social setting ology is becoming a part of our e of a particular patient's problem. day life. Number eight, Clinical Patholo,@y. Number 15 is a collection of items This is the type of professional in- Linder so-called Basic Scicnce, and dividual who heads the backup here is experimental patholo@ , ph@- ,,Y@ I laboratory services which are manda- sics, mathematics, electronics, neuro- tory for the research, training, and chemistry-a whole host of different the actual practical care of patients kinds of people who well may need to in this setting. Now, recall I am be involved in the mix of research in- vestigation at the level of the cere- discussin- the most sophisticated of brovascular research center. patients' setting, the center, the hub And finally, 16. I have put down of the wheel. Clinical pathology, and other administrative types of persons here we see individuals who must 'in having to do with Fiscal Arranl(,,c- some instances look after brain scans, ments, the accomplishment of the and others must of course take care of attaining of various kinds of space, the clot lysis phases of tti(! problem; its remodeling, and that sort of that. chemistry in general, and in certain You see how ridiculous this is in instances, tissue pathology. terms of taking care of Mr. Average I have put down the next one as American with a stroke. As Dr. Endi- the general area of Secrctarial. This cott said yesterday, $25 million for one is the kind of supporting personnel cancer center that can handle a few that is mandatory to the filling Out of hundred patients is not a rcallstl(' the various kinds of fori-ns, transcrib- look at the problem of cancer in the considerable emphasis on the surgery itation may have to be subdivided, as iii(y reports, et cctera. United States. of occlusive disease in the cervical far as personnel is concerned-physi- We go on to number 10, Neuro- So let's chanue cut- a bit and portions of the cerebral circulation, cal medicine, speech, and lancua(TC patholo(7 sav what is possible in a coLintN, corn- "Y- we must reflect that differential di:kg- pathology. Then I put Epz'demiolo,,ay. We are m,,nity in Illinois, or in Missouri or nosis obviously includes other condi- and @ill tli(, supporting .n Florida, outside t]-i(@ irnii c iate t@ilkiiig about tli(., (,enter now, foi- tli(, 1 . settlii- of the @reat medical center. tions inside the head, and when we @trLICtLll'C.; that go around liLti-sltl(', study of the impact of the disoi-clei- get to the subject of hemorrhage, either in terms of prevention, prou- We might look at it from a dif- 0 on the community, the collection and whether subarachnoid or intracere- nosing stroke, or the completed stroke ferent standpoint and sav if we tal@c analysis of data in reference to the I bral, we have a situation that falls setting-this kind of personnel ob- spread of it and its possible meanina the temporal profile of cerebrovasci-i- into the province of the neuro- viously is mandatory to the setting. s. lar disease where can we make an Number 12, Neuro-ophtlialmolo, surgeon. In some settings the neuro- The next oi)c I have put down is 'Y- impact as we begin to structure or- surgeon has become accomplished at @oclal,Yc?@7)lce:. l@in(I of 1)(@rsorill(@l Number 13, N@,7irop,@ycliolo,,,I!, gaiijzatiotiil iiiatr-l(-(,s foi, ,iii itt;i(,K, doing peripheral vascular sut-(,(@rv. So ii(,(@clecl to tli(@ return of Fail liiclivicltltl Ntilill)(,I- 1/1@, for tl)ig kind of number four is surgerv. to the community, the interrelation- business, Computer Methodology. It Well, of course, as Dr. -%Iasland The next one is Rehabilitation. ships between the cost structure of the is fairly obvious as we get further in- ei-nphasized yesterday, we turn to the And in the setting of the research patient and the patient's family-all to the 20th century that the use of matter of prevention and what kinds center the whole concept of rehabil- of this must be worked out through computer teclinolo,,ay and method- of personnel might be involved in a 92 'tiii(@,tion, Consultation, and full corn- and the site of the bleed'n-. In some (@oxiiiriun'ty in screening and ,itt(!rlil)t- so-called minimum level is an inil)or- ing to do something about 1)i-evert- tant matter. We start with some @-incl itiunicatiori with some kind of person locations, bleedin, seems to stop more tion, and what kind of physical facil- of individual who knows something who knows something about the quickly than others, and obviously if ity is necessary. about the brain-this may be an in- brain. the clotting is abnormal, as in leu- I have written down here that one ternist, this may be a man in general Perhaps we will have an oppor- kemia, or in a patient on anticoagu- of the key issues sooner or later must iii(@dl(,lnc who has had some special tunity later on to come back to lants, the bleeding may continue, 1)(@ tli@it a I)fiysician be in t@i(@ iiilx wfio training if we are further CIISCLISSion of the matrix be- when it would c@e in nonnals. knows something about tfic brain. For goin(, to discuss practical prevention cause there is a great deal more to be Even though head injury rep- the moment let's temporarily discard in terms of screening, then action, we said about this. resents a major cause of intracranial the concept of the formal disciplinary have to get action. Dr. BORHANI. Dr. James Toole will bleeding, I have decided today to con- distinction. There have been argu- Before closing I want to. make a talk about intracranial hemorrhage. Sider only bleeding due to disease of ments among some of us at times comment about this. We have to get Dr. TOOLE. Those of you who are the vessels, so-called spontaneous about what kind of a discipline- inclusion of someone who knows experts will have to bear with me hemorrhage, with a very occasional oriented physician could r(,,@illy know soiTi(@thin,,, @ibout vascular surgery, while I -lve you what I would con- allusion to the traumatic injuries something significant about the brain, %whether titled a nCLirosurg(@on or a Sider a basic talk on hemorrhage which are such a great problem as but it has been a belief of some of us general surgeon with special training within the head. Intracranial hemor- causes of hemorrhage. that we can train individuals in short- in vascular surgery. rhage within the head occurs when As mentioned earlier, bleeding may term training experience to at least I want to make a plea before clos- an artery, a capillary, or a vein rup- be arterial, capillary, or venous. Ar- become knowledgeable of some of the ing-I don't know whether I will get tures, allowing blood to spill into the terial blood, being under higher practical aspects and, theoretically, strenuous ob'ection from the panel or surrounding tissues. Depending upon pressure, usually results in more mas- i evcrv physician should have this the audience or not. I want to make the site of the rupture, this Spillane sive bleeding with a more rapid evolu- knowledge, or should have some abil- a plea that we do not construct may result in the accumulation of a tion of events than does capillary itv in this regard, updated from time matrices for the approach to the pre- blood clot which can act as a mass or venous bleeding-obviously with to time by (@ntinuing education tech- vention of stroke in which we put compressing and displacing the adja- some exceptions. Hemorrhage can niques. So that some sort of physician, vascular surgeons in an isolated set- cent structures and tissues and/or occur from any site or from any whether called formally and board- ting to do the whole 'ob. I think that spasm of the arterial tree in which artery or vein within the head-for i certified in neurology is not the issue as we see referred problem patients, the rupture occurs, and lastly a reac- example, vessels may rupture into the at the moment. that one of the commonest sources of tion to the blood itself as in the chem- pituitary gland but some vessels rup- III the first pla(:c, it is not possible problem patients come from settings ical meningitis which occurs when ture more frequently and as a result foi, all the (Communities. where tli(@re has been a very, very there is a subarachnoid hemorrhage. some structures are involved more Dr. Masland, how many are cer- vigorous surgical operative approach Vessels may rupture because the walls often than others. tified in neurology now? to the clotted arteries in the neck by are weakened by disease, occasionally, Again I want to emphasize that I Dr. MASLAI;D. About 1,200. people %vho have not yet had their because the intraluminal pressure is am addressing this talk to those of Dr. iMILLIKAN. Close to 1,500. lifetime medical experience enriched excessive, or because of trauma which you who have not studied the anat- You get the complexity of the prob- by finding out anything about the tears the vessels. omy of the skull, the menin-es, or lem and the impossibility of the prob- brain. And I personally believe that In many instances two, or even brain. lem in terms of distrll)utin,,, these IL is highly important that this sur- three, of these factors may occur in First, I would like for you to con- people to make even adi-ninistrative @,cry not only be conducted by in- combination with one another. sider the venous anatomy of the contact with every citizen in the dividuals who are technically expert Whether the resulting clot enlarges brain. United States. at handling the- problems of vascular depends upon many factors, only two (Slide) You can see that the brain The matter of the surgery at the surgery, but who are working in con- of which are the clotting mechanism is covered by meninges, the dura 93 mater, the arachnoid, and the pia bral spinal fluid, up over the hemi- is another type of aneurysm which therapy for each is dependent upon mater. Outside the dura you can see spheres and down around the brain seems to develop in patients with sus- having a properly trained group of the middle meningeal artery and vein. stem into the spinal theca. Local tained hypertension. These are micro- people available, as was discusse y Rupture of one or the other of these blood clots accumulate, and this can aneurysms which occur in the arteri- Dr. Millikan, with adequate equip- two vessels causes epidural hema- act as a mass lesion, but most of the oles which penetrate the substance of ment for the rapid management and toma-almost always the result of systemic signs are secondary to the the brain. These aneurysms are micro- initiation of the steps necessary to re- trauma to the overlying skull. At reaction to blood in the cerebral scopic in size and appear to be a lieve the condition. times a barely preceptible skull frac- spinal fluid. This results in acute tortuosity of vessels, beads of out- Dr. BORHANI. Dr. William Spencer ture causes rupture of artery or vein, headache, stiff neck, and change in pouching. In some cases, these micro- will talk about the various aspects of with the rapid accumulation of a level of consciousness. About half of aneurysms rupture and produce an rehabilitation in stroke. blood clot, which presses on the brain the patients with subarachnoid have intracerebral hemorrhage which de- Dr. SPENCER. I approached my like a tumor. Evacuation of the blood a ruptured aneurysm. The others are stroys the parenchyma of the brain. part of this perhaps a little differently. clot removes the tumor and ligation of unknown cause. Most people have felt there is very We might entitle it "A Tale of a of the vessels cures the patient, but Most aneurysms arise from the little to be done about these clots once Noncategorical Approach to a Cate- delay even for an hour or two may arterial circle of Willis or the artcries the rupture has Occurred, for it de- gorical Problem," because I think be fatal. which feed or arisc from it. Aneu- stroys structures, many of which are there is some question in your minds Beneath the dura is the pia-arach- rysms are thought to be congenital vital to normal function. Most occur on the relationship of rehabilitation noid and between them are veins and to be the result of herniations of in the region of the internal capsule, to RMP, either as physicians or as which, when ruptured, result in sub- intima through congenital defects in or in the thalamus-areas of the brain administrators or as people concerned dural hematoma, which is another the media. This herniation may be which arc both very difficult for the with the administration of Regional mass lesion within the head caused by brought about by elevation in sys- neurosurgeon to aliproacti. Medical Programs. a blood clot. Bleedin in this instance temic arterial libad pressure. The point to citiphasize about all What is the relationshil) of rehabil- 9 is almost always venous so that the Unfortunately, the development of of these forms of intracranial licinor- itation as a method of patient man- evolution of events is usually more an aneurysm cannot be inticipited. rliagc is that all @ir(@ I)ett(@r 1)rcvciit(@cl a,reirierit to these various categorical chronic, often with insidiously pro- They hardly ever produce localizing than treated. Identification of pa- problems? I suppose stroke is prob- gressive signs and symptoms. signs or symptoms which one could tients who might suffer subaraclinoid ably the most evident one, simply be- (Slide) Here is an example of an utilize in mass screening programs to or intracerebral hemorrhage from cause the person with a completed accumulation of blood clots beside decide whether or not one might either form of aneurysm is partly the stroke very often has problems of the temporal lobe. You can see that eventually have a subarachnoid hem- identification of hypertensive patients mobility or movement, and it is in it presses up on the brain, displacing orrhage. However, in the majority of and it is hoped that the control of the disturbances of movement that the structures which are ordinarily in people who have ruptured aneurysms, hypertension would reduce the inc'- phv ical rehabilitation, at least in a s the midline and resulting in displace- hypertension is found, which gives dence of these tragic diseases. The medical sense, has had reat utility ment of the hemisphere and compres- some hope that control of hyperten- traumatic forms of hemorrha-e-epi- and development. sion of the midbrain which ultimately sion might result in reduced fre- dural and subdural hematomata-are Unfortunatelvl however, this leaves caused the patient's death. quency of this disaster. also better prevented than treated. in your mind a ,residue which is not (Slide) The nexf form of intra- The next type of hemorrhage that In summary, the most common consistent with what is happening in cranial hemorrhage which we will I would like to discuss is hypertensive forms of intracranial hemorrhage are rehabilitation medicine, and that is discuss briefly is the subarachnoid intcrc@ci-ebral hemorrhage. Recall that those secondary to trauma to the i i-e@ilization that rehabilitation offers hemorrhage. In this disease, bleeding we have just discussed aneurysms of head afid hypertensive exti'acerebral a way of plannina for the manage- occurs within the pia-arachnold and the circle of Willis and the major hemorrhage. Each of these can be iiient of an individual so that on the blood flows freely throu-h the cere- arteries at the base of the brain. There prevented at least in part, and the one hand it is possible to limit the de- 94 velopment of those conditions that gor'es-disease categories, we arc In the rehabilitation context, what ticipate the consequences of the long- will lead to his inability to function discussing. this means is that we are seeing im- term situation, to a greater extent in in a life responsibility, and on the What are the trends in this field? proved ability to prognose what will stroke perhaps than in anv other other hand there arc developing pro- These suggest that aspect of rcha- happen to an individual as a conse- condition. cedures and precise methods for I)IIltation as a model of extended care qucnce of stroke in the totality of his We have learned from studies of better, more integrated use of a which has as its focus ultimately not situation. We are learning better how ideally healthy men, simply immobi- variety of health services, health serv- only personal life adjustment but to say whether the realistic outcome lized under bed-rest circumstances, ices which help the individual achieve management of those conditions is going to be cure through natural that there is rapid deterioration of the life adjustment. which will threaten the life of the recovery or improvement through physiological capacity to adapt to the There is another trend in rehabili- individual and his ability to adapt usage of some definitive medical or physical environment, and indeed tation which has particular impor- and adjust. surgical procedure, or whether it is even to the psychological environ- tance to Rc,,ional Medical Programs, First, in stroke we are seeing an lin- likely that with a comprehensive and iiieiit. Irregardless of the pathology, and that is: We are bccominu aware proved ability to predict stroke I)roiie- extended program of a highly inten- the consequences of our circumstances more and more of the anticipatory iicss, as we have heard, by advances sive kind we can help tl-iis individual of care, if they produce inactivity, im- elements of care of the individual. in the quality of the mathemathical to adapt and adjust to nonresolvable mobility, and deprivation of senson The movement of early care which predictive models, as they are called, neuroanatomical impairments. For- and motor input or experiences, considers the individual from a point that are being developed for estimat- tunately these may not be paralleled problems will be created Nvhich we of view of disability potential, from in- the likelihood of these conditions. by identical functional impairments, call the immobilization syndrome- a point of view of the impact of his I think this @vill improve increasingly because the brain is so plastic. Alter- leading to the disabilities which are characteristics is a person, his living 'In the near future so that right away natively we may predict Nviietli(,.r equally as great and devastating as situation, his natural life space upon we will be forced into having a pro- maintenance of life, just simply sus- the or'izinal disease process and these what happens to him in terms of sur- cess or a procedure to care for people tenancc of life is all that is going to can be offset. IV 1 The impact of this on care is that v al and in terms of prognosis. This who have a high risk of increased lia- happen, or whether there will be a is something we have to be concerned bility to these conditions. continuing regression and dissolution the reorganization of community hos- @vith right from the very beginning. Let me illustrate what I mean. On of the person. 1)ital services to prevent disability, to Most of you probably think of re- the one hand, in society we have pro- This is very important to know. Al- prevent the effects of immobility and habilitation as a "Flurnpty-Dumpty" I)oscd advanced automated health though we don't presently have these itiactivity is an essential, realizable, operation, which is to put Humpty- screening. Now, RMP is one of our distinctions in those aspects of mor- early ingredient of what we can do in Dumptv back together again after you few possible solutions to having a pro- bidity statistics, these should be the our RMP programs. We should put have a catastrophic dissolution of cedure or process to do something basis for our planning and our basis this up as a requirement of a satis- every aspect of human behaviors about those discovered once we of deciding what can ,ve do at a local factory operational stroke program if physical, personal, psychological, identify the people who have in- community level or for us to coii- we are going to make an impact on emotional, social, economic catastro- creased risk. It is one thing to know sider at a central level of organization the complete stroke situation. phe. This is the way rehabilitation es- it is going to happen. It is another of health services. The implication of The next thing that this will do is to tablished itself in medicine. That was thing to be prepared to do something such studies is going to have tre- force us into a posture of haviii- to the meaning of the so-called third about it, and I suspect that people mendous impact on the organizational define better triage and prediction of phase of medicine, and I think, too, believe we are giving attention to the structure of health services. those who benefit from intensive perhaps this is the reason that reha- latter more than the former, that they Offsetting disability must be added rehabilitative services and those who bilitation was usually considered late will assume we will do better diag- to medical care as a part of the acute will be adequately managed and can in the course of disease and disability noses and hope that this is matched care process. The acute care process benefit from available community and didn't fit into the neat cate- by an adequate backup of care. has to have built in procedures to an- service. We just have to face up to 95 this because there are not enough pro- will affect greater life adjustment suc- distant goal and yet a realizable goal complished at home., in the local fessionals for restorative services. cess of the stroke person. for our citizens who have stroke, in- (@ommun't@, or ultimately in the long- There are only 600 I)Iiysiatrists. There Fiii@illy, I think we are seeing -,t (@lticlirig ours(-Ives. terrii (@ar(! institution. are probably fewer people than that mand for a high rate of application Dr. BORHANI. I will ask Dr. Mas- We have indicated the resources with any substantial training and con- of research findings in this evaluative land to emphasize and expand on @vlilch the institute has deveoped for cern about this rehabilitation manage- prognostic process, and in this or- what he presented yesterday in terms this. I should point out that, as Dr. ment process in other specialities. oanizational aspect of care. The bar- of resources and activities throughout Mill'kan has so ablv outlined, the The next thing is that we are seeing riers are on the one hand that ad- the country in the field of stroke. neurologist per se is onlv one member an evolution of institutionalization in vances in molecular biology are less Dr. MASLAND. just to recapitulate of a much broader team. Somehow, rehab medicine. If you define broadly applicable to this situation of opti- briefly: I have urged that, recogniz- however, there must be brought to "institutionalization," it is the organi- mizing and providing better health ing that we must start with limited bear on the stroke problem, especially zation of collective human effort in a care than we had hoped in our Itimate objective at the phase of diagnosis and acute programs, our u physical setting. In rehabilitation, this original planning in bridging the gap should be a total program for stroke. therapy, the capabilities of individ- is essential, because if vou need the between research and its application. Such a program comprises, first, uals who have knowledge and under- assistances of -many professions and Paralleling a reorganization of health facilities for the recogn' ion o t e standino, of the function and s-,,mp- it 1 many disciplines you have to inte- care services for stroke and other stroke-prone individual, and for pre- tomatolooy of the nervous svstem. -rate and coordinate -,vhat they do problems that have produced ex- ventive measures applied to such in- Fig. I)* Here is our list of stroke around the patient's needs, and as he tended needs for care is the require- dividuals, highlighting particularly research centers. Some of them are changes. ment that we must very rapidly those with hypertension, with diabetes rather specialized: This means that the institutional understand these organizational fea- and with certain biochemical abnor- Berkelev Center is primarik@ pattern of the intensive care, ex- tures through health services research. malities. I mentioned yesterday that working with the epidemioloav of tended care of the severely disabled, This has not had in any sense the evidences of vascular disease may be stroke. is going to increase in the future attention it needs, if we are going to observed in conjunctiva, and it has 'ne Baltimore Center is also pi-l- rather than decrease if these accruing be in a position to have good alterna- been mentioned today that a high marily epidemiology. numbers are to be diminished. Some tives to suggest to one another. And I level of hemoglobin appears to be The center in Boston is (,on(,cii- kind of model of relationships has to mean to one another, as I hope we found more commonly in the stroke- trating on the manaacnient of be developed between these institu- will find out what every group is prone individual. aphasia. tional resources and the classic corn- doing in rehab aspects of comprehen- Secondly, we need centers for the The others, I think, are dealing munity resources of the hospital. sive patient management. sophisticated diagnosis of the stroke with one or another aspect of the I don't think there are enough pro- In conclusion, I think that rehabili- patient and centers within which clinical characteristics of stroke. fessional people or that there is tation medicine in some elements, par- there (,an be applied the mocl(@rii stir- enough money to model intensive re- ticularlv in the processes of evaluation gical and medical methods of treat- (Fig. 2) * These are individual r(-- search projects. These we have indi- habilitation centers in every commun- of disturbed human function and in ment of the acutely ill patient. ('ated only to point out that here are ity hospital as we have done with development of knowledge about how Next we must provide for pro @pt individuals A,ho have an interest in surgical suites. Not for a long time. to understand adaptive behavior of mobilization and effective remeoia- some aspect of the stroke problem. Therefore, the teaching function of the human in the situation of disease, tion in an effort to achieve the maxi- these specialized resources has to ex- particularly these chronic conditions, mlim restoration of function in the However, many of these are of t pand out of proportion unfortunately will offer to you in lzcgional Medical stro c- isa c Ill 1VI Lia . fLiti(larii(,iit@il research n@itur-(-, @iti(I to the research and the care activities Programs a useful teaching and dem- Finally we have the loii(---terT-n th(@v may have little relevance to the that they are cloin,, if are goiii@@ to olisti-ational iiiod(@l of (,oiiil)i-(!Ii(-nsiv(, I)t'01)1('tll 01' tll(@ life @l(ljtlStTll(@Ilt Of SLI('Il f)t-obl(-rii of N@-itli tli(- stroke I)at' ient. mount any kind of a I)roaram that and extended care which we see as our individuals, whether this is to be ac- 96 *See pages 60-65. I Dr. ?\4ASLAND. In a coi-nmun'ty of (Fig. 3)l- This slio@@,s tli(@ (-(-ntcrs Manpower, fellowships are be'n, pro- and foi- patients, fi-oi)i a real I)i-act' I l I I I I ica @vhci-c@ tli(@i-c Is a stucl@@ of the sul)- veered for nurses to be trained in ncu- standpoint? 100,000 there would be a tremendous araclino'd h(,morrh-,i I Dr. ToOLI,',. One thing I would g(@ and iiiti-a- i-olo,,I(-.al nursing A,Ithin these (@enters. opportunity for such an individual (@rai-iial aii(@ui-N,sriis. And @,,,oit will ))O- ff You @@,aiit Lo have some iitii@es point out to you is t c -u'dc for set- ,NIio had received even that rather tl(,-e in each of these maps there is a trained in the specifics of neui-olo,,Ical tlii(l@ til) a stroke pro-ram which has modest amount of additional corn- p@ttz(!Itv of a(!tlvlt@, N@,(@st of i-it-irsin,,, tli(@ liureatt of Health Man- 'List been distributed by the American 1)ctciice. You might even consider the -.%Ilssisslpl)l. po%vcr can be helpftil. The officials to Heart Association. Dr. Millikan, taking two people-a medically ori- (Fl<,,-. 4)* Here is the cooperative contact are Dr. Jessie M. Scott, Di- Chairman of the Council on cerebro- ciated and a surgically oriented per- stud@ of the value of livpoterisi@,c rector, Division of Nursing, Bureau vascular disease, and a variety of ex- son. Train' e available 1 1 ing programs ar agents in the prevention of stroke. of Health Manpower, or Dr. Faye perts have worked to put together a for each within which, in a relatively This is a study in which a group of Abdellali, Chief, Research Grants manual for just such a community brief period of time of practical ex- patients with hyl)(@rt(.-nsion are man- Branch, Division of Nursin-. as you describe: How to mobilize I)c-rience, they can become kno@vl- 0 1 - 'ondly, within our train' cdgeablc in the newest methods of a,,ed. They are being ,Ivcn hypo Se(, ing pro community activity, what to do, crrams, a number of centers are pro e diagnosis and management. Stipends tensive agents to see whether they whom to recruit, and how to get som, ZD will in fact reduce the frequency of viding special postgraduate training, action started. This is called "A are available to make it possible for stroke. We are hopeful that this will in the management of stroke. If you Guide for Affiliates and Chapters in a person to do this without a com- prove to be the case. have a man in your community who the Stroke Program." plete financial loss. (Fig@ 5) -@ This is the studv sup- wants to become more expert in the Dr. MILLIKAN. I would like to et Dr. HUNT. Hunt, Virginia. I think ported by the Heart Institute, focused diagnosis and management of stroke, in on that hypothetical question. Was 1-nany neurologists in many communi- primarily on the surgical management he can receive a 3- or 6-month or one of the conditions no neurologist? ties, because of the manitude of the of stroke throuch surgery of the in- 1-year fellowship-in effect, a resi- Dr. HEUSTIS. No neurologist. problem, are really unwilling to be- tracranial art(.@rl(@s, It is no%%, a randoii) clency--w'thin @vliicl@i lie can rc(@c'vc Dr. MII,LIKAN. I would put in a (-in the task. Where can be a focal studv in which some are treated sur- special training in the problei-n of strong I)Iug, then, for having some point? Or what is a --ood focal point gicail@, and some medically. stroke. Nvherc the neurologist in the corn- person in the groupina that you did (Fig. 6) * I should have mentioned niunity can be,in to approach the Dr. BORHANI. I would like to open presume would go some place for n @,estei'dav that there are two types of the floor to discussion and questions. some short-term training experience I)roblem Nvithotit this total commit- trainin(, I)ro(,,r,ains. We do have seven Dr. fff-USTIS. A. E. I-Icustis, Micli- specifically referable to stroke. merit? pro-rams specifically directed to%vard iff an. The panel has told us about the I don't know how other members Di-. SPENCER. Well, what was pro- the problem of stroke. Most of these things we ini,ht expect in the larger of the panel would feel about t is. posed in the question before was what are general neui-olo,,ical training cen- (-an be done in a community hospital centers. But I have a hypothetical I would guess that an internist- I . t(@rs whose men will (.ertainly be vilich has some arrav of specialists, case, ,cntlcmen, a community of type individual might be the one. I knowledgeable and helpful regardin,, and which has some interest, appar- 100,000, a good cadre of board-spe- Nvouldn't want to fully earmark this the differential diagnosis and treat- (-ialized internists and sur,eoiis and as a disciplinary requirement. Some entlv, in looking at the problem of ment of stroke. stro@e in that community. o neurologists, an orthopedic sur- individual might be selected for 3, 6 1 also failed to mention yesterday " On the one hand, a great deal of two important elements in this pro- .'eon with a yen toward rehabilita- months of, experience on an active attention has been given to how you (tram of trainin,. Within several of tlon, a special part of a hospital with stroke demonstration unit or an active would build up the diagnostic capa- out- stroke research (Tnt(@rs xv(@ have an interest in rehabilitation. What stroke service. Then that person could bility for this arotip. And I a(,,rce iitirs(-s %vlio skillful ]In i-(-ally (-;in this do, both for the I)ccoiti(! tli(,. for developer) tic(' tliit %,vitli short-term ti-ainln,,, tli(- neurological riLirsin(,,, and in (@ollal)- physicians in the (Community and for on-goin(, activity in your comiflunit@ tcd and susceptible 1)liy- I , most iriteres oration with the Bureau of Health the physicians in the surrounding area of 100,000. sician and physicians may be cap- *See pages 60-65. 97 tured to do this kind of functional ing bond between heart and stroke. ing, social work, visiting nurses asso- "Our problem is lack of optimal tim- evaluation and comprehensive pa- I would suggest that you can whomp ciations and community health orga- ing of physician referral." tient management planning and up the hypertension bit and get a nizations, their involvement? This is Dr. EVANS. And continued super- guidance. screening program going. You are not just a hospital situation. vision. But I think the problem is--@vli.,tt probably aw;ti-(! of tti(, I(-,tivitics of Dr. Si@l,'NCT:.R. I w@is going to say, Dr. Sll[:NCT--R. I think realistically, emphasis should the diagnostic train- one Joseph Wilber, who has had an the third elciii(@rit that you definitely too, we have to look at the adequacy in, or educational experience have? interesting experience in Atlanta in could consider is what we would call of our various care sponsors' i-nethods Should it be in respect to triage or a smaller community in the south- out-of-hosl)ital extended care. And of reimbursement for services to allow sorting of those people that will re- east, where they have done a hyper- here the visiting nurse associations- this to happen. quire very elaborate and complex sur- tension screening. This is now re- in a community of that size I will bet Dr. BORHANI. I see in the audience gical procedures, for instance, versus ported in the literature. The idea there is one or- we have Dr. Carroll Quinlan, who is those that can be probably quite well being to find out those individuals in Dr. EVANS. Probably four. the chief of the Stroke Control managed in that institution itself? the community who have hyperten- Dr. SPENCER. All right, four. Un- program. Now, I think you have to there- sion and to get them into the hands fortunately, what has happened in Dr. QUINLAN. I am sure many of fore assess each individual institu- of their local physicians without these is that the physician is not ex- you are familiar ivith the Heart Dis- tion's capabilities as,,vell is their goals changing the @vhole forrnat of prac- perienceci in how to use them, so it ease Control program. For those of in coming tip with a plan of education ti(@e in that situation. is not a part of his treatment decision you %viio are not, we ti,e an operating which is acceptable to the people in- We all realize, even if you have a making. But capability, @vith proper branch of the National Center for volved. I think you have also got to neurologist, individuals vary in terms planning for this functional evalua- Chronic Disease, and we have re- parallel this with a functional evalua- of their professional disease-oriented tion and the inclusion of community cently changed our name to Heart tion unit in a community hospital di- interest, and you may or may not agencies in this planning process Disease and Stroke Control program, rected by a physician, perhaps part- have someone who is considerably in- around individual patients, should more or less to emphasize our interest time, in a community, a practicing terested in the problem of stroke, or allow the development of proper us- in the problem of stroke. physician who is supported and someone who has a bit of time. But age of such things as can be done. It might seeti-i confusing to you @vho trained for a period of perhaps a if you use a larger,item such as hyper- And there are many things which can perhaps are new in Recional Pro- month in an intensive rehabilitation tension-and I am relating this now be done in the home setting also. But grams, honv we may differ from the center so he learns the methodology to prevention and screening-Nvhy, I think the problem is what he said- National Institutes of Health. The of functional evaluation. you can begin a prooram with ex- how do you get this going? I sug- Institutes by and large, as Dr. Mas- Probably you will find a physical isting personnel, training laymen gested that concept of evaluation land pointed out, are working in the therapist in that hospital, and develop and other individuals to do screen- units. Physicians are familiar with area of fundamental basic research. such an evaluation unit as a support- ing as far as blood pressure observa- and accept laboratories, heart sta- Our laboratory by and large is the ive service to the physicians and to tion is concerned, the initial takin-z community. We are working in the the hospital so you can begin the of blood pressure, and act something tions, and things of this sort. Can we same areas in which you are working. triage process. going. sneak in consideration for function Our purpose is to do research and Dr. MILLIKAN. The question had Dr. EVANS. I would like to address and @ave it under a physician, so you development on ways to put to work to do with how to get going in a com- this question to Dr. Spencer. Bill, can 'lave physician-to-physician re- those discoveries made by the Insti- munity. I would like to sug,est as I -,vould suspect that there are more ferral of consultation? Then you may tlt,s and other areas of fundamental soon as you get home you get going people in the home and other insti- gradually introduce the other disci- r ... arch. There are certain activities on this; and this does not require tutions-not in hospitals-the kind plines that are concerned ,vith corn- in which Nve are presently enga-ed, in elaborate personnel. There is a neat you are talking about-so @vould you prehensive patient management, that %vhich I think perhaps you might have cross-over-hypertension as a cross- address yourself to the role of nurs- exist and are continually telling us, a direct interest. 98 We are at the present time inaugu- form the various activities in which ho@v you can really involve the kind Then the next thing that may be rating a national system of stroke we engage. We would be very happy of planning that is taking place on apractical is to back up these func- registries. We are doing this for sev- to work with any of you in your local level, because each of the social tional units -,vith live communication eral different reasons. One, we are rcg'on'n planning in any way that we workers in the public agency now will links with the resources that can give interested in the nature and extent can. have bracketed into its name every- the more sophisticated decision sup- of the stroke problem. This, as you Dr. SPARKMAN. Would Dr. Mas- thing that comes from Washington portive service, at least to help the know, is very poorly defined, both na- land comment on the nurse training and from the State office of rehabilita- staff in these units to define the tionally and locally, and I would programs, please? t'on. There is a tremendous army of patient that is beyond their scope of commend the idea of a stroke registry - helpers, and I was wondering about management. That is @oing to require Dr. MASLAND, This is a new pro to each one of you, because it seems gram which is ' getting underway. your experience, or your proposals- two-way video and audio linkages. Just to me that if you are not aware in Several of the stroke clinical research how to involve them? This isn't as expensive as people your own region of the nature and centers have very competent nursing Dr. SPFNCER. People get involved think. On a line-of-sight basis we can the extent of the stroke problem, it staffs. We have felt that these people best around an effort to solve a prob- do it now for $4,000 per terminal, is going to be a very difficult one to who are recruited and maintained lem which is of larger scope than any and we have done it experimentally. attack. primarily to support the research ac- one of them can handle. I didn't get I am talking about two-way video Now, as pointed out by Dr. tivities should also be made available to detail further this concept of aand two-way audio. Lilienfeld yesterday, registries have afor the training of other nurses in functional evaluation unit in a hospi- It can be done now. There are al- number of different purposes, and the techniques and problems of tal. It certainly should include the ready netnvorks for visual com- very valuable ones. First of all, they neurological nursing. In order to ac- vocational counselor and the welfare munication developing rapidly by arc most.important in planning and complish this we have established aworker from that community hospi- industry and by national educational programing. Secondly, they are acollaboration with the Bureau of tal concerned with these kinds of television. We have even got a satellite very good instrument for manage- Health Manpower 1 , which is provid- problems. The evaluation process kicked out by NASA which the Inter- ment. And thirdly, and perhaps i-nost ing fellowships for nurses to receive and the commitment process, which national Radio Relay League built. importantly, they are very important training in a well-organlzcd training has to follow up what services are go- We don't have anything like this in in evaluating the effect of your program of the stroke research cen- ing to be committed by whom, is the medicine for medical care and scien- program, ters. The place for you to contact place for their participation. Again, tific communication which is ridic- All of you are beginning to start into 1 Id be the Bureau of Health Man- the problem is how you get this ' tilous in the space age. (,oriimunity programs. I think that it power, our system of medical care under the If you support these community Dr. SOI,OWA-,'. Dr. Faye AI)dellah physiciaii's direction and coordination institutions as, already, experim is well to soiind a not(,, of (@auLlon, and ents tfiat 1.1; this- --that sooner or per- would be the one to contact on this. and integration. This is precisely are showing you can, ,vith tNvo-,,va), c going Dr. I,]-'.V[N. David l,ev'n, C(-n,Lral what lie is not trained t hal)s in several years, you ar o do. So all (,oiiiiiiuni(-ation assistance, so that is try to use to be called upon to justify your pro- N(nv York Advisory l@oard, School of you can do ' this evaluative when they have problems, they have gram, and I think if you have in- Social Work. I wanted to make an consultative device or something that somebody to see and talk to, present augurated this, and know the nature observation that all of the changes is familiar to the doctor. The diag- their problems to, then you have the and extent of the problem, you will that are taking place which we see nostic evaluative process which ex- beginning of next element in educa- ur pro- here, social and rehabilitation services pands his activities and which in- tion. I think this is a valid concept. be able to see what eff(,@(-t yo I grain has had. divisions, in ten-ns of welfare plan- cludes in terms of human function, We know at least that there is real We are working in a number of ning, will mean that you have a re- including social function, may give interest in it on the part of the corn- other cliff communities. One of him real help around a real p nity hospitals. erent areas. N@'e work by source in the 1 atient mti 1 contract and by assignees. In our ex- the questions I would like to address that is his responsibility and produce And the other thing, as Dr. Evans I I the desired res eing realistic hibit upstairs we outlined in written to Dr. Millikan and Dr. Spencer is ult. pointed out, b in terms 99 of the problem, the first is to identify of it to provide as much of what we should not go on and develop stroke hope that the Reolonal Medical Pro- the resources we have got by real, have been talking about as possible. I)ro,rams kvithotit really taking oui- ,rarns N@,111 direct tlieni@cl\-cs to an- indepth analysis of communities other And a huge emphasis has to be placed time and sj)cndlnl- as much tiriie as s%verill,,, these questions. I mentioned than our own, like this hypothetical upon the methods by which the needed-and this will differ from alreadv, in the introductory remarks community of 100,000. You may be people are taught. (@or-niiitinitv to community and from I made, the variations in the aeo- Also, another as ect of this that region to astounded as to what is there in care reg on-to learn what is ,ral)hlc mortality of stroke in \,at' p IOUs resources, and their susceptibility and I have been interested in is redesign really needed in our region. I tl@ilrik it States in the (-ountr\,. We arc I)Ianiiinu willingness to change. The problem is of the home. Very seldom does a is essential that we spend enou(,Ii time to pursue further activities with the we haven't produced or demonstrated physician or other interested person and develop a systematic I)rograrii Support from NINDB, NHI, Heart visibly enouh successful examples or actually -o into the patient's ]dome activity that we know exactly, be it and Stroke Control, and the Re- methods, orcanizational methods, and and see him in his own setting. in the hypothetical community of ,Ional Medical Pro-rams and all the of procedures which these people These two aspects we should not 100,000 that Dr. Heustis mentioned various Federal Government a(,eiicies can use and need that they haven't foract. Perhaps the most practical or whatever region we arc working that can help us, to chart some kind been trained in. thing is stt(,Ii a simple thing as a good in. What arc the resources reallv of a I)ro,ram to finallv learn about assure you, assessi-nent of fun(:- ai-ciiitc(,t or someone who knows how available@) What is the n@iturc of tli(@ the nature of the disease tliroliaho@it tions in the interpretive sense is not to mal@c a person mobil(! and prodtic- problem in that CO]IIITILlrllty? Arid the country. Finally, I think in e,,,erN, simple. I can give you a sl)eci ic in- tive in his own home. what kind of prevention, control and re,,ion it is important for Lis to learn stance. If you get a vital cal)acit%@ Dr. BoRilANT. I think that we (,an r(@liabilitation program is already in what the proportion is of the stroke value expressed as a percent normaI summarize today's session: There existence there that we call build on? (@ases Nvho never -et to the hospital. of lung capacity, -,vhat does it mean are two issues which were em- Nbbodv can tackle this ldroblern Di,. Spencer put it at soi-nething in terms of that pati(,,nt's abilltv to 1)hisiz(!cl, tnci they are not intitt.ially alone. No I)ro,i-@Liyi (7@iii do it alone,. @ti,otincl 80 pei-(@ent. tolerate the cii(,,r(Ity (!xi)(-iicllttii-c of his (@x(-Iiisi%-(.. Ali(], as @loii li(@@ir(i I itilill@ it Is iiiII)ol,t@tilt, if ]if(! Is it I sigiiiii- I,'list ()I, ;III, is (.Vi(It.ll(, tll(!I,(. (-,tiitly declared iiicaSLII-CII)Cllt or not':' @t gi,e@it riceci l'oi- basic, i,ellai)l(,, In- (!I,Illllcllt I)i-o,yi-aiiis, St@it(, 1)i-ogr@tiris, That is Nvhat I mean by functional formation on the magnitude of the and I am sure, local programs that death, and morbidity from this dis- evaluation. You have to interpret problem and the resources available are already in existence. There arc ease, that ,@,e must know, because if measurements in terms of individual in the community for systematic plan- manv people in various disciplines xvc concentrate in our hospitals and functional capacities, and the pa- ning of effective programs of preven- of health already doinol- various ac- centers, and these patients nex,ei@ ffet tient's demands. That is not trivial, tion and control of the (@crebrovas- tivities in this particular field. There to the hospital, then we are 'List IOSino, but this can be done. This is what the cular diseases. are organizations, voluntary health the battle before it is started. doctor is interested in as an antidote And secondly, there is a need for a oran'zatioiis, and official or,an'za- Secondly, we must know about the in to the laboratory measurement explo- systematic application of our knowl- tions, public agencies, that are doinc,- nature of the problem. I think a@-a' Sion and the patient -,vill benefit. edge and resources in terms of pre- certain th'n(ys. I , this i-nust be done on the regional Dr. TOOLE. One aspect which paration of the community and build- I think it is incumbent upon us to basis, and I can -uarantee voti that hasn't been mentioned, and I 'ust in,@ on the resources already in bring these rhinos into focus in the the national data on the cpidem'oto throw it out, is education of the fam- existence in various Communities. region where we would like to de- will provide Useful data and, al- llv into being involved. We are talk- I think thit tti(,s(- two istt(,,s pretty ,,(,Iol) a I)ro@,i-aiii foi- sti-ol@, an(] to tlioiif,li tli(,v (-@iii 1)(, helpful, tlie@@ x@,111 In,- about olti- provision of care to this \%,ell (-heart the w@,iv for the Rc,,,ioii@if take tclvatit@t,,,e of the resources and not be as helpful as the. kind ol' passive person and his passive famllv. Mecll(-al Pi-o.-i-,iiiis throughout the funds available. that voti will collect in your own rc- My attitude is involveriierat of the country. I,\Vo sl)c(-'f'(@ (itic@st'oiis Iran,,(, i-eall@ 'oil, because national Cl@Lta \%,'I] d'fl'ei- familv and mobilization of members I would like to emphasize that we bothered me for a Ion,, time, and I from I)Iac(, to place. 100 I think it is very important for us to develop a systematic program of sur%,eillance-call it registry or what- ever you want-a program which 'II tell the people in charge of the wi 1 re-ion of the nature of stroke in that region, the incidence, the prevalence, the socioeconomic classes of victims, the age groups, and race groups and all the various characteristics, that so tremendously affect the outcome of this disease in various parts of the country. I would think that there is a tre- inendous opportunity for the Re- ,ional Medical Programs to bind all existing programs together, and to build on them a true program of con- trol so that the people will benefit. And I am sure this will be done. 101 GROUP DISCUSSIONS ON .... HEALTH MANPOWER-REVIEW OF COMMISSION REPORT REGIONALIZATION URBAN PROBLEMS RELATED FEDERAL PROGRAMS HEALTH SERVICES RESEARCH CONTINUING EDUCATION AND TRAINING, FOR WHAT? DATA COLLECTION AND REGISTRIES HOSPITALS COMMUNITY INVOLVEMENT OPERATIONAL PROGRAM DEVELOPMENT The group discussions, held simultaneously on Wednesday and Thursday, January 17 and 18, 1968, involved panelists who represented various aspects of the subject areas covered. These sessions were scheduled to provide conferees the opportunity to voice their own ideas and exchange thoughts in each of the 10 topics of common interest. The reports that follow were written by members of the staff of the division of Regional Medical Programs, who attended and recorded each of the sessions. To preserve the flavor of the group discussions as they developed, the content and singular style of each report have been maintained essentially as submitted by the recorder. 292-414 O-GS-8 103 GROUP DISCUSSION Health Manpower" of pertinence to American Medical Association and is questioned in vie@v of the current 1 1 1 TOPIC A: his specific area of interest and other medical societies have assumed trend bv these institutions to remove "HEALTH MANPOWER- ise. 'bil'ty for the (,eneral improve- the education of such professionals expert response I REVIEW OF Dr. Dwight Wilbur discussed four iiient of the quality of iriedical edu- from their curricula. COMMISSION ]'XEIIOI'\'F" issues covered in the ]@el)oi-t--tlie (-@itioti. is g(@n(@t-@illy itii- Dr. Fenninger comm(!ntecl thit supply of physicians, relicensurc of aware of the extent to which the peer the Report addressed itself to the health professionals, foreign physi- i-ev-cw process is already underway. need to improve the health of in- Discussants: 1 search is needed to formulate di%,iduals and of patients as the i,ea- c ans, and peer review. Dr. Wilbur Re James C. Cain, M.D. (Moderator) 1 supported the recommendation that teria by \N,Iilch physicians' perform- son for a system of care and health Consultant 17z Mc(ilcl'nc the numbers of medical schools and @ince arfcl patient (-arc (@an 1)(@ services. The public has demands The Mayo Clinic of students should be increased. He measured. and expectations of services bN, health Rochester, Minn. a,,reed that Federal funds toward the Dr. Ruhe commented on two personnel beyond what can be sup- Leonard Fennincer, M.D. support of medical education are de- points in regard to financial support plied. The Report pointed to lon@- for students. Tli(@, n(@ecl for ,(-)in(, siii Director, Bitri@azi of H(:(zltli. sit-al)l(,, provided tti(- (expansion in Vince short-term issues which include I)OI-L ()I' (-(Itl(';Ltioll Is now (Itl;tlily @ll)(I (Ill;iiitity of tls(. ()I Public Hcaltli, St,-?@vie:i: filefiL ill the of (@(itic,.ttioiial generally still- sl@ills, (-Clti(@;ltioll, MIT)(] C. H. William Ruhc, M.D. programs. I)Ort by the Federal Government of in resources. Di.rector, Division of Medical On the issue of rell(TnsLire of health medical education is supported by During the question and an@vei- Education professionals, a highly c@ontrovei-sial some as a means of bringina in stu- period there was li%,clv discussion ori American Medical Association one over a period of veat-s, it was dents from the IoN,,,cr economic level-, such issues as Regional Medical Pro- Chicago, 111. noted that the Report of society. This is a controversial issil(I grairis and their review Tn(@cti- that rcll(,enstti,c be further (considered which current statistic- fall to stil)- anisin, the improvement of medical A. N. Taylor, Ph. D. by appropriate or(,anizations and port. The implied criticism of the education through the I)ro,ranis, Dean, School of Related Health agencies. The public seems to cren- medical curriculum in the Report is criteria to 'udge quallt\, of medical Services i I erallv support the (-.oncept of i-elicen- not 3'ustified in view of the constant practice, and the deteri-nination of Chicago Medical School su re Ias Chicago, Ill. a guarantee of good quality review and change in the curriculum medical manpower needs and bettei- care. A review of current State conducted by medical educators. Re- tit'li 'on of manpower, 1 zati D@vi-ht Wilbur, M.D. Tloard I)ro(-(,cltir(@s %@,,,is liccn.,;ure, has been discussed sl-)oracl- Presl(l(,,iit-Elt,ct sti,(@sseci @is (@ssential siric(@ health ically since I()32. The Cli@il)liasil.1' American Medical Associatl'olz power is a national asset, and mobility should be on motivation of physicians San Francisco, Calif. between States should be assured through appropriate continuing ed- throu(,h reciprocity. Recorder: ucation efforts to improve their Veronica L. Conley, Ph. D. Di-. Wilbur stressed that the practice. Only then should relicen- Educa z' I is t on Spcc'al' t responsibility, for and ititliority ov(,t- sure be seriously (-onsidercd. Divist'o?i of RcgioizalMt!(Ilcal foreign I)Iiysi(-iatis should r(@si(l(@ in In regard to the Report, Di-. Programs educational institutions. These physi- 'I'aylor stated that the title implies clans, he said, should be required to equal consideration of all health pro- have the same qualifications and pass fessionals when in fact it is devoted '"-ch discussant reviewed those exams comparable to U.S. physicians. primarily to I)hvsicians. The recona- @ aspects of the "Report of the The iml)ortan(,e of peer review at mendation that edification of health National Advisorv Commission on tli(@ local level was (,Tiil)liasiz(,(I. 'I'h(, personnel be assumed by universities 104 (,IZOUP DISCUSSION TOPIC B: "REGIONALIZATION" Discussants: Lester 13reslow, M.D. (Moderator) Professor of Health Adniinistration and Chairnzan, Health Services Division, School of Public Health University of California at Los Angeles Los Angeles, Calif. Walter J. McNerney Executive Director Blue Cross Association Chicago, Ill. William R. Willard, M.D. Vice President University of Kentucky Medical Center Lexington, IICY. Recorder: Roland L. Peterson Chief, Planning Branch Division of Regloitcil Afc(ll'cal zation was particularly stressed. It Mr. McNerney pointed out that and bLl'ldin-D up their own strength I I @is all alternate to Iiiikin(l, to-ether was pointed otiL that tfiei,(,, might 1)(@ had been failures in re- difrercrit bases of regionalization for (,ionalization. 'I'lic resistance to re- %vitli others. differing purposes. Dr. Si.)ai-kiiian ,-Ioiializatioii was historical and Eco?iot?iic.-Thei-c were no incen- he discussion addressed itself to said that "rc-lons" for patient care widespread, and included libraries t' Tthe questions: IN'liat is re-' and continuing education well might and schools. Speaking froi-n his oN@,ii Acii?iz7iistrative.-The administra- onali- zation? What problems does it Pose? differ. Even patient care might re- experience, lie cited the reasons for tl%,e underpinnings were ad hoc and 11@v can it be achieved? (Itilre different "i-e@,lons," as in the the failure of an attempt in the past iticidetital i-atlict- than coiitinuin-- and Regionalization ",as defin(@cl by Di-. (@,ise of aCLItC corollary car(,, versus @it i-e,,-ioii@ilizatioii of hospitals in til)- substantial. l@'Illard as lml)lyiii(, linka,,(,s arnon,, (-ancci- therapy. While the functional Pei- Miclil,,)an. Some of these z@easoiis Sl)eakln,- fi@oiii the audience, Di-. health resources and as a Process Of asliect was clearly recognized, others @vei-c: Charles I,cN%-ls of the Kansas Program, gcttin,,r people involved and al)l)ro- emphasized that geo,,ral)hy and J)eo- Attitudi?2al.-,roo often the insti- saw the principal problem of re-ion- pi-late 1)lannin,, begun. ple are fundamental to regionaliza- tLItions involved in re-lonalizatioii alization as one of social enginerill(r The functional aspect of regionall- tion. were more interested in autonomy He was seconded b@, Nli-. ,%@IcNernev., 105 who pointed out that little is known increasingly sophisticated technol- GROUP DISCUSSION of the problem of delivery of qualitv about the social engineering and ad- ogy. TOPIC C: health care to people, and defining ministrative aspects of regionaliza- "URBAN PROBLEMS" the pu ose of the session as focusing rp tion. The medical center, he observed, Dr. Willard said that if medical on the contributions that Regional is essentially an authoritarian setting. centers and other institutions see Re- Medical Programs can make to the Discussants: Regionalization will require negotia- gional Medical Programs only as an solution of the urban problem. The Paul Ward (Moderator) ig tion and compromise and entering opportunity or additional resource to . . following are h' blights of comments the realm of "brutal politics." do some things they have always Executive Director by the panel members: Dr. Breslow felt that involvement wanted to do, then neither Regional California Committee on might prove to be the solution. He Medical Programs nor regionalization Regional Medical Programs Mrs. Anne Somers: noted that getting the nontechnicians will be successful. San Francisco, lif. The medical establishment has and nonprofessionals to come to grips Roger 0. Egeberg, M.D- both the opportunity and respons' with the problem is perhaps neces- Dean, School of Medicine bility to make significant contribu- sary, since the former have too many University of Southern California tions to the solution of the problem of Los Angeles, Calif. vested and embedded interests. urban health. Mr. McNerney felt that regional- Frank Lloyd, M.D. We kn6@ more of the internal ization must take into account corn- Director of Research channels of the heart vessels on the munity needs and must have Methodist Hospital of Ind' na one hand, and the canals on the za Zs, structure. Successful regionalization Indianapol' Ind. planet Venus on the other, than we requires a delicate balance of the two. Anne R. Somers do about the back alleys of our Dr. Breslow was optimistic about Industrial Relations Section gh'ttos- the future for health regionalization. Princeton University Special aspects of urban problems in New Jersey are: He based this on- Princeton, N.J. Increasing immigration of rural reater experience in this regard, Ray E. Tr-usself, I\I.D. poor from the South to city ghet- 9particularly with regard to area- Director, School of Public Health tos. and Administrative Medtcz'n(! Outmigration of physicians. wide health facilities planning; Columbia University Vacuum of leadership in academic agreater commitment to the con- New York, N.Y. medicine. cept of and need for regionaliza- Recorder: The great potential and promise tion. At the time of the passage Stephen J. Ackerman of Regional Medical Programs- of Hill-Burton, there were a few farsighted individuals but little Associate Director for Pla7i.7iz'".,a "to build a bridge of service be- and Evalual''071 tween science and the people." widespread commitment; Division of Regional Medi.Cal Hopeful developments in New physicians and others, and not Programs Jersey: Just hospitals, are now involved. He The organization of the Depart- cited the number of practitioners ment of Community Affairs un- who had become involved in Re- he moderator, Mr. Paul Ward, der leadership of Paul Ylvisaker gional Medical Programs; Topened the session by pointing which little by little is translat- agreater public understanding for out the distinct diftei-ences between ing 1)an,,-s of conscience about the need of regionalization; rural and urban areas in the solution the needs of the inner citv into 106 I substantive action. them in finding the solutions to these publicity if persons with fiscal control personnel in positions of responsi- Emergence of interests and leader- problems. arc to react. bility. ship action from academic medi- Dr. Frank Lloyd: Regional Medical Programs can How can Regional Medical Pro- cine through the stimulation and Regional Medical Programs can make a contribution to overcome lack grams help underprivileged physi- organization of Regional Medi- of understanding on urban problems cians without staff privileges be- cal Programs. do well by helping to plan a compre- ,_ rough participation of the scientific come part of the system? hensive program with the delivery of ... Specific move in New Jersey to services in the urban area.-,. community which can provide scien- have its program develop leadership By excluding Negro physicians tific data to help public officials. in communitywide planning for de- Neither Regional Medical Pro- livery of quality medical care by from hospital privileges, and from grams nor any other program can bringing together the leadership of educational programs in the health bridge the gap between need and the medical establishment with the professions (Indiana freshman . class service without major public decisions leadership of the urban community, has two), the leadership potential of Negro health professionals in the about what can be done. including the inner city, throuah the Some problems and questions solution of these urban health care cooperation of the Department of problems is removed. It is of prime raised in floor discussion were: Community Affairs. urgency that these deficiencies be How can ideas and information Dr. Roger Egeberg: reversed. be gotten from people in the ghet- The need for emphasis on availa- We are wasting health manpower tos and how can those people be in- bility of care rather than a priority of by making mandatory unnecessary volved in planning? concern for quality. training. Unskilled personnel can be Recognizing the need to involve The need to change the focus from trained to do health jobs but it must the underprivileged consumer, how the provider's standpoint to that of come from bottom up. can leadership be developed among the consumer's, and to change the Paul Ward: these groups? patterns so that the services are pro- The problem of Negro rejection vided as the people want them and To secure the desired changes in of Negro professional leadership can really use them. the delivery of health care and the puts these people in the uncomfort- Regional Medical Programs must utilization of nonprofessional health able position of being needed but be concerned with regionalization, aides, etc., requires the application of not wanted. sub.regionalization, sub-subregionali- strong pressure behind the division With regard to the Piel Com- zation, and perhaps, sub-sub-subre- of Regional Medical Programs in mission Report in New York- which ,gionalization, in order to fit the car, Washington and State, regional, and to the needs of the persons to be local health officials in the field. The tended to preserve two care sys- served, rather than force people into built-in resistance of multiple vested tems, one for the poor and one for the mold of the producers. interests makes progressive action un- the others, the problem of the po- All of the concepts about develop- likely without such firm counter- litical realities of an existing large merit of new systems of care and the body of civil service employment use of new types of paramedical and pressure, forces continues in city hospitals. subprofessional health personnel are Dr. Ray E. Trussell: The problem continues of se- within the scope of the programs, Problems in urban areas are much curing professional acceptance of where resides responsibility to use greater and must get a good deal of the use of subprofessional health 107 GROUP DISCUSSION ach discussant briefly described nitila and project grant mechanisms -ind the Comprehensive Health TOPIC D: Etlic I)i,lncil-)al prorams and ac- on a noiicate,ori(,al basis. Plannin, Pro(,t,ani, I)ai't'ctilai-l@, at tli(, "RELATED FEDERAL tivitics of the acnc@ he represented, Dr. Cliaci@vick described the role of lo(-al-rc,,Ional level. Several persons c PROGRAMS" and went on to discuss the rclation- the National Center foi- Chronic Di,@- i-(-I)oi-teci on the d vclopiiig ex- ship between that agency and R(,- ease Control as 13ciii(ly of most iiiil3or- 1)(-rl(,nce in different parts of tlif, (,'onal Medical Pi-oo-rams. tiiice in the transition I)ct@@!ccn ('OLintrv in iniplemeiitin(,@ these two Discussants: Re,)-arclin- the programs of the Di- activities of the catc(,oi-'cal institutes 1) I-o (r Daniel I. Zwick (Nfoderator) -i,anis in concert. Associate Director for vision of Medical Care Aclmlnistra- of the National Institutes of Heiltli i tion, Dr. Veverk-a emphasized that and the operational activities of Rc- Prograt@z Alanageiiicrit the division and Regional Medical alonal I\Ieclic@al Pi-o@rims. As such, Health Services Office Pro,,rams shared the same goal of its role his been one of deriioiisti-at- Coniniunity Action Prograni bringinff the best possible care to itig the efficacv of neNvIv developed Office of Econontic Opportunity c@,(,rN,one in need in the most effective te(-bniqties 1),ISCCI upon the @i,oN@,tli of .Tames H. Ca%@anaiil,h, Ph. D. incl (,ffi(@i(,nt niinncr. The division, I)ioi-n(@(11(-,i] @,iiowl(-d(l,e. Dirt,clor, ()ffice, of (I iioL(,(I, is (,ool)(-i'atlii@', \@-itli tll(, I))-. Health Pla?i?zz'ng Dcl)at-tirietit Of 11OLISiii,, and Urban of Health Sci-%,](-(@s as the fo(,@ll point Office of the Surgeon General Development in the provision of for the organization and delivery of Public Health Service mort(,a(,c loans for rotil) practice health services. It, thc@i-efore, is facilities. Additionally, the division is (@oticernccl N@@itli the development of Donald R. Chadwick, M.D. concerned with both health man- self-or(,aniziiio- processes to effect this Director, National Center for ])onver and facility needs, and hopes to organization and deliver), which iii- Chronic Dz'sease Cent .1 rOl dovetail these concerns with the activ- clude the I)Iannin, process, (,onsLil- Bureau of Disease Prevention ities of Re,ional Medical Pro-rai-ns tation, and certiin certification and Environi@iental Control in these same areas. procedures. Public Health Service Dr. Cavanati@h described the five Mr. Zwick in dcsci-ibin, the Ncigh- Carruth Wa,,ner, M.D. i-najor areas of the Comprehensive I)orhood Health Centel- program of Director, Bureau , of Health Health Planning legislation (Public tlic@ Office of E(,oiiornl(,. 01)1)ortiinitv 0 1 1 ll'glllillllt('(1 I.,,ixv @19-7@9) and i-el)ortc,c I Public Health @ervice ])]-Offl,css to date. The first three se(,-- thit and Reffioii.,il Mc@clicil Programs. Specifically, lie noted, it merits of this lc(,islation deal prin- Eugene Veverka is the pool- Who SLlffcr the most is a Divisz'oiz of AIedical Care cll)allv with State and areawiclc result of the gap I-)et%vcen k-iiowleciff(, health' planning. These in(@ludc for- I ' Acl7tiz?zi'.@tratio?i ind application. Aclciition-.ill),, li(, ititil@i (@ratits to States for (,oml)rc- Bureau of Health Sci-t.,Ic(,.@ clesc@l-']I)ecl tile (.ollllyloll interest of 11(@lisiv(, li(@altli I)],-tiinln,-, pro' Piibll(7 Ili-(iltli I)otil it) -i'@ints foi, lo(,.,il ,iricl '11,C;Lwi(l(, iiiocl(@ls in tli(- oi,ffaiilz,,itioti @iti(I Recorder: I)IAnniii(,,, -,ind I)i-o.'ect gr,,iiits for delivery of health S(,I-vl('(,S. Lerov (@. Colcli-fian ti-aitiln(,,, studies, and demonstrations I)urin(,, the cltiestion incl aiis%%,ei- Prograin Polz'c), Specialist of health plannin,. The final t@vo scg- portion of the -,@sion, the principal Divisio?i of Regl'o?7al ,Ifctlical in(-nts deal N%,Ith t]-ic provision of focus on tli(, relationships I)(,- P?-o(,raiii.@ health services, tlii-oti,,,h both the for- t%veen 108 (;IZOUP T)ISC,'IjSSION discussion of this panel fell matical i-nodel and appropriate ma- qti isition, availability or sources, Corn- '1'01'IC l@": T'ili(i'to tli(,, following five (1-cnet-al iiil)Ltlatioii. Health services research is prehensiveness, validity, timeliness, 'S 11-(,.Is, Miller \V(,I.(.. in this @il)j)li(,cl i,(,s(,@ircii involving i vit-l(!t@, iii(I use. Cleirly, the qiiantitation of l@ P@' Sl,"A l@c: I ol' @tncl social clis(@il)lliies tii(i health set-vices research depends on Essential nature of health services the application of all manner of the validity and comprehensiveness Discussants: research. methodologies to the complex prob- of the data base. Paul Sanazaro, \I.D. (Moderator) The inherent problems and strat- lei-iis of health care. A data base has five character- Director, Division of Education e,v of dat a collection. Data collectio7i,.-Major problems istics: It must be comprehensive; it Association of American Medical The problems of evaluation. in health services relate to data col- must relate to reality; it must be Colleges A consideration of the priorities in lection. These problems include ac- timcly-I it must be available; and it Evanston, Ill. establishing areas for research. Morris E. Collen, M.D. The special problems and op- Director, Department of Medical portunities in health service re- Methods Research search presented by Regional The Perrnanente Medical Group Medical Programs. Oakland, Calif. Health services research.-The omponents of health services re- Caldwell B. Esselstyn, M.D. c Associate Director search have been identified by Dr. New York Metropolitan Regional Kerr White as descriptive, analytical Medical Program experimental, and evaluative. The .n'tial stage is reportorial and de- New York, N.Y. ' 1 John Thompson scribes the "health system" as it exists. Professor of Public Health and The analytical phase depends upon Director, Program in Hosbital establishing hypotheses and then ap- propriatc data collection. The ex- Administration Yale Univer.5ity Medical @chool pcrimental phase, one which pres- ently is larely undeveloped, depends New I-Iaven, Conn. on testing models and manipulating John N%Iilliainson, M.D. variables. Finally, evaluation, which Division of Medical Care although not research per se, is in- and Hospitals herent in research and requires The Johns Hopkins UniversitY methodologies. School of Hygiene and Public Health services research was briefly Health differentiated from operation re- Baltimore, Md. search and operations research. Recorder: Operation research depends on the Richard F. Manegold, M.D. collection of specific data for estab- Associate Director for Progra?n lishing policy and management deci- Development and Research sion. Operations research and its Division of Rerional Medical component systems analysis depends Progranzs upon the development of a mathe- 109 Although long-term evaluative Regional Medical Programs offer GROUP DISCUSSION must be used. For the most part, Ities, intermedi- to the health service researcher a lab- available data are not comprehensive. goals pose time difficu TOPIC F: Thus, although there are data on the ate goals can be set. These include oratory. They inherently tend to "CON'I'INUING EDUCATION incidence of diseases (so many/pop- T-neastir(-,.; of better resource alloca- stimulate both the proper clticst' AND I-RAININC,, I - ions ulation) there is only fragmentary tioii, beLtci, utilizations, iiiil-)rov(,cl and Vince tli(! (Iti(-st for, til(@, Solutions. information on "service time." more relevant educational programs. ("Service time" is information on the Conventional wisdom may be used Discussants: Patrick B. Storey, M.D. (Moderator) number of patients in the health sys- to bridge the science service gap. tem with a given condition.) Our Clearly, not all "latest" advances are Professor and Chairman present data lack, therefore, is in- advances and some plainly are not Departnzent of Community Medicine Hahnemann Medical Colleae formation on prevalence. feasible. Many "new" procedures do I Evaluation.-Evaluation poses spe- not stand the test of use. Others, Philadelphia, Pa. cial problems. What should be eval- "heart transplants" for instance, Luther Christman, Ph. D. uated? What can reasonably be eval- clearly are not when first developed Dean, School of Nursing uated? What are the regional respon- feasible for the system. Thus, con- Vanderbilt University sibilities in evaluation and what are ventional @visdom can dictate to some Nashville, Tenn. the national responsibilities? degree what should be and can then George E. Miller, M.D. In many instances end result be measured, evaluated. Director, Office of Research evaluation cannot be the measure. Research riorities.-Certain areas in Medical Education Regional Medical Programs deals p basically with chronic diseases that in the health field will yield greater Universz'ty of Illz'nois will not promptly yield to changes in results in the health service fie-Id. Chicago, Ill. management. Further, because of the Some population groups, usually A. N. Taylor, Ph. D. annual increments in the population upper middle class, now have good Dean, School of Related at risk gross mortality and morbidity health care services. Conversely, the Health Services statistics may not show significant poor and many rural areas do not Chicago Medical School changes. have adequate health care. Thus, Chicago, 111. Evaluation is a two stage process. priorities for research in these areas Recorder: First criteria must be established and of health care offer obvious prompt Alexander M. Schmidt, M.D. then a professional judgment must payoffs. Chief, Continuing Education and Trainin, Branch be made. Were the criteria attained? Special opportunities for health In these terms evaluation can be service research.-Regional Medical Division of Regional Medical established on the basis of expert Proorams, by involving the various Progrr-.ris judgment of what should be the ex- components of the health system, pected mortality, the morbidity, and offer special research advantages. r. Storey opened with a -,,cry the cure rate. A comparison between Health service objectives may be es- D i brief statement listing the ptir- expectation and reality then leads to tablished; educational and service pose of Regional Medical Programs: an examination of the realities of the programs designed to serve these To improve medical services in a re- expectations, the deficiencies in ends; finally, evaluation can test the gion and link them to I)atients@ the health care, or both. effectiveness of the innovation. Conference-Workshol): To allow a 110 comparison of notes among regional what he actually needs. Examples: to his benefit, medical education demic peer judgment and its applica- Medical Programs representatives; A.NIA national plan, etc. What is should give to a physician what he bility outside the school need study. and the Discussion Groups: To help needed is educational diagnosis, and needs, when he needs it, in a conven- The experience of the American each other with specific problems of not treatment (more courses). We ient way and at a convenient time, in College of Physicians with the phy- making continuing education efforts have entirely too much treatment. a palatable form. It (the content) sician's self-inventory would suggest relevant to program goals. Q. Can a physician (or other) must have the characteristic of being that physicians aren't reluctant to Dr. Storey asked if anyone had a teach himself? What is the role of applicable to what the learner does, find out about themselves, at least if problem for discussion of the group; teaching machines, TV tape, etc.? and applicable the next day. they are fairly sure there is no built-in there was an instantaneous and A. The problem with self-instruc- One major problem now is with penalty. vigorous demand for the floor. The tion is that one tends to study what he basic medical education. The medical Any doctor really wants to do what next hour and a half plus was is most comfortable with. Also, his student spends time in a series of he does well, or at least as well as occupied by an exchange among re- objectives are too often inappropri- closed systems, each with a finite end his peers. source persons and attendees, num- ate. If a golfer wants to improve his point, usually with some sort of exam Perhaps the physician is over- bering more than 100 and filling the score, he can read and work out by passed at the end. The practice of a worked and tired, and a bit disillu- room beyond its seating capacity. The himself, but he will get little or no profession is open-ended, without the sioned. following summary of questions and better, and maybe worse. He must get built-in motivations of exams, etc. Q. Does the system interfere? discussions reflect that exchange: professional help from a golf pro. Therefore, the medical student must A. Yes, indeed. First of all, most of Q. Dr. Miller has said we already Self-education in medicine is the be indoctrinated from the beginning the medical system, especially the ad- had enough continuing education, same, in a way. At some point a pro- of his medical education to be a self- ministrative system, is 19th century. and that we didn't need any more. fessional educator must help set ob- motivated learner. He must be taught This interferes with everything. What did he mean? jectives, and help one to decide what to use the various self teaching aids Secondly, role perceptions interfere A. (Dr. Miller) I have said we he is really missing, and what he there- available like books, TV tape, etc- all the time. A study of patient care enough iiiforitiatiori. We are foi-c really needs. To accoiril)llsli this, What makes us think that our prac- was done at the University of Illinois drowning in information. What we the student must reveal his igno- titioners know how to use these things (Dr. Miller) and it was found that need is not more information or ways rancc-this is often a painful process. now, just because Regional Medical role perceptions and misperceptions of disseminating the information, but TV tape is like a book, and we have Programs can buy them and put them effectively blocked team-oriented ed- a method of establishing priorities of books now. The problem is really what out for use? ucational efforts. The doctor always what a physician needs. We must the content should be. Medical students should be taught had to lead the team, a nurse couldn't help a learner (physician, etc.) to Q. How, then, is one to motivate to be critical self-learners, perhaps by do this or that, etc. want, then obtain, and then use what a physician (or other) to learn? the process of evaluating what their Yet, team teaching, based on the he actually needs. This is the major (About three-quarters of the discus- I issue. sion revolved around this one point, professors believe and know. care of a patient, is probably vital. Studies have been done as to what motivation.) It is commonly said that the medi- Too little of this is done any place, a physician thinks he needs, or what A. Motivation is tied to need. If cal school atmosphere of peer judg- and probably must be begun in med- he wants; but such are, by and large, one discovers what he really need.s, ment is healthy and should be taken ical schools. But if the "For what?" invalid, as they are based on his own motivation should not be too great a out to the community. But the fallacy is for the care of the patient, then the opinion. This often represents what problem. We use what is known about here is that while the academic sur- education must be centered there, he is comfortable about, or even what the learning process all too little (psy- geon may accept the give-and-take and the real needs must be the patient li(! knows @ilrea(ly. (@liology of learning, etc.). I,Ikc the i,(!g@ir(Iii)g surgery, lie gets pretty il'- needs, in(i this must be the oriciita- .Soiric attempts have been made to golfer, who gets from a golf pro what ritated about being (luestioiicd about tioii, not what a physician wants or help a physician discover for himself he needs and applies it immediately biochemistry. The validity of aca- what a teacher wants to teach. ill GROUP DISCUSSIONS TOPIC G: "DATA COLLECTION AND REGISTRIES" Discussants: Abraham M. Lilienfeld, M.D. (Moderator) Professor and Chairman Department of Chronic Diseases Un'vcrsity The Johns Ilopkl?IS z School of Hygiene and Public Health Baltimore, Md. James F. King, Jr. Office of Program Planning and Evaluation Office of the Surgeon General Public Health Service Andrew Mayer, M.D. Assistant Director American College of Surgeons Chicago, 111. John E. Wennberg, M.D. Program Coordinator Northern New England Regional Medical Program Burlington, Vt. IL Recorder: Maurice E. Odoroff as a basis for planning; the use of can- nity to obtain information useful for to special social research. These Assistant to the Director cer registries for planning and evalu- regional medical purposes by ag- data also permit deteri-ninin- the for Health Data ation; and data collection for use in ,regatin,, small areas' data for such political jurisdiction. Division of Re,,ional Medical evaluation. relevant items as the demographic It permits matching health data Programs Use of 1970 census data for Rc- characteristics and socioeconomic to census data and thus record al. onal Medical Pro,7ram plannin(,.- data. There are three general uses of linkage between health data and The Census Bureau is now testing its these census data: social and economic chai-acteris- he panel organized its clisci-i-,- procedure in Nc@v Haven, Conn., in Use for definlnl- population and tics as a basis for pro-,,idin- sen7icc. Tsion around the following three preparation for gathering 1970 ccn- their characteristics to isolate con- It permits selecting I special areas: The use of 1970 census data sus data. This presents an opportu- centratioii of problems amenable samples to do intensive studies bN@ 112 matching infon-nation from local met; and evaluation of specific GROUP DISCUSSION developed, although there were dis- sources between health agencies projects. TOPIC H: senters, that in general hospital ad- and with other local data, such as Evaluation is essentially a value "HOSPITALS" ministrators as a profession were not housing, economic characteristics 'Lidgment and relates to criteria de- sufficiently involved in the prograxns i and social unrest. veloped for these objectives. Objec- in their re-ions. Consideration was 0 Discussants: (I.@e of re,z"@tries for planning and tives are expressed in terms of Liven to the proper methods for in- D. Eugene Sibery (Moderator) - evaluation.-Cancer registries are a evaluation procedures. The art of xrolvement of hospitals and the proper tool for planned data collection on a evaluation involves discovery of indi- Executive Director involvement of hospital administra- Greater Detroit Area Hospital . continuing basis. The primary objec- cators or measures which allow their tors in Re-lonal Medical Programs Council tive of a cancer re,istr-y is improved assessment. These requirements pre- aL the regional and national level. I'D Detroit, Mich. The following are directions the patient care. The registry must meet sent difficulties in defining objectives i this criteria or else it is A,orthless. The iblc to analytic assess- Pearl R. Fisher, R.N. discussions went and areas thev in terms suscept two major types of cancer registries mcnt because objectives must be ex- Administrator covered: are hospital-based registries and pressed in terms of mortality and Thayer Hospital The goal of the pro-ram is to I)opulation-based central registries. morbidity and efficiency of medical Waterville, Maine improve patient care through 'I'he aim of the hospital-based registry care. The major problem is to find or cooperative arrangements. These is follonvul) of cancer patients, defined develol) indicators which sufficiently John W. Kauffman arrangements will, if effective, Administrator change the behavior of the provid- as returning for examination to dis- measure morbidity. The problem of Princeton Hospital ers of care, and thereby the goal of ible spread to new sites or 'ng morbidity is further corn- cover poss measurl I I Princeton, N.J. the program will be approached. for concurrent disease. The central 1)llcated by the fact that certain dis- idemiolo,,lc in emphasis eases give rise Edward H. Norolan registrv is ep I 1 to several morbid The hospital is the major corn- @iLirii(,cl at (I(,t(-Yriilriln@t @izicl conditions. (](@v(@lol)ii-iciit of in- Execiitiz)e Director iiiLiiiity institution with the poteii- ti@il of focLisin(,- the enc@(,ics of the SLII-%'I','@Ll I'.It('S fOl' indicators S(@ll('Ille foi- Presbyt(@riaii Uiizvcrsit5@ Hospital ;Ill(l L S(@ll('Ill(' FOI' I,(I. J)I-Ovi(let- of (-are. I-lo,,;I)itils, in this @@'ILli ill(- t,il'ylli@ll @iii(I oii(t (!oll(l't' I)el,ccl)- I loll S(.Ilse, tl-(@11(i within ill(,. tli(,. otli(,i,, @iii(I the develol)- Recorder: tioiis from episodic care to corn- 1'rogi-aiiis foi- estal)llslilji(l, central of @t summary set of indicators Richard F. Maiie,,-Old, 1\1.1). 11ILinity and comprehensive care. registries. The concentration needs to of "net morbidity." Associate Director for Progra?ii For this latter role hospitals have be at the local level because a central The requirements to define the Development and Research unique strengths. rec,istr@@ is no better than the quality tv unts, and interrelationshil) Division of Re-zonal Medical These stren-ths are several-fold. I)es, amo of data received from liospital-based of morbidity is a major problem in- Programs First, the hospital represents one of registries. Moreover, there needs to be %,ol\,,Ing a research effort beyond the the community's major resources 'd(@ I of l@e,,Ional Medical c,onsi @rable iriotivatiori at the local c- i)acity for organized and personalized level for good quality data to 1)(@, l'i-of,i-aiiis. iiii)liasis ill the (IiS(@LISSIOTI was first licaltli care. As such, there is neces- achieved. Mortality and efficiency of medical EJ placed on the basic purpose of sarily a community concern. There Data collection for evaluation.- care are more easily measured. The Regional Medical Programs. Follow- is, if not always the reality, at least Evaluation was defined as evaluation failkire to de-,,elol) a full set of indica- in@ this, attention was directed to the potential for professional, of medical care to determine gaps in tors for morbid states implies that the the changing role of hospitals in paramedical, and health educa- riied'Ical care: evaluation of lzeglonal (complete set of issti(@s involved in the health care and the hospitals' unique tiori. There is, also, the experience Medical Programs in terms of stated obj'c(@tives of the program are not con- advantages for fulfilling this role. ill organizing the providers of care I)ro(,raiTi objectives and how they arc sidered in the analysis. With this back,,i-ound, a consensus into effective teams. There is the GROUP DISCU arced that com- economic focus for developing the Equal recognition was given that the SSION T t being generally a@ necessary resources. Finally, in the reasons for this seemingly poor at- TOPIC I: JL munity or consumer involvement hospital administrator, himself, tendance might be explored. If, in- "COMMUNITY is indispensable to success in promo- there is the management compe- deed, the low census of hospital INVOLVEMENT" tion of a Regional Medical Program. tence experience in developing administrators was symptomatic of in- the following issues rapidly emerged up's discuss' plans and putting them into opera- adequate involvement of administra- in the gro ion: Discussants: tion. tors, correction of the causes would Robert M. Cunningham, Jr. Community involvement for what? In spite of these significant re- strengthen Regional Medical Pro- Community involvement of whom' (Moderator) sources, the participants were gen- rams. Who is the consumer? Patients or 0 Editor erally concerned that hospital ad- In closing the session, the interest physicians? Modern Hospital Magazine ministrators were seemingly only of the division in establishing greater Chicago, Ill. Do the community representatives marginally involved. Several strate- liaison with national and State orga- really rel)r(-sent the (@onsui-ners'. gies for involvement were suggested. nizations representing hospitals was Alan C. Davis The difficultv of identifying qtiall- These included the development of voiced and noted. Science Editor fied lay leaders. local advisory groups as in Georgia American Cancer Society The difficulty of explaining, what and the coincident need to develop New York, N.Y. Regional Medical Programs are. areawide planning councils. Howard Ennes, M.P.H. Howard Ennes asked for "con- One somewhat thorny problem rc- sumer modulation," later translated lated to institutional vested interest Assistant Vice President'/or as "comniunity healtfi citizenshil)" in arose. On the one hand, some agreed Com?nunity Servz'ces and Health application. "The times," Ennes said, Education "demand intensified 'consumer mod- that these interests should be diluted TheEqiiitableLifeAssuranceS I.et I oc y for the total community concern. New r v ulation' of health care activities, in- mechanisms of financing using for- New York, A. @ . cluding those related to goal-setting, mulas for reasonable cost and charges Pierre C. Fraley resource allocation, priorities deter- -,vill mitigate some of the competitive Director of Iizfori??.(itz'on iiiination . . . in short, all aspects On the other 1),in(l, several Gre,,ati!r Valley I?o,,glortell ()f tll(- (I(-Iiv(,I-y of- II(.;Ilt 11 S(,r VI(-(.S, ()I(-il- urged that vested interests were in- Medical Program (-osts, and related corriiiiunity deed the source of institutional and Philadelphia, Pa. cisionmaking." professional excellence. At best, one Health care programs for the could hope to coordinate these inter- Marc J. Musser, M.D. community must pass a "4-A test, he ests but should hesitate to dampen Program Coordinator said. "Are they: Appropriate, Avail- them. North Carolina Regional Medical able, Accessible, Acceptable?" Finally, the poor attendance at the Program "I suggest," said Ennes, "the ur- Conference-Workshop and the discus- Durham, N.C. gent need for a nationwide partner- sion itself were discussed. The fact was Recorder: ship to create a concept of 'com- that fewer than 2 percent of the total Edward M. Friedlander munity health citizenship'-an effort conferees at the meeting were hospi- Assistant to the Dz'rector to be joined in by Governmental and tal administrators. Recognition was for Communications and Public private sectors, by professional and given to the fact that greater attend- Infor77zation lay groups, by all levels of activitv- ance at both the panel discussion and Division of Regional Medical Federal, State, local." The object the Conference might be proper. Programs would be to focus on the responsibility 114 of the individual to know and make His personal interest and drive were out that the chosen representatives do GROUP DISCUSSION the most of himself, to utilize health contagious among the various area not necessarily represent the actual TOPIC J: services, and to participate con- leaders, and . . . he worked success- consumers. Musser put in a plug for "OPERATIONAL structively in community health de- fully with them in establishing the the political science book, "Rulers and PROGRAM DEVELOPMENT" cisionmaking. In this direction, "we State of Franklin Health Council, Ruled," as a good source of informa- Discussants: have (literally) done next to Inc. . . . the first organized health tion on the nature and complexities of nothing." planning group." This effort pre- forming working relationships be- @rlarles E. Lewis, M.D. (Moderator) Pierre C. Fraley introduced the ceded the North Carolina Regional tween what someone called, "Us and Program Coordinator "for what?" Fraley pointed out that Medical Program, and involved all them." Kansas Regional Medical Program "the means need to justify and accom- 4,000 persons in seminars on commu- From her experience with promo- Kansas City, Kans. plish the desired end." Fraley cited nity health problems. tion of citizens' health groups in west- C. Hilmon Castle, M.D. the example of Pap smear testing in Alan C. Davis, discussing the dif- em Pennsylvania, Sister M. Ferdi- Program Coordinator New York City. Whether the free ficulty of explaining what a Regional nand advised: "At their first meeting, Intermountain Regional Medical screening station was installed in a Medical Program is, described it as they don't know what they want. Let Progranz midtown department store or moved the first public program in the health them get rid of their frustrations. Salt Lake City, Utah up to Harlem, it tended to attract the care field to involve the practicing Then you have them involved." T. A. Duckworth same intelligent, highly motivated, physician. Davis warned against Whether Regional Medical Pro- Chairman, Regional Advisory Group not-so-poor class of women, mainly bringing in professionals only: "It's grams are designed to help patients or Wisconsin Regional Medical white and mainly Jewish. He sug- the consumers we are ultimately help doctors help patients, there Program gested that the goals of community aiming at," and advised against su- seemed to be no disagreement with Wausau, Wis. involvement should be to increase perimposing concepts or set standards the unidentified voice from the back Albert E. Heustis, M.D. knowledge, to change attitudes or from on high, "Let the people do it." of the room: "The program will be Program Coordinator motivation, and to change behavior. In the discussion, Fraley, joined by judged by improvement in medical Michigan Regional Medical Describing "the successful applica- Dr. Stanley W. Olson from the aud- care." Program tion of a public information program" ience, protested the assumption that East Lansing, Mich. in the "State of Franklin," a seven- the patient is the consumer in Re- county rural area in southwest North gional Medical Programs. "The phy- Donal R. Sparkman, M.D. Carolina, Dr. Marc J. Musser empha- sician is the consumer," said Fraley. Program Coordinator sized the "right man" principle in ob- Olson pointed out that Regional Washington-Alaska Regional taining community involvement. Medical Programs emphasize work- Medical Program "The initial public information ing through established groups and Seattle, Wash. program was carried on by virtually does not provide direct service to con- Recorder: one man, on a person-to-person sumers, i.e., patients. Richard B. Stephenson, M.D. basis," said Musser. "This man is a From the audience, Dr. Henry T. Associate Director for Operations psychologist and member of the fac- Clark discussed the problem of iden- Division of Regional Medical ulty of Western Caroline University tifying quality in lay leaders. "Those Programs at Cullowhee. . . . It was clear to who may get involved often have no him that the seven counties . . . knowledge of the processes involved working together, could do far more in community organization and ac- he discussion was opened by the to solve their mutual problems than tion," he said. Tpanel participants briefly review- each county working independently. A New Jersey discussant pointed ing their own regional experiences 115 with developing operational status. There was also general reconitioii The meeting was then thrown open of the importance of acquiring either for general questions and discussion. a critical mass or of reaching a criti- The eneral area of how to handle cal point in the planning process to- g both the generation and review of ol)- gether with the neecl for concorni- crational proposals was discussed tant evaluation as an ongoin- part from several aspects, beginning with of planning. the involvement of legal action Additional points touched on in- groups of various kinds through dif- cluded the usefulness of the fruits of fering levels of technical or scientific previous planning activities such as review to final regional advisory Hill-Burton and similar activities; group action. Althou h there was the desirability of involving early in 9 considerable variation in the detailed the planning process persons with ex- approach, there was general agree- pertise outside the medical profession ment as to the overall methodology itself; and the fact that the regions as of handling and the necessity of in- identified for the purposes of initial volvement at the different levels. planning grants would in fact be The relationship of planning to ol)- made to regions and not to indivi- erttional activities was explored from vidtial institutions within the region. several different angles. The ques- Finally, it was reemphasized that tion was raised as to whether plan- "there were many roads to Rome," ning should be directed primarily and that it was neither the intent nor toward regionalization or toward the the desire at either the local or the categorical objectives of improving national level for there to be uniform- care of health disease, cancer, stroke, ity or conformity to some master and related diseases. It was agreed scheme for regions to become opera- that planning should do both, but tional, but that diversity and flcxl- that the primary thrust was toward bility were clearly in order. the concept of regionalization as the way in which to accomplish the cate- gorical objectives, with the spin-off of a general upgrading of health care being both desirable and inevitable. Reeni hasized in a number of dif- p ferent ways was the importance of a continued strong planning activity as a program moves into an opera- tional phase together with recognition of the greater flexibility inherent in the operational grant as contrast(.,cl with the purely planning grant. 116 I A NONPROFESSIONAL LOOKS AT Irving J. Lewis REGIONAL MEDICAL PROGRAMS REMARKS Honorable Melvin R. Laird i I t 117 1 A NONPROFESSIONAL demand which for me, and indeed, all not only your hard-earned personal neither clear cut nor infallible, and, LOOKS AT of my colleagues who have been ex- income but also the way in which as I have indicated, our analytical REGIONAL MEDICAL posed to it in depth, has meant a re- society utilizes its people and its techniques are still probably not as PROGRAMS orientation of thinking, a new level natural or physical resources 'and the solid as we would like. of objectivity, and above all, a last- services or social purposes which Still, I hope you will accept that Irving J. Lewis ng respect for a much-maligned and these resources produce. The alloca- this budgetary effort is no simple ac- Deputy Assistant Director little understood executive agency." tion process is never ending-the counting task, but one in which after Bureau of the Budaet I quote Ivan at length so that I larger the Federal budget the greater we fall back exhausted-incidentally, - may publicly accept his compliments the responsibility that Government that will occur for 1969 very shortly- Oflice of the President while at the same time deny that we assumes to channel and direct its re- we have helped the President find a are beady-eyed, and hope that we sources according to rational choices. balance first, among the national are better understood as a result of his I have no crystal ball to tell me how goals of national security, foreign af- am pleased to have this opportu- efforts. Also, despite our passion for large the level of Federal spending fairs, education, health, abolition o nity to be at the Conference- anonymity, we now find that the will be or ought to be. I would only poverty, environmental quality, rec- Workshop on Regional Medical Pro- stageIon which Federal programs are be speculating, and I would be es- reation, housing, transportation, sci- grams. I always welcome an occasion played has become so vast that we pecially speculative if I engaged in ence and technology, and so on; and to show to an unbelieving public that do have to allow for a few occasions the game of "what if we had no Viet- second, among the programs most the men in the Budget Bureau do not which permit us to see local interests nam?" The level will remain high, likely in action to give him progress wcar green eye shades or sit upon at work, or, as we say at the Bureau, however, and the competition for the toward these goals. There is never high stools in their counting houses. the real world. For it is to help in dollars increasingly acute. This acLite enough to go around, and it is little In a recent talk at this same hotel, shaping this real world that presi- competition means that we in the wonder that Maurice Stans, Presi- Dr. Ivan Bennett, Deputy Director of dential goals, policies, purposes, and Budget Bureau must concern our- dent Eisenhower's last budget direc- the Office of Science and Technology proposals are eventually fused into selves with the goals and objectives tor, called budgeting the unifon-n dis- and one of my principal mentors in what is termed "the program of the and the hoped-for results of health tribution of dissatisfactions. the health field, described us in these President." It is the translation of and other programs. We try to refuse There is ample room to demon- words: that program into dollar terms which to go along with the proposals that strate that the worth of social "Some of you, I know, have had leads us in the Budget Bureau to pur- 'shoot from the hip. investment is subject to qualifiable experience with the Bureau of the sue the facts, to question the purposes What I am saying is that while we assessment. There is rather a -,vi e- Budget, where, since the multiple- of programs, to analyze-alas, all too in the Budget Bureau have no special spread effort today in the Government crack system does not exist and there imperfectly-their costs and benefits, wisdom or formulas for sorting out to produce these assessments, going are no fissures that allow for pene- so that the decisionmaker-in our our budgetary goals and priorities, Linder such names as systems analysis tration of local interests into national case, the President-can look at al- the President wants his program to be or program planning and budgeting. policy decisions to influence decision- tematives and evaluate relative pay- tuned to the problems of our society Thus, investment in education is said making and allocation of resources, offs from different kinds of public in- and the need for developing solutions to be more than socially 4c good"-we one has recourse only to putting to- vestments. to those problems. He wants his say it is economically productive, and gether a balanced, persuasive, and As availability of public funds for final choices to be not only good we can even say by how much. We factual argument. It is with real re- public purposes becomes tighter, the choices, but better than other pro- can, by better analysis, show that the spect and admiration that I say that need for questioning is heightened. posals to accomplish the same end, rehabilitation of the handicapped is here are the beady-eyed, hard-nosed Our thirst for knowledge is quickened and to show better returns for the not only socially useful but eco- skeptics, receptive to opinion but de- as we understand that when budget same investment of public funds. To noriiically advantageous. In medical manding iron-clad factual details-a decisions are made we are affecting be sure, the budgetary process is science, similar reasoning can and 118 to Show f;kvol-;Il)](@ fol-(@ll)IY ilill)t-(,Ss ill)oll you tl-l(,. SWC(',I) qovernmcnts. Unfortunately, for ;I(,t,ivjty ill 1,11 so(!I;ll tlios(- who @ij)l)t-oa(-.h governmental i-c- lat'ons simply, no one has contrived ratios foi- (@,xaiijl)l(-, it li@is 1)(!(,f) (loti(! II(-](I. I I in studies in tile I)cl)artjii(@iit of 'I'tic use of tile phrase "liui-nan rc- a simple formula for the execution of I-lealth, Education, and Welfare of sources" has become fashionable in these programs. n t c contrary, we the health of the poor and the health today's intellectual parlance, but I have adopted, probably not always of children. think it signifies that the programs consciously, the approach of prag- But let me cltiickly hasten to clis- roLiped Lindet- this banner constitute matic experimentation. There is not 9 abuse You of any i(le@i that I)Lid@,(-ting a new type of governmental effort, always time to wait for the perfect and its associated decisionrriaking is not to be compared with social lcgis- solution. So, we grope toward it, ac- strictly for budget professionals. This lation of the I)ast-cither the New cepting some risks. We place a high is no system of push buttons or Freedom of Wilson or the New Deal premium on close cooperation and a ivhlrrln,- magnetic tapes. Public pol- of Roosevelt. That legislation-fair flow of information among equals, ill made in the political arena, labor standards, child labor laws, food icy is st and, above all, we are willing to see and it is in this arena that the budg- and drug controls, unemployment in- institutional change come about in (@tary decisions are made. surance, social security, to mention a many forms. We have had to try to A better grasp of the role of public few-reflectcd a simpler social philos- move more and more decisionmaking expenditures in creating social assets ol)hy that Government should pro- out into the field, recognizing that co- does not by itself tell us when to spend vide a basic underpinning by ordination of programs cannot all be achieved by Federal action. The bene- or how much to spend. Our pluralistic interdicting various behavior patterns society responds to pluralistic de- or by providing certain minimum in- fits of decentralization, however, must niands whether they ai-(@ supported by come guarantees. Today, the revolu- be accompanied by the costs of anom- a dispassionate array of facts arid tion of rising expectations in the less MR. LEWIS alies, diversity, inconsistency, and figures or not. Many human needs developed world is paralleled by un- the professional specialists. Too often, even downright error. But deep- clamor for passionate attention, and rest in our own society, and Govern- the professional insists on assump- rcoted social and economic problems many 1)robl(-,ins (-r-y out for solutions iiient is responding by provision of tions, approaches, I-)rograms, or tech- are complex in nature and cannot be ll(-gi(@(.t(-(l @tj'(.;Is of ])III)]' liology of iiiilv(@i-s;tl @ii)l)lical)ility. L(@st ;ttt@L(-.ke(I by simple-minded, single- i(@ ('011(,(Ir,]). "(@l'Vl('(,S oil ;t V(lr-y I)I-o@t(I fi@olit. Certainly, our planning and atialyti- 89th Congress alone produced 21 new we "dehumanize" human resource shot approaches. cal capability is not Treat enough to health programs, 17 new educational prograi-ns, may I stress that the pn'- In his report to the President and have given us in so short a time programs, 15 new economic develop- mary focus of Government in man- the Congress on Regional Medical rationality to clevelol) our present iiicnt programs, 12 new programs to a@ing this array of programs ou,ht Programs, the Surgeon General set array of Federal human resource pro- meet problems of cities, and four new to be on the individual no matter Nvho forth at length a number of issues and grams. About 459 sti(@h programs are manpower programs. he is-Lindcrprivileged, I)<)or, aged, problems which face the Regional des(@i-ll)c(l in the annual (7atalo(, of l,rorri OLII- early clays, we Arr)ericatis migrant, veteran, child, mothers noii- Medical Pro-rams. Some derive from I-'cderal assistance programs pro- have been a "practical" people. And white, retarded, rural, uneducated, or characteristics of the general health dtice,c] by tfl(@ Offi(@(! of I"Collortl'(@ Ol)- '(,,ty t( settiii,, in this country-for example, So oui- so(:l -,jicls to bring into other statutory category. ])Ortunity. I (@oillilicti(I tills catalog being human resource programs that 'I'hese programs, and I include Re- its essentially voluntary and private to your attention. It may hear) You are targeted to specific action areas. gional Medical Programs, have cre- nature, the magnitude and complex- not only to find out whether there is These may be categories of disease or ated a new dimension for Federal ity of what is often termed a $43 bil- a grant program to finance your specific population groups, and-I management and for relations with lion industry, manpower limitations, favorite pro'ect, but it Nvill also rather may adcl-arc too often controlled by the private sector arid State and local and rising medical costs. Others relate i 292-414 0-68-9 to the law itself-definition of a re- public controversy-such as bio- of us needs to be an economist to medicine" may become not disease- gion, significance of disease categories, medical research and academic know that when more funds are oriented, but the area of organizing use of advisory groups, dissemination science- and new activities designed poured into the arena for purchase, the system of care. Of course, another of information relating to advances to finance and make available the the selling system must be more ef- impact, still only seen in general in diagnosis and treatment, and medical knowledge we have. How- ficient or its supply must be enlarged terms, will be seen in the need for others. ever, it is also clear that extremely or the infusion of funds may simply production of more doctors faster. In time, these and other issues will high on the health agenda is the dis- be eaten up by price inflation. Debate The President's Health Manpower be dealt with in the public, executive, tribution of our medical knowledge- continues-and I am no expert- Commission recommended that we and legislative forum. But, as I see what we call the organization and on the extent to which medicare con- develop economic incentives to make Regional Medical Proorams in the delivery problem. I think that it is in tributed to rising medical costs, but this possible. Oliver Cope wrote context that I discussed earlier-our solving this problem and in bringing the rising costs are with us and there- somewhat despairingly of this prob- problem of allocating resources of medical care to people that the Re- fore spur us to examine our system lem of medical education a few men, money, and materials-its prime gional Medical Programs potential of medical care. months ago in Harpcr's Maaazt'ne. I worth to our society will be in its ca- lies. Many speak of Regional Medical would hope that in time we could pacity for improvement of our sys- Medicare and medicaid alone ac- Programs as a unifying focus for the overcome his despair bv responding tem-or systems-of medical care for count for over $8 billion of the health resources of a region, linking to the prod of the Commission. the people served. Let me stress the Federal expenditures of $15 billion patient, physician, hospital, and Through the National Center for word "medical" because too often in for health programs. They have virtu- medical centers to provide the latest Health Services Research and Devel- the past in this country we have used ally eliminated financial barriers for advances of knowledge to the people opment, Regional Medical Programs "health" as a euphemism for medical the aged and have made it possible in this region. But health functions will get invaluable assists through a in view of our unwillingness to con- for poor and near-poor in three- are a continuum, and Regional rising level of supporting investiga- front on a public level the problems of fourths of our States to receive an Medical Programs will have to con- tions and experiments. Another medical care. increasing volume of medical services. sider the problems of distribution, significant actor on the scene is the By now it is established that Gov- These landmark laws of 1965 arc ac- cost and organization of health care. "Partnership for Health," and I guess ernmcnt has set its face in the direc- companied by others in maternal and I would think that, because of the we still have to establish with more tion of tackling the problem of assur- child health. tremendous scope of heart disease, clarity how we want this experiment ing to all its citizens the access and Ironically, many people-and es- cancer, stroke, and related diseases, to tie in with Regional Medical Pro- availability of high quality medical pecially medical professionals-are the task of improving organization grams. There is a tendency to regard care. I regard as idle the discussion troubled over this outpouring of and delivery of medical care through this program as just another State whether we mean such care is a right, Federal funds to diminish the fi- Regional Medical Programs has to be support program. This is an error in like public education, or a privilege. nancial burden of paying for medical viewed in the context of comprehen- judgment, and you will find that it is The goal is clear, and if we are serious care, and they are rightly troubled, sive health services and not in a nar- regarded here in Washington as a about it, we must constantly make because with demand for medical rowly based disease approach. pilot program of some significance. It painful choices as to where we will care now effective, as the economists This task will have, in the long run, is a major breakthrough in changing put our moneys and equally painful say, the pressure is on the profession serious implications for medical cen- the proclivities of professionals and decisions on how to arrange our in- to deliver. In addition, of course, ters and medical schools. The com- their executive and legislative sup- stitutions. there is the vocalized but as yet not fort of biomedical research and in- porters to opt for narrowly-based I do not anticipate that we will effective demand of citizens not yet dividlial case treatment or tcaching categorical programs. There is a seri- experience major trade-offs in Gov- covered-for example, the disabled, may be replaced for many by the rag- ous effort afoot in this town to create ernment spending between previously the migrants, or the rural and urban ing controversies over medical care more manageable packages which well-f unded activities that were of less poor not eligible for medicaid. None costs, doctors' fees, etc. "Interesting permit the local private and public 120 .,(,I to], to ;I( I (](.(.I@@lv(.Iv wall(. I)?(-S(-IV- foI-(.V(.I-:t II(-W('t.ofwoo(I :t (11."Iw(.I. (.1-is'.@()f III(! (@'ti(@s 's;t litlill;tll itl(,Ilt. lz(,g,oll;tl M(!(]'(@:tl Pi-ogl.;Illls irig tli(@ right of tli(.- (;()v(!t-ii- (-)f watei- - it is the despair of uii- crisis and the cities are where we will ti-ics to develop, on the basis of local merit to establish priorities of na- able to aspire to the expression of his find most starkly the poverty of which initiative, new institutions and tech- tional significance. potential as a human being; it is the Colin McLeod spoke. niques to solve health problems. In In the Budget Bureau we have read despair of having no future except For too long our society has in- a sense, Model Cities is Regional with considerable interest the Sur- that of mean survival in misery vested resources in only the physical Medical Programs writ large upon gebn Gencral's priority statement for loaded enclaves surrounded by an aspects of the city, but the Model the total human resources scene. Partnership for Health issued in No- opulent society." Cities program is ampic testimony The Model Cities program has an- vember. This priority statement is There has now been mounted in that human and social needs are the other lesson for Regional Medical very topical, and I suggest that it has the Office of Economic Opportunity dominant theme today. Sixty-three ProgFams-the necessity of citizen great meaning for many of you. This a program by the "medical radicals," cities have been selected for first participation in program develop- statement establishes three budget as Marion Sanders calls them, of generation grants under this top ment and his access to the decision- priorities that are relevant to Re- Neighborhood Health Centers. To- priority program, designed to im- making process. There are many roles gional Medical Programs: day, 46 centers are in operation prove the quality of urban life, de- which we can attempt to define as First: or to be funded, and medical s(,hools clarcd by Congress to be the ii-iost being logical and effective for the prehensive health (:are, dlre(,tcd to at all levels are in the business. This critical domestic problem facing the private citizen in health affairs. Hos- individuals and families, not dis- is more than an incidental change in United States. These 63 cities now pital trustee or planning body mem- eases; attitude. It is recognition that the Na- have the initiative by law to develop ber are obvious roles. Not so obvious Second: Improvement of the tion's health business lies in making programs, for selected neighborhoods and perhaps somewhat more nebu- health status of the indigent; and medical care available to all, and the so as to remove or arrest blight and lous is the role of the private citize.11 'I'filr(]: Us(, @.tri(I training of rol(, of rri(!(Ilcal s(-Iiools ar)cl centers is decay, to make marked progress in is a member of the board of dircc- n(@igfil)orlioo(i r(,sl(l(!nts an(] it)- in this. May f, as a layman, i-(-dii(@itig social @ind educational (Its- tors of a regional medical program. volvement of neighborhood resi- suggest that heart, stroke, cancer, and advantages, ill health, underemploy- I know many of you are thinkin- dents in planning and implementa- related diseases-significantly related ment, and enforced idleness, and to about this role of the citizen which@, provide educational, health, and incidentally, would parallel the con- tion of health projects. or not-will be found among the I would only bore you were I poor in the neighborhood health cen- social services necessary to serve the sumer representation found in the to recite statistics about the health ters. Undoubtedly, many medical poor in the Model City area. You Partnership for Health program. In status of the poor. The evidence of schools are or will be deeply involved should be aware that this is a pro- any case, the nonprofessional role in n both Regional Medical Programs. gram run through the Department of planning a regional medical program unusual disease and high prevalence I of ill health identifies them as a high- and neighborhood centers and both Housing and Urban Development, warrants expansion and the com- s risk population. While the middle and programs should profit from each but that HUD places primary reliance munity members, to play this role, a ther. on other agencies for evaluating the will have the responsibility for asking upper classes in this opulent society 0 t have a malaise and uncertainty about If I am right that Regional Medi- human resources program proposals a number of unpleasant questions 9 their own lives, the health status of cal Programs has not been sufficiently of these Model Cities plans. about the quality of the medical care d the poor is part and parcel of that concerned thus far with the problems The Model Cities program, born in in a region, the availability and acces- complex called poverty which is of the poor, I can extend this lack of the inspiration of a few, dealing with sibility of comprehensive health serk-- d much greater than 'ust lack of in- concern to the cities generally. Not the institutional arthritis of Federal, ices, or the usefulness of Regional i- come. It is what Colin McLeod, in that I ignore the rural poor. The State, and local bureaucracies and Medical Programs in inhibiting the Le his recent AAMC address, eloquently Breathitt Commission reminds us frustrated by the professionalism in rate of cost increase in medical care. @h called "the lack of hope that one can most forcibly that urban poverty has health, education, and welfare, may May I suggest, however, that there ic@ ever rise beyond the despair of being deep roots in rural poverty. But the yet turn out to be our boldest experl- is another consumer role which must i 121 be considered. It is an inevitable role Not too long ago Public Broadcast if human resources programs are to Laboratories televised the sharply reach the people whom they are de- polarized views of the police and the signed to serve. I am speaking here militant Black Power advocates re- of the citizen in the neighborhood who -arding law enforcei-nent by police. will not be satisfied with past patterns It was a fairly chilling experience for of consumer representation, but the advocates of moderation. But I wishes rather through neighborhood found provocatively thoughtful the organizations to make his views minister from Atlanta who calmly known. The requirement of partici- told a nationwide audience that all pation of the citizens in the neighbor- our social, education, and health ef- hood in determining the programs forts were hampered by an essentially which serve them is found increas- ne-ative attitude of Americans to- ingly in Federal law, Model Cities ward the poor and the Negro. If we and Office of Economic Opportunity expect human resources programs, being only highlight examples. The including Regional Medical Pro- prescription of the participation may -rams, to realize their investment Po- vary in differing statutes as may its tential to serve human beings, the administration in practice. But one professional's attitude must be one thing is certain: The voice of the that not only permits him to help citizen consumer will be heard at the the poor and Negro, as he did in the grassroots level in the deliberations past eras of social legislation, but also affecting his future. motivates him to urge their involve- The need of community involve- ment and give them access to the de- ment and citizen participation is un- cisionmaking process. That is our familiar to the medical profession, -oal in Model Cities, Office of Eco- which has survived a long time in nomic Opportunity, and Partnership this country under the slogan, "You for Health. It should be no less in are the doctor." But Paul Ylvisaker Regional Medical Programs. very astutely pointed out at last year's May I tha'nk you for this ol)- conference in this hotel that the portunity to be present at this Con- Regional Medical Programs has too ference, and wish you well in your narrow a professional base, and he endeavors. stated that, if the health professions do not become consumer oriented, within 2 years your medical schools will be picketed by a combination of the American Mayors Federation and CORE. And I'wonder," he said, "if your medical faculties are ready for tliit (!xl)ericiic(-." 122 REMARKS to see that medical services in the saw for the decades of the seventies hands of a very limited medical man- and eighties. on@,er ,roul) could get to patients in And I think the pro,ress that has Honorable Melvin 1Z. l,aird g'oiis of our country )-)ccii made that has coomc from these Meniber, U.S, Ifou.@e of Ltic various i,c i ,iricl the us(-, of this iriccl'(!al iiianl)onver discussions and your report, Dr. Re/) r(.-.5 e! ?i I(it z (-otilci be 2i ftill(!i- f(illei- titili7.a- Co,,Ilesliall, on the work that has gone or) it this shows that as fol.@v:ll.(l into this is fliially,,,ettlii,,, started. tll(! future, @VC (@OLII(l SC(@ tlllt it Nv@isn't It has got a long way to ao, but at caryi(@ here to learn, and I have 'List a CILI('Stion of doctor shortages, least, you are defining the problem. been listening to the morning ses- but it was a cluestion of shortages in sions with a great cical of interest. every area of medical manpower. It is true that I have served on And tli(, l'i-ograiri could the I-lealtli, Education, and W(@l- "love in tli(, (tir(-(@t'oii of making bet- fare Appropriations Committee ever tcr use of the limited supply which had on hand and which we fore- since this department was created, we working very closely with the gentle- man on the other side of the aisle, IT John Fogarty, who was my closest and dearest friend in the Congress. We had a very great association together for some 16 years. I know that he would be proud of the 1)rogr(-ss that the lzcglonal Medi- (@;ll I'l-ogl-@illi ll;IS lll;t(](! it) ;L Vf'l-y ';I)Ot-t period of time. And the fine report on this conference which I @vas privi- lcgcd to hear from you, Doctor, I think speaks -,vell for tfiis pro@ram. When we made the first appropri- ation for this program, of course, Nve ,@,cre concerned about the delivery of the research benefits which we had funded at an ever increasing rate 'or a period of some 12 to 13 years, the dcli%,cry of these research benefits and research findings to a limited iium- her in the medical manl)onver field. But the purpose of this program was HONORABLE MR. LAIRD 123 APPENDICES .... 1. CONFERENCE-WORKSHOP PROGRAM 2. COORDINATORS' STEERING COMMITTEE 3. REGISTERED PARTICIPANTS 4. REVIEW COMMITTEE AND NATIONAL ADVISORY COUNCIL 5. DIVISION STAFF 6. REGIONAL MEDICAL PROGRAMS 7. PUBLIC LAW 89-239 8. REGULATIONS 1 25 APPENDIX I Panel: RAY E. TRUSSELL, M.D., Director, School of Public Health and Administrative Medicine, CONFERENCE-WORKSHOP Columbia University, PROGRAM New York, N.Y. FRANK P. LLOYD, M.D., Director, Medical Research, Methodist Hospital, THEME: ISSUES FOR REGIONAL MEDICAL PROGRAMS Indianapolis, Ind. IN THE IMPROVEMENT OF HEALTH CARE AMOS JOHNSON, M.D. WEDNESDAY, JANUARY 17 Garland, N.C. 8 a.m. REGISTRATION Concourse 12 Noon-6 p.m. DI-"MONSTRATIONS-EXI-IIBITS Terrace FOCUS ON THE ISSUES Special demonstrations and exhibits which reflect regional and other related activities 8:30-10:30 a.m. PLENARY SESSION International Ballroom West have been irranged and will be opened and iTianned during this period. See Appendix A of this printed prograiri for listing of demonstrations and exhibits Chairman: STANLEY W. OLSON, M.D., and their locations. Chairman, Coordinators' Steering Committee and Coordinator, Tennessee Mid-South Regional Medical Pro.-rarn 1:30-3:30 p.m. SERIES I-PAPEI@S ON REGIONAI, ACTIVITIES AND IDEAS Quality and Availability of I-Tealth Care for Heart Disease, Cancer, Stroke, and Related Diseases in the l,uture as l@lated to: Selected 15-minutes papers presenting highlights of regional activities and ideas o Science and Service now being devclop(@ci in the regions will [)(- presented on the following schedul(- in CARLETON CHAPMAN, M.D., adjacent rooms permitting and encouraging conferees to develop it projected schedule Dean, Dartmouth Medical School, so that they can move from room to room at 20-n-dnute intervals to hear those papers Hanover, N.H. in which they have the most related interest: 9 Regionalization Starting LESTER BRESLOW, M.D., lime Afeeti@q room.@ on concourse level Professor of Health Administration and Chief, 1:30 I'@il)(,rs 1 7 1 li 11) 25 :role Division of I lc@iltli Services, 1:50 I'@tl)crs 2 it 1 4 20 2(i :@o(: UCLA School of Public Ifealth 2:10 Papers :i 9 1 5 2 1 27 Los Angeles, Calif. 2:30 Papers 4 10 1 6 22 28 o Development of Personal Health Service 2:50 Papers 5 1 1 1 7 23 29 DWIGHT L. WILBUR, M.D., 3:10 Papers 6 1 2 1 8 24 30A President-Elect, See appendix B for detailed listing of papers, s@ers and room location. American Medical Association, San Francisco, Calif. 3:45-5:15 SESSION I-I)ISCUSSION GROUPS II a.m.-12 Noon PLENARY SESSION (continued) International ]3allrooin West Insofar as possible, discussion subjects ue related to preceding papers and in Some Quality and Availability of Health Care for Heart Disease, Cancer, Stroke, and Related Diseases in the Future @ Related to: cases paper presenters are included as discussants. TOPIC A "Health Manpower-The Commission Report" o The Population TOPIC B "Regiori;tliz@ition" Cli@iirni.iii: IZOGEI@ 0. "I vi,-,-s Los Angeles, Calif. See Appci)(lix (: lot- listing of'p@Li-ticil)@ttits and room location. 126 RICHARD F. MANEGOLD, M.D., Associate Director for Program Development and Research, Division of Regional Medical Prograrm. 9 Operations Research ROBERT BUCHER, M.D. (presenter), Dean, Temple University School of Medicine and Consultant to the Division of Regional Medical Prograrm. JACK HALL, M.D., Director of Medical Education, Methodist Hospital, Indianapolis, Ind., and Consultant to the Division of Regional Medical Programs. HERBERT P. GALLIHER, Jr., Ph. D., Professor of Industrial Engineering, University of Michigan, and es Consultant to the Division of Regional Medical Programs. MAURICE E. ODOROFF, ts Assistant to the Director for Health Data, Division of Regional Medical Programs. 10:30-12:30 p.m. PLENARY SESSION International Ballroom West (continued) as Chairman: JOHN A. GRONVALL, M.D., Co-Chairman, Conferencc-Workshop on Regional Medical Programs, Associate Director and Associate Dean, rs University of Mississippi Medical Center, THURSDAY, JANUARY 18 Jackson, Miss. A National View of New Developments in: REGIONAL MEDICAL PROGRAMS INTO ACTION 0 Heart Disease DONALD S. FREDRICKSON, M.D., Director, National Heart Institute, 8:30-10 a.m. PLENARY SESSION International Ballroom West National Institutes of Health. 0 Cancer Chairman: ROBERT G. LINDEE, KENNETH M. ENDICOTT, M.D., Co-Chairrnan, Conference-Workshop on Regional Medical Programs, Director, National Cancer Institute, Assistant Dean, Stanford University School of Medicine, National Institutes of Health. Palo Alto, Calif. 0 Stroke RICHARD L. MASLAND, M.D., Division of Regional Medical Programs Reports on: Director, National Institute of Neurological Diseases and Blindness, Progress and Issues National Institutes of Health. ROBERT Q. MARSTON, M.D., 12:30-6 p.m. DEMONSTRATIONS-EXIIIBITS Terrace Associate Director, National Institutes of Health, and Director, Division of Regional Medical Programs. Special demonstrations and exhibits which reflect regional and other related activities A New Emphasis have been arranged and will be opened and manned during this period. ALEXANDER M. SCHMIDT, M.D. (presenter), See Appendix A of this printed program for listing of demonstrations and exhibits Chief, Continuing Education and Training Branch, and their locations. Division of Regional Medical Programs. 127 1:30-3:30 p.m. SERIES II-PAPERS ON REGIONAL ACTIVITIES AND IDEAS 3:45-5:15 p.m. SESSION 11-DISCUSSION GROUPS Insofar as possible, discussion subjects are related to preceding papers and in some Selected 15-minute papers presenting highlights of regional activities and ideas now cases paper presenters are included as discussants. being developed in the regions will be presented on the following schedule in adjacent TOPIC F "Continuing Education and Training, For What?" rooms permitting and encouraging conferees to develop a preselected schedule so that they can move from room to room at 20-minute intervals to hear those papers in which TOPIC G "Data Collection and Registries" they have the most related interest: TOPIC H "Hospitals" TOPIC I "Community Involvement" Sta),Iing TOPIC j "Operational Program Development" time Meeting rooms on concourse level See Appendix C for listing of participants and room location. 1:30 Papers 31 37 43 49 55 1:50 Papers 32 38 44 50 56 2:10 Papers 33 39 45 51 57 2:30 Papers 34 40 46 52 58 2:50 Papers 35 41 47 53 59 FRIDAY, JANUARY 19 3:10 Papers 36 42 48 54 60 See Appendix B for detailed listing of papers, speakers and room location. 8:30-10 a.m. PANEL DISCUSSIONS To permit the conferees to relate the presentations on Heart Disease, Cancer, and 'Ti Stroke given at the Plenary Session on Thursday morning, and participate in a dis- cussion of their relationship to Regional Medical Programs, three concurrent panels are sc c e HEART DISEASE Lincoln Room Chairman: JESSE EDWARDS, M.D., President, American Heart Association, Charles T. Miller Hospital, St. Paul, Minn. Panel: THEODORE COOPER, M.D., Associate Director, National Heart Institute, National Institutes of Health. SAMUEL M. Fbx III, M.D., Chief, Heart Disease Control Program, National Center for Chronic Disease Control, Bureau of Disease Prevention and Environmental Control. WILLIAM LIKOFF, M.D., President, American College of Cardiology, Hahnemann Medical College, Philadelphia, Pa. CAMPBELL MOSES, M D, Medical Director, American Heart Association, New York, N.Y. 128 CANCER Thoroughbred Room SUMMING UP AND LOOKING AHEAD Chairman: SIDNEY FARBER, M.D., President-Elect, c 10:30 a.m.-12 Noon PLENARY SESSION International Ballroom West American Cancer Society and Director of Research, Children's Cancer Research Foundation, Boston, Mass. Chairman: PAUL D. WARD, Panel: MICHAEL J. BRENNAN, M.D., Incoming Chairman, Coordinators' Steering Committee, and Scientific and Medical Director, Coordinator, California Regional Medical Program. Michigan Cancer Foundation, Detroit, Mich. 9 Conference-Workshop Summary of Issues JUAN DEL REGATO, M.D., LOWELL T. COGGESHAf,f,, M.D., Director, Vice President Emeritus, Penrose Cancer Hospital, University of Chicago. Colorado Springs, Colo. & Address by . . . 9 KENNETH M. ENDICOTT, M.D., IRVING LEWIS, Director, Deputy Assistant Director, National Cancer Institute, Bureau of the Budget, National Institutes of Health. Office of the President. GUY F. ROBBINS, M.D., d Director of Planning, o Closing Remarks by . . . s- Memorial Hospital for Cancer and Allied Diseases, PHILIP R. LEE, M.D., Is New York, N.Y. Assistant Secretary for Health and Scientific Affairs, U.S. Department of Health, Education, and Welfare. STROKE Hemisphere Room Chairman: NEMAT BORHANI, M.D., 12 Noon ADJOURNMENT Professor of Internal Medicine and Chairman, Department of Community Health, University of California School of Medicine, Davis, Calif. Panel: RICHARD L. MASLAND, M.D., Director, National Institute of Neurological Diseases and Blindness, APPENDIX A National Institutes of Health. CLARK H. MILLIKAN, M.D., LISTING OF DEMONSTRATIONS AND EXHIBITS Consultant in Neurology, WEDNESDAY, JANUARY 17, 1968 Mayo Clinic, Rochester, Minn. THURSDAY, JANUARY 18, 1968 WILLIAM A. SPENCER, M.D., Director, Texas Institute for Rehabilitation and Research, 12 Noon-6 p.m. DEMONSTRA,riONS-EXHIBITS Ilouston,'I'cx. JAMES TOOLE, M.D., Special demonstrations and exhibits which reflect regional and other related activities Professor and Chairman, have been arranged and will be opened and rnanned during this period. The following Department of Neurology, list indicating location on Terrace Level or in Park Suite Rooms includes number Bowman Gray School of Medicine, or letter of exhibit, the name of the exhibitor, and some descriptive information on Winston-Salem, N.C. each exhibit. 129 TERRACE LEVEL [Exhibit No.) and exhibitor Description and (exhibit contact) [Exhibit No.] and exhibitor Description and (exhibit contact) [8-91 Rochester Regional Medical Models of various available types of coronary care Program in Conjunction With units, including that in operation in this Regional Greater Delaware Valley Maps and charts depict the need and method for the Heart Diseise Control Program. (Mrs. Jane Hansen) Regional Medical Program subregionalization of a "mega-region." (Mr. Ward Program of National Center Bentley) For Chronic Disease Control [21 Western New York A 4-panel display of how a region is acting to improve Cancer Control Program of Entitled "Stop Oral Cancer," this visual exhibit high- Regional Medical Program patient care. (Mr. Anthony Zerbo) National Center For Chronic lights special forms of detection and treatment of [31 Disease Control this type of cancer. (Dr. Richard L. Hayes) Missouri Regional A dual display. One includes photographic panels [I 1] Rehabilitation Services A 4-panel display describing the services of vocational Medical Program illustrating various operational projects now under- Administration rehabilitation. (Mr. Tom Brubeck) way in this region. The other is a scale model of the comprehensive medical cire facility now being (121 built in Smithville, Mo., the site of one project. Nationil Heart Institute of Detailing somc related programs of the Institute, (Miss Annette Eberley) the National. Institutes of this exhibit will emphasize its coronary drug project Health to evaluate lipid-lowering drugs in acute coronary [41 disease. (Mr. Donald Bradley) Tennessee Mid-South 3-panel display of nursing care showing how efforts Regional Medical Program of physicians and nurses for superior care can be [13] achieved by vertical organization as opposed to the Washi@gton-Alaska Regional An exhibit designed to explain this program and by fragmenting effects of horizontal organization. Medical Program a special device provide the opportunity to identify (Dr. Stanley Olson) the mortality rate in the three categorical diseases in the various parts of the State of Washington and [5] compare them. Also included is an arrhythmia North Carolina Regional A cooperative exhibit indicating data on acute core- simulator which permits physicians to test them- Medical Program and nary occlusion from 44 hospitals in North Carolina. selves in diagnosis and treatment of acute cardiac Commission on Professional (Dr. Virgil Slee) problems. (Mrs. Marion Johnson) and Hospital Activities [I4] North Carolina Regional An exhibit detailing the stroke control program now [61 Medical Program in Conjunc- underway at the Bowman-Gray School of Medicine. Colorado-Wyorriing Regional A dual exhibit. One section is an exhibit which indi- tion With the National (Dr. James Toole) Medical Program cates development of this program. Combined with Institute of Neurological this will be a videotape presentation showing how Diseases and Blindness of the this program plans to use videotape units for con- National Institutes of I-Iealth tinuing education. (Mr. Robert Vestal) [151 [7] Intermountain Regional A 7-part exhibit including a description of this Heart Disease Control A dual exhibit. One is a descriptive display of the type Medical Program program; description of use of highly portable Program of National Center of work done in the Standirdization and Reference videotape recording system; illustration of this rcgioii's effort to estal3lish ;i "regen(-r@itiv(-" coii- For Chronic Disease Control Laboritories of this progriiii and location of the tiiiuiiig education program; cx@iiiiples of orgiiniz@ - laboratories participating in standardization pro- tionzil planning; visualization of importance of two grams for drugs used in treatment of heart disease. types of data collection; and demonstration of The other is a display of computer analysis of scope and method of this Region's two-Nviy ridio electrocardiograms. (Dr. Gerald Cooper) network. (Mr. Charles Akerlow) 130 [Exhibit No.] and exhibitor Description and (exhibit contact) [211 American Heart Association Materials detailing the activities of this Association as l@PJ REC,"AL they relate to Regional Medical Programs and an m@ P@ example of how a State association is working with one Regional Medical Program will be available in this exhibit area. (Miss Placide Schriever) [221 Iowa Regional Medical Diagrams showing interrelationship between this pro- Program gram and health planning groups in the region. (Dr. Willard A. Krehl) [231 Louisiana Regional Medical Dispiiy includes original drawing.,; for slide pre-scnti- tioll the (ICVC[ol)sllcllt ;Ill(l activities of A. S4i[);itict-) [241 Office of Program Planning This exhibit of maps developed by computer shows of the Surgeon General census data by small geographic area for possible use in Regional Medical Program planning. (Mr. James King, Jr.) [Exhibit No.] and exhibitor Description and (exhibit contact) [251 Mountain States Itcgion;il A visual description of the use of questionnaires to Medical 1'rogrLrii gain planning information and data from the region National Institijt(! of N(@tir(j- I-'Ixliil)it consists of iiiforiii;itioti ;iii(i ;t iii;i[) indicating for use in developing this program. (Dr. Alfred logical I)ise@@ and liliridncss the location of Stroke l@esciircii C(-,ntcr, Training Popma) of the National Institutes of Programs and Aneurysm Studies established and Health underway throughout the country. (Mr. Robert [261 Hinkel) West Virgi@a Regional A visual explanation of initial activities and people [17] Medical Program concerned in the development of the planning phase National Cancer Instittit(, of An exhibit (](!rnonstr;iting the activities ;laid location of this program. (Dr. C. L. Wilbar) tli(- N@itiori;tl Isistittit(-s of of (:(-iit(:rs ;iii(i I J(!altl) 'I'r@iiiiiiig Centers cstal3lishcd and underway through- [271 out the country. (Mrs. Pauline Wall) Division of Medical Care A3-panel exhibit visualizing automated multiphasic Administration of the Bureau screening ranging from patients themselves to the [181 of Health Services use of the computer. (Miss Grace Osgood) Bureau of Health Manpower A 3-panel exhibit describing the organization, function and activity of this Bureau and its relationship to [281 the delivery of health care. (Mr. Wayne M. Bard) American Medical Association Exhibit visualizes the areas of responsibility, available [19] resources, and other health organizations that American Cancer Society A visual display of professional educational printed should be involved with Regional Medical Programs. materials related to various types of cancer. (Mr. (Dr. Howard Doan) Walter James) [291 [20] Division of Regional Medical The standard exhibit currently being used at large Chronic Respiratory Disease Materials describing diagnosis, treatment, and related Programs national meetings and a newly developed smaller Control Program of the activities in emphysema and chronic bronchitis will easily transportable and usable replica to be made National Center for Chronic be displayed and av@iil;iljic. (Mrs. Shclic l,engcl) available for smaller local, area, and regional Disease Control meetings on request. (Mr. Frank Karel III) 131 [Exhibit No.] and exhibitor Description and (exhibit contact) [F-,xhibit letter] room exhibitor Describtion and (exhibit contact) [30) [F] Farragul Room Veterans Administration This exhibit visualizes the long-range VA hospital National Library of Medicine A demonstration of the medical television system in replacement and relocation program, providing operation from the Audiovisual Center of the some idea of future facilities that should be included National Library of Medicine in Atlanta to affiliated in regional planning. (Mr. I-Toward Armstrong) hospitals in various parts of the city. (Mr. John [311 Argyle King) Michigan Regional Medical Describing "Project Echo" (Evidence for Community [GJ,7ackson Room Program Health Organization), this exhibit visually details National Naval A demonstration of the development and use of an on-going environmental appraisal and inter- Medical Center audiovisual materials in medical education. views to assess current health status and needs of the (Ensign T. Galbreath) population of this region. (Mrs. Betty Tableman) (H) Kalorama Room Clinical Center of the A 15-rriinute film demonstrating the automated National Institutes computerized clinical laboratory of the clinical PARK SUITE ROOMS of Health center and the possible application of such a system [Exhibit letter) room exhibitor Description and (exhibit contact) to hospitals on a regional basis. TO BE GIVEN ONLY AT 3 P.M. WEDNESDAY AND THURS- [Al Bancroft Room DAY. (Dr. George Z. Williams and Dr. John California Regional Medical Display portion portrays the development of this pro- Otis) Program gram in the new University of California School of [I] Independence Room Medicine at Davis. The demonstration section shows the medical television programs being carried out L)ivision of Nursing Preliminary information and examples of instruc- at the University of California, Los Angeles. (Harry of Bureau of Health tional systems for training nurses for intensive 0. Bain and Dr. Donald Brayton) Manpower coronary care units and open heart surgery. Based upon educational projects sponsored by the Division [B] Chevy Chase Room of Nursing at Presbyterian-University of Pennsyl- Kansas Regional Medical Specially selected slide presentation of elements of this vania Hospital by Dr. Laurence Meltzer and at Program program designed to be used to inform and encourage Ohio State University by Rita Chow. (Miss Florence cooperation of various groups within this region. Reynolds) (Dr. Charles Lewis) [C] Chevy Chase Room Oklahoma Regional Medical A demonstration of the U.S. Air Force Computer- APPENDIX B Program Based Worldwide System for Continuing Medical Education-as adapted to the Oklahoma program. LISTING OF 15-MINUTE PAPERS (Col. Owen G. Birtwistle) ON REGIONAL ACTIVITIES AND IDEAS [DI DuPont Room Greater Delaware Valley A presentation of the systems analysis approach to PAPERS BY ASSIGNED NUMBER Regional Medical Program planning as utilized in this region. TO BE PRE- SENTED ON THURSDAY ONLY. (Dr. G. WEDNESDAY, JANUARY 17, 1968 Angelides) [El Edison Room Paper Wisconsin l@(.),ioll;ll M('(Ii(-;Il (I (li@il,l;ly N(,. lis@-(l if) this ;Is @t 1)@isis lol- (](.(:isiollill;lliilig on elements of opcration;)l programs. (2)'I'li(@ deinoii- I "I ],'evaluation Studi(-s Utilizing ;I Multiphasic Screen- 1:30 p@m. stration portion covers the Dial Access Mcdic@il ing Center Operating in Coopcr@ition with a Cornprclicn- Lincoln Room Library Service now in operation in this region. sive Health Care Program for Persons in an Urban Poverty East (Mr. Roy Ragatz) Area." LLOYD ELAM, M.D. (Tennessee Mid-South) 132 Paper Paper NO. Title, author, and (region) Time and location NO. Title, author, and (region) Time and location 2 "Provision of Optimum Clinic@il 1,@iboratory Services for 1 :50 P. Ill. 16 "Complementary Relationship Between Iowa Regional 2:30 p.m. :;,(100,00() I'(-oi)lt!." I)AVII) SI-"[.IGSON, M.D. (Cori- l,iiicoll) l@()t)lll M(-(Iic;tl II(-.iltli lll;iiining and Military iiccticut) East Voluntary Comprehensive I le@iltli I'laiining: A Necessary Room 3 "Biochemical Screening in Missouri." JAMES T. PACKER, 2:10 p. M. Accomplishment." JOHN C. BARTLETT, M.A., LL.B. M.D. and HUBERT J. VAN PEENEN, M.D. (Missouri) Lincoln Room (Iowa) East 17 "Problems in Developing the Role of Medical Schools in 2:50 p.m. 4 "A Regional Utilization, Patient Information and Statistics 2:30 p.m. a Regional Medical Program." VINCENT dePAUL Military System." jOf IN D. 'I'HOMPSON (Connecticut) Lincoln Room LARKIN, M.D. (New York Metropolitan) Room East 18 "The Role of a School of Public Health in Developing : p.i-n. 5 "Flanner House Multiphasic Screening Program." IIAII,- 2:50 p.i-n. Regional Medical Program." EDWARD COHART, Military VEY FEIGENBAUM, M.D. (Indiana) Lincoln Room M.D. (Connecticut) Room East 19 "Watts-Willowbrook Regional Medical Program." 1:30 p.m. 6 "Experiment to Test and Implement a Model of Patient 3:10 p.m. DONALD J. BRAYTON, M.D. (California) Hemisphere Care in Hospitals." LUTHER CHRISTMAN, pH. D. Lincoln Room Room (Tennessee Mid-South) East 20 "Council of Regional Planning Directors and Adrriinistra- 1:50 p.i-n. 7 "The Use of a Multi-Media Approach to Enhance the Learn- 1:30 p.iTi. tors." JOSEP14 J. MASON, JR. (Alabama) Hemisphere itig of Health Science Personnel." WILLIAM G. Lincoln Room Room COOPER, M.D. (Colorado-Wyoming) West 21 "Development of Relationship Between the Medical As- 2: 1 0 p.m. 8 "Use of a Telephone Network for Continuing Education." 1:50 p.m. sociation of the State of Alabama and the Alabama Hemisphere RICHARD H. LYONS, M.D. (Central New York) Lincoln RooiTi Regional Medical Program." J. 0. FINNEY, M.D. Room West (Alabama) 9 "Communication Research Unit." WILLIAM STEPHEN- 2: 1 0 p.m. 22 "The Sub-Regional Concept and Liaison Staff." WILLIAM 2:30 p.m. SON (Missouri) Lincoln Room C. SPRING, JR., M.D. and WARD BENTLEY (Greater Hemisphere West Delaware Valley) Room 10 "Community Information Coordinator." WARD L. 2:30 p.m. 23 "The Delineation of Sub-Regional Health Service Areas 2:50 p.m. OLIVER, M.D. (Albany, N.Y.) Lincoln Room as a Basic Step in Regional Medical Planning." CONRAD He@pherc West SEIPP, M.D. (Connecticut) Room I I "Development of Receptive Attitudes Toward New Ideas." 2:50 p.m. 24 "Regional Advisory Group and Review Process." 3:10 p.m. JOI IN S. GILSON, M.]-). (Intermountain) Lincoln l@ooiii CFIARLES E. LEWIS, M.D. (Kansas) 1-1@pherc West Room 12 "The Impact of RMP on Hard Core Poverty Arcas." 3:10 p.m. PAUL D. WARD (California) Lincoln Room 25 "A Proposed Circuit Postgraduate Program in Heart Disease, 1:30 p.m' West Cancer, Stroke and Related Diseases in the Oregon Thoroughbred 13 "The Role of the Voluntary I fcalth Agencies in the Regional 1:30 p.m. Region." M. ROBERTS GROVER, M.D. (Oregon) Room Medical Program in Iowa." WILLARD A. KREI-IL, Military 26 "The Information and Education Resource Support Unit." 1:50 p.m. M.D. (Iowa) Room JOHN N. LEIN, M.D. (Washington-Alaska) Thoroughbred Room 14 "Small Coiritnunity lllaiining."'I'ASKI,"I@ K. IkOlilNE'l"ri", 1:50 p.m. (Wastiington-Alaska) Military 27 "Uhusual Programs for Continuing Education of Physicians 2:10 p.m. Room at Grassroots Level." C. L. WILBAR, JR., M.D. (West Thoroughbred 15 "Coordination of Comprehensive Health Planning and 2: 1 0 p.m. Virginia) Room Regional Medical Program Activities in Western Penn- Military 28 "Community-Ccntercd Continuing Medical Education." 2:30 p.m. Sylvania, 1967." E. WAYNE MARTZ, M.D. and Room C. HILMON CASTLE, M.D. (Intcrnmoutain) Thoroughbred If OWARD I-IOUGIF (Western Pennsylvania) Room 133 pap- PAPERS BY ASSIGNED NUMBER /VO. Title, author, and (regior) Time and THURSDAY, JANUARY 18, 1968 29 "Survey of Continuing Education of the Physicians in 2:50 P.M. red Paper MetropolitanWashington."THOMASW. MATTINGLY, Thoroughb M.D., LEONARD CHIAZZE, JR., SC.D., and MAL Room No. Title, author, and (region) Time and location XAVIER (Metropolitan Washington, D.C.) 30A "Approaches to Evaluation of a Regional Medical Program." 3:10 p.m. 31 "A Study of Physician Office Practice in the Connecticut 1:30 p.m. CALDWELL B. ESSELs,rYN, M.D. (New York Metro- 'I'liorouglibr(!d l@egion." I-)ONALI) pH. 1), ,ind ORVAN W. Lincoln l@ooiyl politan) Room HESS, M.D. (Connecticut) East 30B "Systems Approach to Planning." ANGELO P. ANGEL- 1:30 p.m. 32 "Consumer Health Care Survey." LAWRTNCE J. SHARP, 1:50 p.m. IDES, M6D., LARRY McGOWAN, M.D., ARTHUR DuPont pH. D. (Washington-Alaska) Lincoln Room STANKOVICH (Greater Delaware Valley) Room East 30C "Informal Discussion on Systems Analysis." HERBERT P. 1:50 p.m. 33 "Continuum of Long Term Care in a Local li@th Service 2:10 p.m. GALLIHER, JR., pH. D. (Professor, University of DuPont Area." E. RICHARD WEINERMAN, M.D. (Connecti- Lincoln Room Michigan) Room cut) East 34 "Involvement of Local Hospitals in the Regional Medical 2:30 p.m. Program by the Appointment of Local Hospital Advisory Lincoln Room Groups." J. GORDON IIARI@OW, M.D. (Georgia) East 35 "The Regional Medical Program as a Means of Increasing 2:50 p.m. the Morale of the Fimily Doctor." ROGER BOST, M.D. Lincoln Room (Arkansas) East 36 "Community Hospital Learning Centers." FRANK M. 3: 1 0 p.m. WOOLSEY, JR., M.D. (Albany, N.Y.) Lincoln Room East 37 with a Stroke Car(-, Demonstration [Jnit." I:'iO p.TTi@ INUFEO@ l@. SMI'l@ll, M.1). (Mississil)13i) jeff(!rsoti Itootii I-'ast 38 "System for Clinical Data Collection and Analysis in I':50 p.m. Patients with Acute Myocardial Infarction." C. HILMON Jefferson Room CASTLE, M.D. (Intermountain) East 39 "Cost Benefit Analysis." JOHN E. WENNBERG, M.D. 2:10 p.m. (Northern New EnglancD Jefferson Room East 40 "CotTipreliciisiv(! Cardiovascular Care Unit." GLENN 0. 2:30 p.m. TURNER, M.D., CECIL R. AUNER, M.D. and JOHN Jefferson Room J. McKINSEY, M.D. (Missouri) East 41 "Dataphone EKG Consultation: A Model for Extension of 2:50 p.m. Medical Center Services to Community Hospitals." Jefferson Room JOHN B. HERMANN (Nebraska-South Dakota) East 42 "l,xperi(!iice. with tli(-. WARMII Mock-tip Coronary C@ir(-. 'i: IO p.m. Unit." YAI@NAI,I., M.D. (Washington- J(-fl'(7rsoll IZ()olll Alaska) E,@ t 43 "Nursing in the Regional Medical Progrinis-Alliance for 1:30 pairs Better Patient Care." I-TESTER TF-IURSTON (Kansas) Military Room 134 Paper Paper NO. Title, author, ani (regior) Time and No. Title, author, and (regior) Time and 44 "Continuing Nursing I,-,clklc,@ition Using University Hospital 1 :50 p.m. 58 "Cancer Training and Continuing Education and Com- 2:30 p.m. Nursing Servicc'l'raining Facilities." (Mrs.) MARGARET Military puterized Tumor Registry." CHARLES SMART, M.D. Thoroughbred SOVIE (Central New York) Room (Intermountain) Room 45 "f-lealth Manpower Survey of Western New York." Harry 2: 10 p.m. 59 "Assurance of Adequate Therapy Following Detection of 2:50 p.m. A. SUL'I'Z, JOHN FORTUNE, JOSEPH FELDMAN, Military Cervical Carcinoma." JOHN B. PHILLIPS, M.D. Thoroughbred SPERO MOUTSATSOS (Western New York) Room (Albany, N.Y.) Room 46 "Guest Resident Program." GEORGE ROBERTSON, 2:30 p.irl. 60 "Coordinating High Energy Radiation Therapy for 35 3: 10 P.M. M.D. (Maine) Military General Hospitals." JOHN IVES (Connecticut) Thoroughbred Room Room 47 "Continuing Education Performance Deficits." CLEMENT 2:50 p.m. BROWN, M.D. (Greater Delaware Valley) Military Room PAPERS BY TIME AND LOCATION OF PRESENTATION 48 "Skeleton Program in Continuing Education and Clinical 3: 1 0 p.m. Research." WILLIAM H. McBEATH, M.D. (Ohio Military WEDNESDAY, JANUARY 17, 1968 Valley) Room 4@) "An Experimental Model in Organization of a ltcgional 1:30 p.m. Paper Medical 1'rograrn." L@ICIIAIZD F. HAGLUND (Intcr- I lcmisphcrc Starting time 'Title, author, and (region) No. Location mountain) Room 50 "Multi-Projcct Planning." WILLIAM R. THOMPSON 1:50 p.m. 1:30 p.m. "Health Evaluation Studies Utilizing a I Lincoln Room (Washington-Alaska) Hemisphere Multiphasic Screening Center Operating East Room in Cooperation with a Comprehensive Health Care Program for Persons in an 51 "A Systems Approach to Regional Medical Program Plan- 2: 1 0 p.m. Urban Poverty Area." LLOYD ELAM, ning." DAVID II. GUSTAFSON, Pi 1. D. (Wisconsin) Hemisphere M.D. (Tennessee Mid-South) l@oom "The Use of a Multi-Media Approach to 7 Lincoln Room 52 "Development of a Regional Medical Program Data Source 2:30 p.m. Enhance the Learning of Health Science West Book." LOUISE BELL (Western Pennsylvania) Hemisphere Personnel." WILLIAM G. COOPER, Room M.D. (Colorado-Wyo@ng) )3 "Clinical Data Collection with a Purpose." HOMER 2:50 p.m. "The Role of the Voluntary Health Agencies 1 3 Military WARNER, M.D. (Intermountain) Hemisphere in the Regional Medical Program in Room Room Iowa." WILLARD A. KREHL, M.D. 54 "The Design and D@c@nation of Data Collecting Instru- 3:10 p.m. (Iowa) ments.,, LAURA G. LARSON, R.N. (Mountain States) Herrdspherc "Watts-Willowbrook Regional Medical Pro- 19 Hemisphere Room gram." DONALD J. BRAYTON, M.D. Room 55 "A Cooperative Project for the Care of Cancer Patients by 1:30 p.m. (California) Memorial Hospital for Cancer and Allied Diseases." Thoroughbred "A Proposed Circuit Postgraduate Program 25 Thoroughbred GUY F. ROBBINS, M.D. (New York Metropolitan) Room in Heart Disease, Cancer, Stroke, and Re- Room 5(@ "Cooperative Community Health Program." EDWARD 1:50 p.m. lated Diseases in the Oregon Region." M. L. BURNS, M.D. (Northwestern Ohio) Thoroughbred ROBERTS GROVER, M.D. (Oregon) Room "Systems Approach to Planning." ANGELO 30B Dupont 57 "Community Cancer Coordinator." WILLIAM P. NEL- 2: 1 0 p.m. P. ANGELIDES, M.D., LARRY Mc- Room SON, M.D. (Albany, N.Y.) Thoroughbred GOWAN, M.D., ARTHUR STANKO- Room VICH (Greater Delaware Valley) 292-414 0-68-10 135 Paper Ilaper Location Starting tiriie 'I-itle, author, and (region) No. I,oc(2tioll Starti" tirtir Title, author, and (r@@ion) No. 1: 50 p. iii. @pl.c)visioti of Optiiiiulil Clinical 1,@iborLttot-y 2 Lincoln Rooiii 2::iO p.iii. "A RegionLtl Litiliz@itioll, P@ltiel't fliforiiia- 4 I,iiicolli l@ooiii S(!rvic(.s for :3,000,000 People." ])AVID Etst tioii and Statistics Systciii." jOliN D. East St,-,I,TGSON, NI.D. (Connecticut) 1111 I()MPSON (Connecticut) "LJscofii Tel(@l)lioiicNetwork for Continuing 8 Lincoln Rooiii "Coiliiiiuiiity Iiiforittation Coordii-iator." 10 Lincoln Rooin ]'(Itic@ktioji." \VAlkl) I,. OI,IVI'l@, M.D. (Albztr)y, N.Y.) Nvc.@t l@l('IIARI) 11. 1,YONS, Nvcst M.I-). ((@cntr@it New York) '@CC)IIIPI(-Ill(.Iltllyl@(-Iiltiotisftip B(.tweclllow;l I Military "Slii@ill Coiiililuiiity Planning." 'FASKEI@ 14 Milit@irv l@cgioiiil MC(ii(:@il 1'rogi-aiii-Cojiiprc- R(@oll-I K. lkoI@INETTE (NNI@isfiiiigtoii-Al@isk@i) Rooiii liciisiv(- II(--altli Planning and Voluntary "Council of lkcgiorial Planning Directors 20 1 Icii-Lispli(-i-(@ (@oillpl-(.Ilcll@iV(' I I(-@titti Planning: A Ncces- Adiiiiiiistrator,;." JOSEPI I and Rootii ,;iry Accoii-iplisliiiiciit." J014N (@'. BAR'I'- MASON, JR. (Al;ib@tiiiii) 1,E'l"l', M.A., Lf,. B. (Iowa) "Tli(@ Itiforiii;itioii @iii(i I"(ILI(@;itiorl R(,sotirc(- SLII)-l@CgiOll@ll (ioncept and Liaison 22 1 ]('Illispll(-I-(- 2(i Thorokiglibr(!(l Support tJnit." JOIIN N. l@l,"IN, M,I). Roo[ii St;,tfl'." NVII,I,I.%M (I. SI'IkINC@, ji@., lkoolli (W@isliingtoii-Alaskii) M.D. @iii(I \,VARI) ]IFN'FLEY (Gre@iter "Tnforiiial Discussion on Systciii,; Aii@tlysis." :iOc I)Iipoiit I)el@iw@tr(, Valley) I IEIKBER'I' P. GAf,l,li]Elk, jlk., Pi 1. 1). Ikoolli "(',Olllllltlliity-(:Cllt(-rC(i Continuing M('(IiC;ll 28 llrofcssor, University of' Micliig@iii E(lu(@ittioii." IIILMON CAS'I'I,L, Roolli (Ilit(.I-Illollllt@iiii) 2: 10 p.iii. "Biocliciiii(:,il Screening in Missouri." @i l,iii(@olii Rooiii I loLls(. Scr(.(-Ilillg Pro- Lincoln l@oolli @IAMES T. I'A(]Kt,,R, M.D. and l@@ist gi-@iiii." I IARVI@IN' M.1). l,"@ist IIUBER'I' J. VAN PEI,"NEN, M.D. (Missouri) "C'oiniiiiinic@itioii Research Unit." 0 l,ill(:Olll l@ooiii of @\ttittid(-s 'I'o- I I I,iiicolll Roolli WII,I,IAM STI@llill-"NSON (Missouri) West witr(i New 1(1(,;is." J()IIN S. ('@11,SoN, "(,'oor(iiii@Ltioji of Cotiipr(-l ,I(-Ilsive II(-;iltfi 15 Milit@irv 17 Milit@ti@ l@oolli -giOn@tl M('(IiC@@l I)T-Ogr@till l@oolli ])I;tllllitlg ;Ill(i lk( S(@llools ill @t R(.@ioii;tl Nl(-(Ii(-;il Activities in W(-,;t(-rii I'ciinsyl%,@iiii@i, 10(i7." VIN(@l,,Nl' (I(-I'ALJI, I,.%I@KIN, Ni.1). I,'. WAYN l@' MAIKTZ, M.1). @111(i (Ni-w York %I(,trol)oiit;tii) ll()NIVARI) ['(-iiiisyl- of II(.;Iltil 2@; 1 S(-i-%i(-(- Ai-(,@is as @@ l@@LSiC @St('I) ill l@ooll) "I)cvclopiil(-Ilt of l@(.1@itioiisllil) li('tWc(,Ii 21 1 M(-(Iic;il I)I@tiiiiitig." (:()NI@:\I) Sl,lll)l), the Medical Asso(-i;itioii of til(- St@tt(. of Roolli ((@olill(.Ctictit) Al@it)@iiii@t @Lll(l tli(- Altl)illll@L l@(-,@ioiizii "S'lii-%(-y of, (]()Iltiiitlitig of ill(. Medical 1'rogritiii." l-'INNI@@N', M.D. I'liysici@ilis ill \I(,tl.ol)olit;iii itsiiiil@'toll." "LJiiiisii;tl I)zogi@iiiis for (@olitilitlill@ 27 1,1"()N@\l@D (@IiIAZZI@, Jl@ ;iiiki ii(-;itioll ;it (;I@ISSI'oot; l@oolli Nll.\I, X.\Vll:'1, l'i6 Paper Paper ,$'Iartin@q time 'title, author, and (r@,ion) No. Location time Title, author, and (region) No. Location "l@"xr)(-rirri(,nt to 'I'(-st ;iii(i Lincoln l@oolli 1:50 Join. "Consumer Health Care Survey." LAW- 32 Lincoln Room Mo(i(-l of I,";tst East 1,U'I'Ifl-'It Clf]tIS-I'MAN, I'll. 1). Alaska) nessc(., Mid-South) "System for Clinical Data Collection and 38 Jefferson Room "'I'hc Impact of RMP on Hard Core Pov- 12 Lincoln Room Analysis in Patients with Acute Myocar- East erty Areas." PAUL D. WARD (Cali- West dial Infarction." C. HILMON CASTLE, fornia) M.D. (Intermountain) "The Role of a School of Public Health in a 18 Military "Continuing Nursing Education Using Uni- 44 Military Room I)cvcloping lzcgional Medical Program." Room vcrsity Hospital Nursing Service Training EDWARD COIJART, M.D. (Conncc- Facilities." (Mrs.) MARGARET SOVIE ticut) (Central New York) "Regional Advisory Group and Review 24 Hemisphere "Multi-Project Planning." WILLIAM R. 50 Hemisphere Process." CHARLES E. LEWIS, M.D. Room THOMPSON (Washington-Alaska) Room (Kansas) "Cooperative Community Health Program." 56 Thoroughbred "Approaches to Evaluation of a Regional 30A Thoroughbred EDWARD L. BURNS, M.D. (North- Room Medical Program." CALDWELL B. Room western Ohio) ESSELS-1@YN, M.D. (New York Metro- politan) 2:10 p.m. "Continuum of Long-Term Care in a Local 33 Lincoln Room Health Service Area." E. RICHARD East PAPERS BY TIME AND LOCATION OF PRESENTATION WEINERMAN, M.D. (Connecticut) "Cost Benefit Analysis." JOHN E. WENN- 39 Jefferson Room THURSDAY, JANUAI@Y 18, 1968 BERG, M.D. (Northern New England) East "Health Manpower Survey of Western New 45 Military Ilaper York." HARRY A. SULTZ, JOHN FOR- Room Starting time Y'itle, author, and (region) NO. Location TUNE, JOSEPH FELDMAN, and SPERO MOUTSATSOS (Western New 1:30 p.m. "A Study of Physician Office Practice in the 31 Lincoln Room York) Connecticut Region." DONALD RIEDEL, East "A Systems Approach to Regional Medical 51 Hemisphere pH. D. and ORVAN W. HESS, M.D. Program Planning." DAVID H. GUSTAF- Room (Connecticut) SON, M.D. (Wisconsin) "I-'xp(@ri(@nc(@s witli;tStrok(@ 1)(!tiiotistr;t- 7 Jcfr(@rson ltooti@l 57 Thoroughbred "Community Cancer Coordinator." WIL- tiori Unit." l@. SMI'I'L 1, M.D. I-l;ist LIAM P. NELSON, M.D. (Albany, Room (Mississippi) New York) "Nursing in the Regional Medical Programs- 43 Military Room Alliance for Better Patient Care." II ESTER 2:30 p.m. "Involvement of Local Hospitals in the 34 Lincoln Room THURSTON (Kansas) Regional Medical Program by the Ap- East "An Experimental Model in Organization of 49 1 lemisplierc pointment of Local Hospital Advisory a Regional Medical Program." RICHARD Room Groups." J. GORDON BARROW, M.D. F. HAGLUND (Intermountain) (Georgia) "A Cooperative Project for the Care of Can- 55 Thoroughbred "Comprehensive Cardiovascular Care Unit." 40 Jefferson Room cer Patients by Memorial Hospital for Room GLENN 0. TURNER, M.D., CECIL R. East Cancer and Allied Diseases." GUY F. AUNER, M.D., and JOHN J. McKINSEY, ROBBINS, M.D. (New York Metropolitan) M.D. (Missouri) 137 Paper APPENDIX C Starting time Title, author, and (region) ivo. Location i,js,i'ING Ol,' I'Ai@'ricli'AN't'S ANI) I,OCA'I'l ON Ol-' DISCUSSION GI@OUI'S 2:30 p.rii. "Gu(@st lzcsident 1'rogr@iiii." GI-"OIZGI" 4(; Milit@it-y Wl,"I-)NI@SI)AY, JANUAI@Y 17 IZO]31@"IZTSON, M.]). (N4;iine) Izooril "Development of a l@giotial Medical Pro- 52 1 I(,-inispliere SI-',.SSION I-DISCUSSION GL@OUI'S 3:45-5:15 p.m. grant Data Source Book." LOUISE BELI, l@oorn (Western Pennsylvania) I.incoln l@oom East "Cancer Training and Continuing Educa- 58 Thoroughbred 'I'OPIC A "Health Manpower-lZcview of Commission Report" tion and Computerized Tumor Registry." Izoom CHARLES SMART, M.D. (Intermoun- Moderator: *JAMES C. CAIN, M.D., tain) Consultant in Medicine, 2:50 p.m. "The Regional Medical Program as a Means 35 Lincoln ]@oorn The Mayo Clinic, of Increasing the Morale of the Family East l@oclicster, Minn. Doctor." ROGER BOST, M.D. (Ar- Discussants: LEONAIZD FENNINGER, M.D., kansas) Director, Bureau of Health Manpower, "Dataphone EKG Consultation: A Model 41 Jefferson Room Public I-Icalth Service. for Extension of Medical Center Services East ELEANOR LAMBERTSON, ED.D., to Community Hospitals." JOHN B. Director, Division of Nursing Education, HERMANN (Nebraska-South Dakota) Teachers' College, "Continuing Education Performance Dcfi- 47 Military Columbia University, cits.11 CLEMENT BROWN, M.D. Room New York, N.Y. (Greater Delaware Valley) C. l@l. WILLIAM RUIIE, M.D., "Clinical Data Collection with a Purpose." 53 Hemisphere Director, Division of Medical Education, HOMER WARNER, M.D. (Intermoun- Room American Medical Association, tain) Chicago, Ill. "Assurance of Adequate Therapy Following 59 Thoroughbred *DWIGHT WILBUR, M.D., Detection of Cervical Carcinoma." JOHN Room President-Elect, B. PHILLIPS, M.D. (Albany, New York) American Medical Association, 3:10 p.m. "Experience with the WARMP Mock-up 42 Jefferson Room San Francisco, Calif. Coronary Care Unit." STEPHEN YARN- East ALL, M.D. (Washington-Alaska) Recorder: CECILIA CONRA,rij, Assistant to Chief, "Community Hospital Learning Centers." 36 Lincoln Room Continuing Education and Training Branch, FRANK M. WOOLSEY, JR., M.D. East Division of Regional Medical Prograrm. (Albany, New York) "Skeleton Program in Continuing Educa- 48 Military Room *Members of the National Advisory Commission on Health Manpower. tion and Clinical Research." WILLIAM H. McB EATH, M.D. (Ohio Valley) "The Design and Dissemination of Data 54 Hemisphere Collecting Instruments." LAURA G. Room LARSON, R. N. (Mount-,tin States) "Coordinating High I,"n(!rgy lt;tcli;ttiori (;o 'I'liorOLlglil)r(-d Therapyfor35Gcncralliospit;ils."JO]IN ltoor-n IVES (Connecticut) Military Room Lincoln Room West TOPIC B "Regionalization" TOPIC C "Urban Problerm" Moderator: ROBERT SIGMOND, Moderator: PAUL WARD, Executive Director, Executive Director, Hospital Planning Association of Allegheny County, California Committee on Regional Medical Programs, Pittsburgh, Pa, San Francisco, Calif. Discussants: LESTER BRESLOW, M.D., Discussants: ROGER 0. EGEBERG, M.D., Professor of Health Administration and Chairman, Dean, School of Medicine, Health Services Division, University of Southern California, School of Public Health, Los Angeles, Calif. University of California at Los Angeles, FRANK LLOYD, M.D., Los Angeles, Calif. Director of Research, WALTER J. McNERNEY, Methodist Hospital of Indiana, Executive I)ir(@-ctor, Indianapolis, Ind. Blue Cross Association, ANNE R. SOMERS, Chicago, 111. Industrial Relations Section, WILLIAM R. WILLARD, M.]D., Princeton University, Vice President, Princeton, N.J. University of Kentucky Medical Center, RAY TRUSSELI,, M.D., lexington, Ky. Director, School of Public Health and Ad@nistrative Medicine, l@ecordcr: ROI-AND PETERSON, Columbia University, Chief, Planning Branch, New York, N.Y. Division of 1-tcgional Medical Programs. Recorder: STEPHEN ACKERMAN, Associate Director for Planning and Evaluation, Division of Regional Medical Programs. 139 Hemisphere Room Thoroughbred Room TOPIC D "Related Federal Programs" TOPIC E "Health Services Research" Moderator: PAUL SANAZARO, M.D., Moderator: DANIEL 1. ZWICK, Director, Division of I'citicttion, Associate Director for Program M;tii;tg(@rn(-.rit, Health Services Office, Association of American Mt!(Ii(:;tl (,'oll(-g<-s, Community Action Program, l,"v@iiistoli, 11). Office of Economic Opportunity. Discussants: MORRIS E. COLLEN, M.D., Discussants: JOHN W. CASHMAN, M.D., Director, Director, Division of Medical Care Administration, Department of Medical Methods Research, Bureau of Health Services, The Permanente Medical Group, Public I-leiltli Service. Oikian(l, Calif. @JAMI,'S 11. (:AVANAU(;] I, I'] I. 1)., Associate I)it-(@(@tor, Director, Office of Comprehensive I le-.iltli Planning, New York Metropolitan Regional Medical Program, Office of the Surgeon General, New York, N.Y. Public Health Service. DONALD R. CHADWICK, M@D., JOHN THOMPSON, Director, National Center for Chronic Disease Control, Professor of Public Health and Director, Bureau of Disease Prevention and Environmental Control Program in Hospital Administration, Public 1-teiltli Service. School of Public I-le@ilth, Yale University, CAIZI@tJ'I'll %VA(;Nl-"It, M.1),, N(-w I I:iv(-ii, (:o[iii. I)ir(-ctot-, Iiiit-(-;iti of I [,-;title S(-rvi(-4-.%, I,ul)lic Health Service. J()I IN Wil.1,IAMSoN, M.D., Division of Medical Care and Hospitals, Recorder: LEROY GOLDMAN, The Johns Hopkins University School of Hygiene and Public Health, Program Policy Specialist, Baltimore, Md. Division of Regional Medical Programs. Recorder: RICHARD MANEGOLD, M.D., Associate Director for Program Development and Research, Division of Regional Medical Programs. 140 THURSDAY, JANUARY 18 SESSION 11-DISCUSSION GROUPS 3:45-5:15 p.m. Jefferson Room East Thoroughbred Room I-' "(-:ontiriiiinc,, F@"cltj(7;itioi) ;if)(I l@'or Wll;it@" ('oil(-(7tioii ;iii(I IZ(,gistri(-s" Alt]ZAI IAM NI. [,[ I,l (:oll(.g(., Scliool of I lygiciie, @iii(i I)tiblic I lealtli, Philadelphia, Pa. Johns Hopkins University, Discussants: LUTFIER CHRISTMAN, Ph. D., Baltimore, Md. Dean, School of Nursing, Discussants: JAMES F. KING, JR., Vanderbilt University, Office of Program Planning and Evaluation, Office of the Surgeon General, Public Health Service. f)it(--(,t(jr, Offi(:(! in M(-(Jic;il l-'Iduc@itioii, ANI)I@l@'W MAYI,'R, M.D., University of Illinois, Assistan; Director,' Chicago, Ill. American College of Surgeons, Chicago, Ill. A. N. TAYLOR, Ph. D., HARVEY SMITH. Ph. D., Dean, School of Related Health Services, Director, Research, Survey and Evaluation, Chicago Medical School, University of North Carolina, Chicago, Ill. Chapel Hill, N.C. Recorder: ALEXANDElk M. SCHMIDT, M.D., JOHN E. WENNBERG, M.D., Chief, Continuing Education and Training Branch, Coordinator, Division of Regional Medical Programs. Northern New England Regional Medical Program, Burlington, Vt. Recorder: MAURICE E. ODOROFF, Assistant to the Director for Health Data, Division of Regional Medical Programs. 141 Military Room Lincoln Room East TOPIC H "Hospitals" TOPIC j "Operational Program Development" Moderator: D. EUGENE SIBERY, Moderator: CHARLES E. LEWIS, M.D., Executive Director, Coordinator, Greater Detroit Area Hospital Council, Kansas Regional Medical Program, Detroit, Mich. Kansas City, Kans. Discussants: PEARL FISHER, R.N., Discussants: C. HILMON CASTLE, M.D., Administrator, Coordinator, Thayer Hospital, Intermountain Regional Medical Program, Waterville, Maine. Salt Lake City, Utah. JOHN W. KAUFFMAN, T. A. DUCKWORTH, Administrator, Chairman, Regional Advisory Group, Princeton Hospital, Wisconsin Regional Medical Program, Princeton, N.J. Wausau, Wis. EDWARD H. NOROIAN, ALBERT E. HEUSTIS, M.D., Executive Director, Coordinator, Presbyterian University Hospital, Michigan Regional Medical Program, Pittsburgh, Pa. East Lansing, Mich. Recorder: RICHARD MANEGOLD, M.D., Associate Director for Program Development and Research, DONAL R. SPARKMAN, M.D., Division of Regional Medical Programs. Coordinator, Washington-Alaska Regional Medical Program, Hemisphere Room Seattle, Wash. TOPIC I "Community Involvement" l@ecorder: RICHARD STEPHENSON, M.D., Moderator: ROBERT M. CUNNINGHAM, JR., Associate Director for Operations, Editor, Division of Regional Medical Programs. Modern Hospital Magazine, Chicago, Ill. Discussants: ALAN C. DAVIS, Science Editor, American Cancer Society, New York, N.Y. HOWARD ENNES, M.P.H., Assistant Vice President for Community Services and Health Education, The Equitable Life Assurance Society, New York, N.Y. PIERRE C. FRALEY, Director of Information, Greater Delaware Valley Regional Medical Program, Philadelphia Pa. MARC J. @USSER, M.D., Coordinator, North Carolina Regional Medical Program, Durham, N.C. Recorder: EDWARD M. FRIEDLANDER, Assistant to the Dircctorfor Communications and l'ublic Information. Division of Regional Medical Programs. 142 APPENDIX 2 APPENDIX 3 ANDERSON, Philip C., M.D. Special Assistant to the Director National Institutes of Health COORT)INATORS' STEERING RI'GISTERED CONFERENCE ANDREWS, Neil C., M.D. COMMITTEE I'AIZ'rlCll"AN'I'S Coordinator REGIONAL MEDICAL Ohio Valley Regional Medical Program PROGRAMS ANGELIDES, Angelo P., M.D. ABDELLAH, Dr. Faye G. Director of Medical Education Chief, Research Grants Branch The Lankenau Hospital of Philadelphia Division of Nursing Greater Delaware Valley Regional STANLEY W. OLSON, M.D., J. MINOTT STICKNEY, M.D., Public Health Service Medical Program (Chairman) Program Coordinator, Program Coordinator, Tennessee Northlands Regional ADAMS, Wright, M.D. ARBONA, Guillermo, M.D. Mid-South Regional Medical Program Medical Program, Executive Director Professor of Preventive Medicine and Professor of Medicine, Rochester, Minn. Illinois Regional Medical Program Public Health School of Medicine Vanderbilt University, PAUL D. WARD, AKERLOW, Charles W. University of Puerto Rico Nashville, Tenn. Program Coordinator, Director, Media Services C. HILMON CASTLE, M.D., California Regional Intermountain Regional Medical Program AREND, William P., M.D. Medical Consultant Program Coordinator, Medical Program, ALEXANDER, Chauncey A. Heart Disease Control Program Intermountain Regional Medical San Francisco, Calif. Assistant Director for Program Public Health Service Program, Development-Area IV Associate Dean and Chairman, University of California, Los Angeles ARRINGTON, Clifton W., M.D. Department of Postgraduate Education, California Regional Medical Program Meharry Medical College University of Utah, ALLRED, J. D., M.D. Mid-South Tennessee Regional Medical Salt Lake City, Utah. Program Assistant Coordinator JAMES T. I IOWEI,L, M.D., Maryland Regional Medical Program ARTZ, Invelda M. Member, National Advisory Council AMOS, James R., M.D. Nurse Consultant Heart Disease Control Program on Regional Medical Programs, State Health Department of North Public Health Service Executive Director, Dakota Henry Ford Hospital, North Dakota Regional Medical ASTON, Lydia S. Detroit, Mich. Program Public Health Advisor MARC J. MUSSER, M.D., ANDERSON, Elmer A., M.D. Regional Medical Program West Virginia University Medical Center Program Coordinator, Medical Director North Carolina Regional Medical John Wesley Hospital ATCHLEY, William A., M.D. Program, Los Angeles County Department of Assistant Area Coordinator Durham, N.C. Hospitals California Regional Medical Program WILLIAM C. SPRING, JR., M.D., ANDERSON, H. William University of California School of Program Coordinator, Assistant Director Medicine Greater Delaware Valley Arkansas Regional Medical Program ATTIS, Bari Regional Medical Program, ANDERSON, Ivan D. Information Specialist Wynnewood, Pa. Director of Research National Institute of Neurological Kansas Blue Cross-Blue Shield Diseases and Blindness Kansas Regional Medical Program National Institutes of Health ANDERSON, Otis L., M.D. BACASTOW, Merle S., M.D. Assistant Manager President Washington, D.C., Office of American Medical Care Development, Inc. Medical Association Maine Regional Medical Program 143 BAILEY, David R. BATES, Roswell P., D.O. BERRY, Albert G. BOQUIST, William Program Analyst Executive Director Instructor Information Coordinator Program Planning and Evaluation Maine Osteopathic Association Department of Oral Pathology California Regional Medical Program Office of the Surgeon General Regional Advisory Group Meharry Medical College Public Health Service Maine Regional Medical Program BORHANI, Nemat O., M.D. BERSON, Robert C., M.D. Professor of Medicine and BAIN, H. 0. BAUMGARTNER, Leona Executive Director Chairman, Department of Communitv is) Professor of Social Medicine Association of American Medical Colleges Health Community Relations, California (Dav . Regional Medical Program Harvard Medical School BINGHAM, Fletcher H. School of Medicine University of California at Davis BEASLEY, Steven E. Assistant Director University of California at Davis BAKER, John G. Science Writer Council of Teaching Hospitals BORLAND, Jack Public Relations Counsel National Institute of Neurological Diseases Association of American Medical Colleges Manager, Services Department Wisconsin Regional Medical Program and Blindness BIRCH, Larry H., M.D. Smith, Kline and French Laboratories National Institutes of Health BARD, Wayne M. Program Director BOST, Howard L., Ph. D. Information Officer BECI-IILL, Williirri D. Michigan Regional Medical Program Ohio Valley Regional Medical Pro ram Commissioner 9 Bureau of Health Manpower Administration on Aging BLACK, Louis A., M.D. Assistant Vice President for Program Public Health Service Social and Rehabilitation Service Assistant Program Coordinator and Policy Planning BARNES, Donald R. U.S. Department of Health, Education, Northwestern Ohio Regional Medical University of Kentucky Medical Systems Development and Welfare Program BOST, Roger B., M.D, Laboratory BEDWEI,I,, Maj. Gen. T. C., Jr. BI,AKE, Thomas M. I)ir(-(@tor Heart Disease Control Program I3irector of StifT (,i,or(liriator for Heart Ai-k;irisas Rr-gionil M(,(Ii@il Program National Center for Chronic Disease Assistant Secretary of Defense Mississippi IZ(@gi<)nal M(,(Ii(-ii] I)rogy-@tiii Control Health and Medical 13LAKI-'Y, Thelma M. liOUCIIARD, Richard E., M,D@ Public Health Service Assistant Professor of Medicine BELL, Louise M. Ilea] tli I-dLicator University of Vermont BARNHART, Gilbert R., M.D. Research Associate American Cancer Society Director of Coronary Care Program Bureau of Health Services Western Pennsylvania Regional BLASINGAME, J. T., Jr., M.D. Northern New En land Regional Medical Public Health Service Medical Program Member Advisory Group Program 9 BARR, Daniel M. BENJAMIN, Clement Georgia Regional Medical Program BOWMAN, C. W. University of Missouri Assistant Chief BLAZER, Mrs. Rexford S. Program Representative School of Medicine Educational Studies and Development Vice Chairman, Regional Advisory Group South Carolina Regional Medical Program BARROW, J. Gordon, M.D. Section Ohio Valley Regional Medical Program Director National Medical Audiovisual Center BOYDEN, George M. Atlanta, Ga. BLESS, Stuart R., M'D, Chairman, Education Committee Georgia Regional Medical Program Assistant Chief, Coronary Section New Mexico Regional Medical Program BENTLEY, Ward Heart Disease Control Program BARTLETT, John C. Chief, Area Liaison National Center for Chronic Disease BOYLE, Richard E., M.D, Assistant Program Coordinator Greater Delaware Valley Regional Control Department of Continuing Education Iowa Regional Medical Program Medical Program U.S. Department of Health, Education, Colorado-Wyoming Regional Medical Program BASALYGA, R. G., M.D. BERNSTEIN, Arthur, M.D. and Welfare Chief, Program Development Section Cardiac Program BLOOM, Cliarlotte BRAUNSTEIN, Norman W. Heart Disease and Stroke Control New Jersey Regional Medical Program Information Specialist Public Health Advisor Program Bureau of Health Manpo%%-er Chronic Respiratory Disease Program Public Health Service BERNSTEIN, Lionel, M.D. Acting Assistant Chief Public Health Service Public Health Service BATES, Barbara, M.D. Medical Director for Research and BOHANNON, Richard L., M.D. BRAWNER, Donald L. Rochester (New York) Regional Medical Education Former Surgeon General Chairman, Tulsa Subregional Committee Program Veterans Administration U.S. Air Force Oklahoma Regional Medical Program 144 BRAYTON, Donald, M.D. BROWNING, Levi M., M.D. CALDWELL, Dale CHAMBERS, J. W., M.D. Coordinator for Alaska Director of Information Program Coordinator Coordinator-Area IV at Los Angeles Washington-Alaska Regional Medical Oregon Regional Medical Program Georgia Regional Medical Program University of California California Regional Medical Program Program CALLAHAN, Thomas E. CHAMBLISS, Cleveland R. BRUCE, Dr. Harry Regional Advisory Group Office of Program Planning BRENNAN, Michael J., M.D. Ilresident, Michigan Cancer Foundation Chief, Manpower and l@"ducation Western Pennsylvania Regional Medical Office of the Director Division of Dental Health Program National Institutes of Health Professional Advisory Committee on Public Health Service CAMPBELL, Guy D., M.D. CHAPMAN, Carleton B., M.D. Cancer Regional Advisory Board BRYAN, James E. Coordinator Dean Michigan Regional Medical Program Executive Secretary Mississippi Regional Medical Program Dartmouth University Medical School American Federation for Clinical Research BRESLOW, Lester, M.D. CANNON, Wilson P., Jr. CHASE, Beatrice A. Professor of Health Administration BUCCI, Barbara Echols Chairman, Regional Advisory Group Director, Services Community Planning Chairman, If(--attli Services Division Research Assistant Hawaii Regional Medical Program for Nursing S(@llool of Ptll)li(: ll(!@lltli 'I'lic Johns I lol)kins University Senior Vice President National League for Nursing Uriivf-rsity of I)ef)artni(!rit of Medical Care Hospitals Bank of Hawaii CFIATTERJEE, Manu, M.D. BRICKER, Sandra BUCHER, Robert, M.D. CARPENTER, Robert R., M.D. Program Coordinator Editorial Assistant Dean, Temple University Institutional Liaison Officer Maine Regional Medical Program Ohio Valley Regional Medical Program School of Medicine Baylor University College of Medicine CHRISTMAN, Dr. Luther BURK, Lloyd B., Jr., M.D. CARSON, Bruce F. Dean, School of Nursing BRINKLEY, Sterling B., M.D. Metropolitan Washington, D.C. Chief, Legislative Reference and Liaison Vanderbilt University Chief Medical Officer Regional Advisory Group Branch CICARELLI, Sara Marie Rehabilitation Services Administration BURNEY, Anita W., M.P.1-1. Office of Program Planning U.S. Department of Health, Education, President- ect and Welfare Health Services Advisor National Institutes of Health American Society of Medical Technologists U.S. Department of Housing and Urban CASELEY, Donald J., M.D. CLAMMER, George R., M.D. BROIDA, Joel H. Development Vice Chairman, Regional Advisory Group Associate Coordinator for the State of Physical Therapy Consultant BURNS, Edward L., M.D. Illinois Regional Medical Program Pennsylvania Heart Disease and Stroke Control Chairman, Regional Advisory Group Medical Director and Associate Dean Greater Delaware Valley Regional Program Northwestern Ohio Regional Medical University of Illinois Hospitals Medical Program Public Health Service Program CASTLE, C. Hilmon, M.D. CLARK, Henry T., Jr., M.D. BROOKS, Fredrica BURTON, Marvin H. Program Coordinator Program Coordinator Public Relations Director Physician Education Coordinator Intermountain Regional Medical Program Connecticut Regional Medical Program New York Metropolitan Regional Medical New Jersey Regional Medical Program CAVANAUGH, James H., Ph. D. CLARK, John Kapp, M.D. Program BUTLER, Josephine Director of Comprehensive Health Chief, Regional Medical Program Activi- n BROWN, Charles E., M.D. Washington, D.C., Tuberculosis Planning ties President Association Office of the Surgeon General University of Pennsylvania Charles Drew Medical Society BYRON, T. X., M.D. Public Health Service CLARK, Sister M. Ferdinand California Regional Medical Program Medical Representative CAZORT, Ralph J., M.D. Chairman, Subcommittee on Community Postgraduate Programs Involvement BROWN, Charles R. California Regional Medical Program Dean Regional Medical Program of Western Administrative Assistant CAIN, James C., M.D. Meharry Medical College Pennsylvania Indiana University Medical Center Consultant in Medicine CHADWICK, Donald R., M.D. Administrator of Mercy Hospital of BROWN, Clement R., Jr., M.D. The Mayo Clinic Director, National Center for Chronic Pittsburgh Director of Medical Education CALDWELL, Charles W. Disease Control CLEMENT, Edward C. Chestnut Hill Hospital Director, Program Development and Field Bureau of Disease Prevention and Administrative Services Department Greater Delaware Valley Regional Services Environmental Control North Carolina Regional Medical Medical Program Iowa Regional Medical Program Public Health Service Program 145 COBB, Alton B., M.D. COOK, Ernest W., Ph. D. CROCKETT, Charles L., Jr., M.D. DAVID, Wilfred, M.D, Chairman, Regional Advisory Group Medical Care and Education Foundation Consultant, Continuing Education and Deputy Director Mississippi Regional Medical Program Rhode Island Regional Medical Program Regional Planning National Center for Chronic Disease Director, Division of Chronic Illness COOLEY, George W. Virginia Regional Medical Program Control State Board of Health Medicil Society of the District of Roanoke Memorial Hospital liur-(-@iu of Discis(@ 1'revcntion tnd COCCESFIALL, Lowell T., M.D. Columbia CROSS, l,'Idwai-d B., M.D. Environmental Control Vice President Chief, Adult Heart Control Section Public Health Service University of Chicago COOPER, Gerald R., M.D. Heart Disease Control Program DAVIES, Dean F., M.D. Chief, Heart Disease Control Standardi- Public Health Service Memphis Regional Medical Program COHART, Edward M., M.D. zation Laboratory Professor of Public Health National Communicable Disease Center CROSWHITE, Margaret D. DAVIS, Alan C. Yale University Department of Epidemi- in Atlanta Office of Communication Science Editor ology and Public Health COOPER, Henry R., M.D. Alabama Regional Medical Program American Cancer Society COHN, Roy, M.D. Member, Regional Advisory Group CROUCH, Boyden L. DAVIS, Burnet M., M.D. Chairman, Stanford-Area III Florida Regional Medical Program Coordinator of Communications and Research and Training Division Regional Medical Programs COOPER, Theodore, M.D. Continuing Education National Library of Medicine Stanford University Medical Center Associate Director Arizona Regional Medical Program Public Health Service COLE, Clifford H., M.D. National Heart Institute Research Assistant, University of Arizona DEAN, C. Robert, M.D. Chief, Neurological and Sensory Disease National Institutes of Health School of Medicine Associate Regional Health Director- Control Program CROW, Harry R. Region II COOPER, William G., M.D. Sales Manager New York Metropolitan Regional Medical Public Health Service Director, Unit Teaching Laboratories Wilson Gill, Incorporated Program COLEMAN, James Walker, III University of Colorado Medical Center Program Representative COPELAND, Murray M., M.D. CROW, Richard S., M.D. DEARING, W. Palmer, M.D. Medical Officer Executive Director South Carolina Regional Medical Associate Director National Center for Chronic Disease Group Health Association of America, Program M.D. Anderson Medical Hospital and Control Inc. Medical College of South Carolina Tumor Institute Texas Medical Center Public Health Service DEBAKEY, Michael E., M.D. COLLEN, Morris E., M.D. CUGLIANT, Anne Professor and Chairman, Department of Director, Department of Medical Methods CORNELY, Paul B., M.D. Staff Coordinator, Data and Research Surgery Research Head, Department of Preventive New York Metropolitan Regional Medical College of Medicine, Baylor University The Permanente Medical Group Medicine Program Division of Regional Medical Programs COLLINS, William T., M.D. Howard University CULBERTSON, James W., M.D. Advisory Council Secretary, Regional Advisory Group CRAYTOR, Josephine K., R.N. Program Coordinator DeGRASSEi Richard V. Northwestern Ohio Regional Medical Rochester (New York) Regional Medical Memphis Regional Medical Program Program Manager Program Program Northern New England Regional Medical Lima Memorial Hospital University of Rochester CUNNINGFIAM, Robert M., Jr. Program CREVASSE, Lamar, M.D. Editor, Modern Hospital Magazine COMBS, Robert C., M.D@ Chicago, 111. Del GUERCIO, Marie T., R.N. Area Director, Irvine@Area VIII North Central Florida Subarea Health Education Coordinator California Regional Medical Program Coordinator DAITZ, Bernard D., M.D. New Jersey Regional Medical Program CONNOLLY, Eleanor C. Florida Regional Medical Program Special Assistant to the Chief Del REGATO, Juan A., M.D. College of Medicine Division of Medical Care Administration Director, Penrose Cancer Hospital of Consultant University of Florida Ptil)li(: Health Service Colorado Springs National Tuberculosis Association K(@ritictli ]@., M.D. I)ANI-'Olt'I'll, William 11., M.D. National Advisory Carit:t-r Council CONNOLLY, J<)Iin'l'. Meiril)(!r, l@'xecutive Committee Vice Cliaii(@elloi- for Medical Affairs DEMARIA, William J., M.D. Staff Co-)rdinator, Program Development Virginii Regioriil Medical Program Wisfiington University, St. Louis I)irt,(@tor, Continuing Education New York Metrol)olitin Regional M(-(Iicil University of Virginia Medical l'i-ogriiii Coordinator North Carolina Regional Medical Program School Bi-State Regional Medical Program Program 146 DENTON, I larriet A. I-DDINGER, John W. ESCOVITZ, Gerald I-I., M.D. FEARN, James A. I)ir(@(:tor of Information Acting Chief, Continuing Education Field Representative Public Health Service Maryland Regional Medical Program Branch Susquehanna Valley Regional Medical U.S. Department of Health, Education, I-"Dl,"N, Raymond I,. Division of Physician Manpower Program and lvclfare California Regional Medical Program Bureau of Health Manpower FEIGENBAUM, Harvey, M.D. DIE]@'ENBACH, Viron L., 1).D.S. Public Health Service Indiana Regional Medical Program Regional Advisory Groul) Director, Division of Dental Health I-'Ixccutive Director, California Heart ESSELSTYN, Caldwell B., M.D. Associate Professor Public Health Service Association Associate Director Indiana University Medical Center DIETZ, J. Herbert, Jr., M.D. New York Metropolitan Regional Medical FENNINGER, Leonard D., M.D. EDWARDS, Jesse E., M.D. Program Consultant in Rehabilitation Mcclicine , President Director Ne@%, York University Medical Center anci American Heart Association ESTES, E. Harvey, Jr., M.D. Bureau of Health Manpower Memorial Hospital Center Director, Community Health Sciences Public Health Service DOAN, Howard W., M.D. Charles T. Miller Hospital Duke University Medical Center FETTER, Franklin C., M.D. Director EGEBERG, Roger O., M.D. ETHRIDGE, Clayton B., M.D. South Carolina Regional Medical Colorado-Wyorning Regional Medical Dean Chairman, Regional Advisory Group Program Program University of Southern California Associate Dean, George Washington Dean, Medical College of South Carolina DRISCOLL, Dr. Edward J. School of Medicine University Hospital FIELDS, Cleo Associate Director for Extramural EHRLICH, Frank EVANS, Lester, M.D. Rochester, New York Regional Medical Programs Chief, Budget Management, Section 11 Associate Director (Education) Program National Institute of Dental Research Financial Management Branch Connecticut Regional Medical Program Heart Disease and Stroke Control Program American Society of Oral Surgeons Office of Administrative Management EVANS, Lloyd, M.D. Public Health Service DitBEAU, Normand National Institutes of Health Office of the Dean, College of Medicine FINNEY, J. O., M.D. Ohio State University Associate Director Assistant Director, Information and Corn- ELAM, Lloyd, M.D. EYMANN, Carolyn Alabama Regional Medical Program munications President l,nfon-nation Services FISHER, F. David, M.D. Missouri Regional Medical Program Meharry Medical College Kansas Regional Medical Program Office of the Dean DUCKWORTH, T. A. ELDER, Jerry 0. FAHS, Ivan J., Ph. D. College of Medicine Chairman, Regional Advisory Group Assistant Director, Survey and Planning Medical Sociologist Ohio State University Wisconsin Regional Medical Program Oregon Regional Medical Program Minnesota Regional Medical Program Employers Insurance of Wausau FALK, Leslie A., M.D. FISHER, Pearl R., R.N. DUKE, Arnold ELLWOOD, Paul M., Jr., M.D. Tennessee Mid-South Regional Medical Administrator Planning Assistant Executive Director Program Thayer Hospital of Waterville, Maine Oklahoma Regional Medical Program Aineric;tn Rehabilitation I,'oundation Chairman, Department of Community FISK, Shirley C., M.D. i@AS'I'WOOD, ]Zi(@tiar(l,r., I)li.D. I-,NI)ICOTI', K(@rinctli M., M.D. Health New York Metropolitan Regional Medical I Meli;irr-y Medical College Program Executive Vice President Director Texas Medical Center, Inc. National Cancer Institute FARBER, Sidney, M.D. Columbia University College of Physicians National Institutes of Health President-Elect and Surgeons EBERLY, Annette American Cancer Society FITZ, Reginald M.D. Assistant to the Assistant Director for ENNES, Howard, M.P.H. Director of Research I Public Education Information Assistant Vice President Children's Cancer Research Foundation Program Coordinator %lissouri Regional Medical Program I-'Iquitable Life Assurance Society FAUBER, John, D.D.S. New Mexico Regional Medical Program Secretary, Council on Hospital Dental Dean, School of Medicine ECKBERG, D@vain L., M.D. ERICKSON, Frederick K. Service University of New Mexico Scientist Administrator Acting Director Division of Research Facilities and Division of Allied Health Manpower American Dental Association FLAGLER, Philip B. Resources Bureau of Health Manpower FAZEKAS, Joseph F. Service Manager National Institutes of Health Public Health Service New Mexico Regional Medical Program Smith, Kline and French Laboratories 147 FLANDERS, Sarah E., M.D. FRANCIS, John O'S. GILSON, John S., M.D. GREEN, Jerome G., M.D. Assistant Visiting Physician Executive Office of the President Associate Coordinator Associate Director for Extramural Goldwater Memorial Hospital Bureau of the Budget Intermountain Regional Medical Program Programs New York University Medical Center FREDRICKSON, Donald S., M.D. University of Utah Medical Center National Heart Institute FLANNAGAN, William H. Director, National Heart Institute GLOVER, Homer B. National Institutes of Health Member, Executive Committee on National Institutes of Health Area Liaison Officer GREENE Charles R., M.D. Regional Medical Programs FRIEDRICH, Rudolph H., D.D.S. Greater Delaware Valley Regional Goordinatr, Downstate Medical Center Roanoke Memorial Hospitals Chairman, Department of Oral Surgery Medical Program State University of New York New York Metropolitan Regional Medical FLEISHER, Daniel S., M.D. Columbia University GOLDSMITH, Katherine I,. Program Associate Professor of Pediatrics American Society of Oral Surgeons Assistant Director - Area VII I CRIFI-'I'I'll, John 1-1. Temple University School of Medicine Chairriian, Committee on Regional California Regional Medical 1'rograrn Research Associate FLEMING, George M., Ed.D. Medical Programs GOODHART, Robert S., M.D. Commission on Professional and Hospital Director/Coordinator, Allied Health FULLARTON, Jane Evalyn Coordinator, New York Academy of Activities Texas Regional Medical Program Assistant Chief, Legislative BrLncli M(-.di(@iri(! C;RTZZLE, Claude O., M,D, Methodist Hospital Office of Progrztrn I)Ianning New York Metropolitan Regional Medical I)irt-i7tor, Wyoming Division Baylor University College of Medicine Natiori;tl Itistittit(-s of Ife@tIL]i 1'rograrri Mountain States Regional Medical Pro- FLORIN, Alvin A., M.D. GAINES, Barbara, R.N. COTO, Unoji, M.D. gram Assistant Director Acting Coordinator Continuing Education Chairman, Heart Advisory Committee GRONVALL, John A., M.D. New Jersey Regional Medical Program Oregon Regional Medical Program President, Hawaii Heart Ass(>ciation Associate Director and Associate Dean University of Utah Medical Center FOLEY, Joseph M., M.D. GALLIHER, Herbert P., Jr., Ph. D. GOTTOVI, Daniel, M.D. Co-Chairman, Coordinators' Steering Coordinator of Postgraduate Medical Professor of Industrial Engineering Medical Consultant Committee Education and Professor of Neurology The University of Michigan Heart Disease and Stroke Control Pro- Conferencc-Worksh<)p on Regional Medi- Case Western Reserve University School GANZ, Aaron, D.D.S. gram cal Programs of Medicine Chief, Program Planning Office Public Health Service GROVER, M. Roberts, Jr., M.D. FOLLMER, Hugh C., M.D. National Institute of Dental Research GRABER, Mrs. Joe Bales Program Coordinator Associate Director for Nevada National Institutes of Health Special Assistant to Director Oregon Regional Medical Program Mountain States Regional Medical GARCIA-PALMIERI, Mario R., M.D. Bureau of Disease Prevention and GRUBB, Donald A. Program Professor of Medicine Environmental Control Assistant Program Coordinator FORBES, Charles M. School of Medicine Public Health Service Northwestern Ohio Regional Medical University of Puerto Rico Program Vice President GRAEBER, Fred O., M.D. Memorial Sloan-Kettering Cancer Center GARVEY, Henry T. Assistant Director of the Idaho Study GUSTAFSON, David H., Ph. D. FORDHAM, Robert A. Information Officer Mountain States Regional Medical Planning Coordinator Coordinator of Federal Programs Heart Disease and Stroke Control Program Wisconsin Regional Medical Program University of Vermont Program GRAHAM, William D., M.D. GUTHRIE, Eugene H,, M.D. Public Health Service Deputy Director Associate Surgeon General FOX, Samuel M., III, M.D. GETZ, Richard R. Hawaii Regional Medical Program Public Health Service Chief, Heart Disease Control Program Executive Director Leahi Hospital, Honolulu HAGLUND, Richard F. National Center for Chronic Disease Medical Television Network Program Manager Bureau of Disease Prevention and GILLESPIE, Guy T., M.D. GRANDON, Raymond C., M.D. Intermountain Regional Medical Program Environmental Control Cancer Coordinator Chairman, Regional Advisory Group University of Utah Medical Center Public Health Service Mississippi Regional Medical Program Susquehanna Valley Regional Medical FRALEY, Pierre C. University Medical Center Program HAGOOD, William J., Jr., M.D. Speaker, Congress of Delegates Director of Information GILLESPIE, John W. GRANING, Harold M., M.D. American Academy of General Practice Greater Delaware Valley Regional Medical Planning Officer Assistant Surgeon General Member, Executive Committee Program Alabama Regional Medical Program Public Health Service Virginia Regional Medical Program 148 HALL, Jack, M.D. HASEGAWA, Masato M., M.D. HENNINGS, Arthur G. HOHMANN, Thomas C., M.D. Director of Medical Education Senior Member, Steering Committee Member, Regional Advisory Group Chairman, Regional Advisory Group Methodist Hospital, Indianapolis Hawaii Regional Medical Program Steering Committee Subcommittee on Stroke IIAMMERSLEY, Don W., M.D. HATCH, Charles L. Coordinator, University Health Center of Western Pennsylvania Regional Medical Chief, Professional Service Field Representative Pittsburgh Program American Psychiatric Association Susquehanna Valley Regional Medical HENRY, Barbara Whitmore HOLBROOK, W@rd C. HAMPTON, H. Phillip, M.D. Program Area Liaison Officer Executive Director, Health and Welfare Chairman, Executive Committee HATCH, Thomas D. Greater Delaware Valley Regional State of Utah Florida Regional Medical Program Executive Officer Medical Program HOLLAND, Charles D. Division of Allied Health Manpower HERMANN, John B. Assistant Director HANSEN, Jane Bureau of Health Manpower Planning Director, The Creighton West Virginia Regional Medical Program Information Specialist Heart Disease and Stroke Control Public Health Service University HOLLOMAN, John L., M.D. Program HAYES, Donald M., M.D, Associate Coordinator Past President I)ublic ff(-alth Service Assistant Professor of Medicine Ncbraska-South Dakota Regional National Medical Association I IAI'Pl-',I,, Roderick l@owriian (;ray School of Mcdi(@in(@ Medical Program Mcinlier, Regional Advisory Group Assistant (,(@r(iiii;ttor III-"US'I'IS, All)(@rt E., M.D. New York Metropolitan Regional Medical (@reater Delaware Val I(!y Regional IIAYI,"S, Ioliri J. Director ProgranL I)ir(!(:Lor, Hospital Division Michigan Association for Regional Medical Program North Carolina Regional Medical Pro- HOLMBERG, R. Hopkins, Ph. D. Medical Programs, Inc. Director HARDIN, Neal H. gram Head, Continuing Education and Health HAYES, Richard L., M.D. HILDEBRAND, Paul R., M.D. Health Systems Science Division Professions Assistant to Chief Program Coordinator American Rehabilitation Foundation Oklahoma Regional Medical Program Cancer Control Program Colorado-Wyoming Regional Medical HONICKER, Franklin, Jr. HARE, Edgar National Center for Chronic Disease Program Liaison Officer Dcl;iwar(@ Liaison R(@prc,,(@nt@ttiv(! Control 1-1 I 1,1,, David B. Greater Delaware Valley Regional Greater Delaware Valley Regional l'ul)li(@ Health Service 1'rofcssor Of COrIlITILinity Medicine Medical Program Medical Program HAYES, Robert H., M.D. University of Vermont HORENSTEIN,Simon, M.D. HARRIS, John H., Sr., M.D. Associate Coordinator HINE, Maynard K. Associate Professor of Neurology Chairman, Special Board Committee Nebraska-South Dakota Regional Chairman, Research Committee Case Western Reserve University Susquehanna Valley Regional Medical Medical Program American Dental Association HORTON, Odell Program HELLER, William M., Ph. D American Association of Dental Schools Director of Hospitals and Health HARRISON, Donald C., M.D. Director, Department of Scientific IIINKEL, Robert Services Chairman, Subcommittee on Heart Services Information Specialist City of Memphis Disease American Society of Hospital Pharmacists National Institute of Neurological Dis- Stanford-Area III eases and Blindness HOUGH, Howard E. California Regional Medical Program HELLMAN, Louis P., M.D. National Institutes of Health Associate Director for Community Program Planning and Evaluation Involvement HARTFORD, Thomas J., M.D. Maryland Regional Medical Program HISCOCK, William McC. Vice President, Area Medical Programs University of Maryland School of Deputy Director Western Pennsylvania Regional Medical Arri(-ri(!ari Cancer Society, Inc. Medicine Office of Program Planning and Evalua- Program HARVEL, Alvin E. HENDRYSON, Irvin E., M.D. tion HUBBARD, William N., Jr., M.D. Assistant Representative for Regional Associate Director Office of the Surgeon General Dean, School of Medicine Organization New Mexico Regional Medical Program Public Health Service University of Michigan Office of the Surgeon General HENNESSEY, Florence D., R.N. HOHMAN, Robert J. Chairman, Regional Advisory Group Public Health Service Chief, Nursing Service Executive Secretary Virginia Regional Medical Program HARWOOD, Theodore H., M.D. Veterans Administration Hospital American Heart Association HUBER, Warren V., M.D. Program Coordinator Member, Regional Advisory Group Program Planning Committee Metropolitan Washington, D.C. Regional North Dakota Regional Medical Program Ohio Valley Regional Medical Program Northlands Regional Medical Program Medical Program 149 HUDSON, Charles R. JENSEN, John L. Kl,"NNI,'It, Harris M., M.D. KNOX, Van W., III Assistant to the Coordinator Art Director Assistant Director, Programs Research Analyst Mississippi Regional Medical Program Department of Communication Services Section Health I-'Iconomics Research Section HUGHES, Gerald E. University of Kansas Medical Center I feart Disease Control Program Smith, Kline and French Laboratories Secretary for Meetings JOHNSON, Amos N., M.D. Public Health Service KORNFELD, Jack P. American Academy of Pediatrics Garland, N.C. KENNEY, Howard W., M.D. Director of Data Analysis HUNT, Andrew D., Jr., M.D. Medical Director, John A. Andrew I-los- Washington-Alaska Regional Medical JOHNSON, Marion 1-1. pital Program Michigan Regional Medical Program Director of ConirnLinic@itioris rtiskeg(-e I iistititte Dean, College of Human Medicine Washington-Alaska Regional Medical KOWALEWSKI, Edward J., M.D. Michigan State University Program KENNEY, John A., Jr., M.D. National Review Committee HUNT, William B., Jr., M.D. Professor and Head American Academy of General Practice Chairman, Medical School Committee JOHNSON, Robert O., M.D. Division of Dermatology University of Virginia Hospital Assistant Regional Coordinator Froward University College of Medicine KRAMER, M. A. Virginia Regional Medical Program Wisconsin Regional Medical Program Metropolitan Washington, D.C. Regional Field Representative Cancer Study Group Medical Program American Medical Association HUNTER, Oscar B., Jr., M.D. University of Wisconsin President KENRICK, Margaret, M.D. KREHL, Willard A., M.D. College of American Pathologists KAISER, Raymond F., M.D. Delegate Program Coordinator HUSTON, Samuel R. Deputy Regional Health Director American Academy of Physical Medicine Iowa Regional Medical Program Region IX-San Francisco ,iri(i Rehabilitation Director, University Hospitals Associate Director for Institutional Ilublic Health Service University of Iowa Affairs KING, James C., M.D. Northern New England Regional Medical KASSEL, Henry W., M.D. Associate Regional Health Director KRYSTYNAK, Leonard F. Program Regional Health Director (Chicago) Research Assistant HUTCHISON, Dorothy J., R.N. Region VIII-Denver Bureau of Health Services University of Michigan Chairman, Nursing Committee Public Health Service Public Health Service KUMMER, Theodore G. Wisconsin Regional Medical Program KAUFFMAN, John W. K ING, James F., Jr. Special Projects Administrator INGALL, John R. F., M.D. Administrator l'ul)lic I fealtli Analyst Smith, Kline and French Laboratories Program Director Princeton Hospital Office of Program Planning and KUTTNER, Dena Western New York Regional Medical KEAIRNES, Harold W., M.D. Evaluation Exhibit Officer Cancer Control Program Pz-ogrwn Assistant Coordinator for Research and Office of the Surgeon General Public Health Service INGERSOLL, Ralph, Ph. D. Evaluation ijl)llc Health Service Director of Research in Medical University of Kansas Medical Center KISSICK, William L., M.D. LAGACE, Arthur E., Jr. Education KELLER, Martin D., M.D. Director Health Administration Specialist Ohio State University College of Office of the Dean Office of Program Planning and Colorado-Wyoming Regional Medical Medicine Department of Preventive Medicine Evaluation Program IVES, John E. Ohio State University Office of the Surgeon General LAMBORN, Emiley Director Public Health Service University of Connecticut, McCook KELSO, John H. KITCHING, William M. Director of State-Federal Relations Hospital Executive Officer Field Services Consultant National Rehabilitation Association JANEWAY, Richard, M.D. Public Health Service Adult Health Protection Branch LARKIN, Vincent depaul Assistant Professor of Neurology KEMP, Marguerite W. Division of Medicil Care Administration Director Program Aclministritor, Cerebral Staff Assist;iti 1, I ion OfFi(-(- lltli-l-;ili of I f(,;Illll N(-w York Mi-ir(tl)oli(;tti M(-(Ii(-;tl Vascular Iti-si-;tr-i-li I @tiit ,( I ltowiii.iii (;r@ty School of M(-(Ii(-iiii- I Si-I vi(.(@ KNI,'],', Cli;tr-](-s W., Jr. 1,Al@SON, Carol M. JEFFERS, James R. KENNI-"DY, Paul K. Office of Pul)li(@ Relations and Nursing Consultant-Cor<)n-,iry Care Coordinator, Economics Section I-)(-I);trttiietit of Planning and Goorclin;iti(-n Communications Heart Disease Control Program Iowa Regional Medical Program Alabama Regional Medical Program South Carolint Regional Medical Program Public Health Service 150 LARSON, Laura G., R.N. LEWIS, Charles E., M.D. LYLE, Carl B., Jr., M.D. McFADDEN, Catherine L. Associate Director Coordinator Associate Professor of Medicine Heart Disease Control Program Mountain States lt(!giori;il Medical Ktris;ts Itegiori@kl Medical 1'rogr;iiii University of North Carolina School of iltil)lic fic@ilLh S(,rvice l'i-(iFi,r@iiii M(.(ii(,ill(@ M(:(;II.I., iteiiry C@., Jr., M.D. 1.1" W I S, I I-vi lig J. institutional Coordinator LAWRENCE, Clifton F., Ph. D. Deputy Assistant Director LYNCH, George Texas Regional Medical Program Associate Secretary Bureau of the Budget Audio-Visual Coordinator American Speech and Hearing Association Office of the President Bowman Gray School of Medicine McGOWAN, Larry, M.D. LAWTON, Robert P. LEWIS, Sandra E. LYNCH, Richard V., Jr., M.D. Greater Delaware Valley Regional Associate Dean Executive Assistant to the Director President, Medical Program Yale University School of Medicine Northern New England Regional Medical West Virginia State Medical Association McKENZIE, Richard B. Program Chairman, Regional Advisory Group Program Coordinator LAYTON, Margaret West Virginia Regional Medical Program Susquehanna Valley Regional Medical National Cancer Institute LIKOFF, William, M.D. ardiology McBEATH, William H., M.D. Program National Institutes of Health President, American College of C Hahnemann Medical College and Hospital Program Coordinator McLAUGHLIN, Margaret LEARNARD, William E. Ohio Valley Regional Medical Program Chief Nurse Officer Associate Director LILIENFELD, Abraham M., M.D. Public Health Service Health and Welfare Activities Professor and Chairman McCALL, Charles B., M.D. McNERNEY, Walter J. Smith, Kline and French Laboratories Department of Chronic Diseases Associate Professor Johns Hopkins University School of University of Tennessee College of President LEE, Lyndon E., Jr., M.D. Hygiene and Public Health Medicine Blue Cross Association, Inc. Director of Surgical Service Chief, Extra Veterans Administration LINDEE, Robert G., M.D. McCARTHY, Dr. Thomas McNULTY, Matthew F., Jr. Research Assistant Dean Office of the Director Director, Council of Teaching Hospitals Veterans Administration Stanford University School of Medicine Bureau of Health Services Associate Director, Association of Amer- Chief, Grants Review Branch ican Medical Colleges LEE, Dr. Marina D. LINDSLEY, George A., M.P.H. Public Health Service McPHAIL, Frank L., M.D. Chief, Medical Division Assistant Executive Director Director, Montana Region Science Information Exchange Illinois Regional Medical Program McCONNELL, Thomas S., M.D ' New Mexico Regional Medical Program Mountain States Regional Medical Pro- Smithsonian Institution LLOYD, Frank P., M.D. School of Medicine gram LEE, W. Boyd Director of Research University of New Mexico MACER, Dan J. Dental Consultant Methodist Hospital of Indiana McCORMICK, Calvin Director Cancer Control Program Veterans Administration Hospital National Center for Chronic Disease LOBUE, A. J., M.D. Senior Project Coordinator Member, Regional Advisory Group Kidde Construction, Inc. Chairman, Regional Advisory Group Control California Regional Medical Program Western Pennsylvania Regional Medical Public Health Service McCUNE, William S., M.D. Program LEEDS, Dr. Alice A. LOGSDON, D. N., M.D. President MACLAGGAN, James, M.D. Special Consultant on Comprehensive Chief, Professional Service Section Medical Society of the District of Vice Chairman Planning Division of Medical Care Administration Columbia California Regional Advisory Group National Institute of Mental Health Public Health Service McDANIEL, Valcta K. MACON, N. Don Public Health Service LUKEMEYER, George T. National Communicable Disease Cente@ Planning Director LEIN, John N., M.D. Program Coordinator Heart Disease Control Standardization Texis Regional Medical Program Associate Dean Indiana Regional Medical Program Laboratory Program Coordinator for University of ublic Health Service Texas University of Washington School of Associate Dean, Indiana University School p of Medicine Medicine McDONALD, Byron A. MAGRAW, Richard LEVINE, Dr. David L. LUMMIS, Wilbur S., Jr., M.D. Systems Engineering Consultant Assistant Director Associate Dean, School of Social Work Deputy Director Northern New England Regional Medical Bureau of Health Services Syracuse University Hawaii State Department of Health Program Public Health Service 151 292-414 0-68-11 MAMIYA, Richard, M.D. MAYER, William D., M.D, MITCHELL, John A., M.D. MURBACH, Edwin R., M.D. Leahi Hospital Dean and Director President Northw@t District Chairman Hawaii Regional Medical Program University of Missouri Medical Center Charles L. Drew Society Northwestern Ohio Regional Medical MARKEY, William A. MEEK, Peter G. MIYAMOTO, Robert M., M.D. Program Deputy Director, USC-Area V Executive Director President Elect MUSSER, Marc J., M.D. California Regional Medical Program National Health Council I I-,iwaii Medical Association Executive Dire(@tor' University of Southern California School North Carolina Regional Medical of Medicine MELICK, Dermont W., M.D. MOOLTEN, Sylvan E., M.D. Program MARTIN, Samuel P., M.D. Program Coordinator GI)-,IirT-naii, Task Force Committee on MYKY'I'EW, Marion, M.D. Arizona Regional Medical Program Medical l,ducation Program Coordinator University of Arizona College of Medicine I\/Iiddlesex G",Ieral Hospital in New Jersey Assistant Coordinator Florida Regional Medical Program Wisconsin Regional Medical Program Provost, J. Hillis Miller Medical Center MELTON, William K. MOORE, Charles W. Marquette School of Medicine MARTZ, E. Wavne, M.D. Director of Education Associate Coordinator, Administration NADEL, Eli M,, M.D. The American College of Radiology and Institutions Associate Director, Continuing Education Kaiists Regional Medical Program Associate Dean Western Pennsylvania Regional Medical MERRITT, Betty L. St. Louis University School of Medicine Program Communications and Iiiforryiatiori Officer MOORE, George NJ,-@1,LIGAN, William D. NIAR'I'Z, Dr. Heleri E@ Georgia Regional Medical Program Deputy Regional II(-altli Director Executive Director Staff Assistant for Planning Ml,TCAI,FE, Robert M., M.D. Region 111-Charlottesville Ariicrican College of Cardiology Medical Assistance Administration Associate Director Public He@iltli Service NELSON, Kinlcch, M.D. Social tnd Rehabilitation Service Tennessee Mid-SoLith Regional Medical MORGAN, Harold S., M.D. Program Coordinator Public Health Service Pr(@grani Program (Coordinator Virginia IZ(@giOtial Medical Program MARY, Charles C., Jr., NI.D. 'I'lioriias C., M.D. N(@I)i-;tskt-Soittli Dikot;t Regional Medical M(@(licil College of Virginia Associate Director Program Charity I-lospitil of New Orleans Cliairiiiin, l'ostgra(Itiatc! Education C@orri- Nl-',I,SoN, Willi@iiii 1'., 111, 'v[.D. mittee MORGAN, Robert J., M.D. Professor of Postgraduate Medicine MASLAND, Richard L., M.D. University of Wisconsin Medical S(@liool Chairman, Regional Advisory Committee Director Nebraska-South Dakota Regional Medical Albany Medical College National Institute of Neurological Dis- Mfl,I,ER, George E., M.D. 1'rogriiii NEMIR, Paul cases and Blindness Director, Office of Research in Medical I)ir(,(@tor, Division of Graduate Medicine National Institutes of 1-fealtli I,'dLication MORRISSEY, Edward F. University of Pennsylvania MASON, Joseph J., Jr. University of Illinois College of Medicine Assistant Director Associate Director for Administration Division of Regional Medical Programs Connecticut Regional Mcclicil 1'rogi-arii NEWELL, Agnes M. National Review Committee Nursing Consultant Alabama Regional Medical Program MOSES, Cimpbell, M.D. Stroke Progri MASSEY Dr. Robert U. MILLER, Winston R., M.D. Medical Director Heart DiscasemControl Section Lovelace Foundation for Medical Educa- Program Director American Heart Association Public Health Service tion and Research Northlands Regional Medical Program MOU,'I'homas W., M.D. NEWMAN, T. R. Nc%v Mexico Regional Medical Program MILLIKAN, Clark El., M.D. Assistant to the Coordinitor %(Iministrative Officer MATOREN, Gary M. National Advisory Council on Regional Central New York Regional Meclicil Ohio Villev Regional Medical Program Associate Coordinator Medical Pro grams Program New Jersey Regional Medical Program Consultant in Netirology NIGAGLIONI, Adan, M.D. MATTINGLY, Thomas W., M.D. Mayo Clinic MOU'I'SATSOS, Spero Program Coordinator Program Coordinator Project Director, Heilth Manpower Regionil Medical Proqriiii of Puerto Rico N,fetropolitan @Vasliingtoti, D.C,, Regional MITCHF',I,f,, l@'rank L., M.D. Western New York R(-,gioii;il M(,(Ii(-;il Mi-cli(-:tl D(@l)tity (:Iiif-f, Office of I'il(-l to MAYER, Andrew, I)i%-isi,,il,)f I)il,e(.t I M U 1, 1, I", IZ, J;l 11 NILSON, .Nssistaiit Director, Professional Activities liLit-t@;iti of I l(@altli Services Assisttzit Director -Wisliijigtoii Office .Assistant Program Coordinator .,American College of Surgeons Public Health Services Ain(-ric@iii Nurses Association Regional Medical Program 152 NOROIAN, Edward II. PAREI,IUS, M. Ronald PAYNE, W. Fixon, M.D. PETERSON, Stanley S., M.D. Executi%-c Dire( Lor Oregon Medical Ili-ogi,aiii Acting Director, 1161)kitis%,ille, Kentucky District Consultant Presbyterian University Ilosl)it@il PAI@Kl-'R, f,orraine Area Missouri Regional Medical Program Western M(.(Ii(-;Il Tennessee Mid-SOLItli Regional Medical Sriiith-GI),n-C-.Lllaway Clinic Prograrii Communications and Information I'vogi-ani PETIT, Donald W., M.D. NORTON, Joseph A., MD. North Dakota Regional Medical Program Jennie Stuart Memorial Hospital Director, USC-Area V llr(@sid(-nt, Arkansas NI(@di(-@il Society Itill)li C., Jr., M.D. PEARSON, David A. ranch California Regional Medical Program ?vlcziil)cr, Rcgion@il Advisory Board l'i-ogi-iiiii Coordinator Deputy Chief, Health Econoiriics B Arkansas Regionil Medical Program Rocii(@stcr (New York) Regional Medical Division of Medical Care Administration PHILLIPS, John B., M.D. O'DOHERTY, Desinoiid S., M.D. Program Bureau of Health Services Assistant Professor of Postgraduate Chairman, Regional Advisory Committee Public Health Service Medicine Metropolitan Washington, D.C. Regional PARKS, Raymond E., M.D. PECHMANN, David K. Albany Medical College Nfedical Program Associate Dean Administrative Officer POLLEY, Donald B. Professor and Chairman, Department of University of Mixiiai School of Medicine Virginia Regional Medical Program Television Coordinator Neurology I'ARRE'I'I'E, Robert N. PECK, Cecil P. Bowman Cray School of Medicine (;corg(@t(,%@,i) University I li'SI)it@ll Physical 'I'li(-r@tl)y Consultant American Psychological Association OGDI,'.N, Michael, iNI.1). llul)lic Health Service Chief, Psychology Division POPMA, Alfred M., M.D. Program Director Chief, Professional Assignment and PASCASTO, Anne, Ph. D. Department of Medicine and Surgery Mountain States Regional Medical Research Associate Research Professor Veterans Administration Central Office Office of Program Services University of Pittsburgh PEREZ, Eugene R., M.D. Yrogram Division of Indian Health Member, Division of Regional Medical Program Director POSKANZER, Charles N., Ph. D. Public Health Service Programs Review Committee Virginia Regional Medical Program Professor of Health Education OLIVER, Ward [,., M.D. I'ATE, James W., M.D. PERKINS, Miles L., M.D. State University of New York Assistant Professor of Postgraduate Chairman, Professional Committee Director College at Cortland Medicine Memphis Regional Medical Program Bureau of Medical Care Central New York Regional Medical Albany Medical Collcg(-- Professor, University of Tennessee Maine Department of Health and Wel- Program Albany, Nc%v York Regional NIcdical Pro- College of Medicine fare POTTER, Jacobus L., M.D. gram. PATTERSON, John W. M.D. PERRY, Frank A., M.D. Coordinator OLSON Edith V., R.N. Dean I Coordinator for Meharry Medical College New York University School of Medicine Nursing birector University of Connecticut School of Tennessee Mid-South Regional Medical Rochester (Ne%v York) Regional Medical Medicine Program POTTER, John, M.D. Program PAUL, Oglesby, M.D. PERRY, Lowell W., M.D. Associate Professor of Surgery OLSON, Stanley W., NI.D, Regional Advisory Chief, Pediatric Section Georgetown University Hospital Chairman , Illinois Metropolitan Washington, D.C., Regional Director Group Heart Disease Control Program Medical Program Tennessee Mid-South Regional Medical Professor of Medicine Public Health Service Program Passavant Memorial Hospital PETERS, Richard C. POWERS, Helen K. Assistant Coordinator Chief, Health Occupations Education PACKER, James T., M.D. PAYNE, Ethel Maryland Regional Medical Program Bureau of Adult, Vocational and Library Associate Director Nursing Consultant .VfisSoLiri Regional Medical Program Heart Disease Control Program PETERSON, John F., M.D. Programs University of %Iissoiirii%l(@(li(-al Center public Fl(,@iltli Service Director, Loma Linda Area Office of Education (',,tliforiiia Regional M(-clical Pz-ograni U.S. Department of Health, Education, I'AINTI@'R, ]Robert C., M@1). I'AYNE, Gerald H. Loma Linda University School of Medi- and Welfare North Dakota Regional \I(@cii(-al llr(,graiii Chief, Adult Hetrt Preventive Programs cinc I-"iliil S,.(Ii,)Il I'],'' 'ItSoN, Osl(-i, I,., M.D. PRICE, Derck W. II(';Ir'L I)is(-@ist' ;III(] Stroke Control I)j-o- Associate I)ii-ectot- Survey Dirc(-Lor Region III Charlottesville grani 'rri-State Regional Medical Program University of California at San Diego 1-fealtli Public Health Service Harvard Medical School California Regional Medical Program 153 QUINLAN, Carroll B., M.D. RICE, Walter G., M.D. ROBERTO, Edward A. RUHE, C. H. William, M.D. Deputy Chief Dean, School of Medicine Administrator Director, Division of Medical Education Heart Disease and Stroke Control Medical College of Georgia Brown County General Hospital American Medical Association Program Georgia Regional Medical Program Chairman, Committee on Community National Center for Chronic Disease RICH, Susan, R.N. Hospitals RUTH, William E., M.D. Public Health Service Assistant Director Ohio Valley Regional Medical Program Representative Councilor RAKITA, Louis, M.D. Survey and Planning ROBERTS, Dean W., M.D. American Thoracic Society Associate Professor of Medicine Oregon Regional Medical Program Chief, Regional Medical Program SABATIER, Joseph A., Jr., M.D. Cleveland Metropolitan General RICHARDS, Carol Activities Program Coordinator Hospital Staff Assistant Hahnemann Medical College Louisiana Regional Medical Program Western Reserve University Carnegie Corporation of New York Greater Delaware Valley Regional SADLER, Alfred M., Jr., M.D. RAMSEY, Lloyd H., M.D. RICHES, Roger J. Medical Program Office of the Director Department of Medicine Assistant Operations Officer ROBERTS, Frank National Institutes of Health Vanderbilt University Heart Disease and Stroke Control Administrative Assistant to the Director SADLER, Blair L. Tennessee Mid-South Regional Medical Program Louisiana Regional Medical Program Program Analyst Program Public Health Service ROBERTSON, George J., M.D. Office of the Director RANBERG, Robert A. RIDGES, J. Douglas, M.D. Medical Director National Institutes of Health Research Director Medical Officer Bingham Associates Fund SAGEN, Oswald K., Ph. D. Susquehanna Valley Regional Medical Medical Systems Development ROBERTSON, Julius D., D,M.D. Assistant Director Program Laboratory Institutional Liaison National Center for Health Statistics Public Health Service National Center for Chronic Disease Texas Regional Medical Program RAPAPORT Elliot, M.D. Control SANAZARO, Paul J., M.D. Area Coordinator-Area I ROBINETTE, Tasker K. California Regional Medical Program Public Health Service Director, Health Care Planning Director, Division of Education Association of American Medical Colleges Cardiopulmonary Laboratory RIEDEL, Donald C., Ph. D. Washington-Alaska Regional Medical San Francisco General Hospital Associate Professor of Public Health Program SAPPENFIELD, Robert W., M.D. Yale University Medical School ROBINS, Edith G. Assistant Director READER, George G., M.D. Louisiana Regional Medical Program Coordinator for Cornell Medical School RIKLI, Arthur E., M.D. Information Officer New York Metropolitan Regional Medical Chief of Operations Division of Medical Care Administration SARACHEK, Norman S., M.D. Program Missouri Regional Medical Program Public Health Service Medical Consultant Heart Disease Control Program Professor of Medicine RINGLER, Robert L., Ph. D. ROBINS, Morton National Center for Chronic Disease Chief, Institutional Research Programs Chief, Statistics and Analysis Program Control REDING, Mary josita National Heart Institute Heart Disease Control Program Public Health Service Director, Executive Board National Institutes of Health Public Health Service SASULY, Richard American Association of Medical Record ROBBINS, Guy F., M.D. ROCK, James A., M.D. Librarians Coordinator of Program Development Director of Planning Vice Chairman, Regional Advisory California Regional Medical Program RENTHAL, Gerald, M.D. Memorial Hospital for Cancer and Allied Committee SCHACHTER, Joseph Director Diseases Western Pennsylvania Regional Meuicai Program New York Metropolitan Regional Medical Statistician joint Committee on Medical Care Program Director, Laboratory Services Heart Disease and Stroke Control Program Education Public Health Service Lee Hospital in Johnstown American Public Health Association ROBBINS, Lewis C., M.D. SCHATZ, Irwin J., M.D. REYNOLDS, Florence Special Assistant to the Chief ROGATZ, Peter, M.D. Wayne State University School of National Center for Chronic Disease Director, Long Island Jewish Hospital Medicine Chief, Information and Reference Control ROSS, Mabel, M.D. Michigan Regional Medical Program Services Bureau of Disease Prevention and Regional Health Director SCHELLPEPER, William L. Division of Nursing Environmental Control Region I-Boston Nebraska-South Dakota Regional Public Health Service Public Health Service Public Health Service Medical Program 154 SCHIEVE, James F., M,D. SHELLEY, Roger SKELLEY, Thomas J. SOVIE, Margaret D. Assistant Dean Director of Public Relations Chief, Division of Disability Services Director of Nursing Education Office of Continuing Medical Education Rutgers University Medical School Rehabilitation Services Administration State University Hospital University of Cincinnati College of SHIELDS, George S., M.D. U.S. Department of Health, Education, Central New York Regional Medical Medicine Associate Professor, Department of and Welfare Program SCHMIDT, Roland E., M.D. Internal Medicine SLEE, Virgil N., M.D. SPARKMAN, Donal R., M.D. Associate Professor of Pediatrics Cincinnati General Hospital Director Program Coordinator West Virginia University Medical Center Ohio Valley Regional Medical Program Commission on Professional and Hospital Washington-Alaska Regional Medical SCHNAPER, H. W. SHINE, Patricia A. Activities Program Associate Director Director of Nursing Affairs SLEETH, Clark K., M.D. SPARKS, Robert D., M.D. Alabama Regional Medical Program Western New York Regional Medical Dean, School of Medicine Assistant Director SCHNEIDER, Aleene Program West Virginia University Medical Center Louisiana Regional Medical Program Tumor Registry, Data Collection SHOREY, Winston K., M.D. SMART, Charles R., M.D. SPENCER, William A., M D. Bi-State Regional Medical Program Program Coordinator Intermountain Regional Medical Program Texas Regional Advisory Group Arkansas Regional Medical Program University of Utah Medical Center Director SCHOOLMAN, Harold M., M.D. Dean, University of Arkansas School of Texas Institute for Rehabilitation and Director, Education Service Medicine SMITH, Patricia Ann Research Veterans Administration Centra cc SHULER, Virginia Coordinator Planning for Library and SCHOR, Stanley, M.D. Special Assistant for Program Information Services SPICER, William S., M.D. Temple University School of Medicine Oklahoma Regional Medical Program Program Coordinator Development Maryland Regional Medical Program Greater Delaware Valley Regional Heart Disease and Stroke Control SMITH, Robert, M.D. Medical Program Program Stroke Coordinator SPITLER, James D. Assistant Planning Director SCOTT, Ralph M., M.D. lltil)lic I I(-aitli S(-rvi(@(- Mississippi Regional Mccli(@al Program Professor of Radiology SIBI"Ity, 1). l,'Itigeil(@ SMITH, Robert li. W., Col. University of Texas Medical Branch University of Louisville 1. ' Texas Regional Medical Program executive Director U.S. Air Force Ohio Valley Regional Mcdi(@;il llrograin Greater Detroit Area Hospital Council Deputy Director of Professional Services SPRING, William C., Jr., M.D. SEIPP, Conrad, Ph. D. Michigan Regional Advisory Group Office of the Surgeon General Program Coordinator Greater Delaware Regional Medical Associate Director, Research and SIDEL, James, M.D. SMITH, Robert R., M.D. Program Evaluation Medical Consultant Associate Director Connecticut Regional Medical Program Heart Disease and Stroke Control Program Georgia Regional Medical Program STANKOVICH, Arthur SELIGSO Public Health Service Director of Management, Information N, David, M.D. SMITH, Robert Ray Systems Professor of Clinical Pathology SIDES, Jerry D., M. Sgt. Stroke Program The Lankenau Hospital Yale University School of Medicine Continuing Education for Paramedical Mississippi Regional Medical Program Greater Delaware Valley Regional SEMINGSON, Howard Personnel SMYTHE, Cheves M. Medical Program President, North Dakota Hospital Gunter Air Force Base, Alabama Associate Director STAPLETON, John F., M.D. Association SIEBER, Harry F., Jr. Association of American Medical College Associate Dean and Professor Administrator, Trinity Hospital Instructor, Temple University Medical School SOFFER, Alfred, M.D. Department of Medicine SHANHOLTZ, Mack I., M.D. Greater Delaware Valley Regional Medical Director, Scientific Activities Georgetown University School of Medicine State Health Commissioner Program American College of Chest Physicians Heart Coordinator, Georgetown Virginia State Department of Health University Hospital SIEBERT, Dennis F. SOLOWEY, Dr. Mathilde Virginia Regional Medical Program Information Officer Chief, Program Projects and Clinical STAUFFER, Lee D. SHARP, Lawrence J., Ph. D. Heart Disease Control Program Center Grants Assistant Director Research Associate and Sociological Public Health Service Extramural Programs Department of Continuing Medical Consultant SILVER, David National Institute of Neurological Diseases Education Washington-Alaska Regional Medical Director and Blindness Assistant Professor of Public Health Pro.-ram Diabetes Detection Program National Institutes of Health University of Minnesota Medical School 155 STEARNS, Norman F., M.D. STRAUSS, William T., M.D. TAPP, Jesse W., Jr., M.D. TITTLE, C. Robert, Jr., M.D. Acting Director Assistant Professor of Postgraduate Associate Professor of Community Program Coordinator Tri-State Regional Medical Program Medicine Medicine Northwestern Ohio Regional Medical STEARNS, Perry, M.D. Albany Medical College University of Kentucky Program Assistant Coordinator Albany Regional Medical Program Institutional Coordinator Ohio Valley Regional Medical Program TOKARS Jerome I., M.D. Maryland R(-,gionil Medical 1'rogr-.ini SUIIRLAND, George, M.D. I@Llfl'@110 (@t!%v York) Regional Nledical STEINICKE, David G. Department of Medicine TAYLOR, A. N., Pli. D, Program Regional Medical Program Representative Michigan State University Dean, School of Related Health Sciences Michigan Commission on Professional and University of Chicago Medical School TOLLMAN, James P., M.D. SULLIVAN, Dean Program Director Hospital Activities Washington, D.C., Office TEWART, Braxton E. Nebraskt-South Dakota Regional ),Iedical STEPHENSON, Dr. William Smith Kline and French Laboratories Program Associate Program School of journalism SULLIVAN, Jaiti(-s 11. New Jersey Regional Nledical Program University of N(,I)riski University of Missouri Assistant (:ooi@(iiii;ttor- 'I'OMI'KINS, l@ol)t-r-L (;., M.D. project Director Wis(@orisiri Rt-giori2il M(,di(!@il I)rogr;itii Stisclu(-Ii@Liiiia Valley l@(-giotixl Medical Coordinator for Tulsa Area Missouri Regional Medical Program SULLIVAN, W. Albert, M.D. Program Oklahoma Regional Medictl Program STEWART, Donald E., M.D. Director THOMAS, John F., M.D. President, Minnesota Cancer Society Department of Continuing Medical Chairman, Regional ,\dvisory Committee TOOLE, James F. Executive Committee, Northlands Education Texts Regional Medical Program Chairman, Neurology Department Regional Medical Program University of Minnesota Coll(-gc of 'I'IIOMPSON, DtriL Ilowrnari Gray School of %fcdicine S'I'ICKNEY, J. Minott, M.D. m(@(ii(-iiic Aciriiiiiistr@itor TOOMI,'Y, l@ol)(-rt 1". Pro.gr-,ir@i Cof)rdinitor SU l,'I'Z, I lat-i-y A. Maine I losi)it@ll liosl)iLtl Nortlil@inds Regional Medi(:@il 1'rograni System Associate Professor THOMPSON, John D. South Carolina Regional Medical STITH, Marion C. Department of Preventive Medicine Department of Epidemiology iiid Public Program Administrator State University of New York Health C. S. Wilson Memorial Hospital of Director, Program in Hospital TORGERSON jean T. Johnson City, N.Y. SUMMERALL, Charles P., III, M.D. Administration Chronic RespirIatory Diseases Control STOKES, Joseph III, M.D. Program Coordinator Yale University Program Coordinator, San Diego-Arca Vii South Cirolina Regional Medical Program Nitiorial Center for Chronic Disease California Regional Medical Program SU'I'ER, James 'I'. 'T'IIOMIISON, Julia C. Control STONE, Lily M. Res(tarcli Consultant Director, Washington Office Public flealth Service American Cancer Society Division of Hospital and Medical Artierican Nurses Association Facilities THOMPSON, Spencer G., M.D. TOWNSEND, Thomas E., M.D. STONEHILL, Robert B., M.D. Public Health Service Associate Coordinator Chairman, Regional Advisory Board Program Director Arkansas Regional Medical Program Indiana Regional Medical Program SUTHERLAND, John Texas Regional Medical Program STORER, Edward H., M.D@ President THOMPSON, W. R. TRENT, George T,@ (@liairiii;iii, Assistant to tlii- I)irt-(-t<,r Ilrogr@tin Associate I)rof(-ssor SYPHAX, Oricanna C. Program University of Tennessee College of Chief, Institutional Programs Section THORPE, Thomas TRUSSELL, Ray E., M.D. Medicine Division of Manpower Development and Director, Communications and Public Associate Dean STOREY, Patrick B., M.D. Training Information School of Public Health and Professor of Community Medicine Office of Educition Administrative Medicine Hahnemann Medical College U.S. Department of Health, EdLIC@ition. North Carolini Regional Medical Chairman. Task Force on Continuing and Welfare Program Columbia University Medical Education TABLEMAN, Betty THURSTON, Hester TUCKER, Norman Greater Delaware Valley Regional Medi- Planning and Administration Assistant Coordinator for Nursing Division of Physician NIanpoN%-er cal Program Michigan Regional Medical Program Kansas Regional Medical Program Public Health Service 156 TUF)OR, @V. J. VOI,I,AN, DOLlgli.9 D., M.D. WELD, Francis Minot, M.D. WILLARD, William R., M.D. l@i-St@Lt(- M(!(Ii(-itl Program Coordinator, UC@-D@i%,is-Ar(@a II Medical Consultant Vice President Southern Illinois University California Regional Medical Program Heart Disease Control Program University of Kentucky Medical Center WA(;Nl-'R, (:itri-titti J., M.D. lltil)lic Health Service WILLIAMS, James D. So( ial Work CoitiL.Itaiit WELLS, Benjai-nin B., M.D. Chief, Planning Assistance Section .,ktlan(aR(@gitinalOffi(:c- l@egionIV liLIrC@ILI of Health Services Director Office of Comprehensive Health Planning I'Lll)li(! II('altfl Service l'ul)lic Health Service Alabama Regional Medical Program Public Health Service TURNER, Glenn O., M.D. WAKERLIN, George E., M.D. WELTON, David G@, M.D. WILLIAMS, Robert G. W., Jr. Project arid -%fedical f)irector Director o Tanning President-Elect Assistant for Personnel NliSSOLiri R(-gi(,rial Nl(@clical I)r-ograiii Missouri Regional Medical Program Medical Society of the State of North Office of the Deputy Assistant Secretary T@@'f SS, Nlaitrine University of Missouri Carolina of Defense C@)jiiititini(:ations SI)c(@ialist WALL, PaLtline WENNBERG, John E., M.D. Health and Medical Urii@-crsity of Mississippi NI(@di(@al Center Nitional Cancer Institute Program Coordinator WILLIAMSON, John, M.D. UI,I,NfAN, Alice National Institutes of Health Northern New England Regional Assistant Professor Assistant Program Coordinator WARD, Paul D. Medical Program The Johns Hopkins University Cornell Nlcdical College Coordinator and Executive Director WEST, Kelly M., M.D. School of Hygiene and Public Health ULNIER, Robert J., '.%4.D. California Regional Medical Program Director WITTEN, Carroll L., M.D. WARLICK, William J. Oklahoma Regional Medical Program Chairman , Medical Practices Committee .Nl(!jrtl)cr, Regional ,\d@,isory Groul) North Dakota Regional Nledical Program Project Director WESTLAKE, Robert B., M.D. Ohio Valley Regional Medical Program UTTERB.,kCK, Robert A., M.D, South Carolina Regional Medical Program Past President WOOD, Courtney B., M.D., M.P.H. Professor, College of -Nfcdicinc WARNER, Horner R., M.D. American Society of Internal Medicine Coordinator, Mt. Sinai School of Medicine University of Tennessee Project Leader WHALEY, Storm New York Metropolitan Regional Si.it)(@orii@iiitt(@c on Stroke Intermountain Regional Medical Program Vice President of Health Sciences Medical Program 'Nfcifipliis Itegional I't-ograiii Lzittcr Day Saints Hospital University of Arkansas Medical Center WOOD, Owen J. V,%LJN, William S., Ni.1). WI-'Iili, 1)(-iiiiis R. Sales Manager Consultant WHIIIPLE, Dr. Gerald Chairman, 'I'ri-St,,it(- Regional Advisory Video I-' ngincering Company, Inc. -(! Adiiiinis ' Washington, D.C. Division of Mccli(:@il Cai tration Council Greater Delaware Valley l@(@gif)nal llul)li(: Health Service University Hospital, Boston WOOLSEY, Frank M., Jr., M.D. Nf(,dical Ilrograrri WI-'Bli, Hamilton, Col., USAF (MC) Program Coordinator Assistant for- lll@iiis, Health and Medical WHITE, Charles H. Albany Regional Medical Program ,f the Deputy Assist@itit S(@crctary Associate Director f'til)li( Inf(,r-iii;itiott Officer Ohio Itegiorial Medical Program WRIGHT, Jane C., M.D. (:oloi-@i(l(.-Wy,@iiiinL, l@(-giori,-tl M(!Cli(-;il ,f 1)(.f(.rls(! 1'rogi-aiii of 1)(-f(@ris(@ Coordinator for NeNv York Medical WHITMAN, Sariiu(!I, M.D. College VEVI@@11,KA, ]",Llgcnc NV., M@D. WEEKS, William Associate Dean New York Metropolitan Regional .,@ssistant Director Administrative Assistant to the Associate S,ll,,),,l of Medicine Medical Program Division of Medical Care Administration Director Case Western Reserve University Ptil)li(: If(-alth Service New Mexico Regional Medical Program IVU, Dr. S. Y. %71CKERSTAFI-', Hugh WEIL, Clifton C. WILBAR, Charles L., Jr., M.D. Professor of Economics Tennessee -.%lid-South Regional Medical Administrator Director University of Iowa Program Flint Goodrich Hospital of New Orleans West Virginia Regional Medical Program WURZEL, Edward M., M.D. VREELAND, EllwN-iine NI. WEINBERG, Harr), B., M.D. WILBUR, Dwight, M.D. Executive Director Nurse Consultant I Chairman, Regional Advisory Group President-Elect American Association of Medical Clinics Di%@isic-n of Nursiii@. Intramural Rescar(@ll Iowa Regional Medical Program American Medical Association XAVIER, Mal Brari(-fi WEIN'ERMAN, E. Richard, M.D. WILKINS, Robert J. Administrative Assistant But-(@au of II(-alt[i Nianpo%ver Ili-ofessor of Medicine and Public Health Associate Director Metropolitan Washington, D.C., Regional llul)lic Health Service Yale University Medical School Nortlitands Regional Medical Program Medical Program 157 YAKEL, Ruth M. APPENDIX 4 Samuel H. Proger, M.D. Helen G. Edmonds, Ph. D. Executive Director Physician-in-Chief Dean, Graduate School The American Dietetic Association DIRECTORY OF Tufts-New England Medical Center North Carolina College REVIEW COMMITTEE Boston, Mass. 021 1 1 P.O. Box 432 YARNALL, Stephen R., M.D. Durham, N.C. 27707 Director, Project Development AND NATIONAL David E. Rogers, M.D. Washington-Alaska Regional Medical ADVISORY COUNCIL Professor and Chairman Bruce W. Everist, M.D. Program ON REGIONAL Department of Medicine Chief of Pediatrics University of Washington Hospital School of Medicine Green Clinic YATES, William M. MEDICAL PROGRAMS Vanderbilt University 709 South Vienna Street Administrative Assistant Nashville, Tenn. 37205 Ruston, La. 71270 Tennessee Mid-South Regional Medical REGIONAL MEDICAL PROGRAMS C. H. William Ruhe, M.D. John R. Hogness, M.D' Program REVIEW COMMITTEE Assistant Secretary Dean, School of Medicine YOUNG, James R. Kevin P. Bunnell, Ed. D. Council on Medical Education University of Washington Information Officer Associate Director American Medical Association Seattle, Wash. 98105 West Virginia Regional Medical Program Western Interstate Commission for 535 North Dearborn Street James T. Howell, M.D. YUNG, E. V., M.D, Higher Education Chicago, 111. 60610 Executive Director Director, Survey and Planning 30th Street Robert J. Slater, M.D, Henry Ford Hospital Oregon Regional Medical Program Boulder, Colo. 80302 President Detroit, Mich. 48202 Geor e James, M.D. The Association for the Aid Clark H. Millikan, M.D. ZWICK, Daniel I. 9 Dean, Mount Sinai School of Medicine of Crippled Children Consultant in Neurology Associate Director of Program Fifth Avenue and East 100th Street 345 East 46th Street Mayo Clinic Management New York, N.Y. 10029 Ne%v York, N.Y. 100 1 7 Rochester, Minn. 55902 Office of Economic Opportunity Howard W. Kenney, M.D. Mr. John D. Thompson George E. Moore, M.D. Medical Director Professor of Public Health and Director, Director, Public Health Research John A. Andrew Hospital Program in Hospital Administration New York State Department of Health Tuskegee Institute, Ala. 36088 Yale University Medical School Roswell Park Memorial Institute Edward J. Kowalewski, M.D. New Haven, Conn. 06520 666 Elm Street Chairman, Committee of Environmental Executive Secretary u Medicine of the Academy of Mrs. Martha L. Phillips Edmund D. Pellegrino, M.D. General Practice Chief, Grants Review Branch Vice President for the Health Sciences Akron, Pa. 17501 Division of Regional Medical Programs Director of the Medical Center George E. Miller, M.D. National Institutes of Health State University of New York Director, Office of Research in Bethesda, Md. 20014 Stony Brook, N.Y. I 1 790 Medical Education Alfred M. Popma, M.D. College of Medicine NATIONAL ADVISORY COUNCIL Director, Mountain States University of Illinois ON REGIONAL MEDICAL Regional Medical Program Chicago, 111. 60612 PROGRAMS 525 West je erson Street hilip M. Morse, Pli. D. Boise, Idaho 83702 p Director I-'Idwin L. Crosby, M.D. Mack 1. Shanholtz, M.D. Operations Research Center Director State Health Commissioner American Hospital Association State Department of Health Massachusetts Institute of Technology Cimbridge, Mass. 02139 Chicago, 111. 60611 Richmond, Va. 23219 Anne Pascasio, Ph. D. Michael E. DeBakey, M.D. Ex Officio Member Assistant to the Vice Ilresident Cliaii-iii@iii Willi@trii 11. St(-w@irt, M.1). Health Professions Department of Surgery Surgeon General University of Pittsburgh College of Medicine Public Health Service 443 Scaife Hall Baylor University 9000 Rockville Pike Pittsburgh, Pa. 15213 Houston, Tex. 77025 Bethesda, Md. 20014 158 APPENDIX 5 Evaluation Branch: Rlioda Abrams.... ............. Program Analyst. DIRECTORY OF Arthur B. Hiatt, Jr .............. Program Analyst. DIVISION OF REGIONAL Suzanne G. Paul ................ Program Analyst. Laura J. Shouse ................. Program Analyst. MEDICAL PROGRAMS Mary A. Teller ........ ......... Program Anaylst. Edward S. Walsh ................ Program Analyst. Statistics and Analysis Branch: OFFICE OF THE DIRECTOR Mary V. Geisbert ................ Public Health Analyst. Immediate Office: Loren D. Hellickson .............. Public Health Analyst. Robert Q. Marston, M.D ..... ... Director. Leah Resnick. . @................ Public Health Analyst. Karl D. Yordy ......... ..... Deputy Director. Jackie M. Rosenthal ............. Statistical Assistant. Margaret H. Sloan, M.D.. . . . Associate Director for Organizational Liaison. Maurice E. Odoroff. . ........ Assistant to Director for Health Data. OFFICE OF ASSOCIATE DIRECTOR FOR OPERATIONS Leroy G. Goldman ............ Program Policy Specialist. Richard B. Stephenson, M.D ...... Associate Director for Operations. Eva M. Handal. . .... @ @. @ ...... Committee Management Officer. Elizabeth F. Fuller ............... Secretary to Director. Operations Staff. Oifice of Executive Officer: Ira R. Alpert ................... Operations Officer. Charles Hilsenroth ...... ....... Executive Officer. Robert C. Anderson ............. Operations Officer. Nicholas G. Cavarocchi. Financial Management Officer. Vincent J. Carollo, M.D .......... Operations Officer. Robert L. Quave. Administrative Officer. John R. Hamilton, III, M.D ...... Operations Officer. Norman E. Prince, Jr ....... Personnel Officer. Robert M. O'Bryan, M.D ........ Operations Officer. Anna V. Windsor ..... .......... Budget Analyst. Alphonse Strachocki ............. Operations Officer. Lorraine H. Hughes .... ......... Administrative Assistant. Grants Management Branch: Mary J. McCormack. . ....... Office Services Supervisor. James Beattie ................... Chief. Thomas McNiff ............... Grants Management Officer. Ofice of Communications and Public InIformation: i Edward M. Friedlander .......... Assistant to Director for Communications Gerald L. Teets .... ........... Grants Management Officer. and Public Information. George F. Hinkle ................ Grants Management Officer. Frank Karel III ................. Public Information Officer. Arthur Curry ................... Grants Management Specialist. Judith J. Fleisher ... ....... ... Public Information Specialist. Donald M. Fox ................. Grants Management Specialist. Ellen D@ Carter ...... .... Public Information Specialist. Grants Review Branch: Simone D. Biren. . .... ....... Editor. Martha L. Phillips ....... ....... Chief. OFFICE OF ASSOCIATE DIRECTOR FOR PLANNING AND EVALUATION Grants Review Section: Peter A. Clepper ................ Public Health Advisor. Stephen J. Ackerman ......... Associate Director for Planning and Evaluation. Robert E. Jones ................. Public Health Advisor. Planning Branch: Patricia K. McDonald ............ Public Health Advisor. Roland L. Peterson ........... Chief. Harold F. O'Flaherty ............ Scientific Grants Assistant. Thomas Kinser.,. . @ . @ @ @ :... Program Analyst. Jessie F. Salazar ................. Public Health Advisor. Theodore L. Koontz, Jr .... ..... Program Analyst. Grants Operations Section: Lyman G. Van Nostrand ......... Program Analyst. Lorraine M. Kyttle ............... Head. 159 OFFICE OF ASSOCIATE DIRECTOR FOR PROGRAM DEVELOPMENT AND RESEARCH Richard F. Manegold, M.D ....... Associate Director for Program Dcvelol-ijiient -iiid ]Zescircli. Continuing Education and Y'raini@g Branch: Alexander M. Schmidt, M.D ...... Chief. Phyllis E. Carnes, Ph. D.......... Education Specialist. Veronica L. Conley, Ph. D..... @.. Education Specialist. Cecilia C. Conrath ............... Assistant to Chief. David @V. Golde, M.D ........... Training Consultant. Frank L. Husted, Ph. D.......... Head, Education Research Group. Elsa J. Nelson.. @ ........... .... Health Services Officer. Herbert 0. Mathewson, M.D ...... Training Consultant. Marjorie L. Morrill ... ...... Public Health Advisor. Rebecca R. Sadin ...... ........ Public Health Advisor. Sarah J. Silsbee ..... ...... Public Health Advisor. Jack J. Schneider, M.D ... ...... Training Consultant. ,John C. 'I'@ipp, M.I) ..... ........ 'I'r;tiiiiiig Consultant. Charlotte F. 'I'urner .............. Education @ind'l'raiiiiiig Spcciilist. Regional I-lealth Services Branch.- Philip A. Klieger, M.D ......... Heid, Clinical Programs Section, 160 APPENDIX 6 DIRECTORY OF REGIONAL MEDICAL PROGRAMS The Directory lists Regional Medical Programs for which planning or opera- tional grants have been awarded or which are in earlier stages of development. Regions were defined for planning pur- poses in the planning applications. State designations do not necessarily indicate that the regions are coterminous with State boundaries. The original definitions of the regions may be modified on the basis of experience. Region page Awarded is of April 26, 1968. NEW JERSEY (see also Greater Delaware ,,ley, @6 ........................... 169 NEW ........................... 169 INDEX NEW YORK, see Albany; Central New Region page York; New York Meiropolitan Area; ALABAMA (see also Tennessee Mid- Rochester; Western New York. South) ........ ........................ 162 NEW YORK METROPOLITAN AREA ..... 169 ALASKA, see Washington-Alaska. NORTH CAROLINA ...................... 169 ALBANY ............ ............... 62 NORTH DAKOTA ............... ........ 170 ARIZONA ....... ........................ 62 NORTHEASTERN OHIO ................. 170 ARKANSAS (see also Memphis) .......... 16@ NORTHERN NEW ENGLAND ......... 170 BI-STATE... 163 NORTHLANDS ........ .................. 170 CALI FORN 163 NORTHWESTERN OHIO ............. ... 171 CENTRAL NE@'Y6'@k','." . ... ...... 163 OHIO STATE (see also Northeastern COLORADO-WYOMING. . ...... Ohio; Northweitern Ohio; Ohio Valley).. 171 ....... ...... . .63 CONNECTICUT ......... 164 OHIO VALLEY. ................ ....... 171 ...... .. . OLA HOMA ............................. 171 DELAWARE VALLEY, see reater Del ware Valley. OREGON ............................ ... 172 FLORIDA ...................... ...... 164 PENNSYLVANIA, see Greater Delaware GEORGIA .............. ................ 164 Valley; Susquehanna Valley; Western GREATER DELAWARE VALLEY .......... 164 Penns RTCVvani HAWAII ........................ 165 PUE RICO ....... .............. 172 IDAHO, see Intermountain; M un am RHODE ISLAND, see ate. States. ROCHESTER, ....... ................... 172 ILLINOIS (see also Bi-State).. @.......... 165 SOUTH CAROLINA .................. 172 INDIANA (see also Ohio Valley) .......... 165 SOUTH DAKOTA, see Nebraska-South INTERMOUNTAIN ....................... 165 Dakota. IOWA ................ I .. @ ................ 166 SUSQUEHANNA VALLEY.... ....... 173 KANSAS ................ ................ 166 TENNESSEE MID-SOUTH (see also Mem- KENTUCKY, see Memphis; Ohio Valley; phis) ................................... 173 Tennessee Mid-South. TEXAS ........ .................. 173 LOUISIANA .............................. 166 TRI-STATE ............................. 173 MAINE ............ .................... 166 UTAH, see Intermountain. MARYLAND ............................. 167 VERMONT, see Northern New England. MASSACHUSETTS, see Tri-State. VIRGINIA ............... .............. 174 MEMPHIS ............................. 167 WASHINGTON-ALA!SKA ........... ..... 174 METROPOLITAN WASHINGTON, D.C... 167 WASHINGTON, D.C., see Metropolitan MICHIGAN ............................ 167 Washington, D.C. M I N N ESOTA, see Northlands. WEST VIRGINIA (see also Ohio Valley).. 174 MISSISSIPPI (see also Memphis) ........ 168 WESTERN NTERSTATE COMMISSION MISSOURI (see ilso Bi-State: Memphis). 168 FOR HIGHER EDUCATION (WICHE), MONTANA, see Intermountain; Mountain see Mountain States. States. WESTERN NEW YORK ........ I ......... 174 MOUNTAIN STATES .................... 168 WESTERN PENNSYLVANIA ... ........ 175 NEBRASKA-SOUTH DAKOTA ............ 168 WISCONSIN ............................. 175 NEVADA, see Intermountain. WYOMING, see Colorado-Wyoming; Inter- N EW HAM PSH I R E, see Tri-State. mountain; Mountain States. 161 Name of Region 81-State California Central Now York Colorado-Wyoming Preliminary Planning Area Eastern Missouri and Southern California Syracuse, New York and 15 Colorado and Wyoming Illinois surrounding counties Estimated Population 4,775,000 19,160,000 1,760,000 2,200,000 al Coordinating Headquarters Washington University School of California Committee on Upstate Medical Center, State University of Colorado Medical Medicine Regional Medical Programs University of New York at Syracuse Center Program Coordinator William H. Danforth, M.D. Paul D. Ward Richard H. Lyons, M.D. Paul R. Hildebrand, M.D. Vice Chancellor for Medical Affairs Executive Director Director, Regional Medical University of Colorado Medical Center Washington University California Committee on Program of Central New York 4200 East Ninth Avenue 660 South Euclid Avenue Regional Medical Programs 750 East Adams Street Denver, Colo. 80220 St. Louis, Mo. 63110 Room 304 Room 1500 655 Sutter Street State University Hospital (tel: 314-361-6400, ext. 3013) San Francisco, Calif. 94102 Syracuse, N.Y. 13910 (tel: 415-771-5432) (tel: 315-473-5600) Program Director Howard W. Doan, M.D. University of Colorado Medical Center 4200 East Ninth Avenue Denver, Colo. 80220 (tel: 303-394-7506) Chairman, Regional Advisory G. Duncan Bauman Roger 0. Egeberg, M.D. Wilfred W. Westerfeld, M.D. John J. Conger, Ph. D. Group Business Manager Dean, School of Medicine Acting President Vice President for Medical Affairs St. Louis Globe-Democrat University of Southern California Upstate Medical Center and Dean, School of Medicine 710 North 12th Street 2025 Zonal Avenue 766 Irving Avenue University of Colorado St. Louis, Mo. 63101 Los Angeles, Calif. 90033 Syracuse, N.Y. 13210 4200 East Ninth Avenue (tel: 315-473-4513) Denver, Colo. 80220 Grantee Washington University School of California Medical Education Research Foundation of State UniversityofColorado Medical Center Medicine and Research Foundation University of New York Effective Starting Date of April 1, 1967 November 1, 1966 January 1, 1967 January 1, 1967 Planning Grant Amount of Planning Grant $603,965 $1,575 096 (1 st year) $289 522 (ls year) $361 984 (lst year) $2,974,'497 (2d year) $268,'634 (2dtyear) $339,'605 (2d year) Effective Starting Date of Operational Grant Amount of Operational Grant 163 Greater Delaware Valley Georgia Florida Easte Pennsylvania all(i portions Of rt' Connecticut ersey ard Delaware Nan,e of Region Georgia New J Floricia 8 TOO Connecticut - 4 510 600 000 Preliminary Planning Area ---- orgia University City Science C(, --2,925,000 M@(3,c,@A,,-Iiatioll of G(, i tion l@ori@l,, @dv,,,,@y C,,,,ncil, Inc. Yale Univ( t George C@ani[iier, M.D. Coordinating Headqt an(] Ullive Wynnewood @iouse Schoolof ja Regional ter Aveiiiie coo 300 East Laricas M. D. m f Georgia Wynnewood, Pa. 19096 ,@o g C..,dnat-r ator Me, N E. -4100) onal Medical 938 (tel: 215-649 Program Street Atl 272 George 06510 (tel: 904-376-3211, ext. 5377) New Haven Conn. (tel: 404-876-7535) (tel: 2C)3-776-6872) Barr M. Dit ia Regior'31 ram on 0f Georgia program Director M( reet N.E. 93 09 At (tel: 404-875-0701) D Glen (-,Oil g Dea@ mp on, M.D. of evard 330( 33606 Phil; ring Company (tel: 813-253-0991) 06720 @,ty@c ",C(, University ssociatioll of Georgia ry Council, Inc. Medic - 1967 April 1, 1967 Grantee jankiary 1, @ve ever 1, 1967 july 1, 1966 31,494 Effective Starting Date $240 Ogg (lst year) Of Planning Grant - $240,000 $51)5@079 (2d year) 4@(3) 6 6 2 2 t -.r) I' ye Amount Of $, 513 2,J Y planning Grant Effective Starting Date of Operational Grant A n'ou nt of operational Grant 16i Name of Region Connecticut Florida Georgia Greater Delaware Valley Preliminary Planning Area Connecticut Florida Georgia Eastern Pennsylvania and portions of New Jersey and Delaware Estimated Population 2,925,000 6,000,000 4,510,000 8,200,000 Coordinating Headquarters Yale University School of Medicine Florida Advisory Council, Inc. Medical Association of Georgia University City Science Center and University of Connecticut School of Medicine Program Coordinator Henry T. Clark, Jr., M.D. Samuel P. Martin, M.D. J. W. Chambers, M.D. George Clammer, M.D. Program Coordinator Coordinator for Georgia Regional VVonnewood House Provost, J. Hillis Miller 3 Connecticut Regional Medical Medical Center Medical Program East Lancaster Avenue Program University of Florida Medical Association of Georgia Wynnewood, Pa. 19096 272 George Street Gainesville, Fla. 32601 938 Peachtree Street NE. New Haven, Conn. 06510 (tel: 904-376-3211, ext. 5377) Atlanta, Ga. 30309 (tel: 215-649-4100) (tel: 203-776-6872) (tel: 404-876-7535) Program Director J. Gordon Barrow, M.D. Director for Georgia Regional Medical Program Medical Association of Georgia 938 Peachtree Street N.E. Atlanta, Ga. 30309 (tel: 404-875-0701) Chairman, Regional Arthur M. Rogers H. Phillip Hampton, M.D. Arthur P. Richardson, M.D. Glen R. Leymaster, M.D. Advisory Group Director of Traffic I Davis Boulevard Dean hool of Medicine Dean, Woman's Medical College Scovill Manufacturing Company Tampa, Fla. 33606 Emor@SUcniversity of Pennsylvania 99 Mill Street Atlanta, Ga. 30322 3300 Henry Avenue Waterbury, Conn. 06720 (tel: 813-253-0991) Philadelphia, Pa. 191 Grantee Yale University School of Medicine Florida Advisory Council, Inc. Medical Association of Georgia University City Science Center Effective Starting Date July 1, 1966 November 1, 1967 January 1, 1967 April 1, 1967 of Planning Grant Amount of $406 622 @lst year) $240,000 $240 098 Ist year) $1,531,494 Planning Grant $338:513 2d year) $555:079 @2d year) Effective Starting Date of Operational Grant Am ount of Operational Grant 164 Name of Re,iion Hawaii Illinois Indiana Intermountain ProlitTiinary Pl;jnnin,l Aro@i linwmii lllitioi!; Utah. and portions of Wyoming, Mori@'in,l, iLlatio, and Neva da Estimated Population 740,000 10,895,000 5,000,000 2,220,000 University of Hawaii College of Coordinating Committee of Medical Indiana University School of University of Utah School of Coordinating Headquarters Health Sciences Schools and Teaching Hospitals of Medicine Medicine Illinois Leon 0. Jacobson, M.D. Robert B. Stonehill, M.D. C. Hilmon Castle M.D. Program Coordinator Masato Hasegawa, M.D. sociate Dean and Chairman Suite 105 Dean of Biological Sciences Indiana University Medical Center As Medical Arts Building Chairman, Coordinating Committee 1 1 00 West Michigan Street Department of Postgraduate 1010 South King Street of Medical Schools and Teaching Indianapolis, Ind. 46207 Education Honolulu, Hawaii 96822 Hospitals of Illinois University of Utah College of 950 East 59th Street (tel: 317-639-8492) Medicine 50 North Medical Drive (tel: 808-944-8499) Chicago, 111. 60637 Salt Lake City, Utah 841 12 (tel: 312-MU4-6100) (tel: 801-322-7901) Program Director William D. Graham, M.D. Wright R. Adams, M.D. Deputy Director Executive Director Hawaii Regional Medical Program Illinois Regional Medical Program Lez!hi Hospital 122 South Michigan Avenue Honolulu, Hawaii 96822 Suite 939 Chicago, Ill. 60603 (tel: 312-939-7307) h.i,m.., Regional Advisory Wilson P. Cannon, Jr. Oglesby Paul, M.D. George T. Lukemeyer, M.D. Kenneth B. Castleton, M.D. Group Senior Vice President Professor of Medicine Associate Dean, Indiana University Dean@ University of Utah Bank of Hawaii Northwestern University School of Medicine college of Medicine P.O. Box 2900 School of Medicine Indiana University Medical Center University of Utah Medical Center Honolulu, Hawaii 96802 Passavant Hospital 1100 West Michigan Street Salt Lake City, Utah 84112 303 East Superior Street Indianapolis. Ind. 462C)7 Chicago, Ill. 60611 (tel: 317-639-8877) (tel: 801-322-7211, ext. 7201) (tel: 312-WH4-4200) University of Hawaii College of University of Chicago Indiana University Foundation unive sity of Utah College of M Grantee Health Sciences edicine Effective Starting Date of July 1, 1966 July 1, 1967 January 1, 1967 July 1, 1966 Planning Grant $384,750 Ist year) $456 415 @Ist year) Amount of Planning Grant $108 00(, @Ist year) $336,366 $497,837 @2d year) $363:524 2d year) $194:771 2d year) Effective Starting Date of April 1. 1967 Operationa I Grant $2,038,123 (lst year) Amount of Operational Grant $2,215@234 (2d year) 165 Name of Region Iowa Kansas Louisiana Maine Preliminary Planning Area Iowa Kansas Louisiana Maine Estimated Population 2,755,000 2,275,000 3,660,000 975,000 Coordinating Headquarters University of Iowa College of University of Kansas Medical Center Louisiana State Department of Medical Care Development, Inc. Medicine Hospitals Program Coordinator Willard A. Krehl, M.D., Ph. D. Charles E. Lewis, M.D. E. Lee Agerton Manu Chatterjee, M.D. 308 Melrose Avenue Chairman, Department of Preventive Director Program Coordinator University of Iowa Medicine and Community Health Louisiana State Department Maine Regional Medical Program Iowa City, Iowa 52240 University of Kansas Medical Center of Hospitals 295 Water Street 39th and Rainbow Boulevard 655 North Fifth Street Augusta, Maine 04322 (tel: 319-353-4843) Kansas City, Kans. 66103 Baton Rouge, La. 70804 (tel: 207-622-7566) (tel: 919-AD6-5252, ext. 271) Program Director Joseph A. Sabatier, Jr., M. D. Program Coordinator Louisiana Regional Medical Program Claiborne Towers Roof 119 South Claiborne Avenue New Orleans, La. 70112 (tel: 504-522-5678) Chairman, Regional Advisory Harry B. Weinberg, M.D. George A. Wolf, Jr., M.D. Charles B. Odom, M.D. Merle S. Bacastow, M.D. Group Iowa Heart Association Provost and Dean, School of Past President President i333 West Lombard Street Medicine Louisiana State Medical Society Medical Care Development, Inc Davenport, Iowa 52804 University of Kansas Medical Center 134 North 19th Street Director of Medical Education Rainbow Boulevard at 39th Street Baton Rouge, La. 70002 Maine Medical Center Kansas City, Kans. 66103 Portland, Maine 04102 Grantee University of Iowa College of University of Kansas Medical Center Louisiana State Department of Medical Care Development, Inc. Medicine Hospitals Effective Starting Date December 1, 1966 July 1, 1966 January 1, 1967 May 1, 1967 of Planning Grant Amount of Planning $291,348 (Ist year) $197,945 (ist year) $490,448 (lst year) $193,909 (lst year) Grant $290,591 (2d year) $281,627 (2d year) $454,445 (2d year) $204,709 (2d year) Effective Startin ,2 D to June 1, 1967 of Operational ranat Amount of Operational $699,852 Grant 166 Name of Region Maryland Memphis Medical Region Metropolitan Washington, D.C. Michigan Preliminary Planning Area Maryland Western Tennessee'Northern District of Columbia and contiguous Michigan Mississippi, and portions of counties in Maryland (2) and Arkansas, Kentucky, and Missouri Virginia (2) Estimated Population 3,685,000 2,425,000 2,160,000 8,585,000 Coordinating Headquarters Steering Committee of the Regional Mid-South Medical Council for Com- District of Columbia Medical Society Michigan Association for Regional Medical Program for Maryland prehensive Health Planning, Inc. Medical Programs, Inc. Program Coordinator William S. Spicer, Jr., M.D. James W. Culbertson, M.D. Thomas W. Mattingly, M.D. Albert E. Heustis, M.D. Acting Coordinator Professor and Cardiologist Program Coordinator I 1 1 1 Michigan Avenue Mar land Regional Medical Program Department of Internal Medicine Metropolitan Washington. D.C. Suite 200 Y'@ 550 North Broadw.@5 College of Medicine Regional Medical Program East Lansing, Mich. 48823 Baltimore, Md. 2 @2 University of Tennessee District of Columbia Medical Society 858 Madison Avenue 2007 Eve Street N.W. (tel: 517-351-0290) (tel: 301-955-7444) Memphis, Tenn. 38103 Washi@ton, D.C. 20006 (tel: 901-JA6-8892, ext. 437) (tel: 202-223-2230) Program Director Chairman, Regional Advisory William J. Peeples, M.D. Frank M. Norfleet Clayton Ethridge, M.D. William N. Hubbard, Jr.. M.D. Group Commissioner Vice President Associate Dean, School of Medicine Dean, School of Medicine Maryland State Department of Parts, Inc. 901 23d Street N.W. University of Michigan Health 601 South Dudley Washington, D.C. 20037 1335 Catherine Street 301 West Preston Street Memphis, Tenn. -38104 Ann Arbor, Mich. 48104 Baltimore, Md. 21201 (tel: 313-764-8175) Grantee The Johns Hopkins University University of Tennessee College of District of Columbia Medical Society Michigan Association for Regional M edicine Medical Programs, Inc. Effective Starting Date January 1, 1967 April 1, 1967 January 1, 1967 Junel,1967 of Planning Grant Amount of $518,443 @l st year) $173,119 $203,790 (lst year) $1,294,449 Planning Grant $412.227 2d year) $216,322 (2d year) Effective Starting Date March 1, 1968 of perational Grant Amount of $418,318 Operational Grant 167 Name of Region Mississippi Missouri Mountain States Nebraska-South Dakota Preliminary Planning Area Mississippi Missouri, exclusive of St. Louis Idaho, Montana, Nevada,and Nebraska and South Dakota Wyoming Estimated Population 2,350,000 4,605,000 2,160,000 2,110,000 Coordinating Headquarters University of Mississippi Medical University of Missouri School of Western Interstate Commission for Nebraska State Medical Association Center Medicine Higher Education Program Coordinator Guy D. Campbell, M.D. Vernon E. Wilson ' M.D. Kevin P. Bunnell, Ed.D. Harold Morgan, M.D. Mississippi Regional Medical Executive Director for Health Affairs Associate Director Program Coordinator Program University of Missouri Western Interstate Commission for Nebraska-South Dakota Regional University of Mississippi Medical Columbiii, Mo. 65201 Higher Education Medical Program Center University East Campus 1408 Sharp Building 2500 North State Street (tel: 314-449-2711) 30th Street Lincoln, Nebr. 68503 Jackson, Miss. 39216 Boulder, Colo. 80302 (tel: 402-432-5427) (tel: 601-362-4411) (tel: 303-443-21 1 1, ext. 6342) Program Director George E. Wakerlin, M.D. Alfred M. Popma, M.D. Director, Missouri Regional Program Director Medical Program Mountain States Regional Medical Lewis Hall Program 406 Turner Avenue 525 West Jefferson Street Columbia, Mo. 65301 Boise, Idaho 83702 (tel: 314-449-2711) (tel: 208-342-4666) Chairman, Regional Advisory Not identified Nathan J. Stark George D. Humphrey, M.D. Robert J. Morgan, M.D. Group Group Vice President President Emeritus President Operations University of Wyoming Nebraska State Medical Association Hallmark Cards, Inc. P.O. Box 3067, University Station 916 West 10th Street 25th and McGee Trafficway Laramie, Wyo. 82070 Alliance, Nebr. 69301 Kansas City, Mo. 64108 Grantee University of Mississippi Medical University of Missouri School of Western Interstate Commission for Nebraska State Medical Association Center Medicine Higher Education Effective Starting Date of July 1, 1967 July 1, 1966 November 1, 1966 January 1, 1967 Planning Grant Amount of Planning Grant $454,206 $398 556 @Ist year) $876,855 (1 st year) $350,339 (1 st year) $324:254 2d year) $1,082,107 (2d year) $349,367 (2d year) Effective Starting Date of April 1, 1967 March 1, 1968 Operational Grant Amount of Operational Grant $2,887,903 (lst year) $206,913 $3,484,039 (2d year) 168 Name of Region New Jersey New Mexico New York Metropolitan Area North Carolina Preliminary Planning Area New Jersey New Mexico New York Cit@and Y@stchester, North Carolina Nassau, and uffolk Counties Estimated Population 7,000,000 1,005,000 11,480,000 5.030.000 Coordinating Headquarters New Jersey Joint Committee for University of New Mexico School of Associated Medical Schools of AssociationfortheNorthCarolirta Implementation of Public Law Medicine Greater New York Regional Medical Program 89-239 Program Coordinator Alvin A. Florin, M.D. Reginald H. Fitz, M.D. Vincent de Paul Larkin, M.D. Marc J. Musser, M.D. New Jersey Regional Dean, School of Medicine New York Academy of Medicine Executive Director Medical Program University of New Mexico 2 East 103d Street North Carolina Regional Medical goo Stanford Drive N.E. New York, N.Y. 10029 Program 88 Ross Street Teer House East Orange, N.J. 07018 Albuquerque, N. Mex. 87106 (tel: 212-427-4100) 4019 North Roxboro Road Durham. N.C. 27704 (tel: 201-675-1100) (tel: 505-277-2321) (tel: 911)-477-8685) Irvin E. Hend son, M.D. Program Director University of r@ew Mexico 900 Stanford Drive N.E. Albuquerque, N. Mex. 87106 Joseph R. Jehl, M.D. Not identified Vernon Stutzman George W. Paschal, Jr., M.D. Chairman, Regional Regional Medical Program President, Medical Society of State Advisory Group President New York Academy of Medicine of North Carolina The Medical Society of New Jersey 2 East 103d Street i 1 10 wake Forest Road 315 West State Street Raleigh, N.C. 27604 Trenton, N.J. 08618 New York, N.Y. 10029 Foundation for the Advancement of University of New Mexico Associated Medical Schools of Duke University Grantee Medical Education and Research in Greater New York New Jersey Effective Starting Date July 1, 1967 October 1, 1966 June 1, 1967 July 1, 1966 of Planning Grant $297,466 $449 736 @Ist year) $967,010 $435 851 @ist year) Amount of $773 674 2d year) Planning Grant $553:270 2d year) Effective Starting Date March 1, 1968 of Operational Grant $1,5iO,796 Amount of Operational Grant 169 Name of Region North Dakota Northeastern Ohio Northern New England Northiands Preliminary Planning Area North Dakota 12 counties in Northeastern Ohio Vermont and three counties in Minnesota Northeastern New York Estimated Population 640,000 4,170,000 570,000 3,580,000 Coordinating Headquarters University of North Dakota Case Western Reserve University University of Vermont College of Minnesota State Medical Association Medicine Foundation Program Coordinator Theodore H. Harwood, M.D. Frederick C. Robbins, M.D. John E. Wennberg, M.D. Winston R. Miller, M.D. Dean, School of Medicine Dean, School of Medicine Program Coordinator 375 Jackson Street University of North Dakota Case Western Reserve University Northern New England Regional Saint Paui,Minn. 55101 Grand Forks, N. Dak. 58201 2107 Adelbert Road Medical Program Cleveland, Ohio 44106 University of Vermont Co] lege of (tel: 612-224-4771) (tel: 701-777-2514) Medicine 25 Colchester Avenue Burlington, Vt. 05401 (tel: 802-864-4511, ext. 244) Program Director Willard Wright, M.D. Program Director North Dakota Regional Medical Program 1600 University Avenue Grand Forks, N-. Dak. 58201 Chairman, Regional Advisory Lee A. Christoferson, M.D. Irvine H. Page, M.D. Edward C. Andrews, M.D. 0. L. N e I so n, M. D. Group The Neuro-Psychiatric Institute Consultant Emeritus Dean, College of Medicine Chairman, Advisory Group 700 First Avenue South Cleveland Clinic University of Vermont Northiands Regional Medical Program Fargo, N. Dak. 58102 Division of Research 25 Colchester Avenue 601 Medical Arts Building 2050 East 93d Street Burlington, Vt. 05401 Minneapolis, Minn. 55402 Cleveland, Ohio 44106 Grantee North Dakota Medical Research Case Western Reserve University University of Vermont College of Minnesota State Medical Association Foundation Medicine Foundation Effective Starting Date of July 1, 1967 January 1, 1968 July 1, 1966 January 1, 1967 Planning Grant Amount of Planning Grant $188,010 $285.783 $316,186 @Ist year) $370,904 (1 st vea r) $702,504 2d year) $529,250 @2d @ear) Effective Starting Date of Operational Grant Amount of Operational Grant 170 Name of Region Northwestern Ohio Ohio State Ohio Valley Oklahoma 20 counties in Northwestern Ohio Central and southern two-thirds of Greater Dart of Kentuc@y and Oklahoma Preliminary Planning Area Ohio (61 counties, excluding contiguous pa!-t@ of Ohio, Indiana, Metropolitan Cincinnati area) and West Virginia Estimated Population 1,360,000 4,680,000 6,000,000 2,500,000 Coordinating Headquarters Medical College of Ohio at Toledo Ohio State University College of Ohio Valley Regional Medical University of Oklahoma Medical Medicine Program Center C. Robert Tittle, Jr., M.D. Nell C. Andrews, M.D. William H. McBeath, M.D. Kelly West. M.D. Department of Program Coordinator 2313 Madison Avenue Assistant Dean, College of Medicine Director, Ohio Valley Regional Professor and Head, Toledo, Ohio 43624 Ohio State University Medical Program Continuing Education 410 West 10th Avenue 1718 Alexandria Drive University of Oklahoma Medical (tel: 419-248-6201) Columbus, Ohio 43210 Lexington, Ky. 40508 Center 800 Northeast 13th Street (tel: 614-293-5344) (tel: 606-255-6684) Oklahoma City, Okla. 73104 (tel: 405-CE 2-8561) Program Director Chairman, Regional Edward L. Burns, M.D. Richard L. Meiling. M.D. Louis Wozar James L. Dennis, m.b. Advisory Group Northwestern Ohio Regional Dean College of Medicine Presidentand General Manager Director and Dean Medical Program Oh i. @tate University Tait Manufacturing Company University of Oklahoma Medical 2313 Madison Avenue 410 West 10th Avenue 500 Webster Street Center Toledo, Ohio 43624 Columbus, Ohio 43210 Dayton, Ohio 45404 800 Northeast 13th Street Oklahoma City, Okla. 73104 (tel: 614-293-5344) (tel: 513-224-9871) Grantee Medical College of Ohio at Toledo Ohio State University College of The University of Kentucky University of Oklahoma Medical Medicine Research Foundation Center Effective Starting Date January 1, 1968 April 1, 1967 January 1, 1967 September 1, 1966 of Planning Grant Amount of $309.180 $126,182 $346 760 @lst year) $177 963 @Ist year) Planning Grant $407:238 2d year) $282:100 2d year) Effective Starting Date of Operational Grant Amount of Operational Grant 171 Name of Region Oregon Puerto Rico Rochester South Carolina Preliminary Planning Area Oregon Puerto Rico Rochester, New York and 1 1 South Carolina surrounding counties Estimated Population 2,000,000 2,670,000 1,270,000 2,600,000 Coordinating Headquarters University of Oregon Medical School University of Rochester School of Medical College of South Carolina Medicine and Dentistry Program Coordinator M. Roberts Grover, M.D. A. Nigaglioni, M.D. Ralph C. Parker, Jr., M.D. J. C. Chambers, M. D. Director, Continuing Medical Chancellor, School of Medicine Cl, nical Associate Professor of Medical College of South Carolina Education University of Puerto Rico Medicine 55 Doughty Street University of Oregon Medical School San Juan, P.R. 00905 School of Medicine and Dentistry Charleston, S.C. 29403 3181 Southwest Sam Jackson University of Rochester Park Road (tel: 174-723-5210) 260 Crittenden Boulevard (tel: 803-723-9411) Portland, Oreg. 97201 Rochester, N.Y. 14620 (tel: 503-228-9181, ext. 519) (tel: 716-473-4400, ext. 3112) Program Director Chairman, Regional Advisory Herman A. Dickel, M.D. Not identified Frank Hamlin William M. McCord, M.D., Ph. D. Group Member, Council of Medical Papec Machine Com@any President, Medical College Education Shbrtsville, N.Y. 145 8 of South Carolina Oregon Medical Association 80 Barre Street 511 Southwest 10th Avenue Charleston, S.C. 29401 Portland, Oreg. 97205 Grantee U n iversity of Oregon M ad ical School University of Rochester School of Medical College of South Carolina Medicine and Dentistry Effective Starting Date of April 1, 1967 Application under review October 1, 1966 January 1, 1967 Planning Grant Amount of Planning Grant $123 527 @lst year) $219,168 (lst year) $306 985 @lst year) $231,125 (2d year) $318:286 2d year) $379:246 2d year) Effective Starting Date of March 1, 1968 March 1, 1968 Operational Grant Amount of Operational Grant $221,191 $343,749 172 Name Of Region Susquehanna Valley Tennessee Mid-South Texas Tri-State ia Eastern and entral Tennessee and Texas contiguous parts of Southern Massachusetts, New Hampshire, Kentucky and Northern Alabama and Rhode Island Estimated Population 2,140,000 2,700,000 10,875,000 7,010,000 Vanderbilt University School of U n iversity of Texas Medical Care and Educational Medicine and Meharry Medical Foundation, Inc. College rogram Coordinator Richard B. McKenzie Stanley W. Olson, M.D. Charles A. Lemaistre, M.D. Leona Baumgartner, M.D. 3806 Market Street Professor of Medicine Vice-Chancellor for Health Affairs Medical Care and P.O. Box 541 Vanderbilt University University of Texas Educational Foundation Camp Hill, Pa. 17011 Clinical Professor of Medicine Main Building 22 The Fenway -3252) 110 Baker Building Boston, Mass. 02115 (tel: 717-761 Meharry Medical College Austin, Tex. 78712 110 21st Street South (tel: 512-GR 1-1434) (tel-. 617-262-3040) Nashville, Tenn. 37203 (tel: 615-255-0692) Spencer G. Thompson, M.D. Regional Medical'Program of Texas Suite 724 Sealy'Smith Professional Building Galveston, Tex. 77550 (tel: 713-505-2425) Chair'" an, Regional Raymond C. Grandon, M.D. Thomas P. Kennedy, Jr. John F. Thomas, M.D. Mac V. Edds, Jr., Ph. D. Ad visory Group Secretary President, Executi Committee Committee on Cancer Division of Medical Sciences Dauphin County Medical Society Health and HospitavlePlanning Texas Medical Association Brown University 131 State Street Council 918 East 32d Street President, Medi&al Care and Harrisburg, Pa. 17101 Vanderbilt University Medical Center Austin, Tex. 78705 Educational Foundation, Inc. Hospital Board St. Thmas H ospital 22 The Fenway P.O. Box 449 8oston, Mass. 02115 Nashville, Tenn. 37203 Vanderbilt University University of Texas Medical Care and Educational f Foundation, Inc. Ef active Starting Date June 1, 1967 July 1, 1966 July 1, 1966 December 1, 1967 of Planning Grant Amount Planning 0 $265 841 @lst year) $1 271 013 @ist year) $439,037 Effective Starting Date $524:738 2d year) $1:577:612 2d year) of Operational Grant February 1, 1968 Operational Grant $1,630,304 173 Name of Region Virginia Washington-Alaska West Virginia Western Now York Preliminary Planning Area Virginia Washington and Alaska West Virginia Buffalo, New York and 7 surrounding counties Estimated Population 4,535,000 3,360,000 1,800,000 1,935,000 Coordinating Headquarters Medical College of Virginia and University of Washington School of West Virginia University Medical School of Medicine, State University University of Virginia School of Medicine Center of New York at Buffalo, in coopera- Medicine tion with the Health Organization of Western New York Program Coordinator Kinloch Nelson, M.D. Donal R. Sparkman, M.D. Charles L. Wilbar, Jr., M.D. John R. F. lngall, M.D. Dean, Medical College of Virginia Associate Professor of Medicine West Virginia Regional Medical Director, Regional Medical Program 1200 East Broad Street School of Medicine Program for Western New York Richmond, Va. 23219 University of Washington West Virginia University Medical School of Medicine. State University AA 312 University Hospital Center of New York at Buffalo (tel: 703-Ml4-9851) Seattle, Wash. 98105 Morgantown. W. Va. 26506 Buffalo, N.Y. 14214 (tel: 206-543-8540) (tel: 304-293-4511) (tel: 716-833-2726, ext. 32, 50) Program Director Eugene R. Perez, M.D. William E. Chalecke, M.D. Program Director R.D. 2 Horton Road Virginia Regional Medical Program Jamestown. New York 14701 700 Building, Suite 1025 700 East Main Street (tel: 716-483-1840) Richmond, Va. 23219 (tel: 703-643-6631) Chairman, Regional Advisory Mack 1. Shanholtz, M.D. Donal R. Sparkman, M.D. Clark K. Sleeth, M.D. Douglas M. Surgenor, M.D. Group State Commissioner of Health Associate Professor of Medicine Dean, School of Medicine Dean, School of Medicine State Department of Health School of Medicine West Virginia University Medical State University of New York at Bank and Governor Streets University of Washington Center Buffalo Richmond, Va. 23219 AA 312 (University Hospital Morgantown, W. Va. 26506 101 Capen Hall Seattle, Wash. 99105 Buffalo, N.Y. 14214 (tel: 206-543-8540) (tel: 716-831-2811) Grantee University of Virginia School of University of Washington School of West Virginia University Medical Research Foundation of the State Medicine Medicine Center University of New York Effective Starting Date of January 1, 1967 September 1, 1966 January 1, 1967 December 1, 1966 Planning Grant Amount of Planning Grant $545,454 $266 248 @Ist year) $150798 lstyear) $149,241 (lst year) $655:148 2d year) $208:910 @2d year) $383,717 (2d year) Eff ctive Starting Date of February 1. 1968 March 1, 1968 Op:rational Grant Amount of Operational Grant $1,032,003 $357,761 174 Name of Region Western Pennsylvania Wisconsin Preliminary Planning Area Pittsburgh, Pennsylvania and 28 Wisconsin surrounding counties Estimated Population 4,200,000 4,190,000 Coordinating Headquarters University Health Center of Wisconsin Regional Medical Pittsburgh Program, Inc. Program Coordinator Francis S. Cheever, M.D. John S. Hirschboeck, M.D. Dean, School of Medicine Wisconsin Regional Medical University of Pittsburgh Program, Inc. M-240 S6aife Hall 1 10 East Wisconsin Avenue 3550 Terrace Street Milwaukee, Wis. 53202 Pittsburgh, Pa. 15213 (let,. 414-272-3636) (tel: 412-621-1006) Program Director Chairman, Regional Dan J. Macer T. A. Duckworth Advisory Group President, Veterans Administration Senior Vice President Em Hospital o@loyers Insurance of Wausau University Drive 4 Grant street Pittsburgh. Pa. 15240 Wausau, Wis. 54402 Grantee Universit@ Health Center of Wisconsin Regional Medical Pittsburg Program, Inc. Effective Starting Date January 1, 1967 September 1, 1966 of Planning Grant Amount of $340,556 11 st year) $344,418 Planning Grant $326,765 (2d year) Effective Startin C? Date September 1, 1967 of Operational rant Amount of $630,149 Operational Grant 175 APPENDIX 7 the td-inistration of hospitals, and in co- ing, diagnosis, and tre@itment reliting to "Grants foi- Pla?i?iitig operation ivitli practicing physicians, medi- heart disease, cancer, or stroke, ind, at the cal center officials, hospital administrators, option of tl)e applic@int, related disease or "SEC. ')O'. (a) The Surgeon General, upon PUBLIC LAW 8@239 and rel)resent-,iti%,es from @ippropriate voliin- but Only if ,;iieli group- - the recoillitio@ii@l,'Itioii (@f tli(, N.,ttionfil @(1- 89TH CONGRESS, S. @).W tilry health Wiseacres. Nvitiliri it g@,ogr;lr)llil- OC'I'Oltl@lt I;, J!)(W'k "A llillol-izflti,)), )f of ,f oli,! (,I- i,ior,@ f,-,. ill, lit] AN AC"I' "SP,'C. 1)01. (:I) Tli4,r@! !Ll'l- lltli,I,OIIZ(,Id III %%it], be itpl)ropri-@itf,(] $50,000,000 for tli(@ fiscal ri@gtilittioil,;, to be ['or @t rry- .. ...... year ending June 20, 1966, $90,000,000 for ilig out the 1)url)o@(@,.,, of this title; institutions,, all([ )tlier public oi- the fisetil year ending June 30, 1967, and "(2) Consists of out-, or iiior(@ medical nonprofit @ig(,tici(,s :,act institutions Heart Disease, Cancer, and Stroke Amend- $200,000,000, for the fiscal year ending June (,eiit(,rs, one or iiiort@ (-Ijllie@ll e(,Yi- to assist tile,,, ill Pl@I]IT]jlll, the ments of 1965 PO, 1968, for grants to assist public or noii- ti!rs, ttrid one or more liosliitals; and of regional iii(@(lic@ti profit private universities, medicil schools, "(3) has ill effect cool)(@rati,,e arriin,-e- "(1)) GI',lilt,,; under this (,etioll lll;l@- 1)@@ research institutions, and other public or nients @11110,19 its component I, air,,; Nvl)icll olll.N- upon application tli(,@r(,,for at)- To amend the Public Health Service Act to I)r nonprofit private institutions and @,igenc' the Surgeon (,'cner@il finds will be O"('(1 by tll(, Sijrge,)ii General. kii3- sliel) assist in combating heart disease, cancer, ics stroke, and related diseases. in planning, ]it conducting feasibility studies, for (@ffectiv(@ly e@ii-rying out the litirposes of ;Illf)li(-:ttion be :Lppl'Ol'e(I only if it (,oil- @in(I in operating pilot Projects for ill(! c tab- this title. :iiit,, or is ,lil,l)ort(,(l bN,- m@s "(1) r(,@i.@oziab](@ ii."ilrilnee@ tilllt Be it enacted 'by the Senate and lioll8c of li,,Iinient of regional medical progra s of "lb) The t(@riii "Ile(lic,'tl cent(,i" means :I ,Ill(l (leiiion'tr, ti(,n Representatives of the United @tates of research, training, tiv- Tll('(Ii('Ill School or other medical itIStittitiOTI [laid I)tirsti@iiit to iny ,ueli Anterica in Congre88 assembled, That gl,;tll.c this ities for cirrying out the purposes of tills l@c)stgr:t(lu;it,@ medical] training %%ill 11" ''sell 0111@- for the I)tirpos(@., Act may be cited as the "Heart Disease, title. Stims ,ipprol)riated under this ;ectlon :"'(I 011(@ or more hospitals :Ifflliat(,d tliei,(,- for ivliicii 1)@ii(i Bell ill @itll CANCER, STROKE, AND RELATED for any fiscal year sliill remain available for with for te@ieliiiig, :[]Ill (lettioll- file @it)l)lic:lblc I)I.Oxi.,iolis of tili@,, fit],, @In't SEC. 2. The Public Health Service Act making such grants until the end of the fiscal strittion purposes. the r(@gtilittiolis thereunder; .v(,ar following the fiscal year for which the "(c) The terrTi '(Critical center' "(2) that tli,@ (42 U.S.C., ch. 6A) Is amended by t(l(ling it :11)illi(-;trit Nvill f@,i- ,tich the end thereof the following new title: OI)T,i:ltioli is means itii iri@,titiiti,)ii (Or (if art tr(,] :Ll)ll fill([ "lb) A gi,:iiit iiii(](@r this title t)(, for tioll) ill(! primary filll(-tl(,Ii (.1, iviliell is r(@- ;it,,- "TITLY,, IX-EDUCATIO@-s, RESEARCH, part or Lll Or til(@ cost of the 1)]@Ltii)irig or ,search, training of specialists, @iii(I (leiiion- of @ill(i TRAINING, AND DE@IONSTRATIONS IN Other ilcti%'Iti(@l,' witli respect to which the sti,:itioiis ;tiid i%,Illcli, ill coil['(-(-tioil there%%,itti, ('Ontario l'ol' site]) funds; THE FIELDS OF HEART DISEASE, application is made, except thLt any fuel 1)roN,i(les specialized, Iiigli-(Iii,,ility (li@i,-Ilostic "(:I) reasonable fissurzinces that tlic, @il)- CANCER, STROKE, AND RELATED grant with respect to construction of, or DISEASES :Ind treatment services for inpatients @iii(i I)Iietlrlt will Intake(, such reports, in ,iieli provision of built-in (as determined in ac- outpatients. form and containing such inrorniition @is "Ptirpo8e8 cordance with regulations) equipment for, "((I) The term 'hospital' iiit,,in., it lioslii- the Surgeon General may from time to tiny facility may not exceed 90 per centtim of "SEC. 900. The purposes of this title are- , tzil as defined in section (;25(c) or other time reasonably require, @inti will keep the cost of such construction or (,(Iuipiiieiit. ,ueli recortis in(] ,ifford s(Icli ;iece:,s theret(, "(a) Through grants, to encourage and I)i!altli f@icility in which local (,,capability for assist in the establishment of regional co- "(C) Trends appropriated l@ursti,,tnt to tills (]!Ztgllo,.4is @111(i treatment is supported :Ind :is the Stir,-eoii G(,iier@il ziece.,- operative arrangements among medical title sliall not be itvallable to pay the cost S;tl,y to :ts.@,iire the iti,l schools, research Institutions, and hospitals of hospital, medical, or other care of patient,,, ;iti@iiiL@iited by the I)t-o;,r@iiii established all- (-@ition of such reports ; and for research and training (including con. except to the extent it is, as determined in (I(@r this title, "(4) ,i satisfactory 911ONViDg that the tinuing education) accordance with regulations. incident to "(e) The term 'iionr)ro8t' its to ,-applicant has designated an ii(l%,isory and for related le on- ose research, training, or demonstration tiny Institution or agency means all institu- group, to advise the - ,tpplicant (@tnd the in the f in ill strations of patient care lds of ativities which are encompassed by the tion or agency which is owned and operated institutions and agencies participating in heart disease, cancer, stroke, and related purposes of this title. No patient shill be by one or more nonprofit corporations or the resulting regional medical progra In) diseases : furnished hospital, medical, or other C.IM Dissociations no part of the net turnings of in formulating @ind (,;trr,@-ing )iit the I)I@iii "(b) To afford to the medical profession at any facility Incident to i,esetircli, training, ,and the medical institutions of the Nation, or d(@nioristratiori iictl%,Itics carried out with Nviii(,Ii iiiilr,@s, ,r may l@iwftilly to tll(@ for tli(, est@' bli,@firrierit ;in(I ol)f@r,,ttiori of through such cooperative arrangements, the funds :appropriated I)ursii@int to this title, 11(@riet'it or a iii, iii-i@iti@ or such regional iiie(lic@if program, @vlil(-Ii opportunity of making available to their p,,L- unless lie has bc@tn referred to such facility individuate. @ttli,isory group recreates practicing I)Ily,@i- tients the latest advances In the diagnosis by it practicing physician. (f) Tli(,, t.(-riii 'construction' Includes (71@Lns, medical center liosf)itiii ,lDd treatment of these diseases ; and Reiteration, major repair (to the (@xterit per- iiiinistr@itors, representatives from @ipl)t-o- "(c) By these means, to improve gen- "Definitions initted by r(,gtil@ltiODS), remodeling :Ind I)t,iztte medical societies, voliint-@ir3, health erally the health manpower and facilities "SEC. 902. For the purposes of this title- renon,iition of 4@xistiilg buildings (iiie@ltidirig and representittii-ts of other available to the Nation, and to accomplish "(a) The term 'regicnil wedic@il program' initi@il (-(Iiiipnient thereof), ;iri(i i'@-lil;tcerii(@nt (,transitions, institution.,, ,Lzid igenei,,s these ends without interfering with the Pat- ine@ins a cooperative @irrfiiigenient @imon.@ IL of ol)So]L't(-, built-in (;is il(-ti,rtriiii(@(I !it :I(.- %%,itli ,I(.ti%,ttieg of tll(@ kirif] to terns, or the methods of financing, of Pa. grotilk of ptil)ll(, or iioril@rollt liriv:ttc filstil@ll- N%Illl regulations) I),- oil iiii(ii-r the program ,iiiii tient care or Professional practice, or with tions or tigeiieles engaged in research, triiii- (!xistirig buildings. itietribers of the public formulae ivitli thi, 176 need for the services provided tinder the accordance ivitli the Davis-Bacon Act, as the Council, shall be entitled to receive com- interested national professional organiza- program. amended (40 U.S.C. 276a-276a-5) ; and pensation at rates fixed by the Secretary, tions. the Secretary of Labor shall have, with but not exceeding $100 per day, including "Grants for EBtabli8hn4ent and Operation of respect to the l@ibor standards specified in traveltime, and while so serving away from Report to President and Congress leegioizal Ile,lical Progi-ain.3 this piirfigrapli, the authority and func- their homes or regular places of business they "SEC. 908. On or before June :30, 1 a(3 7, f@04. (;i) ']'II(! Stirg(@ori tion,, set fortli lit Iteorgitilziitiori ri.@tri may be @ill(@wo(I tr;tvel ex[)eyis@', including than Surgeon General ;tfter cozistil@,.itioii with Niiiiilj,-r(!(] 1,1 (,f I!)50 (15 10.11. :@17(;; !-, lit@r iliem lit licti of siil)sisteii(!e, it@, itijtliorize(i file (Political, ,4itill iiil)rtiit to Ili(! I:t:@z 15) :,,,,I )r (li@, Act [,.N 5 )f iii,, to tli@, ;All(] trial! ]:I, A,-l @l' II)-II; (5 7:tl, '-') f,@i, lit (11 tili@ it report of file activities schools, r(-searcli institutions, ;irid otlil.], 27(;(:). the Govi-riiiii(@ii;t (-@iiil)loy(xl iiiteriiiit.- tinder this title together with (1) a state- public or nonprofit private @igencie,.s, and "National Advisory Council on Regional teiitly. meet of the relationship between Federal institution to assist in establishment and Ifcdical Progrg,?ji,3 Applications for financing and financing front other sources operation of regional medical programs, grants, recom- of the activities undertaken pursuant to this including construction and eqUiPMCDt Of kl)pointinent of mendations. title, (2) an appraisal of the activities as- facilities in connection therewith. members. sisted under this title in the light of their "lb) Gr@,ints tin(if@r this section may be ,)O.-). (;I) Surgeon (,encriil, with "(d) The Council shall advise and assist effectiveness in carrying out the purposes of :it)- t.lic Stirg(!oii G(-iieral lit the preparation of this title, ,in(i (3) recommendations with ill(- Sijrgi,ort Any sti(-]) lit(, itlilir(,N@;tl of ill(! S(@(!ret@iry, m@iy @IPI)Oillt, i,(,gtil;ttioiis for, ;iiid :is to policy matters respect to extension or modifictition of this ii,@iy be only if it is r,-(@- witliiiiit to the civil ;ervice laws, it ;tri,,,,ing with respect to, the administration title lit the light tliereof. 1)3, the @t([N,!,(,ry groul) described N@iti(iii;tl A(Ivisi)i-y Council oil Regional 1\ledi- of this title. The Council sliill consider all lit section 903(b) (4) and contains or is stip- cal Ilrogr@inis. The Council shall consist of applications for grants under this title ,ind "'Reco?,ds a?id Audit fiorted 1)3- i,e@isonable a.,,siirane(@s that- tried Surgeon (;enerzil, who shall be the chair- shall make recommendations to the Surgeon "SEC. 900. (a) Each recipient of a grant ,,(I) l,'e(leral funds paid pursu@int to ni@in, @iii(I twelve members, not otherwise in General with respect to approval of applica- tinder this title shall leep such records as @iiiy such grant (i@) will be used only for the r(@gtilar full-time employ of the United tions for in(] tlic, amounts of gr@,iiits tinder the Surgeon General may prescribe, incliltl- tlii@ I)iirpo.,(@s for which 1)@tid :tied II) :I(,- States, who ire leaders in the fields of the this title. ing records which fully disclose the amount %vitli tlif@ of fiiiiiliini(@jit@il sciences, the medical scieric(@s, "I?cqizlatiotis :itld deposition by such recipient )f tit(, this till(, ;tit(] flif! rf,giil;it,i,)Til; .r public ;tlTair,;. At@ two of tli(@ !II)- proceeds of such grant, to tot@,il cost of iii(!ijil)(!rs sli@ill 1)(! I)riictili-iiig pliysi- "Sic. 90(;. The Stirg(@oii file l@roject or undertaken;,,, in coiinectioil iii,t, faults tit; rt, shall 1)(@ ('11tit;Lxl(lltig ill file study, ('oliSUlt@:lt!Oll %%'itli file (@'OUDCil, shall I)r(@- :tviiiliibl4,, for (!.@t.,tl@lislim(!nts at' with which ,iucli grant is made or used, in(I I)r(,gr:irli tli;ignosi@, or treatment of heart disease, one scrib() general regul@itions covering the terms' the :iznount of that portion of the cost of his project or undertaking supplied by other 1)(@ outstanding lit tli(@ study, diagnosis, :tji(I conditions for iipl)ro%@itig @tl)plie;i 'io"'@ with to NN,Iiicli thi@ grtrit is ni@i(le ; or treatment of ctincer, an(] one shall be out- for grants under this title and the coordi.@,,- ,1(2) the will r@rovi(le for such st@in(ling in the study, diagnosis, or treat- tion of programs assisted tinder this title sources, and such records as will facilitate -in effective audit. fiscal control and fund accounting I)roce- inent of stroller with programs for training, research, anci "lb) The Secretary of Health, Education, (lures as are require(] by the Surgeon demonstrations relating to the same diseases and Welfare and file Comptroller General of General to assure proper (lisbtjrs(,@inent Of Term (,f office. -issisted or authorized tinder other titles of the United States, or any of their dulv an4l @teci)tinting for such funds "(t)) Each ,tl)pointed member of the Cotin- this Act or other Acts of Congrc%s. ;authorized representatives, ,:Iiall lian,o access IZ(@cords, cil sliill hold office for a term of four years, ,rnformatioit oil Special Treatiytc?tt att(I for file purpose of audit and examination to except filar any member appointed to fill @l @raiiii?ig Centers any books, documents, papers, and records "(3) the tpl)licant will make such re- vacancy prior to the expiration of the term of the recipient of any grant under this parts, in such form and containing such for which his predecessor was @ippointed "SEC. 907. The Surgeon General shall title which ,ire pertinent to any such grant." information as the Surgeon General may shall be appointed for the remainder of such establish, and maintain on a current basis. SEC. 3. (a) Section I of the Public Health from time to time reason@tbly require, and term, and except that the terms of office a list or lists of facilities in the United will keep such records and afford such Service Act is amended to read as follows of the members first taking office shall expire, States equipped and staffed to provide file "SECTION 1. Titles I to IX, inclusive, of access thereto @is the Surgeon (@eneral @is designated b.@- the Surgeon General at the most advanced methods and techniques in this Act may be cited as the 'Public Health may fin(] necessary to asstire the cor- time of appointment, four at the en(] of the the diagnosis .in(I treatment of heart disease, r(!ctnt@ss and verification of ,iicii r(@ii(,rt., ; first Service Act'." four ;it@ fli(, en(] (if tli(@ ,;e(@ori(I year, ciiic(,r, or stroke, together with such related and ;iri(I four at till! end of the third year @ifter ixifoi,iii@itioii, including the :availability of lb) The Act of Jul3- 1, 194-1 (58 Stat. "(4) an3- laborer or meelianic the (]at(! of apl)ointiii(!nt. Ali ,ippointed mem- ,tdv;izicc(l il)eciLlty training it) such facilities,;. 1;82), as amended, is further @imended b3, re- by @iny contractor or subcontractor lit the I)ei, shall riot be t-ligil)le to serve continuously @is lie cleeiiis useful, and sll,,Lll make such list numbering title IX (as in effect prior to the performance of work on any construction for more than two terms. or lists and related information readily ciitictment of this Act) as title X, and by i-enumbering sections 1)01 through 1)14 (as aided by payments pursuant to ,Lny grant ;available to licensed practitioners and other in effect prior to the enactment of this Act). iin@](@r till.,; ,f!(!ti(@n ivill 1)(! late(] wage,,, lit Compens@ition. lierson,, requirin, such Information. To the and references thereto, its sections 1001 rates not ]@'s Than tlio@f! prevailing oil "(c) Appoiiit(@(I members (if tells Launch, (Laid of iii;tkiii;, such list or lists and other through 1014, r(,sl)eetivel3-. siinil;tr fit tire! loc@ility @is i%-Iiilc @itt(,ri(lirig meetings oi, conferences information itiost useful, the Surgeon Gen- APPROVED OCTOBER 6, 1965, 10:15 determined by file Secretary of Labor in thereof or otherwise serving on business of eral shall from tiiii(@. to time consult ivith A.,Nf. 1 77 Legiaative History: APPENDIX 8 (j) "Advisory group" means the group (d) AdvisorV group; e8tabU8hment; evi- designated pursuant to section 903(b) (4) dence. An application for a grant under sec- House Report No. 963 accompanying H.R. of the Act. tion 903 of the Act shall contain or be 3140 (Comm. on Interstate and Foreign REGULATIONS (k) "Geographic area" means any area supported by documentary evidence of the Commerce). REGIONAL MEDICAL that the Surgeon General determines forms establishment of an advisory group to prnog Senate Report No. 368 (Comm. on Labor and PROGRAMS n ,,,,mic and socially related region, vide advice in formulating and carryi Public Welfare). MARCH :L8, 1967 takig into consideration such factors as out the establishment and operation ofa Congressional Record, Vol. 111 (1965) present and future population trends and program. June 25: Considered in Senate. patterns of growth ; location and extent of (e) Advisory group; membership; descrip- June 28 : Considered and passed Senate. SUBPART E-GRANTS FOR transportation and communication facilities tion. The application or supporting material Sept. Z3: H.R. 3140 considered In House. REGIONAL MEDICAL PROGRAMS and systems ; presence and distribution of shall describe the selection and membership Sept. 24 : Considered and passed House, educational, medical and health facilities of the designated advisory group, showing amended, in lieu of H.R. 3140. and programs, and other activities which in the extent of inclusion In such group of Sept. 29 : Senate concurred in House (Added 1/18/67, S2 PR 571.) the opinion of the Surgeon General are ap- practicing physicians, members of other amendments. AUTHORITY: The provisions of this Sub- propriate for carrying out the purposes of health professions, medical center officials, part E Issued under see, 215, 58 Stat. 690, Title IX. hospital administrators, representatives from see. 906, 79 Stat. 930 -, 42 U.S.C. 216, 299f appropriate medical @ieties, voluntary Interpret or apply sees. 900, 901, 902 , 903: [] 54.403 ELIGIBILITY. agencies, representatives of other organiza- 904, 905, 909, 79 Stat. 926, 927, 928, 929, In order to be eligible for a grant, the ttons, institutions and agencies concerned 930, 42 U.S.C. 299, 299a, 29ab, 299c, 299d, applicant shall: with activities of the kind to be carried On 299e, 2991. (a) Meet the requirements of section 903 under the Program, and members of the pub- or 904 of the Act; lie familiar with the need for the services 54.401 APPLICABILITY. (b) Be located in a State; provided tinder the progrnm. The provisions of this subpart apply to (e) Be situated within it geographic area (f) Construction; purposeR, pla", ati,l grants for planning, establishment, and appropriate under the provisions of this sub- specilicatie;ns; narrative description. With operation of regional medical programs as part for carrying out the purposes of the Act. respect to an application for funds to be authorized by Title IX of the Public Health used In whole or part for construction as Service Act, as amended by Public Law ED 54.404 APPLICATION. (leflned In Title IX, the applicant shall fur- 89-239. (a) For7n8. An application for a grant nish In sufficient detail plans and speciflea- M 54.402 DEFINITIONS. shall be submitted on such forms and in such tions as well as a narrative description, to Indicate ay -the needi nature, and purpose of the manner as the Surgeon General m (a) All terms not defined herein shall proposed construction. prescribe. (g) Advisory group; recommendation. An have the meaning given them in the Act. (b) Execution. The application shall be (b) "Act" means the Public Health Serv- executed by an individual authorized to act application for a grant under section 904 of ice Act, as amended. for the applicant and to assume on behalf the Act shall contain or be supported by a (c) "Title IX" means Title IX of the of the applicant all of the obligations speci- copy of the written recommendation of the Public Health Service Act as amended. fled In the terms and conditions of the grant advisory group. (d) "Related diseases" means those dis- including those contained in these regula- F-1 54.405 TERMS, CONDITIONS, eases which can reasonably be considered to tions. AND A-SSURANCES. bear a direct relationship to heart disease, (c) Description of program. In addition cancer, or stroke. to any other pertinent Information that the In addition to any other terms, conditions, (e) "Title IX diseases" means heart dis- Surgeon General may require, the applicant and assurances required by law or imposed ease, cancer, stroke, and related diseases.- shall submit a description of the program by the Surgeon General, each grant shall be subject to the following terms, condition, (f) "Program" means the regional medi- in sufficient detail to clearly Identify the and assurances to be furnished by the cal program as defined in section 902 (a) of nature, need, purpose, plan, and methods of the Act. the program, the nature and functions of grantee. The Surgeon General may at any (g) "Practicing physician" means any the participating institutions, the geographic time approve exceptions where he finds that physician licensed to practice medicine in area to be served, the cooperative arrange- such exceptions are not inconsistent with the Act and the purposes of the program. accordance with applicable State laws and ments In effect, or intended to be made ef- currently engaged In the diagnosis or treat- fective, within the groul>, the justification (a) Use of funds. The grantee will use grant funds solely for the purposes for which meiLt of patients. supported by a budget or other data, for the (h) "Major repair" includes restoration amount of the funds requested, and financial the grant was made, as set forth in the ap- of an existing building to a sound state. or other data demonstrating that grant proved application and award statement. In the event any part of the amount paid a (1) "Built-in equipment" Is equipment funds will not gupplant funds otherwise affixed to the facility and customarily in- available for establishment or operation of grantee is found by the Surgeon General to luded in the construction contract. the regional medical programme have been expended for purposes or by RD3' c 178 methods contrary to the Act, the regulations designated in the application as responsible (g) The geographic distribution of grants generally accepted and established account- of this subpart, or contrary to any condition for the coordination of the program shall throughout the Nation. ing practices or as otherwise prescribed by to the award, then such grantee, upon being continue to be responsible for the duration the Surgeon General. C] 51.407 TERMINATION. Funds notified of such finding, and In addition to of the period for which grant funds are made (b) Direct costs in general. any other requirement, shall pay an equal available. The grantee shall notlfy the Sur- (a), Termination by t)ie Surgeon General. granted for direct costs may be expended by amount to the United States. Changes in geon General immediately if such official Any grant award may be revoked or termi- the grantee for personal services, rental of grant purposes may be made only in accord- becomes unavailable to discharge this nated by the Surgeon General in whole or space, materials, and supplies, and other ance with procedures established by the responsibility. The 'Surgeon General may in part at any time whenever be finds that items of necessary cost as are required to Surgeon General. terminate the grant whenever such official in his judgment the grantee has failed in a carry out the purposes of the grant. The (b) Obligation of funds. No funds may be shall become thus unavailable unless the material respect to comply with requirements Surgeon General may issue rules, struc- charged against the grant for services per- grantee replaces such official with another of Title IX and the regulations of this sub- tions, Interpretations, or limitations sup- formed or material or equipment delivered, official found by the Surgeon General to be part. The grantee shall be promptly notified plementing the regulations of this subpart pursuant to a contract or agreement entered qualified. of such finding In writing and given the and prescribing the extent to which partic- Into by the applicant prior to the effective r@ns therefore ular types of expenditures may be charged date of the grant. 0 54.40,6 AWARD. (b) Termination by the grantee. A to grant funds- ('a) Inventions or discoveries. Any grant Upon recommendation of the National grantee may at any time terminate or cancel (c) Direct costs; personal services. The award hereunder In whole or in part for re- Advisory Council on Regional Medical Pro- its conduct of an approved project by notify- costs of personal services are payable from search is subject to the regulations of the grams, and within the limits of available ing the Surgeon General In writing setting grant funds substantially in proportion to Department of Health, Education, and Wel- funds, the Surgeon General shall award a forth the reasons for such termination. the time or effort the Individual devotes to fare as set forth In Parts 6 and 8 of Title 45, grant to those applicants whose approved (c) Accounting. Upon any termination, carrying out the purpose of the grant. In as amended. Such regulations shall apply to programs will in his judgment beat promote the grantee shall account for &II expenditures such proportion, such costs may Include all any program activity for which grant funds the purposes of Title IX. In awarding grants, and obligations charged to grant funds: direct costs incident to such services, such are In fact used whether within the scope the Surgeon General shall take into con- Provided, That to the extent the termination as salary during vacations and retirement of the program as approved or otherwise. sideratiod, among other relevant factors the Is due in the judgment of the Surgeon Gen- and workmen's compensation charges, in ac- Appropriate measures shall be taken by the following: eral to no fault of the grantee, credit shall cordance with the policies and accounting grantee and by the Surgeon General to assure (a) Generally, the extent to which the be allowed for the amount required to settle practices consistently applied by the grantee that no contracts, assignments, or other ar- proposed program will carry out, through at costs demonstrated by evidence amt1stELc- to all Its activities. rangements inconsistent with the grant obli- regional cooperation, the purposes of Title tory to the Surgeon General to be minimu m (d) Direct costs; care of patients. The gation are continued or entered Into and IX, within a geographic area. settlement costs, any noneancell&ble obliga- cost of hospital, medical or other care of that all personnel involved In the supported (b) The capacity of the institutions or tions Incurred prior to receipt of notice of patients Is payable from grant funds only to activity are aware of and comply with such agencies within the program, Individually termination. the extent that such care is incident to the obligation. Laboratory notes, related tech- and collectively, for research, training, and research, training, or demonstration activi- nical data, and information pertaining to In- demonstration activities with respect to Title m K4.408 NONDISCRIMINATION. ties supported by a grant hereunder. Such ventions or discoveries made through activi- ix. Section 601 of Title VI of the Civil Rights care shall be incident to, such activities only ties supported by grant funds shall be (e) The extent to which the applicant or Act of 1964, 42 U.S.C. 2000d, provides that if reasonably associated with and required maintained for such periods, and filed with the participants in the program plan to no person in the United States shall, on the for the effective conduct of such activities, or otherwise made available to the Surgeon coordinate or have coordinated the regional ground of race, color, or national origin, be and no such care shall be charged to such General or those he may designate at such medical program with other activities sup- excluded from participation In, be denied the funds unless the referral of the patient Is times and in such manner as he may deter- ported pursuant to the authority contained benefits of, or be subjected to discrimination documented with respect to the name of the mine necemry to carry out such Department in the Public Health Service Act and other under any program or activity receiving Ped- practicing physician making the referral, regulations. Acts of Congress including those relating eral financial assistance. Regulations Imple- the name of the patient, the date of referral, (d) Reports. The grantee shall maintain to planning and use of facilities, personnel, menting the statute have been issued as Part and any other relevant Information which and file with the Surgeon General such prog- and equipment, and training of manpower. 80 of the Title 45, Code of Federal Regula- may be prescribed by the Surgeon General. ress, fiscal, and other reports, including (d) The population to be served by the tions. The regional medical programs pro- Grant funds shall not be charged with the reports of meetings of the advisory group regional medical progrum and relationships vide Federal financial assistance subject to cost of- convened before and after award of a grant to adjacent or other regional medical the Civil Rights Act and the regulations. (1) Care for lntercurrent conditions (ex- under section 904 of the Act, as the Surgeon programs. Each grant Is subject to the condition cept of an emergency nature where the inter- that General may prescribe. (e) The extent to which all the health the grantee shall comply with the reqtlre- current condition results from the care for (a) Records retention. All construction, resources of the region have been taken into ments of Executive Order 11246, 30 @: which the patient was admitted for treat- financial, and other records relating to the consideration In the planning and/or estab- 12319, and the applicable rules, regul. 0 to- ment) that unduly Interrupt, postpone, or use of grant funds shall be retained until lishment of the program. and procedures prescribed pursuant there . the grantee has received written notice that (f) The extent to which the participating terminate the conduct of such activities. the records hav ' been audited unless a differ- institutions will utilize existing resources 0 54.409 EXPENDITURES BY GRANTIDR. (2) Inpatient care if other care which c ent period is permitted or required in writing and will continue to seek additional non- (a) Allocation of costs. The grantee would equally effectively further the pur- by the Surgeon General. federal resourcw for carrying out the objec- shall allocate expenditures as between di- poses of the grant, could be provided at a (f)@ Responsible offloial. The official tives of the regional medical pr(>@ rect and indirect @ lr6 a@rdance with smaller cost. 179 (3) Bed and board for inpatients in excess continued use of the facility or equipment of the cost of semiprivate accommodations for the, grant purposes. In determining geon Gen- unless required for the effective conduct of i@-lietli(-r good cause exists, the Sur such Lctivities. For the purpose of this er,'Ll Slltll take into consideration, among paragraph, "semiprivate accommodations" other factors, the extent to ivhich- means two-bed, three-bed, ,Lnd four-bed (1) The facility or equipment will be de- accommodations. voted to research, training, demonstrations, or other activities related to title IX Fl 54.410 PAYMENTS. diseases. The Surgeon General shall, from time to calling for a (2) The circumstances time, make payments to a grantee of all or change in the use of the facility were not ,t portion of any grant award, either in ad- I;nown, or with reasonable diligence could vance or by way of reimbursement for ex- not have been known to the ,Lpplicant, at the penses to be incurred or incurred to the time of the application, ind arc circum- extent be determines such payments neces- stances reasonably beyond the control of the sary to carry out the purposes of the grant. ipplicant or other owner. (:t) tire refi@'onal)le assurances that n 54.,Ill DIFFEITENT USI@, Olt TRANS- facilities riot previously utilized for rER : GOOD CAUSE FOR Title IX purposes will be so utilized and are OTHER USE. substantially the equivalent In nature and (a) Compliance by grantees. If, at any extent for such purposes. time, the Surgeon General determines that n 54.412 PUBLICATIONS. the eligibility requirements for a program are no longer met, or that any facility or Grantees may publish materials relating equipment the construction or procurement to their regional medical program without of which was charged to grant funds is. dur- prior review provided that such publications ing its useful life, no longer being used for carry a footnote acknowledging assistance the purposes for which it was constructed from the Public Health Service, and Indi- or procured either by the grantee or any cating that findings and conclusions do not transferee, the Government shall have the represent the views of the Service. right to recover its proportionate share of the value of the facility or equipment from n 54,.41- COPYRIGHTS. either the grantee or the transferee or any Where the grlnt-supported ictivity results Institution that is using the facility or in copyrightlble material, the author is free equipment. The Government's proportionate to copyright, but the Public Health Service share shall be the amount bearing the same reserves i royalty-free, nonexclusive, irrevo- ratio to the then value of the facility or cable license for use of such material. equipment, as determined by the Surgeon El 54.,il4 INTEREST. General, as the amount the Federal partici- Interest or other income earned on pay- pation bore to the cost of construction or riients I]TI(ler this subpart shall be paid to procurement. the United States as such interest is received (b) Different use or transfer; notification. by the grantee. The grantee shall promptly notify the Sur- geon General In writing if at any time during its useful life the facility or equipment for construction or procurement of which grant funds were charged is no longer to be used for the purposes for which it was con- striieted or procured or is sold or otherwise transferred. (e) Forgiveness. The Surgeon General may for good cause release the grantee or other owner from the requirement of con- tinned eligibility or from the obligation of 180 U.S.GOVMNMENTPRINTINGOFFICE:1968 0-292-414 Public Health Service Publication No. 1774 I