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                       NATIONAL LIBRARY OF MEDICINE


                         REGIONAL MEDICAL PROGRAMS
                               Bethesda, MD
                             December 6, 1991


                                Session II

Lindberg:  At the end of the last session, Dr. Marston introduced
a theme that I want to extend in a small way.  He introduced the
question, what sort of motivation was RMP trying to provide vis-
-vis what he described in the current legislation programs as
essentially pitting one financial interest against another.  I
want to add a personal element before introducing this next
panel, because it has more to do with how did RMPs function and
what did they accomplish.  It does involve Dr. Vern Wilson, but
he's in a later part.        I got recruited to Missouri by a
conversation with Dr. Wilson, and I recall describing life at
Columbia Presbyterian as a Vanderbilt clinic in which about every
third patient was a potential case report, superb practice of
medicine and laboratory medicine, a Harkness pavilion in which we
were treating Averell Harriman, Fritz Chrysler, Aga Khan, Madame
Chiang Kai-shek, Liz Taylor (which was really much more
impressive to me than all the rest), and what did he have in mind
to do in Columbia, Missouri.  Well, I got recruited to RMP in
1960 before there was an RMP because what Vern said to me is,
"Well, what we intend to do is provide first-class care for
everybody."  To me, that's what Missouri was all about.  It's
also what Regional Medical Programs was all about.  
     The next panel is going to describe to us the
accomplishments, the phase of implementing and accomplishing, and
it will be chaired by Dr. Stanley Olson.  You all have so many
accomplishments in the world that it would take all of our time
to cite them.  We have agreed that I will say two things about
Dr. Olson.  One, he ran an RMP at a local level in the state of
Tennessee and Upper Southeast before he became to Washington to
be head of RMP, which he was from 1968 to '70.  He will introduce
the rest of the panel.   
Olson:  Dr. Lindberg's introduction reminded me of an experience
that I had when I was invited to speak to a group of medical
students at Emory University School of Medicine.  The chairman of
this group had written to my secretary, asking for a curriculum
vitae so that he could introduce me.  She sent a copy of my
vitae.  At the time of the meeting, he got up and he said, "I
wrote to Dr. Olson's secretary for some information, and she sent
me this here poop sheet," and he waved it.  He said, "I looked at
it and I saw where he'd been to school and the degrees he had and
so on, and I decided that would take too much time.  The
important thing is that he was born in Chicago, Illinois, in
1914, and he was naked like the rest of us."  Then he sat down. 
[General laughter]  And I've never underestimated sophomore
medical students since that time.        We have had an
interesting discussion at the first session.  I certainly learned
a great deal from that.  I'd like to take a moment just to thank
Dr. Lindberg and his staff for the idea of bringing this group
together for this 25th anniversary.  It certainly has a good deal
of meaning for all of us who participated in the program, and we
hope that when you publish it, which I'm sure that you will, that
it may be a document which will be of value if in some future
time there should be a comparable program, because many of the
people who participated legislatively in the first RMP will be
off the scene by that time.        I think what we have in mind
here is not necessarily preaching to the choir, which this may
sound like, but rather we are, in fact, documenting something for
posterity and we hope that it will be used and we hope it will be
necessary to use a document such as this.
     With respect to the function of the Regional Medical
Programs and what they accomplished, one could elaborate, but I
think it's important to say that one of the striking features
about the program was the quality of the people who were
recruited to become coordinators.  We saw this time after time as
we worked with the individual programs, that the people who
caught the vision, who joined the program, were people of
outstanding qualifications.  Many of them had been identified
with universities, some had not, but they were all people of
considerable stature.  I think this, in turn, contributed greatly
to the ability to organize and to accomplish what was
accomplished during the few years of the program's existence.     
  Having had the opportunity to work at the local level, one of
the things that struck me about the function of the coordinator
was that while all of the input from the various members of the
advisory committee and from the people who were in charge of the
cooperating institutions was important in terms of formulating
the policy of that particular region.  It seemed to me that the
function of the coordinator was to take all of that input and to
generate a concept which could then be perhaps discussed,
modified, but nevertheless it was important that there be a
concept, some central theme or groups of themes around which a
program could be built.  I'm sure that this was the experience of
a good many individuals who functioned as coordinators.      I
suspect that in terms of what the programs accomplished, we have
hundreds of anecdotes that we could relate, and I hope members of
the panel will, in fact, recount some of the specifics.  What we
should like to do now is to have each of the panelists take
perhaps five minutes to talk about either how their program
functioned or specific things that were accomplished.  
     I think it's of interest that these three panelists
represent three different kinds of regions.  Dr. Rikli was the
coordinator for a program that was essentially a single-state
program.  Sure, some overlapping of coordinating, but
nevertheless essentially a state boundary.  Dr. Ingall had
several counties in Western New York and dipped down into
Pennsylvania and picked up a couple of counties there.  Dr.
Hilmon Castle had a multi- state region out in the West, and that
region, i suspect . . . 
[Begin Tape 3]

Unidentified:  . . . when I started to serve as a coordinator of
the Missouri Regional Medical Program February 1, 1968. 
Initially Dr. Wilson and Dr. Lindberg had made a national study
of the activities which were promising to improve the health care
services in the United States, and they pulled together the
initial program which incorporated the use of computers in many
various ways.  
     The program was developed not only by the two distinguished
gentlemen who are with us today, but had active cooperation from
the medical society which Dr. Wilson had worked very actively
with visiting all the local medical societies in the state during
his term as dean of the medical school.  He was able to bring
together in the state the medical leadership to participate
actively in our program.        The projects that made up the
Missouri Regional Medical Program started out with one of Dr.
Lindberg's favorite programs, "Consider," a differential
diagnostic system, and later Dr. Ludwig [phonetic] had a program
which was useful in making diagnosis of radiological problems,
particularly in bone disease.        Another essential element in
the Missouri Regional Medical Program was the transfer of medical
knowledge.  There were three projects which were not uncommon in
other programs as well.  One was called the telelecture project,
the automated message center, which is still prominent in many
locations around the country and even in Missouri, and we had
many opportunities, therefore, for the medical school to reach
out to the individual hospitals in Missouri and provide lectures
and an exchange of information on a real-time basis.        I
think during the past twenty-five years, a number of those
projects have been incorporated into our health care system
today.  Some were referred to in our video here, and I won't
repeat the work that has been done with the electrocardiogram,
which has been one of the most prominent diagnostic procedures
accepted by many hospitals today, and also the work that has been
done in providing emergency medical care to the coronary patient. 
Originally the ambulances, you recall, were primarily provided by
the morticians in the community, and today they are provided by
hospitals and manned by paramedics who have good communication
with the hospital and are able to bring the patients to the
hospital alive for treatment in intensive care facility for the
coronary patient.  I think the training of the ambulance drivers
and the staffs in the hospital have made a prominent role in
improving health care to the heart patient.  
     A rather dramatic finding is the change in mortality of the
cardiovascular or the heart patients and the stroke patients. 
There has been a 25 percent decrease in the mortality rate for
heart disease.  It's changed from 253 per 100,000 in 1970 to, in
1988, 166.  For stroke, the decrease is even more apparent.  It's
been reduced from 66 per 100,000 to 29, almost a 50 percent
decrease.        Today our expenditures for medical care are
rather amazing.  We are now spending over $3 billion per year on
just three different conditions--[unclear] renal disease, the
coronary bypass surgery, and cataract surgery.  It seems to me
that the $500 million that was invested in Regional Medical
Programs during a ten-year period looks like a pretty good
investment when you compare it to the amount we're now spending
on each of these conditions.  As we are seeking to improve access
to high quality medical care at reasonable cost in the United
States, it is well that we are attempting to reevaluate the role
that Regional Medical Programs have played in the past and may
play in the future.  

Olson:  Thank you very much.  I would like to ask Dr. Ingall if
he would comment a little more pointedly on how the coordinator
and the regional advisory councils functioned and what part those
individuals who were on those councils played in developing the
program within the region.   
Ingall:  As you know, the title of this session is "How did the
RMPs function and what did they accomplish?"  This, on my part,
initiated a series of contacts with members of my old regional
advisory group, some of whom I feared might have passed on to
celestial service of a more permanent nature.  [General laughter] 
But this proved not to be so, which speaks well for the climate
of living in Western New York.  It also reflects that in my
incumbency as director of the Regional Medical Program, I made a
large number of lasting friendships and I learned a great deal.  
     Dr. Olson, for advice and for decision-making, we had the
support of a county committee from each of the eight counties of
the region whose activity and education were actively supported
by the RMP's core staff.  I must emphasize to you that selection
of a core staff is a tremendous responsibility by the director of
the Regional Medical Program, and I thought it was one of the
most serious obligations in my incumbency.        These county
committees, in turn, chose delegates and alternates to the
regional advisory group, and this met monthly and was very often
considered excessively large, but in my view it worked very well. 
Even in inclement weather, which occasionally assails Western New
York, we had tremendous representation.  We also used our
telelecture network, which was one of the early ones installed
under the RMP aegis.  We used that to extend committee
participation and, of course, education to those that were
remaining at home in their own counties.  This caused some rather
flippant remarks on occasion.  On the whole, I would say we had
constructive comments through this medium.  
     An essential element in our function was the emphasis of a
population perspective.  This we profited from the School of
Allied Health and some of the other colleagues in the
epidemiology department, but it was a pervasive theme within the
program and got people to see problems on a community basis,
which I thought was very important.  
     Interests from individual entrepreneurs was not disdained in
that their drive would be harnessed and judged for the good of
the populace.  The concept of evaluation and the objective of
ultimate self-support were both stressed.  In fact, those were
the absolute rules of the program, and we found that that made
for much greater understanding by all the participants.  One of
our project physicians reported that the Regional Medical
Programs were a manifestly sincere mechanism for government to
bring about a favorable change in medical care delivery via a
mechanism that the private sector understood.  In fact, the
private sector was excluded before the advent of the RMP.  The
good investment that you alluded to, Buck, was well appreciated
by my region.  It resulted very much in education of the private
sector on what public agencies could do and brought a large
number of the practicing community into an understanding of
research and at the same time it tapped private resources.  We
were not above tapping private resources to augment what an RMP
could do.        There's no question in my mind that the
convening function of the Regional Medical Programs have allowed
individual contact with participants in the health education,
planning, and service areas which is singularly absent now on a
national basis.  Another feature--and I speak from the comments
made in the regional workshops held in my program and I've
brought the records of those with me--is that funds seen as
previously consumed by the major institutions in education and
medical care delivery are now responsive to a population
perspective in planning and not solely a means to ensure capital
and overhead to the benefit of a single agency.      We chose as
our local motto "Communication, cooperation, and science to
service."  We needed and obtained great visibility with our
projects and many of them still exist in Western New York and
Erie, Pennsylvania.  Erie, Pennsylvania, was doubly important at
that time because Russell Roth was the president of the AMA.  We
felt that a record, however basic, should be made of our
activities, and I bring my sole surviving copy of a book entitled
Challenge and Achievement, which gives our perspective on the
history of the RMP and was produced by a member, an editor from
the Niagara County advisory group.  I am convinced that the
participation of the community will be greater and more positive
if it sees itself in a developmental role with tangible outcome
and not constrained to a regulatory role, which was the fate of
Comprehensive Health Planning.  This book lists what we did, what
we achieved, where we failed, and how much it cost to fail.   
Olson:  Thank you very much.  Dr. Hilmon Castle has had quite a
reputation in the field of continuing education.  Continuing
education was one of the dominant features of many of the
Regional Medical Programs.  I don't know whether this is what he
wants to talk about, but let me at least advise you that he's an
expert in that field.  

Castle:  Thank you, Stan.  That was a major emphasis in our
program and it made it easy to work with the physicians through
continuing education.  I followed diligently the instructions to
come unprepared, so my comments have not had much thought before. 

     It didn't bother us too much in Utah that the commission's
recommendations were changed to cooperative arrangements instead
of centers, because we only had one real medical center in a
large geographic area, the University of Utah.  We had just
opened in '65, having come from an old county hospital with a
four- year medical school, and moved on campus.  So we had a
center to build with.  There was enormous need in the whole area,
so we included Utah and parts of five states, kind of a watershed
referral area we took as our region.  
     All I can say about the program was it was extraordinarily
exciting to develop, didn't really encounter resistance.  The
medical center was the first step, to get the faculty on board
and to get people there supportive of it.  I was in continuing
education as an associate dean at that time.  I was also in
cardiology, so it was kind of natural for me to get involved in
it.  I already knew some of the needs in the distant areas. 
After getting the medical center on board, which was not
difficult to do because we've always been a state without very
much, and needed resources, so we saw it as a way to enhance and
to build the resources that we had in the medical center already. 
We had great needs there.  I think other people saw it the same
way.        Then we focused on community hospitals, a lot of
hospitals in the area, but widely separated and not very much in
between.  So we developed coordinators of continuing education in
each of the hospitals, perhaps sixty or seventy hospitals.  So
that gave us a link into the hospitals.  We were already doing
things like two-way radio and continuing education by open
circuit television.  Those were things that we had done before,
so we really extended that to these hospitals.  We didn't have
really a medical library, and we helped in initiating activities
there and developed a regional medical library service that
extended out to all of these hospitals.  We jumped into cardiac
care because it was the right time for it.  Coronary care units
had just been introduced.  I think we had remnants of maybe two
or three small beginning units in Salt Lake City, in the larger
hospitals, and that was one of our first programs.  We entered it
through education of nurses and then physicians, then helping
them build their facilities, but within one year we moved from
two or three to seventy units that were active.  As you probably
know, Intermountain [phonetic] was one of the first regional
programs funded for operational activities. 
     The development of coronary care, these things that I'm
mentioning, are things that are still in effect.  They're still
in service.  As a matter of fact, if you went to Utah now and
looked and evaluated Regional Medical Programs, you could find
remnants of almost all the projects and programs that we started
that are still in effect.  
     We started a cancer registry regionwide, including all these
six states.  We started an outreach traveling cancer education
program.  Naturally, that resulted in referrals to the center
that we were trying to build.  We developed a stroke
demonstration unit within the university hospital.  I don't think
any others developed, but that served as a model and a focal
point for bringing physicians in and doing educational programs
in that area.  We really strengthened the medical center.  I
think that's one thing we did.  We brought in people who
developed programs, our artificial heart program and transplant
program and renal dialysis and renal program, all came about
because we recruited Willem Kole [phonetic] from the Cleveland
Clinic, who was interested in coming there, who was supported by
Regional Medical Program.  I don't know if the staff really ever
knew that, but he was for three years. [General laughter]  Then
after that, no one needed to support him because he knew how to
support himself.  
     We brought in new investigators in cardiology, who started
programs of research that are still ongoing now.  That was all
done by Regional Medical Program.  We even developed a
neighborhood health center, the last one that was funded by OEO
and then the Public Health Service.  It all came out of Regional
Medical Program planning and developing and grant-writing.  We
developed a central regional laboratory service which is still in
effect.  We still get samples from the distant areas.        We
had a lot to do with the development of Intermountain health care
regional hospital network.  I wouldn't want to take credit for
having developed that, because a lot of other forces came
together, but many of the staff, when RMP phased out, moved into
that system as it developed and I think came about because of
what Regional Medical Program had done earlier.
     We thought the legislation was very open and relaxed.  We
thought the guidelines were the same.  The central staff was
enormously helpful in encouraging us to make application early,
which we did, and to use our creativity in developing a program,
and we did that.  There were a lot of things taken out of the
commission's recommendations like no support facilities, but
there were some guidelines that said that under certain
circumstances you could get some support for facilities, and we
were able to do that.  The example I would give you, we had moved
into a medical center, but we'd been there a year, and within a
year all the space had been taken up.  So there was no space left
to put the program, and I thought it was essential.  I'd been in
the medical center since my training, had never left, had not
been out of the academic environment, and I thought it was
important to be there.  I believe that was the case, that it was. 
But there was no space.  We found a basement, an enormously large
area, I think about 5,000 square feet, and it had a dirt floor
because it was the basement.  When I was trying to get support,
the central staff said, "The guidelines here say we can help you
renovate, but we can't help you put together new space.  That's
impossible."      Finally the suggestion came, "If that space
only had a floor, then we'd be able to consider it."  So I spent
$5,000 flooring a concrete floor, and then the several
hundred-thousand we got to renovate the space, tore up the floor
for us and rebuilt it the way we wanted it.  [General laughter] 
So I think we were able, within the guidelines, to be creative
and get the program done.  It's still a puzzle to me that the
program was considered not a success nationally, because locally
in our region it seemed the legislation was written for our
problems, and we did benefit enormously from it.  I think we
could do it again.  Things certainly have changed, but I think
still that region needs something that would enhance
regionalization of services which we did through the mechanism
that we used.  
     I did move on in 1971.  I started as the first coordinator,
but moved on in '71 to head a new department that actually grew
out of Regional Medical Program, again was supported the first
year or so.  It was a Department of Family Preventive Medicine. 
That department is thriving and, I think, providing the service
that many people saw that we needed, additional providers for
primary care.  It's the largest department in the medical school
in terms of providing practicing physicians who do stay in that
area and physicians' assistants and other people who we trained
and are still training.  So I went on and left RMP only because
this new department was needed.  It was a part of RMP, so I moved
on to head that department until 1982.  Then from '82 to '84 I
made the transition back to cardiology, where I came from, and am
now doing cardiology full time, wishing that we had a Regional
Medical Program to support some of the things that I want to do
in this community hospital where I work full time.  
     Thank you.

Olson:  Thank you very much.  Before we go to the questions, I'd
like to comment very briefly about the function of RMP at the
national level.  I had been director of the Tennessee Mid-South
Program, and at Bob Marston's invitation I had agreed to take on
the position as director.  I had assumed that I was going to be
working with Bob in the National Institutes of Health.  Midway
before I got here, the reorganization had shifted RMP out of NIH
into the newly developed HSMHA, which was Health Services and
Mental Health Administration.  I must say that I felt pretty much
like an orphan in that new organization, because it did not have
a permanent director at that time.  More than that, shortly after
we came on board, we shifted from a Democrat organization to a
Republican organization, and that in itself left everybody pretty
much wondering what was going to happen.  
     But I'd like to pay tribute to some of the people who made
that program function despite the difficulties, including moving
three times before we finally settled down.  There are at least
three of them who are here that I know of.  There may be more,
but I would certainly like to recognize Martha Phillips and Judy
Silsbee and Lorraine Kyttle.  I wonder if they would stand for a
moment so we could recognize them and thank them for the work
that they did.  [General applause]  Are there others who were on
the staff at the time that I didn't recognize?  If so, would you
stand up and tell us who you are?   
Unidentified:  Karl Yordy.

Olson:  Karl was over at NIH.  He was a very important person
early on, but he deserted us.  I think one other person that I
would certainly like to recognize is Irv Lewis.  Irv, stand up
and take a bow.  [General applause]  Irv was the person who
almost more than anyone else had the long history in government
policy that helped us understand some of the things that were
taking place around us.  While he couldn't stem the tide, he
certainly could at least predict what the level of the tide would
be at twelve o'clock, and he helped us greatly in that fashion.
     The rest of the program will start with some questions by
three people who have been selected.  Dr. Packard, who was a
coordinator from the RMP in Alabama, please come up to the
lectern and pose your question, and we'll see if we can answer
it.  

Packard:  Thank you, Stan.  Picking up on what Hilmon Castle
said, many of the projects that we started in Alabama are still
going on.  One of the most useful, I think, is the MIST program,
Medical Information Service by Telephone, which has gone national
and this year will surpass 1 million calls in and out of the
medical center.  It really began to break down the ivory tower. 
I can recall one instance when I was walking down the hall behind
a couple of residents who had answered a call from a doctor in a
real small town who was handling a case of diabetic acidosis. 
One was saying to the other, "How can he possibly do that without
having sodium and potassium?"  They began to recognize some of
the limitations we had rurally.        With all these excellent
projects which are remnants or still going on all across the
country, is anybody trying to document what these are, analyze
why they have survived after RMPs stopped, and to learn any
useful lessons about starting other similar needed projects?  
     I would also like to follow up with a second question.  As a
result of this program which I commend Dr. Lindberg for, I think
we're going to find out some common threads that made them
succeed at least at the start, and identify the factors that led
to their demise.  Do you see any possibility of starting some of
them again, probably in the rural areas, such as the mountain
states or even in Alabama, Georgia, and some of the poor areas of
the country, Mississippi, to boot?

Olson:  First let's take the question about whether any of this
is being recorded for posterity.  Obviously this is what Dr.
Lindberg and his staff had in mind in having the 25th anniversary
conference.  Dr. Lindberg, I gather that you do have quite an
archival file of materials about the program.  Can you tell us
how extensive that is and whether there is any possibility of
adding to it in some other fashion? 
Lindberg:  There is a collection which we're building.  It is
insufficient.  We have been amazed to find out how difficult some
of these materials are to acquire.  We welcome the participation
and contributions you all can make to it, and we will continue to
acquire.  John Parascandola? 
Parascandola:  The only other thing I might add, we have acquired
a fair amount of material and we've also learned about the
existence of much more material, some of which is on its way to
us.  For example, many of you may remember that you send in
materials for an evaluation study, sent materials to Idaho for a
study.  We've discovered through Ed Smith and others that that
material survived and it's in a state library there, which is
willing to give it up to us.  They were happy to keep it, but
they're even happier to make it available, because it was
basically in storage there, to the library.  That is quite
extensive documentation of what went on in all of the programs.
     In addition, I've got packages that I'm collecting today
that people are bringing me or telling me about materials.  We're
also discovering what is in other libraries, the National
Archives or about to be placed in archives, what is in many
libraries around the country.  The records of some of these
programs or part of the records went to all different kinds of
libraries, local libraries, state historical societies,
university libraries.  So more has survived than we might have
thought.  
     One of the other things the library is hoping to do is to
have a history, a full-scale monograph length history of the
program written.  That's one of the things this conference will
contribute to.   
Olson:  Thank you very much, John.  Dr. Packard, I think we might
leave your second question to the afternoon panelists, because I
think they probably will get into some of that.        When Dr.
Roger Egeberg was first appointed as Assistant Secretary for
Health, he was frequently described as avuncular.  Uncle Roger,
do you have a question?   
Egeberg:  An avuncular one?  [General laughter]  I've been
enjoying this very much.  This felt like old home week last night
it began.  I want to thank you very much for the idea and John
Parascandola for all the work that you've done up to here in
carrying this out.  I would also like to mention Paul Ward, who
really should be here, who had a tremendous influence on the
whole national program.  I think he made the government pay back
$100-and-something million by his efforts in instituting suits. 
He's had some peculiar disease which has not been diagnosed yet,
but it's beginning to get better after two or three years, so I
think he'll be joining our groups pretty soon.  
     I had two or three questions, but maybe before I ought to
say a couple of things that I felt myself.  I felt very strongly
when I was asked what I thought was the most important thing that
I got out of the RMP, or what the RMP gave to us, and I felt the
first one was what we really did to help raise the level of
medical care way out in the smaller communities and really in the
rural areas.  I think we should remember that at that time there
were still many physicians who had been given their degrees by
that very large number of medical schools which the Flexner
[phonetic] Report had eliminated as medical schools.  So there
was a great deal of variation in the practice of medicine.  Also
there was the damnedest bunch of paranoia that you can imagine,
paranoia of the doctors against the government or against the
hospitals or the hospitals against the medical schools, the
public wondering what the hell we were doing, and it was a
peculiar time.        I think I told Diane Rehm that I was head
of the medical service at Wadsworth Hospital, which was, I think,
the largest one the VA had and was in Los Angeles.  After a while
I thought perhaps I ought to get a California license.  You could
practice there with any state license, but I wanted to get a
California one.  After I'd taken some examinations, I was brought
in for an interview with a man who said, "Oh, yes, we're so glad
you've come here.  It's a growing city and we need people."  He
went on like that.  Before I began to vomit, he said, "Where are
you practicing, by the way?"  I said, "Well, I'm in the Veterans
Administration out at Wadsworth."  "That ogre?  Thank you."  And
he left the room.  Well, that wasn't unusual.  That was a very,
very strong feeling about people against people.  
     I feel that the Regional Medical Programs, while they did a
lot of good for the medical schools, I'm sure, and for the
people, they did show us that if you got people who disagreed and
put them in the same room and treated them courteously, you could
get them talking after a while and you could make decisions
without having one group here either fighting until they lost or
won, and having all the antagonism that went on.        This is a
question I wanted to ask Dr. Rikli.  You mentioned that the
stroke units, or the cardiac units, were something that you had
established in your area.  They still exist and had grown from
there.  I think that is a very good concrete example for
somebody.  Mention a few others that have lasted. 
Rikli:  Probably the one that has the greatest impact in the
state of Missouri was the kidney program.  The state legislature
initially asked the Missouri kidney program, the Missouri
regional program, to take on $100,000 to help and stage kidney
patients.  Today the state is providing $4 million for the
Missouri kidney program, so that's one of the strong supporting
programs that's left.  Certainly the intensive care units for
coronary disease are now prevalent in most of the hospitals in
the state and the emergency medical services we've talked about,
which are examples of the major survivors of Regional Medical
Programs.   
Egeberg:  Thank you.  Those are examples of an extension of our
Regional Medical Programs.  Dr. Ingall, as you talked, you
mentioned several times your advisor committee.  I wonder who you
had on your advisory committee.  Did you have any plumbers?  

Ingall:  I assume you're referring to urologists, Dr. Egeberg? 
[General laughter]   
Egeberg:  That's as close as you got to plumbers?

Ingall:  That's probably as close as we got to plumbers, but we
did, in fact, open the county committees up to builders, if you
can consider them embracing plumbing.  We had quite a lot of lay
people, and this was an area of quite interesting confusion
because they wondered what they were doing on the Comprehensive
Health Planning agencies and on the Regional Medical Programs at
the same time.  But one of the things that comes through quite
saliently with these people is that they had something tangible
to look forward to.  They were planning prospectively.  They were
going to develop something.  For instance, the aphasia program
for the stroke program in Jamestown still exists.  The pulmonary
care program for Western New York still exists.  The coronary
care training program of Western New York and the school and the
technician training school all are outcomes of the Regional
Medical Program, which answers your question to Buck Rikli, but
also, secondly, we did, by virtue of our county committees, have
an opening for the lay person to have very considerable and
imaginative input.

Egeberg:  Thank you.  We had everything from union
representatives on down and up.  We got a lot of comments from
people who weren't medical people on our program, and about half
of them were very useful.  [General laughter]  Well, half of them
from the doctors might have been considered useful, too. 
[General laughter]
     Dr. Castle, I was intrigued by the way your program and your
ideas of what you were going to do kept going like this, and that
you either got requests or you had ideas of your own, and you
left the feeling that maybe you could have taken over the health
care of the United States via logical extension of what you told
us.  How much of that came from outside and how much of it came
from inside, that stimulation? 
Castle:  I think initially most of it came from inside, because
as we got people involved from other states and other hospitals,
they saw that we really could do something.  They saw that the
funds did come and that they were enhanced, so they came with
ideas.  I can remember in Idaho, Pocatello and Idaho Falls being
two separate communities, ideas about projects and things to be
done there came from them.  We had representatives from all those
states.  We only had an advisory committee of fifteen.  We tried
to keep it small enough that we could operate.  But people always
came to those meetings.  They were always there.  They stayed as
long as they needed to, to get the job done.  But ideas came from
the outside in time.  The planning period was very short because
we wrote a planning grant, which was funded, and then we jumped
into putting ideas that we had initially in the original proposal
to get operational.  But as soon as we got operational, I think
people saw things could happen and therefore they brought their
energy and ideas to us.   
Egeberg:  Thank you.  One of the things that we practically loved
was the open-ended situations that Marston, Olson, and others had
passed down to us, without too much specificity as to how we were
to solve problems, as to what those problems might be, and I
think they hoped that each region might come up with different
solutions, different problems.  I think the feeling that we had
quite a bit of say for ourselves was a very important part if
you're looking to the future.  Don't tell them, "You put your
period here and your comma here."  
     Thank you, Dr. Olson.

Olson:  Dr. Manu Chatterjee was coordinator for the Regional
Medical Program in Maine, and he's one of the questioners.  

Chatterjee:  It certainly is a pleasure to be here, and it's
certainly a pleasure to see the enthusiasm of everybody who is
here.  It is most unique.  The whole medical programs were a
pretty gutsy bunch of people, and I'd just like to follow up on
the comment that was made about the $100 million.  Jack Ingall
and his staff must have been really very courageous, because he
was one of the original ones who decided whose program permitted
this rather unique lawsuit to go on, for which then certainly
Paul [Ward] became a leading participant, as did all the other
RMPs, which I think is important, to the tune of $100 million. 
It's a unique program.      One of the things that impressed me
the most about my experiences in Maine, and I could go on at some
length relative to what Maine is doing and what they have
continued to do, gratifyingly similar to what we've already heard
about, but one of the things that impressed me about the whole
program was the tremendous amount of interest and participation,
not just of the staff and not just of the Washington group, but
of the provider community, practicing physicians, the nurses, the
small-hospital personnel, without whom none of these advances, at
least in Maine, would have taken place.  This kind of
participation seemed to derive from their real interest in doing
what the program was supposed to do, which is to get the wonders
and miracles of medicine to the patient.  That's a wide open
mandate.  But that was exciting, very exciting.      People were
motivated.  They wanted to do something that was medically
important, that was socially important.  I'm mentioning this
because I'd like to ask a question, as this is an essential
element in how RMP functioned, in addition to what has already
been mentioned.  Dr. Castle commented that to have that kind of
convening group available at the present time, the way the RMP
was structured originally, can it function in today's climate? 
Would we get the same kind of participation that we see here
today?   
Lindberg:  Good question. 

Castle:  I can only respond in relation to the region in which we
work with the RMP and where I still am.  I think it would work
extraordinarily well.  I think the RMP was the first time that I
saw (and I had been there for some time) any communication or
interaction or collaboration among the practice community and
people in the academic institutions.  We truly were isolated in
the medical center. 
[Begin Tape 4]

Castle:  . . . both surgeons and neurologists, and this includes,
in addition, people in otolaryngology and ophthalmology, who
depend very heavily upon the kind of expertise that he and his
associates can bring to a small 250-bed Catholic hospital which
functions as a kind of center for neurological problems in that
area, which extends perhaps 250, 300 miles.  I think even in the
town where I live, Rockford, Illinois, for example, we have three
centers, three hospitals, and we have three open-heart programs. 
Now, I don't defend that.  I would think we'd be much better off
if we had one good program instead of three programs, but the
fact is that there are now sufficient people who have been
trained at various centers around the country, who can indeed
provide fairly highly specialized services, even in these
relatively small communities.  So this, I think, is one of the
differences that exists between the way things were in 1965 and
at the present time.        I think that if Regional Medical
Programs were to be established, you would find that there wasn't
the same kind of need to bring the specialized information from
the centers out to the smaller communities.  In fact, what has
happened is that the well-trained specialists are doing that each
in his or her own field.        I think now we would like to
entertain questions from other members of the audience.   
Lindberg:  Yes, please.  Dr. Green?

Green:  Jerry Green from NIH.  The question that you're
addressing is what were some of the accomplishments of the
Regional Medical Programs, and several very outstanding examples
have been given.  But it seems to me there are examples
applicable or examples achieved regionwide in rather smaller
communities or in rural areas.  I'd like to ask if there are
outstanding examples that can be stated for the large
metropolitan areas as well, New York, Chicago, Los Angeles,
perhaps.  Something quite incidental, recently I became aware of
a federal agency which was having a great deal of difficulty
defining in an operational or pragmatic sense what is rural. 
They came up with a wonderfully creative definition: "Any area or
district that is more than fifteen miles from a McDonald's."  

Lindberg:  That's "frontier"!  [General laughter]  

Olson:  Is there anybody here from one of the metropolitan areas
who would like to take a crack at it?  Mort? 
Creditor:  I directed the Illinois program which included the six
medical schools in the state of Illinois, and had responsibility
for the Chicago metropolitan area, as well as the rest of the
state.  I think there was a program in St. Louis that argued a
bit that they had some responsibility for the southern part of
the state, but in general we viewed the state as our turf.  
     I think the best example of a program that has persisted, or
the results of which have persisted, is the programs that were
cooperatively engaged in concerning the epidemiology and
management of cardiovascular disease and hypertension.  I believe
our whole ethic concerning the management of those diseases were
derived out of those early studies that were supported by RMP and
the Chicago Heart Association, Schonberger [phonetic] and that
whole group.  That's a specific example that I can mention.     
I'd like to take the opportunity to say that I thought the
program in Illinois was a smashing success largely as a result of
the unusual cooperation among multiple academic institutions as
well as all of the professional associations, boards of health,
enormous participation on the part of a very, very array of
individuals.  Again, I can't remember if we had a plumber in the
group, but we certainly had a spectrum of lay participation.  
     In a metropolitan area such as ours, which also had
responsibility for a broader community, the most important single
function that we were engaged in was the convening function.  We
were the only one that anybody could look to who might be
interested in trying to take leadership in addressing and
hopefully solving a problem.  I think we addressed more than we
solved, but I think the RMP in Illinois served its most prominent
role as a convener for a large number of projects for which we
couldn't take personal credit except from the point of view of
getting the folks together to talk about trauma system and the
renal dialysis program, etc., which didn't cost us very much.  
     I viewed my role as a matchmaker with a dowry, and even
though we had a good program for the size of population we were
concerned with, the dowry was really quite small, but it was a
dowry.  The ability to have some incentive to get people together
worked very, very well in that situation.   
Lindberg:  The problems of the city are different from the
problems of the rural area.  Dr. Rikli and I both worked on EKG
in the case of the Missouri program, which is really to put in a
statewide system a system in which the basic research has been
done by Caesar Casaris [phonetic] in the Public Health Service
earlier.  But basically we were spending around $300,000 a year
subsidizing this system in some twenty-two sites and getting
people used to the idea and getting it used and getting
high-quality interpretations delivered and so forth.  The first
city in which that was adopted was San Francisco, and they made a
million bucks a year the first year.  There's no problem. 
There's a population density, there are local telephone calls,
there's a need and expectation, there's sophistication.  It's a
different set of problems entirely.  Buck, am I out of line on
this?   
Rikli:  Not at all.  Of course, I've been interested in
computerization of electrocardiograms for a long time, but when
you talk about bringing high tech services to the rural area,
probably our most popular project and most controversial project
was the automated physician assistant, where we brought the
automatic diagnostic equipment and history-taking equipment and
other automated systems into Billy Jack Bass' office in Salem,
Missouri, where the opportunity for the patient to choose either
the automated system or the manual system was up to them. 
Interestingly enough, patients seemed to prefer the automated
system over the manual system.  In addition to that, they had
much less fear, I believe, of the computer than the physicians. 
Lindberg:  Monte?

DuVal:  Before you recess this session, I'd like to share with
you something that came out of the RMPs that I suspect only a
handful of folks probably know in this room.  There was a
practical and, frankly, political reason at that time why it was
not talked about.  The first planning grants for approximately
150, maybe 160, of the contemporary HMOs were all funded out of
the experimental authority of regional programs by Vern Wilson. 
Most people do not know that, but it antedated the HMO Act of
1973 by better than two years.  That's fascinating that that was
the origin of the contemporary movement.   
Lindberg:  That is very interesting.  I think Dr. [Matthew]
McNulty was next. 
McNulty:  My comments are going to be informational.  [Unclear
portion]  The RMPs were cited and the CHPs were cited.  I think
RMPs played a role in convincing a number of the leadership of
the AAMC that while living on the Northwestern campus in Evanston
was delightful and rewarding academically, intellectually,
socially, and in every other way, it wasn't going to be the scene
of action.  If the AMA had an office in Washington, the AAMC had
one.  So that was of great assistance.  They did vote.  I didn't
play the role that most of my colleagues at the AAMC thought I
should play.  I went to college in 1914, Stan, and I worked
during the summer driving a bus.  Many of my colleagues who were
in opposition to the move thought I should have driven the van
and took all the furniture [unclear].  [General laughter]  But I
squeezed out somehow.        At the same time, the second charge
was to start a council of teaching hospitals, which, in
conclusion, I was very fortunate in doing.  The RMPs played a
role in that regard, not so much in Roger's area because the
hospitals were already getting together and talking to each
other, not so much in Dr. Castle's area because you had the Utah
plan or the Utah empire working very well at that time, but a
number of other places.  New York.  The hospitals joined the
hospital council in a defensive mechanism.  Those upstarts from
Upstate New York and Cornell weren't going to participate in an
organization that was the right and privilege of Columbia and
NYU.  You could say the same for Philadelphia and a number of
other areas.  If these were coming along, the academic teaching
hospitals, be they associated with medical centers or be they
free standing, were going to have to play a role.  In the rural
areas, it was easy also for a number of reasons that you've
cited.  Aggressively they wanted to get involved, because that
means they could set up better coordinated associations or, if
they were really overly aggressive, they could get the patients
from that place down the hill, which shouldn't have started a
hospital in the first place.
     The third, the intellectual impact that was so useful, many
of the hospitals wanted to establish a forum in which they could
enhance RMPs in opposition to the only forum then existing, which
was the AHA, American Hospital Association, which had disparate
membership and, therefore, disparate positions on the issue.  
     The second is they wanted to join the deans in collaboration
to enhance RMP, enhance Community Health Planning, enhance a
number of ventures, and that enticed them to do it.  Finally,
they did it for a voice for action.  They looked upon RMP as an
action orientation.  Comprehensive Health Planning they looked
upon as an intellectual exercise that may or may not get anything
done.  I mention all of those in relation to the fact that RMP
was the peripheral motivating force.  
     Thank you.