* l@lij i(ill iiiii iiii iiii jo iiii * UI - 67084758 AU - Marston RQ AU - Yordy K TI - A nation starts a program: Regional Medical Programs, 1965-1966. LA - Eng MH - *Education, Medical, Continuing MH - *Legislation, Medical MH - *Public Health Administration MH - *Research Support MH - United States PT - JOURNAL ARTICLE DA - 670325 DP - 1967 Jan IS - 0022-2577 TA - J Med Educ PG 17-27 SB A SB M ZN Zl.107.567.875 IP 1 VI 42 JC J13 EM 6705 SO J Med Educ 1967 Jan;42(l):17-27 UI 67084758 AU - Marston RQ AU - Yordy K TI A nation starts a program: Regional Medical Programs, 1965-1966. LA Eng MH *Education, Medical, Continuing MH *Legislation, Medical MH *Public Health Administration MH *Research Support MH United States PT JOURNAL ARTTCLE DA 670325 DP 1967 Jan IS 0022-2577 TA - J Med Educ PG - 17-27 SB A SB M ZN Zl.107.567.875 IP -I VI - 42 JC - J13 EM 6705 SO J Med Educ 1967 Jan;42(l):17-27 A Nation Starts a Procram: ZD Regional Medical Programs, 1965-1966* ROBERT Q. MARSTON, M.D. AND KARL YORDY National Institutes of Health, Bethesda, Maryland Preprinted froni The Journal of Medical Education Vol. 42, No. 1, January, 1967 Printed in U.S.A. .A Nation Starts a Prooram: ZD Regional Medical Programs, 1965-1966* ROBERT Q. MARSTON, M.D.t AND KARL YORDYT National Institutes of Health, Bethesda, Maryland This month [October, 1966] marks the lems being encountered in implementing first anniversary of P. L. 89-239, the this legislation are influenced by large Heart Disease, Cancer and Stroke Amend- issues and historical trends which can be ments signed by President Johnson on seen only incompletely at any one time October 6, 1965. The legislation was and from any one place. hailed by some as a landmark in the While the historian of the future will history of American medicine. It was focus on forces that we can perceive only strongly criticized by others, both for dimly at present, reflection on the possi- ,,that it said and what it did not say. ble impact of the programs brings to Even some of those who supported the mind a view of history presented by Rob- legislation in principle still maintained ert Bolt (1) in A Man Fo?- All Seasons. ,i wary Curiosity concerning the imple- His theme is that an examination of the mentation of such general legislative trends and forces will illuminate only a language. The philosophical hopes and portion of any historical event. What is fears of a year ago have been replaced of interest is the way it happened, the by actual events, real problems, and iden- way it Nvas lived. " 'Religion' and 'econ- tifiable progress. It is appropriate at omy' are abstractions which describe the this time to report on the extent to which way men live. Because men work we the Regional Medical Programs legisla- may speak of an economy, not the other tion has been implemented. way round. Because men worship we It is estimated that there will be 48 may speak of religion, not the other way or 49 programs: 45 planning grant ap- round." plications or declarations of intent have BACKGROUND been submitted to date. These programs will actually be defined in large measure There are a number of long-range fac- through the activity of those people who tors and trends which constitute a com- will make them operative. It is this mon heritage for the Regional Medical characteristic of the Regional Medical Programs and which set the scene for Programs that makes them a fascinating the passage of the authorizing legislation. experiment in federal health policy. The most important of these factors is Obviously, experience with the devel- the impact of science on the nature of opment of these programs is still quite medicine and medical practice. The dy- limited, and many of the difficult prob- namic growth of medical research in this country during the past twenty years and 'Presented at the 77th Annual Meeting the resulting advances in knoivledge form of the Association of American Medical Col- leges, San Francisco, October 22, 1966. the scientific base which is the beginning t Associate Director; Director, Division of point for the program. Following are Regional Medical Programs. some of the factors which contributed I Assistant Director, Division of Regional medical Programs. to the development of the legislation: 17 VOL. 42, JANUARY, 1967 18 Journal of Medical Education the forty-year discussion on regionaliza- Administration Is proposal. Many changes ervices; the evolution were made in the original bill, primarily tion of medical s of hearings before the of the medical schools with the acconi- as the result panying development of great medical House Interstate and Foreign Commerce centers; and underlying social factors Committee, chaired by Congressmaii relevant to health concerns, including the Oren Harris. By its action, Congress rising expectations of the consumer of made it clear that this program would health services who is increasingly com- be built upon cooperation among existing ing to expect that modern medical science institutions and that local initiative will have the solutions to his health would play adetermining part in the de- problems. velopment of the Regional Medical Pro- The legislation was directly influenced grams. The law emphasized the role of by such publications as the Coggeshall the required regional advisory group and Report, Planning for Medical Progress the intent that this group be broadly through Education (2) ; the Dryer Re- representative of all health interests and port, "Lifetime Learning for Physicians" include practicing physicians and repre- (3) ; and the Reports of the Association's sentatives of the interested public. Eighth and Tenth Teaching Institutes The House Committee was impressed "Medical Education and Medical Care: with the potential contribution that the interactions and Prospects" and "Medi- Regional Medical Programs could make cal Education and Practice: Relationships to the more effective utilization of man- and Responsibilities in a Changing So- power. Therefore, it stressed the role ciety" (4, 5). However, the actual im- of continuing education and training petus for the introduction of the bill in accomplishing the purposes of the was the publication of the Report of the legislation. President's Commission on Heart Dis- Although the bill as originally written ease, Cancer and Stroke (6), which provided authority for new construction, focused on the relationship between sci- this section was eliminated before the ence and service in medicine. The man- legislation was passed. date of the President's Commission did Finally, Congress authorized the pro- not include the drafting of legislation; gram for three years and made clear its that task was performed under the intent that this initial period be an ex- leadership of Dr. Edward Dempsey, then ploratory phase which would constitute Special Assistant to the Secretary of the the learning experience on which future Department of Health, Education, and extension and modification of the legis- Welfare for Health and Medical Affairs, lation could be based. and Dr. Dempsey's Assistant, Dr. Wil- Preceding the signing of the legisla- liam Stewart, now Surgeon General. The tion, the administrative decision was bill that was sent to the Congress by the made that this new responsibility of the Administration contained the elements Public Health Ser'vice would be adminis- which have proved to be most important tered by the National Institutes of to the development -of the program over Health. This action emphasized the the past year, including the emphasis on fact that the Regional Medical Programs the relationship of academic medicine to concept focused on the relationship and medical practice, the creation of work- interaction between the development of able cooperative arrangements among new knowledge and the provision of bet- health resources, and the use of competi- ter medical care. In the period preceding tive grants rather than formula grants. and following the final approval of the Congress did not rubber stamp the legislation, Dr. Stuart Sessoms, Deputy A Nation Starts a Pi-ogi@at@t,@Ma?-ston a@td Yf)@'cly 19 20 Journal of t@ 61@epyi'Ot? o rnastetpla-n? FIGURE 1 Director of NIH, was the focal point for f act that the flexibility of this legislation NIH concern with this legislation, as- was deliberate public policy and that this sisted by Mr. Karl Yordy. Much of the flexibility is central to the concept of a early implementation which will be de- regional medical program. scribed later in this paper occurred under The legislation clearly prescribed that the leadership of Dr. Sessoms, who bore the program be carried out oil a regional the major responsibilities until February, rather than a national basis. The law basis in accom 1966. represents a vote of confidence in the On October 6, 1965 there were no ex- willingness of the regions to accept the objectives. perts on regional rricdieal programs, no basic responsibility for devising the pro- m@,ster blueprints of how a regional grams to accomplish the purposes of the REASSURANCE A N medical program would work. During law. The flexibility of the legislative Experience w this period, questions from prospective provisions highlights this transference of naturally into s applicants and other interested parties responsibility to the regional level. A The first spans attempted to probe the flexibility of the clearly defined national medical program ing of the leg legislation in order to determine whether would have led to fewer questions. How- about February or not there was a specific blueprint for ever, even if workable, it would have much of the e implementation (Figure 1). How do meant less opportunity for creativity, authors, and o vote define a region? How many regions fewer opportunities to develop diverse viding reassur will there be? Who can apply' What answers appropriate to diverse problems, will be the responsibilities of the appli- and less assumption of responsibility at groups concern cant? What is the exact nature and role the local level. program as defi of the regional advisory group? Tell me After one year of experience, there is still feared th in specific terms what a regional medical considerable evidence justifying this a federal medic program will do and how it will function. law's almost naive trust and faith in the vert patients t The answers, or some would say lack of ability of formerly divergent medical with no concer answers, to these questions reflected the interests to cooperate on a voluntary practicing phvs 20 Joit?,iial ot . ille(lic(it Edit(,atio@i VOL. 12, JANUARY, 1967 kjHRONOLOGYOF REGIONAL MEDICAL PROGRAMS (Public Law 89-2 39) October, 1966 DEC@ FS. JULY OCT@ DEC@ FEB. APRIL JUNE MY AUG. OCT-NOV.DEC@ FtS@ MAY @j UNE OF THE REPORT s MEETINGS OF THE NATIONAL ADVISORY COUNCIL W4MI@ON -CW@RESSIONAL- FEARINGS PUELIC LAW REPORT TO) OTHER @239 ENACTED THE PRESIDEN REPORTS AND SICSED BY THE I'D IH EMALQ PRESIDENT PREUMINARY CURRENT CONGREssf PUBUCATION OF "GUIDELINES" "GJIDELINES!' PUBLISHED DIVSION OF,REGIMAL FIRST ANNIVERSARY M@ PROGRAMS OF THE LAW ESTABLISHED APK PR JULY OCT, FIGURE 2 basis in @iecomplishing important health of the medical school f@iculty @Lnd admin- objectives. istrators feared that their medical centers were being asked to assume the total re- DEVEI,OPTVIENT sponsibility in their regions for medical REASSURANCE @.ND DEFINi,rioN care in the fields of heart disease, cancer, Experience with the program divides Lnd stroke. Non@iffiliated hospitals feared naturally into several phases (FigLii@e 2). that they would have no role to play in The fii@.gt spans the period from the sign- the program (Figure 3). iiig of the legislation in Octol)el, until However, along with the fears and anx- about February, 1966. During this time, ieties, there was a ground swell of in- much of the effort of Di,, Sessotr-s, the tel@est in the Regional Medical Programs authors, and others was spent in pro- expressed by @i very wide variety of viding reassurance to various medical health organizations, institutions, and iii- groups concerning the nature of this dividuals. Meetings were held in regions program is defined in the law. For some throughout the country to discuss imple- still feared that the program N@otilcl be meiitation of the program. The staff at 'I federal medical system which would cli- NIH was contacted by litei-@ill@, hundreds vei@t patients to distant medical centers of medical organizations and groups ex- @vith no concern for the role of the locii pressing interest and support. The Re- practicing physician oi, hospitil. Some giozial Medical Programs appeared @is t A Nation Stai-ts a Pi,ogi-akii @Mat-ston and Yoi,dy 21 22 We'll be s@ql@o-@ @y 9 FIGURE I 9 w topic for discussion in the programs of Council as required by the law. Members v a number of major medical professional of the Council and the ad hoc consultants r organizations. became increasingly articulate in inter- c In December the Division of Regional preting and defining the program in Medical Programs was established and its speeches, in theii- own professional or- i National Advisory Council held its first ganizations, and in the development of c meeting. individual regional plans. d 9 REGULATIONS, GUIDELINES, AND OUTLINES RECEIPT AND REVIEW OF APPLICATIONS r The second phase of the program ex- The period from April through June p tended from February Until April. Spe- constituted the third program phase. cial groups of consultants with expertise During this time, the emphasis changed in such relevant fields as continuing edu- from reassurance, definition, and prep- a cation, community health planning, and aration to the receipt of applications for hospital administration were called to- planning grants and the review of those 0 gether to advise the Division on the applications (Figure 4). No deadlines 0 implementation of the program. Regula- for the receipt of applications were pub- c tions were drafted and proposed. Pre- licized. Instead, it was the Division's t liminary guidelines for applications and the application forms themselves were stated intention to hold frequent review meetings so that applications could be developed and widely distributed. Another considered without iindue delay and with- meeting of the @National Advisory Cotin- cil was held and a process for the review out the development of a crash program. of applications was developed, consisting Therefore, the National Advisory Cotin- of a preliminary review by staff and bv cil met to consider pplications in April, a group of ad hoc consultants prior to June, and August, preceded each time the review by the National Advisory by a meeting of an ad hoc initial review 22 Jo@ii,i?(tl of ille(licul E(Iiicatio@i N'OL,. 42, JANUAPY, l@)67 FIGURE 4 group representing a vai,iet@, of back- in the actual review of plaiiiiiiig-gl-,Ilit grounds in health affairs. These groups applications. were able to consider applications with varying approaches to the planning of a NEGOI'IATIONS AND AN'TICIPATION regional medical program and reach a During the final phase of the first year consensus on the merits of the proposals of the program, lasting from June until in terms of the purposes of the law. Dtir- October, concern was with (a) colitin- ing this phtse, 39 planning-grant appli- ued review of applications for planning cations were received-ovei-whelming evi- grants; (b) a rapid buildup of activities deiace of the willingness of regional in continuing education; (c) preparation groups throughout the country to tccept for the required Report to Congress in responsibility for the development of a June, 1967; and (d) anticipation of ap- planning program. lications for operational grants. In reviewing the first applications, the In considering the applications, the re- Division iv.Ls able to identify certain view groups found that a straight "yes" areas of emphasis and problems, which or "no" answer was seldom sufficient to @vei,e then reflected in the organization communicate the intent of their actions. of the Division's staff and development Therefore, the National Advisory Council of Division policies. Examples are the requested that the Division staff dis- consideration given to continuing ecluca- Cuss with each applicant the action that tioii @s a major function of the Regional was taken and the reasons for that Medical Progi@,tms and the proposed action. It was felt that this interchange lai@ge-scale use of systems analysis tech- and discussion between the applicant DiqLies in the planning of specific regional group and the staff of the Division would rneclictil programs. As a result, the guide- contribute to a better understanding on lines document (7) issued by the Divi- both sides of the nature of the proposal. sioii on July I was based not onh- on the On many applications the National Ad- intent of the Congress and the judgment visory Council required that additional of the National Advisory Council and information be obtained from the appli- other advisors but also on experience cant before the application could be A Natio'n Sta@-ts (i P@-og?-ai??,,.Ilai-ston aii(I l'o?-(Iy 23 recommended for approval and a grant pited in the development of applications. awarded. When the additional infoi-mi- Actually, many have now given in their tion requested would not affect the basic regions the same type of talks staff mem- soundness of the proposal, the Council bei,,, were giving a few short months recommended approval, conditional upon ago. receipt by the Division of clarifying in- formation. If the information to be pro- PLANNING-GRANT APPLICATIONS vided wis more substantial, the Council One of the most productive Sources of deferred action on the application until information it this relatively early stage it Could consider the additional informa- of the program has been the grant ippli- tion supplied by the applicant. On other cations themselves. They provide pre- applications the Council did not feel that liminary insights into the types of ac- it could recommend approval of the @ip- tivities to be carried out on behalf of the PliCatiOn until substantial revisions had Regional Medical Programs as well as been made in the proposal. In recommend- a rough gauge of the extent to which "re- ing revisions, the Council emphasized the gional cooperative arrangements" among fact that it expected to see the revised medical schools, research institutions, hos- application at its next review meeting pitals, ind other health agencies and in- and that in negotiating these revisions, stitlitions have developed to date. the staff of the Division would not re- Foi-ty-thi,ee applications have been i-ee- qtiii@e that applications conform to aommended for approval or are currently standard pattern. The Council wanted tinder consideration. They cover regions these applications to retain their unique which contain about 80 per cent of the characteristics; but it felt a strong sense nation's population. Certain of the major of responsibility that the award of fed- metropolitan centers account for most of eral grant funds could only be recom- the remainder of the population. As mended after satisfactory evidence had might have been expected, MLIlti-medical- been presented that the proposal, what- center urban areas have had particularly, ever its proposed approach, Could reas on- difficult problems in developing the coop- abl,@, be expected to result in a plan for erative arrangements essential to the Re- a regional medical program that aceom- gional Medical Programs. However, pend- plished the objectives of the legislation. ing applications and discussions with This phase of the program saw the groups in New York, Philadelphia, Chi- appointment of a blue ribbon ad hoc com- cago, and Boston, for instance, have led mittee, which has now had 2 meetings to the conviction that effective ways will to focus on the Surgeon General's Report be found of bringing together the many to the President tnd Congress, due June health interests that exist in these urban 30, 1967. Also during this phase, ini- tial plans were made for a national meet- areas. ing to be held January 16-17, 1967 in The applications which have been re- response to a number of requests for ,i,7ed indicate that the initial planning such a meeting and also because of the of the Regional Medical Programs will need to get grass-roots opinion for the generally include 4 major types of activi- Report to Congress. ties: (a) organization and staffing; (b) At this time, a change in the types of studies to collect and analyze data on re- questions which medical groups asked Sources, problems, and needs; (c) devel- staff representatives became apparent, opmentofways to strengthen communica- primarily because increasingly large pro- tions and relationships tmong the health portions of audiences had ictively partici- institutions and agencies of the region; 24 Joiii-nal of medical Ed?icatio?i VOL. 42, JANUARY, 1967 .inci (d) preparation of proposals for health manpower, facilities, and special- operational pi@ojects. ized capabilities. Most of the applica- The approaches to the organization tions include proposed studies of the dis- and staffing of the programs widely. tribLitioii of Ind needs for medical and In a majority of cases (26), the formal nursing manpower. They ilso give high ,ipplic,Liit-the institution acting as the priority to problems associated with the programming headquarters" or ",agent" ,;hortages of laboratory tiici other allied foi- the i,egioii-has been a medical health personnel. school; this situation is I)ai-tictilai,l@ Most of the applications include plans likel@, when thei@e is only one medical for continuing education activities foi- school in the region find that iiistittitio@i tllied health personnel as well as for ph,@-- is p@ii-t of i state tiniversit@- sN,stem. sicians, dentists, and nurses. There htve been 4 applications from The strengthening of Communications medical societies, 2 from existing private and relationships among the existing and nonprofit agencies, and one from a state potential participants in the Regional agency. In 10 of the 43 i,egic@iis ne@@, Medicil Programs through i N-,Iriety of corporations have been established to be devices is planned. the applic@int. It has been suggested that In view of the critical importance of these new organizations may be of con- cooperative arrangements in the Pro- sicierable significance for the develop- grams, the following delineation of the ment of more effective cooperation among membership of the regional acIN7isor@, major, health resources. groups miy provide an initial measure of In addition to the applicants them- how effective the programs Ire likely to selves, well ovei@ 400 other cooperating be in engendering these arrangements: agencies or institutions are represented 1. Practicing physicians iiici medical in the applications, with hospitals, both center officiils each make LIP -,ibout 20 -affiliated and nonaffiliated, constituting per cent of these advisory groups. the largest group, Among the other key 2. Hospital administr@itors, i-epresenta- participants ire medical societies and tives of the voluntary health agencies, state or municipal health agencies. otbei- health professionals, and public It is clear from the applications that health officials each account for about 13 LltiliZ',ItiOll of existing health personnel is per cent of the total. planned; experienced senior health ad- 3. "Public" members, including law- ministi-ators and educators being yers, industrialists, labor leaders, and Sought and found to fill major positions. housewives, account for the remaining 8 It is also evident that man@, of the per cent. grantees will be looking to others disci- 4. The state governors have been in- plines and to other Liniversity faculties volved, in one way oi, another, in about foi@ issistance. For example, there have one-half of the cases. been a number of proposals for the par- ticip,,ttion of such individuals as sociol- 5. The state health officer or a member ogists, economists, and communication of the state board of health from the specialists. In addition, applicants will staff of related health departments is a seel@ advice and assistance in areas such member of the regional idvisorN, group ,is computer technology and operations in almost every case. research on a contractual basis, either 6. Staff members of area-wide hospital from universities or from private firms. pl@inning agencies are members of about The surveys which ire most commonly one-half of the groups. In all other mentioned in the applications are con- cases a representative of the appropriate cei@ned with the collection of data on hospital association is named. A Natio,@t Sta@-ts a Ila?-Stoo a@l(I lol@(IY 25 ge taer FIGURE 5 7. The groups have representation from negotiations with applicants represent heart associations and cancer societies. beginnings in the development of these OPERATIONAL GRANTS relationships. The creation of a branch for consultation and assistance under the The purpose of the planning grants is direction of Dr. Margaret Sloin resulted to develop operational programs (Figure from a recognition of this need. Further, 5). IA'hile continued planning is a erli- applicants are being advised to make cial part of the programs, it is antici- free use of supplemental applications so pated that onlv a few new planning that their programs can more easib, be grants will be submitted and that in- developed by incremental steps. creasingly the focus will be on the need 2. It is necessary to develop flexible but for supplemental support for planning specific involvement of other federal and and for the initiation of operational com- nonfedei,al sources of support, including ponents. A number of applications for their review and approval processes. It operational grants have been submitted is recognized that just as the program or ire in preparation. calls for an integrating and synthesizing The Division has been deeplv involved 'ivity on the regional level, the Divi- in the development and clarification of acT the review and approval processes which sion has a synthesizing and integrating will be required for these applications. responsibility to the grantees. In some As a result of this Study, it has become instances it is clear that specific proce- apparent that this process must estab- dtires Must await the opportunity to lish 3 new types of relationships: @vork with concrete examples. 1. There must be a continuing and spe- 3. The review and approval process cific relationship between the Division developed on the national level must be staff, the review committee (now ap- related to the review and approval mech- pointed on a permanent basis), the Na- anisms which exist in the various i-e- tional Advisory Council, and the grantees. gions. Basic to the goal of establishing The frequent meetings of both the review the decision-makiiig mechanisms on the committees and the National Advisor@, local level is the assumption that differ- Council as well as the extensive staff ent priorities exist in different parts of 26 o.f Ileclical-Editcatio@t N'OL. 42, JANUARY, 19C)7 the coLiiiti@%. However, neither the Na- law anticipates the use of i-eseii-ch iiid ex- tioiiai Ad\-i2,oi-N- Council nor the Public I)ei-imeiits, and the initiation of activities Health Service can delegate its ftinda- which, when evaluated, can be modified mental responsibility and accountability as indicated. (c) Criteria for specific for the wise expenditure of federal funds. projects must be developed. The scope The mechanisms of the review process and flexibility of this legislation is such can be simply described. The regular that there is no difficulty in listing great process -will be a familiar one: gi-ants numbers of meritorious and needed proj- will be received and reviewed b3, the ini- ects which could be supported. Suggested ti,tl review committee; additional infor- criteria for setting priorities are as m,itic)n will be gained by site visits, follows: @vhich in niiii@- instances will be con- 1. The degree to which the project CILIcted by members of both the committee @vould assist in the wise utilization of and the Council: and then there ivill be manpower. As one ipplicant noted, the ,i i,econimeiidi'lon by the Council and the regional group is not interested in tying final action involving administrative de- up resources with fine projects for which cisions 1)@@ the Public Health Service. the necessary manpower is not readily In addition to this regular process the tvailable. staff will clistoni-tailor the review proc- 2. The degree to which proposed proj- ess to meet the particular needs of indi- ects involve multiple institutions and vidtial grants. In many instances this types of institutions and, therefore, will mean obtaining additional informa- would leid to more effective development tion on scientific merit or other aspects of cooperative arrangements, particularly 0 from the existing expertise in other in- in the initial steps. statutes or bureaus of the Public Health 3. The degree to which the proposed Service or other agencies in the govern- project relates science to service. ment to instii@e that acceptable standards 4. The degree to which the project will are maintained; and it will also involve contribute to continuing education and exploring the potentialities for support. training for physicians and other health The development of a (lecision-making personnel. process in each region is a prerogative 5. The degree to which latent talent or of thit region, and much time and effort unique regional resources might be uti- have ali,eaci@. been devoted to this area by lized more effectively. the Division and bv applicants through- 6. The degree to which the proposed out the nation. Some factors relevant project represents a critical area which, to evolving effective processes seem to be if supported, will beneficially affect a either easil@@ identifiable or particularly larger program. A regional medical pro- pertinent: ((t') The initiation of the first gram offers the opportunity to bridge steps in the operational program along gaps and to support new and innovative with continued planning should represent ipproaches which of themselves ma@, be movements to@vard the fuller development only a smtll portion of much more ex- of the regional program. (1)) On the one tensive activities. hand there will be a need to determine Fintlly, of course, the fact that this is the appropriate balance bet@veen depend- @t broadl3, categorical program in the ence on retrospective data, opinions, and area of heart disease, cancer, and stroke the experiences of others, and on the must be taken into consideration. other hand there will be the need to ini- The Division has been convinced thit tiate tctivities ivhich will themselves pro- as the programs proceed into the opera- vide the basis for future decisions. The tional phase, grantees will be well ad- A Natio@z Sta@,ts a Pi-ogi-a@@i, Ila@-sto)z a@id l'o?-(Iit 27 vised to select those activities which they that did not previously seem connected, can see clearly-, rather than depending on stretches a more ' enibi-@icifig framework, the development of some master plan in moves to@%,ai-(l lai,gei,, more inclusive under- value tDd unexplored areas. Therefore, standing. it is ,inticipated that manv will choose The beneficial changes which have been those initial steps which will contribute effecteci by the program twenty years to further refinement of the basic deci- from now will depend upon the extent sion-m,tkiiig processes which the@r have to ,@-hich it has stimulated creative per- established. foi@niiiices @vhich have contributed to coii- As those who are involved in the, pro- staiit improvement in the quality of gram move along this not uncomplicated medical service in the nation. path, it is worth remembering the way t REFERENCES dean once described the problem of the 1. BOLT, R. A Alan for All Seaso)is. vice president foi, health affairs in bring- London: Heineniann, 1961. ing togethei, groups with nonidentical COC(,ESIIALL, L. T. Plait)ii)ig for Me(li- goals. After speaking to the value of Ccil Ili-og)-ess Titi-o@tgli E(li@catioit. Evan- such activities, he n, ised a word of ctti- stc,,n, Illinois: Association of American tioii in the following way: -)Iedic,--il Colleges, April, 1965. What do they do? In short they try to 3. DIIYER, B. V. I,ifetii-ne Learning for hitch niules and cows to the same plow and Ph@.sicians: Principles, Practices and then drive the rig. What do they try to do? Proposals. .1. @lc(l. E(litc., 37: June, They try to assemble the team, woi,l@ to- Part 2, 1962. gether, combine assets, etc. To continue to 4. SHEPS, C. G., WOLF, G. A., JR., and enlarge upon our metaphor of hitching t@vo JACOBSEN, C.(Eds.).",Aledical Education thou.-,and-pound beasts together without rec- and Medical Care: Interactions and ognizing that the objective of one is to pull Prospects." Report of the Eighth Teach- and the other to be milked could end with in.- Institute of the Association of one going Lini-nilked and the other sitting American Medical Colleges. J. Ifed. down, Both have highly and equally coni- Edite., 36: December, Part 2, 1961. rnendable objectives, but working together 5. WOLF, G. W., JR., and DARLEY, W. as a team neutralizes the effectiveness of @'-Iledical"Education and Practice: Rela- each. tionships and Responsibilities in a The goal of the Regional Medical Pro- Changing Society." Report of the Tenth grams, like that of the vice president for Teachiy Institute of the Association health affairs, is to make the activities of American Medical Colleges. J. Med. of its members more effective in their E(I?tc., 40: January, Part 2, 1965. pursuit of their own goals. 6. President's Commission on Heart Dis- ease, Cancer ind Stroke. Report to the CONCLUSION President. A National Pi-og)-ai@t to Con- The success of the Regional Medical qit(,i- He(t?-t Disease,, Cancer and St?-oke. (@'olunie I.) Washington, D.C.: U.S. Programs requires that medical schools Government Printing Office, 1964. as well as all other participants share 7. G@ti(lelii@cs-Regio)z(tl Ale(licctl P,@-ogi-aipts. authority as well as responsibility. Gard- U.S. Department of Health, Education, ner (8) made the following statement in -,in(i Welfare, Public Health Service, hi,-, monograph, Self-7-eneival: The Indi- -@ational Institutes of Health, Division vid,ual and the Innovative Society: of Regional Medical Programs, July, Every great creative performance since 1966. the initial one has been in some measure a 8. GARDNER, J. W. Self-Re7teioal: The bringing of order out of chaos. It brings I?idiz.!idit(tl and the Innovative Society. about a new relatedness, connects things @ew York: Harper & Row, 1965, P. 39.