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                       NATIONAL LIBRARY OF MEDICINE


                         REGIONAL MEDICAL PROGRAMS
                               Bethesda, MD
                             December 6, 1991



Lindberg:  Winter in this city, with a number of viruses sort of
sweeping through, it means almost temporarily while in between
one flu bug or another.  I know that in the case of some
[unclear] after considerable amount of medical attention, so even
that requires a little modification.  That remains me of
something, a distinction that was way back in the old RMP days,
namely consumers and providers.  I remember a story a doctor told
me back in those days.  He had encountered a health planner,
which I think was a sociologist, probably, and they had had a few
barbed encounters.  Following that, the doctor fell ill and had
something done to him, acute gall bladder or something like that,
and he reappeared, more or less metaphorically, hobbling about at
the next meeting and said as far as he could tell, he had, he
supposed, changed into a consumer of health care.  The planner
stared at him with a steely eye and said, "No.  You are a sick
provider."  [General laughter]  So the distinctions were
sometimes very firmly made.  
     There is a tie-in with NLM [National Library of Medicine],
too, that I want to bring out, and it won't get emphasized,
probably, until the end of the day.  In the recommendations of
the President's Commission on Heart Disease, Cancer, and Stroke,
which Dr. [Michael] DeBakey chaired, there were thirty-five, as I
recall, and number thirty got to the question of the regional
libraries or the lack of a national network to provide medical
information.  That didn't create the National Library of Medicine
that had been created roughly 1836, but from that particular
recommendation flowed the Medical Library Assistance Act, which
paralleled Regional Medical Program authorization.  That is still
in effect, and the country does have a national network of
libraries of medicine now, directly resulting from that
recommendation and that legislation.  So while it paralleled RMP
and started out perhaps more modestly, it did persist.  So
there's an interesting parallelism for this institution.       
What we hope you will do today is to analyze the strengths and
weaknesses of the Regional Medical Program activities perhaps
from the vantage point of information that maybe only you all
will have in some circumstances, and we hope perhaps you will
share that with us.  Perhaps you will extract from all this some
guidance for the nation as it looks as its plans for improving
health care in the future.  That is to say that all of what we're
assembling having to do with RMP we intend to put in the domain
of the historian.  Obviously I wouldn't hold myself forward as
any sort of a historian, let alone an historian of medicine. 
John Parascandola, head of the History of Medicine Section, is
qualified in that respect.  We hope that if there are materials,
particularly print materials, but also slides and photos and
films that are relevant to particularly the achievements or maybe
the shortfalls of Regional Medical Program activities in your
possession, you wills end these to John.  At least let him copy
them, because I can guarantee that if they fall in the hands of
NLM, they'll be safe and I can also guarantee you that many, many
documents in this field are totally unavailable to us even now,
surprisingly, even though there's only twenty-five years.       
With that same point in mind, as the day goes forward, this room,
while a lovely room, is a little more formal than we'd like it to
be, but it's fine.  You don't actually need the four language
simultaneous translation.  If you don't mind, we'll use English
today.  But part of the paraphernalia in front of you is a button
that calls for attention.  When you touch it, that will light up
and will make the microphone in front of you alive and,
therefore, part of our circuit and, therefore, recordable.  So
when you make comments, please push the button, give your name,
and then you'll be, so to speak, once again part of history, at
least our local history.      A last word about the TV
interviews.  We were able to get the time and the people for
about two dozen interviews of people active in the RMP programs
as it began and ended.  There is a list of that which Dr.
Parascandola has, and we intend to make those interviews intact,
unedited, that is to say unexpurgated, available by interlibrary
loan.  So what you said is there for historians.  Of course, each
of those is roughly twenty-five minutes.  We didn't have any
sponsor time, so we used all the tape.  We didn't have to have
any commercials.  But on the other hand, we didn't think you
wanted to sit here for twelve hours and watch all of them either. 
So composites have been made from at least the earliest ones. 
The latest ones, those of you who couldn't get in here until
late, we simply couldn't get it all incorporated, so each of the
sessions will start out with a short video and we hope that will
set the tone for the discussion and compress many of the
wonderful pieces of information that you individually provided.  
     On a personal note, why am I interested in this?  I guess
just because of laboring in these vineyards back in the sixties
at University of Missouri in association first with Vern [Vernon]
Wilson and then "Buck" [Arthur E.] Rikli in the Missouri Regional
Medical Programs.  In that capacity, I'm not sure if I was a foot
soldier.  I know I was in the trenches, so I might have been at
least a second lieutenant, but I know that in addition to
acquiring a lifelong admiration for Dr. Wilson, I might say, too,
that I knew and admired some of the other participants through
another associations.  Bob [Robert Q.] Marston and "Monte"
[Merlin K.] DuVal I knew through the Markle Fellows Program.  Dr.
DeBakey I had already encountered out in the wilds of Kansas,
giving continuing medical education talks.  I was amazed that you
would do it even then.        But I loved the work of RMP.  I
thought its goals were lofty.  I thought we were a success.  It's
always amazed me to discover that from the point of view of
Washington, be it the White House or the Congress or the halls of
power in the executive branch, it's somehow seemed a failure.  I
never understood that and I still don't understand it.  But I'm
beginning to get some more information about it from the point of
view of all this background, and maybe today will elucidate for
us the ways in which we either did or didn't succeed, or did or
didn't succeed in communicating the successes to the others who
mattered.        Without further ado, then, first we'll show the
TV and then we'll assemble the panel.  I'll sign off for the
moment and we'll do the TV.  
                               [Video shown]
     We're going to go now to our panel.  Dr. DeBakey is
Chancellor at Baylor and chairman and professor of surgery.  Dr.
Marston was the first director.  We welcome you both.   
DeBakey:  As a matter of fact, the video has helped a great deal
to constrict my remarks.  It was extremely well done, I thought,
put together very well.  I would, however, like to start off by
first commenting a little bit about the commission, because
that's where the concept began and while it was changed in the
legislation, as indicated by the video, for practical reasons, to
be pragmatic, it had to be changed in order to get legislation
and get authorization.      The commission worked very diligently
and we were fortunate in having a good staff of very able
individuals who helped put together the report.  We also were
fortunate in the makeup of the commission with individuals who
were experts in their respective fields, heart disease, cancer,
and stroke, and who were willing to assume responsibility in the
work of the commission, divided by the organization of the
commission into panels that concentrated upon each one of these
specific areas, the three major areas.        The final objective
of the commission was to promote and in a way find mechanisms by
which the latest information in both diagnosis and treatment, as
well as prevention, in the field of heart disease, cancer, and
stroke would be available to all the people of the country. 
There was no question at that time there was a gap because of the
sort of pioneering developments in these fields and the rapid
explosion of knowledge in these fields.  There was a gap, in a
sense, between the knowledge in the centers in which these things
were developing and in the actual practice of medicine.  There
were good studies showing that this gap existed.  We had a number
of things that brought this evidence very clearly, studies, for
example, in which a specific area or population was studied for
hypertension, for example, and it was found that less than 5
percent of the people with hypertension were getting adequate
treatment for hypertension, when good treatment was available. 
As you know, this has continued.  Today, for example, the
evidence clearly is that more than 60 to 70 percent of the people
with hypertension are being properly treated.  But at that time
there was this large gap in both the knowledge that was available
and the availability to people.  That's what the commission
concentrated on, and then tried to develop mechanisms by which
this gap could be erased.  So these recommendations were
generally developed along the lines I've indicated to meet that
gap.        The Regional Medical Program really developed out of
the concept of so-called regional centers of excellence, and it
was the idea that by establishing centers of excellence in these
three fields, you would have a source for the dissemination of
this knowledge and its rapid proliferation to the public.  We did
not conceive of Regional Medical Programs as the legislation
finally came out.  It was considerably modified by the
legislation, and as indicated by the video, that was primarily a
pragmatic factor because there was great opposition to the
recommendations as we finally came out with them.  But as time
went on, we were able to develop some sources of support for
this.  Bob, you'll talk about that a little bit in terms of how
we were able to develop some support.  Otherwise, it would have
been really completely dead and never gotten anywhere.      By
making some modifications in the legislation, and particularly by
insisting that no change would be made in the patterns of medical
practice, we were able to get at least some form of legislation
established primarily to provide authorization for money, for
funds, or nothing could be done, as you know.  Don [Lindberg]
referred to what I think and I'm proud of, as far as the
commission is concerned, perhaps one of the most important
recommendations that came out of the commission's report and that
is the regional medical libraries.  As you know, these constitute
an extremely important part of our medical source, both
information and education.  The regional medical libraries have
turned out to be one of the truly great developments, I think,
next to the establishment of the National Library of Medicine,
perhaps the most important activity that has been developed in
the health field, and has been a great success.      I would like
only to comment on one further matter, and that relates, once the
legislation was established, to the development of the program. 
There was considerable discussion as to where this should be. 
That is, where do you put the Regional Medical Program?  I
happened to like the idea of putting it at the NIH in the same
fashion that I like the idea of putting the National Library of
Medicine at NIH.  This was not a popular decision at the time.  I
can tell you that there was a certain amount of objection to it,
and I always had the feeling that perhaps that was a mistake. 
It's my impression that this is one of the factors that may have
contributed to the problems that later developed with the
program.  I'm not sure that the subsequent move from the NIH
helped, either.  
     So there were first modifications in the original concept
that really limited the capability, I think, of the concept being
widely established and widely accepted.  Secondly, I think that
in the administration of the legislation--and by that I don't
mean the administrators.  I'm not talking about Bob Marston as
director or any of the directors.  But in the way it was placed
in the government area for the development of the program, I
think that it was handicapped by that means.  I think in a way it
certainly accomplished some things, but the way the program was
limited in terms of the original concept by the commission, by
the pragmatic necessity of getting legislation, limiting, for
example, construction funds, and limiting its activities by
insisting that there would be no change in the patterns of
practice, created some of the problems that later the program
found itself handicapped.  I think the directors themselves found
themselves also handicapped.  Despite the fact that I must say I
admired tremendously particularly what Bob Marston tried to do
originally and the others that followed him, in spite of all of
these limitations, there were, I think, some very good things
that were done by the program, and hopefully as we go through
today we'll have an opportunity to maybe learn some lessons from
it.  At least I hope so.
     Bob, I think that's all I need to say at the present time. 
I'll leave it up to you to comment, particularly upon some of the
things I brought out.

Marston:  Thank you, Mike.  It's good to be with you.  One of the
things I've told Mike many times over the years, the ease with
which one could get in touch with Mike DeBakey, you could always
call him at four o'clock in the morning and find him, and I did
this fairly often, right? 
DeBakey:  Yes.  

Marston:  That's the type of program, in a sense, it was.  It was
one that was exciting.  At the end of the first year of Regional
Medical Program and statute of limitations, all these things,
Don, have passed long since, I think we had 100 people on board,
and I think, Karl [Yordy], you and I were the only ones who were
legitimate at that time, a type of thing you couldn't think of
doing now.  It was a time of excitement.  It was a time of
handicaps.  It was a time in which it was, in fact, difficult to
describe precisely what the Regional Medical Programs was.  Irv
[Irving] Lewis, who used to examine us on that, raised the
question from the Bureau of the Budget that it wasn't clear.  He
became convinced and, of course, moved over.  As he told me
earlier this morning, it changed his life, the whole
relationship.  
     One other point.  It's been interesting to get some reaction
to this meeting.  L______ Barry [phonetic] called me and talked
to me, Mike, about a half hour on Sunday morning, one of the most
delightful conversations, reminiscing his role on the council and
saying, Don, that he was going to send some information to you
and to be sure that I told you it was on the way.  But his sense
of some of the changes was interesting.  I've gotten calls from
others saying this program and that program continues to exist
and would not have come into being if it had not been for the
Regional Medical Programs.        I was a busy dean, working
primarily with the AMC at that time.  Then Stu Sessems [phonetic]
and John Sherman came to a meeting and asked me if I would be
interested in the Regional Medical Programs.  I was not sure
whether I would be interested or not, but one of the people who I
had known through the Rhodes Scholarship activities was Carlton
Chapman, and Carlton was at that time the immediate past
president of the American Heart Association.  The support of the
American Heart Association, with modifications, including
detailed review and approval by the AHA and Carlton's own role
and enthusiasm for the program, I think was one of the things
that was helpful during the congressional hearings on it.  Stu
Sessems, when I came here, the RMP was staffed by Stu, who was
deputy director of NIH, and Karl Yordy, and that was it.  Stu
continued to look over our shoulder and to be helpful, especially
during that first year.      I don't know the details of the
evening when the decision was made.  It was, in fact, a vigorous
debate as to whether it would go elsewhere in the Public Health
Service or go to NIH.  That decision had been made by the time I
came on board.  One thing that decision did was it gave immediate
credibility for the program in the academic health centers in the
country.  It also set a debate between the Regional Medical
Programs and Comprehensive Health Planning, which was part of the
Public Health Service, overlapping.  I spent a lot of time with
Bill Stewart talking about how we could possibly straighten out
the confusion that was abroad in the land.  Some people thought
Comprehensive Health Planning was going to do the planning and
Regional Medical Programs was going to do the implementation. 
The state health departments tended to look at Comprehensive
Health Planning as their primary program.  The academic health
centers and really the larger hospital groups and, in later
stages, the AMA looked more toward Regional Medical Programs. 
But it was a program in which it was not that difficult to
recruit people to come to Washington and give up their homes and
a great deal of uncertainty to come here and to work very hard. 
It was very exciting.        The record of the first RMP
conference in the Washington Hilton is well documented.  Wilbur
Cohen then was Secretary of HEW, and Wilbur had been in
California a couple of weeks before at an AMA meeting in which he
had been criticized rather vigorously.  He had fallen in the tub,
had hurt himself, and he'd gotten good medical care, but he got
up on the stage full of confidence and said, "See?  I don't have
any horns and I don't have a tail."  And a voice from the
audience came out, "Yeah, Wilbur, but you don't have wings and a
halo, either."  [General laughter]  And that's the way the first
conference [began], which was really sort of advertised as being
a confrontation between the various components involving Regional
Medical Programs.  It was not a confrontation; it was a serious
intellectual discussion of what one can do with strong views on
all sides.        It was something that occurred in this country
that had a lot of interest elsewhere, in countries with more
organized health systems.  Sweden, with its development of its
health system, or the county organization that had been developed
for completely other reasons.  We had a lot of discussions there
of the British system and the other systems.  If there's a
sadness about the passage of Regional Medical Programs, it's that
intellectual conceptual discussion among the various players of
how can you do something better than how you are doing it.  We
were able to get through, I felt, especially at the local levels,
at the national level, too, but especially at the local levels,
of bringing together groups that had not talked before.  You ask
whether federal dollars should be spent into bringing groups
together for group grope sessions, and that was one of the
criticisms.  But we heard continuously from people who had not
been involved in the health field and--I am hesitant to call
names, but who found in this something that was intellectually
challenging and at least directed toward doing something of
serious importance in the country.
     I am involved now in the late stages of putting together a
report from a commission on "Medical Education: the Sciences of
Medical Practice."  I must say some of those same issues are
there.  The difference that I see, Mike, today is the progress of
the science base, which is different than it was then and at
least can be articulated differently than even two or three years
ago.  It's the development of the strategic plan of NIH that's
going to come out sometime in the spring, points out the unity of
the new sciences.  We are going to say that the change in the
science base mandates change in medical education, and we're
running into some of the same issues of the people who want to
talk about the organization delivery of health services.  There's
a report that's come out recently that does not mention science
as being a major factor in the education and the organization
delivery of health services in the future.  Because our mandate
is to look at science, we will come out as saying that the
current science does not fit with the departmental organization,
the basic science departments in schools, that it's absurd to
look at a two-year course that gives you all the science that
you're going to need for your life, and on and on.  I don't want
to spend time on that report, but I do want to say that some of
these same issues of how to bring the best that's available in a
rapidly advancing, exciting science to apply it to the health
needs of the people is still not resolved.  I don't know whether
it would have been better resolved if the Regional Medical
Programs had continued, but that is still a major need in the
country.  I think it's especially appropriate that we review
this.
     Everything else on Regional Medical Programs, almost, during
my time has been written in either preparing for the legislation
or in the conferences that we had.  It was one of the most
exciting periods of my life.  It was one of the most exciting
really because of a lot of the people in this room.  The council
was a great support.  
     Shall we talk about that first council meeting?

DeBakey:  Yes.

Marston:  The first council meeting we had, we had a dozen
applications.  Mike wanted to fund them all.  [Laughter]  We had
some members of the commission who didn't want to fund any of
them.  We ended up at noon and we didn't know what we were going
to do.

DeBakey:  That's right.  [Laughter]

Marston:  We had some discussions over lunch and came out with, I
thought, a rational allocation of funds, in which we did fund a
large proportion, some at some levels and some at other levels,
and one or two, I guess, that we didn't fund.  But it was a
background of moving into areas that people had had no experience
before and being absolutely reliant, because of the nature of the
legislation, on developing consensus, support, building
confidence, and allowing people to express their differences but
still to work together for an important program.  

DeBakey:  Bob, what you might comment about, because I think it
did have an effect upon the program, when you really got started,
the way in which the program was conceived by different people. 
For example, you may recall when we came to considering Regional
Medical Programs in a place like New York, there were certain
concepts about how you would develop a program for that region,
particularly when you had a number of educational institutions in
the region, and how would you, in a sense, coordinate those
activities.  I think there was considerable discussion and some
differences, considerable differences of opinion about how to do
it.  You might just comment briefly about the learning period
that occurred during the first year.   
Marston:  You're right, Mike.  Clearly, it was much easier to
establish the types of relationships called for by the
legislation in rural areas than it was in urban areas.  We went
through the business of whether state lines were important or not
important.  You got to a place like the state of Washington, and
clearly that served a population from Minneapolis to Alaska and
south to San Francisco.  So the state lines, I think, fell fairly
early as being a criterion.  But the urban centers, in the first
place, in their view--and we had some very good representatives
from the urban centers working with us, including from New York
City--it was a very tough business, and they never went as well
or as rapidly as in the more rural areas.  I don't know that we
arrived at anything that was all that helpful to them.  We had
individual programs and lots of very interesting contributions
from individuals.  But the legislation essentially required that
you not tell the regions what their lines should be and not tell
them specifically what it was.  So we had to have some early
successes, which we had, all in rural areas, and then we would
point to those and say, "These are the examples of how you might
want to do it," rather than going in and saying, "This is the way
to do it."   
DeBakey:  I think, Bob, you might also comment a little bit about
the effect that the program had upon the development of the
educational institutions themselves, particularly in the rural
areas.  When I say rural, particularly areas like the South and
the West, where I believe the program had quite a healthy effect
upon the educational development of the institutions.  The
funding for that kind of education was never available to the
institutions before, and here now we had funding for them.  There
developed a great deal of enthusiasm within these institutions,
don't you think?

Marston:  I think so.  Again, as I look around this audience,
there are people who felt that.  One of the anecdotal ones are
the three schools in North Carolina, all of them headed by deans
who were in the Markle program and who knew each other.  Despite
that, if it had not been for the Regional Medical Programs, I
don't think there would have been a chance of the type of
combined programs that came out of those three schools.   
DeBakey:  In that sense, I think it accomplished a great deal at
that particular time.  I think it's important to, in a sense,
recognize that aspect of the program as being really successful. 
At least I felt very strongly.  Perhaps this will come out later
in the next session when Stan Olson will be able to comment about
this, because he was very closely linked to that aspect of it.  I
think you and I might limit ourselves now to allowing some
discussions from the floor.

Whaley:  I am one of those illegitimate people who worked with
the RMP in its early days.  My personal background was with a
rural state medical center, greatly concerned with many of the
things that have been talked about just a moment ago here.  But I
had known Dr. Marston in his situation in the South and came then
on board with the Regional Medical Programs on a part-time basis. 
It amounted to about a third time.  My people didn't really know
where I was, and I'm not sure they did up here.  I know one of
the problems I got into was that somehow my name appeared on the
bulletin board listing the officials of the Regional Medical
Program, and I was listed as an official.  Some alert reporter,
Vic Cohen, actually, from the Washington Post, saw my name there
and called me at Arkansas, where I was, and asked me how come I
was holding down two jobs, a federal job and a state job.  I had
to assure him that my job up here was, in a sense, honorary, and
that I was on a consultant basis.
     But I did get into a very enthusiastic crowd.  You felt like
you'd been in a hurricane when you had made a visit to the RMP. 
It was almost a cult.  There was a real fervor about this, and I
can recall the luncheon meetings that were held over in a
building that was not yet completed, a wing of 31.  There they
would get together just to talk about the very things that Dr.
Marston has mentioned.        I'm glad that Dr. DeBakey mentioned
the effect on academic medicine, because from my point of view in
my particular setting, this was an extremely important benefit
from Regional Medical Programs.  I know you're here to talk about
benefits and results this afternoon.  Our thinking was greatly
shaped by the fact that our medical center, in a rural state and
not in a very good relationship with the state medical
society--the town and gown thing was pretty severe
there--unfortunately, as often happens, the state legislature was
in the arms of the state medical society, which left us in a kind
of difficult spot.  Here was a reward, really, for conversation
between our doctors and the doctors in the state society, and
they did find that they could get along with each other and work
together.  It seemed to me that this is one of the great
benefits.      Was the modification of academic medicine, of the
relationship within the community faculty to the town, considered
much as you thought about the program?

DeBakey:  I think it's a very important question to raise, and
there's no question that in some areas this became very intense. 
In other areas, I know from my own visits to some of the areas
particularly where the local medical societies and the state
medical societies took a very strong position, and where the
town-gown situation was more intense, that as time went on, they
were able to see that particularly with the financing that came
about, that this was a useful mechanism for even the doctors
themselves who were in practice and that they were not being
harmed financially, so to speak.  Their practice was better, if
anything.  So it did take a certain amount of time to overcome
that, but I think in time, in most places, it did overcome it.    
   Actually, I think the worst situations were in the large
centers of population like New York and Philadelphia and Chicago. 
But when you get out into the other states, at least my
impression was that this was a much less intense fight.  Over a
period of time it improved.   
Marston:  I think by the time I became involved in it, that
aspect really was very firm, that this was an opportunity both to
encourage academic health centers to extend beyond their
boundaries to become less isolated, and a basic requirement of
any funding project was that that be achieved.  Whether that was
a part of the commission and later on or not, it was bigger.  In
the tapes, just the few that I've seen, there is some discussion
about the relationship with AMA.  Bill Ruhe is here, who knows as
much about Regional Medical Programs as I do.  My sense is that
despite variations at the state levels, in which some cases
Regional Medical Programs stimulated closer relationships with
the academic health centers, and in some it didn't, as Mike has
indicated.  My own sense at the level of the Council of Medical
Education and of the AMA leadership, as such I felt a lot as
director of the Regional Medical Programs I felt as things moved
on, as their opinions were asked and they were involved in being
a participant in the program, that it was a good relationship. 
With suspicion and with all of the other problems that don't go
too far, but I felt that the relationship during those first
years improved steadily.  

DeBakey:  I think that's true.  

DuVal:  Monte DuVal.  I would ask the question of Bob Marston
that Mike DeBakey asked, that I'm not entirely convinced you
handled as fully as you could.  Why did you end up deciding to
move the RMP program from the NIH over to what was then HSMHA?  

Marston:  Well, I didn't decide it.  We can spend all day, all of
us talking about things, but what happened is that John Gardner
asked me to take over as administrator of Health Services Mental
Health Administration, and he said, "Bob, I know you only planned
to come here for a couple of years and this means you'll have to
stay longer."  I've always regretted that I didn't say, "John,
I'll stay as long as you do," because that weekend he went to the
ranch and had the debate with Johnson and came back, and the next
week John resigned.  But I was moved.  Then I know Mike was
consulted on that.  Health Manpower was moved into NIH.  The
Library of Medicine was in NIH.  There was a fairly strong
feeling that Comprehensive Health Planning and Regional Medical
Programs should be.  You pick it up, because you were asked, and
I think I know what your answer was at that time.  I'm not sure
whether it was right or not.  [Laughter] 
DeBakey:  Actually, the NIH leadership at the time really wasn't
that enthusiastic about the Regional Medical Program, although
they supported it.  There was a certain amount of, "Well, this is
not research.  This doesn't belong at NIH."  We had the same
problem with the National Library of Medicine.  I actually had to
meet with Jim Shannon in Lister Hill's office and actually debate
with him whether or not the National Library of Medicine ought to
be at the NIH.  Fortunately, Lister Hill sided with me and again
Jim, and Jim just accepted it.  There wasn't anything else he
could do about it.  
     The move from here, I think came about largely because of
the Comprehensive Health Planning program and the idea that
somehow this needs to be worked out together and it would be
better worked out downtown than at the NIH.  I agreed with that
at the time because it seemed to me that there was a need to
coordinate these programs, and hopefully that would develop.  I
must tell you that I had originally objected to the Comprehensive
Health Planning program and its legislation.  I even talked to
President Johnson about my objections to it.  I was afraid that
first it would interfere with this program and, secondly, it
would in time become perhaps too dictatorial.  I was worried
about that aspect of it.  But in spite of my objections,
legislation went through.  There was strong support for it.  Even
now I'm not sure that I wasn't right originally. 
Marston:  There's no way in the world that you could, in the
reorganization, put Health Manpower, as you know, and the Library
of Medicine in NIH and not move Regional Medical Programs. 
DeBakey:  Yes.  

Marston:  It couldn't have happened under the reorganization. 
DeBakey:  I have to confess, Bob, that I sneaked a look through
John Parascandola's good offices, of an interview that you gave
at the LBJ ranch and contributed to the archives of President
Johnson, and in that you did say that you personally advised
against the move out, but then, of course, became a good soldier
and carried it out.  Do you still think that it was a mistake to
move it out of NIH? 
Marston:  I don't think there was any possibility.  This was part
of a total reorganization of the health components of HEW.  It
was when FDA and HSMHA and NIH were elevated and the heads were
put at assistant secretary levels.  When you start dividing up
the responsibility, I don't think it could have been done in any
way other than that, from a practical standpoint.  I was in a
terrible position.  I was going to have a program I liked follow
me into a new organization, and I liked that part of it.  I
didn't know it was going to be there only six months.  Because of
my experience, I liked it the way it was.  I liked the Regional
Medical Programs tied to the science base of the nation, because
I thought, and still think, that the advances in the biological
and the behavioral and social sciences are, and will be for a
long time, a major--not the only one--driving force in our
ability to deliver medicine.  I think that's easily forgotten.   
Egeberg:  Dr. DeBakey, toward the end of your talk a little while
ago, you started to almost mumble about the reasons that you
thought that the setup for the Regional Medical Programs had had
built into it causes for its failure.  Of course, I never thought
it failed.  Could you explain that, or do you want me to
interpret what I thought you meant?  [General laughter]

DeBakey:  Roger, why don't you expound on it and then I'll be
glad to comment about it. 
Egeberg:  I thought you meant that there were too many
organizations involved in making decisions and that because of
that, there were--I know at that time there was paranoia all over
the medical area, a bit like Yugoslavia, I guess.  But we felt,
or I felt, very strongly that the opportunity to face people that
I thought had both horns and tails and find out that they didn't. 
They might not have had halos or wings, but they could listen to
some reason.  It made me feel that we learned a great deal about
how we might work together, including the people we were serving
and the people who had most to do with the various phases of it. 
That is what I interpreted.  You felt that there were too many
people challenging too many ideas. 
DeBakey:  Let me just say that from a personal standpoint, I had
been identified with Medicare.  I don't know how many of you will
recall, but when President Kennedy proposed Medicare, there was a
very, very strong opposition by, you might say, the medical
profession in general and the AMA in particular.  Just to quickly
tell you a little story about that, one of President Kennedy's
aides called me in and said that the president wanted to have a
press conference in the Rose Garden to show that there were some
doctors supporting the concept of Medicare, and he knew that I
supported it.  He asked would I be willing to come up and be with
him.  He wanted to show that there were some prominent doctors
who did support Medicare, and he asked me if I would call and see
if I could get some of my colleagues as professors of surgery in
different parts of the country to come up.  I can tell you that I
couldn't get a single one after calling several. 
Lindberg:  They were busy, though, weren't they?

DeBakey:  They all had a good excuse why they couldn't make it. 
I was the only one that showed up at the conference, with the
exception of a general practitioner whom I didn't know, and I
don't think anybody else knew, either, from some small town, and
some Ph.D.s.  There were about eight or ten of us who showed up
at the press conference.  So it gives you some idea of how strong
the opposition was to Medicare.  But I was identified with it,
and that, to some extent, identified me as being perhaps too
liberal, so to speak.  There were those who thought that I was
supporting a national health policy, nationalized medicine or
socialized medicine.  Of course, I never did believe in that.  In
any case, I was identified with that.        So to some extent,
when we came out with the report and the centers for excellence
and these other recommendations, there was a concern immediately. 
Of course, when we tried to translate this into the legislation,
as Paul Rogers himself pointed out, and Paul was helpful a great
deal in trying to do this on the health side, and Hill, of
course, was one of the main sponsors for the bill, we were able,
finally, to get enough into the bill that met the objections of
organized medicine, particularly the AMA.  As Bob indicated, we
were really fortunate in having Carlton Chapman, who at that time
was one of the leaders in cardiology, and who gave the support of
the American Heart Association to the program as it finally
developed.      But you must understand that the legislation that
set up the RMP differed considerably.  If you read the report of
the commission, you will see that our concept of it was more
concerned with, in a sense, the practice of medicine, because we
were trying to find a way to bridge this gap that we thought
existed, and we had evidence that it did exist in order to give
more people the knowledge that was available in the care of heart
disease, cancer, and stroke.  The Regional Medical Program, as it
finally came out in legislation, had to be modified in order to
get the legislation, in order to get authorization for funds. 
That was why it changed.  I think in some respects this limited
its capability.  
     Bob is very modest about what he says about the way they
operated, but I think that Bob and his staff really did a
tremendous job in getting this thing off the ground and getting
it going and accomplishing some of the objectives that the
commission had in mind, despite the limitations that Bob and all
the staff had to work under.  There were limitations both in
concept and in funding.  For example, there were no funds for
construction at a time when construction was badly needed.  So
there's no question that we went into the Regional Medical
Program with one hand tied behind our back. 
Olson:  Mike, you originally commented that you weren't sure that
the program ought to have been identified with NIH.  This was
sometime before the reorganization that finally put it over in
the HSMHA program.  Where would you have put it, looking at it
from the point of view of what existed at the time that you were
thinking about it?

DeBakey:  What I had hoped we could do--in fact, I had talked to
Wilbur Cohen about it--is to have a special agency for this
purpose.  This would have given it a position that would have
been, in a sense, almost independent, given it a higher level in
the government and given it greater support.  In other words, the
director would have been an assistant secretary.  That's what I
wanted and that's what I tried to do.  I compromised, really,
with the idea of giving it to the NIH because I felt, frankly,
the reason that I wanted it at that point not in the NIH was
because I didn't feel the leadership in the NIH supported it. 
There was not enthusiastic support for it within the NIH, despite
the fact that Bob makes a great point, I think, of the fact that
it should have a science base.  There's no question about it.  

Lindberg:  Original ideas, even at NIH, take a little while
before they penetrate and are adopted. 
Lewis:  Irv Lewis.  I guess I'm still in the same subject.  How
and why were RMPs established?  Why was the legislation passed? 
We know what the administration proposed, basically the regional
medical center concept.  Why did the Congress buy this package in
modified form?  What were they trying to get at? 
Lindberg:  Good question.  

Lewis:  I have a sense that the answer to the "why" is a
political answer, not pragmatic, but political in the sense that
President Johnson had an enormous legislative push on in 1965
across the whole front, covering what Kennedy had and had been
unable to get through, all the Medicare/Medicaid legislation that
was sitting around, a whole host of matters, the poverty program
and such.  So it was impossible for the Congress to say no to the
program, so they had to say something with the AMA pulling at
their sleeves and saying, "Make it something where people sit
around and with a wiggle and a giggle maybe they help fix up the
health care system."  When the reorganization occurred within
HEW, it was clear that the federal government had decided to move
on some kind of a front with respect to the organization and
delivery of care, having done education, having done research,
having done hospitals.  As Bill Kissick pointed out in an article
which he wrote a number of years ago on this subject, the
government thought it was going to deal effectively with
organization and delivery, and that's why when the state and
territorial group were able to get CHP through, CHP had to be
tied into RMP, given the brains of the young people who were in
RMP and working on organization and delivery.        Well, if you
have a sense that the answer to the "why" is essentially
political, forgetting that RMP was abolished, if RMP had stayed,
what, in your judgment, might would have been the essentially
criteria by which to judge success?  What would be the criteria,
given the fact that the government had said, "We're moving on the
organization and delivery front"?  I take into account also your
comment that you weren't for nationalized or centralized
medicine.  

DeBakey:  Let me say that I agree with you that this, no
question, had a highly political aspect.  President Johnson, as
you will recall, was very strongly influenced by health
legislation.  In fact, from a record standpoint, he passed more
health legislation than all previous presidents put together.  So
he was greatly involved and interested in health legislation. 
There's no question about that.  Whether or not RMP would have
had a greater impact upon, let's say, health policy in general in
this country, particularly in terms of medical health care, if it
had survived, is a question that I think is very interesting.  I
personally believe it would have, and I think it would have
modified our method of providing health care and hopefully would
have made it more efficient as time went on, particularly with
bringing together the CMP with the RMP.  I think it would have
created a more efficient program for health care.  

Lindberg:  Does that answer you, Irv?

Lewis:  No.  I want to stay with it a little bit, because you've
indicated that things went better.  You and Bob both indicate
that things went better in the rural areas than they did in the
highly complicated urban area where I spent the last fifteen to
twenty years in the New York City area, and I have formed my
judgments by now pretty clearly about medical schools and their
relationship to programs such as RMP.  What was it in the RMP
that was threatening to the American medical school, that made
them in the complicated urban areas so unwilling to be very
active participants?  

DeBakey:  That's a very good question.  I presume in a way it was
related to how they would fit into the concept of a
regionalization of medical activity, particularly in a place like
New York City where you have pretty highly structured medical
programs, particularly relating to the various educational
institutions.  They already have a certain structure that exists,
and they're naturally concerned with any change that might
threaten that structure.  The threat to any change to them, I
think, was one of the factors that created problems.  Perhaps,
Bob, you could comment on it.

Marston:  The commissioner of health in New York City was more
powerful than any dean.  The commissioner of health in some of
the rural states were not more powerful than some of the deans. 
The organization delivery of health services in the urban areas
was not deemed to be anything that the academic institutions had
much to contribute to.  

Lindberg:  I'd like to bring out one point about this.  It's an
interesting question you raise about why did the Congress
actually go for the bill.  No doubt President Johnson's support
was tremendously important.  But I discovered, in reading Bob
Marston's interview with the LBJ Library, that it actually only
passed by one vote.  I hadn't realized that, and I haven't had a
chance to go back and check up on it to be sure it's absolutely
right, but I think you were making the point that when it was
renewed three years later, it was very strongly positive, almost
unanimous, whereas the original passage is said to have been
very, very marginal.  Mike, do you remember?  Is that correct?

DeBakey:  That's right.  Very marginal.

Lindberg:  That wasn't an exactly resounding endorsement.

DeBakey:  No.  In fact, right up to the last minute, virtually,
there was some question of whether it was going to get passed at
all, the opposition was so strong.

Lewis:  The reason I raise this is the implications that are in
the last session, the lessons for the future.  There are a lot of
lessons to be drawn, both from what happened and what didn't
happen with respect to RMP. 
Lindberg:  It is interesting, though, that the AMA became
positive supporters of it.  They got convinced, the doctors who
were recruited.  The Congress was recruited.  The more support it
got, the closer it got to abolition.  That's interesting.  

Marston:  To reemphasize one of the things that I said early on,
I think whatever else was lost, the loss of the RMP as an
intellectual conceptual forum that thoughtfully looked on the
problems was lost, and to probably be mean-minded in this a
little bit, is that the substitution of micromanipulation of
financial reward systems is a poor substitute for thinking.

Lindberg:  Or even good motivation.  Okay.  Let's get coffee and
come back at eleven.