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Interview with Dr. T. Franklin Williams
Date:  July 26, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Diane Rehm
Transcriber:  Techni-type Transcriptions/DDR



Rehm:  The interview you are about to see is one of a series
designed to record and document the history of Regional Medical
Programs.  With me today is Dr. T. Franklin Williams, who has
just left his position as Director of the National Institute on
Aging to return to the University of Rochester School of Medicine
and Dentistry.  Dr. Williams worked with RMPs both at the
University of North Carolina and the University of Rochester from
1966 until the end of the Regional Medical Programs. 
     Welcome, Dr. Williams.  It's good to have you here.

Williams:  Thank you, Ms. Rehm.

Rehm:  Please talk a little about your own involvement with the
RMPs and exactly what your own responsibilities were.

Williams:  I was working as Associate Professor of Medicine
interested in diabetes, in particular, at the University of North
Carolina in the mid-sixties when the Regional Medical Program
began.  One of my major interests was in improving patient
conduct, or carrying out of the rather complicated measure that
are involved in good diabetic management, trying to get better
education, helping patients to manage their diabetes better,
helping professionals to do this.  It seemed to me and others
that the Regional Medical Program was really made to order to
help spread the knowledge and help doctors and nurses and
patients do a better job with diabetes regionally through using
this resources.  
     So we developed a statewide program on diabetes consultation
and education which involved the several medical schools in North
Carolina.  We developed several prongs of the program--
consultation services for physicians on difficult patients,
educational programs for physicians, nurses, and patients, also a
good bit of literature to use in this, and then finally we used
this as a way to develop a statewide Diabetes Association, an
organizational structure.  The Regional Medical Program in North
Carolina served as a natural model for this type of regional
addressing of a major challenge, namely to improve care of people
with diabetes.  
     In 1968 I moved to the University of Rochester in Rochester,
New York, and there I helped others to develop essentially the
same type of model for the Rochester Regional Medical Program. 
So the RMP really provided funds and a structure and consistent
goals to try to make a big difference in everyday care of
diabetics and to also serve as a way to take our newest knowledge
about diabetes from our universities and get it into the
mainstream of care.

Rehm:  As you describe it, and certainly from what I've read, it
sounds as though the thrust of the RMPs was two-pronged; that is,
both in terms of care and in terms of disseminating education. 
Was that your understanding of the intellectual thrust of the
program to begin with?

Williams:  Exactly.  Exactly.  To try to do both.  We, in fact,
carried out both aspects in our diabetes-related program.  The
program started as Regional Medical Program for Heart Disease,
Cancer, and Stroke, but actually heart disease and stroke are
very much influenced by diabetes.  Diabetes is a very major risk
factor for both heart disease and stroke.  So it was a natural
relation to the nominal lead diseases of the RMP to bring
diabetes in, and it was very appropriate.

Rehm:  At the same time, would you concede that perhaps taking on
both care and education was a rather large order?

Williams:  Yes, that's true.  I think that as time went on,
certainly more of our efforts went into education.  We did
provide consultative services for difficult problems in patients,
to physicians or to patients directly, but the great portion of
our effort which involved nurse specialists and teachers, as well
as physicians, was in educational activities for physicians,
seminars and special education meetings, the same for nurses, and
then the development of a variety of educational materials for
patients.

Rehm:  From your perspective as someone long interested in health
services research, what do you believe the major accomplishment
of the RMPs was?

Williams:  I think there were several very important
accomplishments.  One was almost philosophical.  That is, where
was a commitment from federal leadership and transmitted down
through regional levels, a commitment to make a difference in the
ongoing care of patients, of people with some of our major
crippling and death-dealing diseases.  So the commitment, the
positive directions being taken, was an important message.
     Secondly, the regional nature of the RMP was very important
because it meant that people within a region, people who needed
to work together and could work together within a more or less
defined region, were the lead movers.  Now, it might be a whole
state, as it was for us in North Carolina, or it could be a
region of a state, as it was in the Rochester region of Upstate
New York.  But it was a natural grouping of people concerned with
these problems, who could work together.  So this regional
principle was very important.
     Then, I guess finally, it was obviously the fact that here
were some funds that could help do things that weren't happening
otherwise, or at least not well enough, particularly, in my
instance, in the area of education for patients and
professionals.

Rehm:  The notion of the regional nature of the program sounds as
though it may have had both its pluses and its minuses.  When
you're working in any kind of regional program, there may be
others within the same region who perhaps perceive themselves to
be in competition.  So I wonder whether you ran into that as you
worked both in North Carolina and in Rochester.

Williams:  It would certainly be a possibility, but I think we
took that into consideration in our particular instances, in our
planning.  After a small group of us who were eager to move
forward with it had sort of gotten organized, what we sought out
in the first instance was an interest in communities with what we
might offer them.  This meant finding one or more physicians in a
given community who said, "Yes, it would be a help to me (or to
us) to have more input on diabetes."  Then we would work together
to say, "Okay.  How can we do it?"  
     I think that through what I think is sensible working
relationships, we really never did run into any conflict.  It was
a common interest throughout the community of professionals
within the given region.

Rehm:  Let me understand, Dr. Williams, whether there were
certain physicians and health professionals who worked within a
certain region as part of the RMPs, and then were there also
local health officials who worked with those same people who were
working specifically with and for the RMPs?

Williams:  Yes, more or less in this way.  In the instances I
took part in, in North Carolina we involved, in the first place,
the diabetic specialists in the three medical schools, all three. 
So we had the leading medical specialists in diabetes for the
state, and also in one or two of the other large cities where
there were also diabetes specialists.  These were involved from
the beginning.  We served as sort of the core faculty, if you
will, or resources.  But then in various communities throughout
the state, or the region, in the Rochester region, we would find
out through inquiries just which physicians in a local town or
community was particularly interested in working with us, so they
would become the local person.  I have accounts in some of my
notes of that period of very warm relationships where a physician
might present a few of his problem patients or call on several
physicians in the community at a hospital conference, and we
would all discuss how best to manage them.

Rehm:  Given the fact that you've just resigned from the National
Institute on Aging, and given your career involvement with
questions of aging, what do you think that the RMPs had actually
to contribute to our understanding of the problems affecting the
aging?

Williams:  I think they were a big step forward in that way, too,
because they were addressing the most common killers and some of
the most common disabling conditions which mainly affect older
people.  Over half of all cancer deaths are in older people. 
Over half of all cardiovascular deaths are, probably 75 or 80
percent of all stroke deaths are, and the disabilities that go
with these conditions are, for the most part, a fact of life for
older people rather than younger.  
     I think today if we were going to start the Regional Medical
Program again--and I think it would be a good idea--we would
certainly add Alzheimer's Disease because it's such a huge
epidemic, and we'd probably add a few other things.

Rehm:  Did working with the RMPs actually move you in the
direction of working with the aged?

Williams:  I think it helped.  I was interested in the long-term
care aspects of chronic diseases.  I started with diabetes and
there it's a lifelong condition for most people and it calls for
long-term care planning and efforts to control and manage.  So I
was very much interested in the long-term care aspects of chronic
diseases.  That gradually led me more into the fact that these
are really a characteristic of older people and I needed to be
more involved with more of the facts about older people.

Rehm:  You've said a couple of times that you believe that were
the RMPs to be reinaugurated today, you feel that they could work
out; indeed, that they would be very useful.  How would you see
the institution, or the reinstitution, of RMPs today, if you
could oversee such a process?

Williams:  I think there are at least two directions that such a
concept might move.  One would be similar to the previous RMP,
disease-focused, select the major disease conditions that are
such threats to not only survival, but also disability.  I would
add a few like osteoarthritis, probably, and, as I say,
Alzheimer's Disease to the list of conditions that are major
burdens on society and on costs.  One could start with a disease
focus like this again.
     The other possibility would be to try to develop, on a
regional basis, models for comprehensive total care.  This
interests me because as we try to grope for a national
comprehensive health care program, working at it but not making
much progress thus far, it seems to me that we could get there
quicker, perhaps, if we tried some regional models and just
tested out, at a more reasonable level, what it takes to make a
workable comprehensive inclusive health care program that would
include all of these and every other disease, too, both acute and
chronic care, preventive services, for sure, and learn at a
reasonable level.  
     One of the great blessings, again, about the RMP was that we
were working among people who had to work with each other.  I
mean, in a defined community, if you will, using community to
mean a whole region or maybe a whole state.  But I think that we
could learn how to handle comprehensive health care at that level
probably quicker than we're going to, to try to do the whole
nation in one fell swoop.  

Rehm:  You're talking about it primarily from a programmatic
point of view, but what about the bureaucratic end of it?  What
about the structural end of it?  How would you restructure it
similar to, or different from, the way it was?

Williams:  This would take some careful thought, and I think the
ideas I would have, first of all, thinking back about the
Regional Medical Program as we had it before, there was a
director for each region for the whole program.  I mean, the
heart disease, cancer, stroke, diabetes, any other elements, all
came under one officer and then there were advisory boards and
there were various channels of connections.  I think that served
fairly well for the type of program it was.  Under this one
director there would be subdivisions.  For example, our division
on diabetes had its own budget.  We reported to the director of
the whole region, and the same with heart disease, cancer, or
stroke.  So it was fairly clearly organized, but with reporting
channels.  
     I think if we were going to try my suggestion of a
comprehensive regional care, it would take more of a structure. 
It would call for some type of corporate body with clear
representation of the public, the payers, the professionals, the
hospitals, the nursing homes.  It would take a fairly careful
structure.

Rehm:  You don't feel that that careful structure was there
sufficiently during the earlier incarnation?

Williams:  I don't think it was called for, really.  I don't know
that it would have been considered necessary for the purposes of
those RMPs.  I don't think it was lacking because no one did it,
but rather because it really didn't quite fit into the overall
design.

Rehm:  Tell me what you feel we learned--and I say "we" in the
collective sense as a society.  What did we learn about diabetes
and what were we able to transmit to the general understanding of
diabetes that actually came out of the RMPs?  

Williams:  One very important stimulus and resources that led to
further ongoing activity was the whole effort at education of
patients and professionals more thoroughly about diabetes.  A
second output that has persisted was an organizational structure
for diabetes.  Diabetes education centers were organized, not
only in the two I mentioned, but in other parts of the nation,
with the help of the RMP, and these have persisted in many
instances as a real resource continuing.  Another organizational
structure were Diabetes Associations, local chapters or statewide
organizations that have eventually become part of the American
Diabetes Association, for the most part.  
     So there were organizational payoffs that have continued, as
well as a host of new knowledge both about educational methods
and educational materials.

Rehm:  You talked earlier, Dr. Williams, about the commitment
that existed for the RMPs.  Was that commitment existent within
primarily the medical profession itself or did you sense a
commitment on the part of the body politic as well?

Williams:  I'm not sure.  That's a good question.  I know that
there was no trouble to get good sparks of interest from the
medical profession and the nursing profession, a great interest
among nurses.  They were an integral part of the whole effort. 
Then among people who had diabetes, or their family members, once
you raised some of these possibilities, there was a real
interest.  Now, how much initiative came in the first place from
the public, I'm not as sure.  I have the sense that this was a
proposal that began with some imaginative thinking in Washington
or similar.  Of course, President Johnson initiated the program,
with advice, I'm sure.  But I think that the real spark came
there rather than sort of rising up out of the roots.

Rehm:  I know that you were with the programs until they were
terminated, Dr. Williams.  Why do you think they were terminated?

Williams:  I'm just not sure.  I was very disappointed to see
them terminated, and I have letters in my files writing my
congressmen, urging that they not be terminated.  I would want to
say that this was only a relatively small part of my efforts at
the time.  I had other responsibilities, so that it wasn't that
my salary was involved or anything personal, but rather that I
just felt that these were very valuable programs, and I could see
no good reason for terminating them.  My recollection is that it
was a budgetary matter that it was decided that something was
going to be cut, and so we'll cut these.  I never heard or saw
any rational justification for cutting them, but that's perhaps
my bias.

Rehm:  Following up on that, then former HEW Secretary Caspar
Weinberger said the program had great difficulty in defining a
clear role for itself and in concentrating its efforts on even a
few well-selected target areas.  Do you feel that was an unfair
criticism?

Williams:  Yes, I do.  Absolutely.

Rehm:  Why?

Williams:  Because I not only could see the benefits in these two
different sites--and they're quite disparate sites, one serving a
predominantly rural state at that time, the other serving a
cosmopolitan much more industrialized community and surrounding
areas.  My experience was very positive in their benefits and
very easy to define.  What I could see in the other components of
the programs, particularly I got to know some of the other
components particularly well in the Rochester area, in the cancer
and heart disease area, was also very successful.  So I have no
way to understand why that judgment was made.

Rehm:  Secretary Weinberger and others went on to say that they
felt the program was far too ambitious, that instead of finding a
single niche, it had taken on too much.  For example, the notion
of both care and education, when, in fact, one approach would
have been more than sufficient, more than ample, for the RMPs.

Williams:  That I would have to see examined pretty carefully.  I
think that certainly it would be open to review, and I assume was
reviewed, but if, for example, that were a judgment with some
basis, then the program could certainly have been trimmed or
redirected or focused rather than abandoned.  

Rehm:  But it clearly had an insufficient number of political
supporters when the suggestion came to cut that budget, so one
wonders whether in any such program part of building support for
the program is building political support.

Williams:  I would be sure that would be true, and I don't know
exactly why that wasn't more apparent with the Regional Medical
Program.

Rehm:  What was the most exciting aspect of the whole experience
for you, Dr. Williams?

Williams:  I think the most exciting or satisfying aspect was the
responsiveness of professionals, fellow professionals, in the
caring situation who were so glad to have this collegialship with
others who had similar interests.  It was especially striking,
perhaps, among nurses, because the attendance of nurses at
workshops that we put on was enormous, from various channels of
nursing, from hospitals, nursing homes, physicians' offices, all
sorts of settings, and a real great desire to learn more and
appreciation for these efforts.  And the same applied among many
physicians. It wasn't quite as enormous, but I think the
satisfaction of finding colleagues in the health professions who
really found that this was helpful to them was probably the
biggest satisfaction.

Rehm:  Perhaps you were in contact with others in other Regional
Medical Programs, and I wonder whether there were some that were
more successful than others, and what reasons might have been
given for the success of some and the slight less success of
others.  

Williams:  It's a good question, and I don't think I have a very
good answer.  I did know people working in other programs, but
the ones I knew were enthusiastic people.  I guess I didn't see
very much of those who weren't as enthusiastic, so I can't really
make a sound judgment about what may have been lacking in those
situations.  But there certainly were many around the country
which had similar enthusiasm.  That part I can vouch for.  I
can't really offer much of an evaluation of the places that
didn't do so well.  I'm sure there is information on this, or
should be, from, for example, the directors of the overall
programs.

Rehm:  That's really the point, whether it was leadership,
whether it was commitment, whether it was the distribution of
funds, whether it was the use of talent.

Williams:  Yes, I think that's right.  

Rehm:  Any and all of the above.

Williams:  Yes.  I really don't have a good picture of how much
careful evaluation was done.  One of our four-pronged efforts in
our program was to evaluate what we were doing, so we had
evaluated data and information on our own program, but I don't
really have much information on how the overall program was
evaluated.

Rehm:  Dr. Williams, what do you think we can learn from the RMP
experience?

Williams:  I think we can learn some of the things I've already
been emphasizing.  I think we can learn that we can go much
further than we often have in improving the care of people with
various conditions through some organized efforts at consultation
and especially at education, both professionals and the public. 
Secondly, I felt we learned that we could organize effective
approaches at the regional or statewide levels in whatever the
natural groupings are, whichever, regional or statewide, and that
we can really do what the original purpose of the RMP was stated
to be; that is to translate our latest knowledge into care of
patients.

Rehm:  If those RMPs were indeed reinstituted, reorganized today,
do you think they would, in fact, work better with a single focus
such as care, rather than both care and education?

Williams:  I'm not at all sure.  I think that care and education,
particularly with chronic diseases, go so much hand in hand that
if you want to improve care, you've got to be educating, and
there's not much point in educating unless there's some care
goals.  I think they go hand in hand.  It's perhaps a matter of a
mix of exactly where you put your resources into each, but I
think the goals are common.  

Rehm:  If, in fact, such regional medical programs were to be
reestablished today, would you be one of the first to step
forward?

Williams:  Sure.

Rehm:  Are there any other specific recollections you'd like to
put forward today?

Williams:  I guess the only other one that I recall is again the
sense of commitment that I felt I saw in the directors of the
programs, at least the programs I was associated with, the
overall programs, as well as the subdivisions.  I think many
people who did have a lot to offer in the way of leadership in
health care saw these as real opportunities to do something they
hadn't been able to do before, so I think the commitment and
enthusiasm of at least many of the leaders was something I would
want to note.  

Rehm:  Dr. Williams, I want to thank you so much for being with
us today.  It was a real pleasure to talk with you.

Williams:  Thank you very much, Ms. Rehm.

Rehm:  From the National Library of Medicine, I'm Diane Rehm.

[End of interview]