fill 1011111911 411@illl#l A Nation Starts a Prooram: 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 Program: Regional Medical Programs, 1965-1966* ROBERT Q. MARSTON, M.D.t AND KARL YORDY$ 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- what 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 For All Seasons. a 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 was 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 gronvth of medical research in this country during the past twenty years and *Presented at the 77th Annual Meeting the resulting advances in knowledge form of the Association of American Medical Col- the scientific base which is the beginning leges, San Francisco, October 22, 1966. f Associate Director; Director, Division of point for the program. Following are Regional Medical Programs. some of the factors which contributed *Assistant Director, Division of Regional Medical Programs. to the development of the legislation: 17 18 Journal of Medical Education VOL. 42, JANUARY, 1967 the forty-year discussion on regionaliza- Adiiiiiiistration's proposal. Many changes tion of medical services; the evolution were made in the original bill, primarily of the medical schools with the accon-i- as the result of hearings before the panying development of great medical House Interstate and Foreign Commerce centers; and underlying social factors Committee, chaired by Congressman 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 a determining 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 Intefactions 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 Affaiys, 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 Service 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, Di,. Stuart Sessoms, Deputy A Nation Starts a Progra,)it,, Marston and Yoi-dy i9 V- 6luepy",t? 'W.fw FIGURE 1 Director of NIH, was the focal point for fact 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 -,vill 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 on a regional the major responsibilities until February, rather than a national basis. The law 1966. represents a vote of confidence in the On October 6, 1965 there were no ex- Nvillingness of the regions to accept the perts on regional medical programs, no basic responsibility for devising the pro- master blueprints of how a regional grams to accomplish the purposes of the medical program would work. During law. The flexibility of the legislative this period, questions from prospective provisions highlights this transference of applicants and other interested parties responsibility to the regional level. A attempted to probe the flexibility of the clearly defined national medical program legislation in order to determine whether would have led to fewer questions. How- or not there was a specific blueprint for ever, even if workable, it would have implementation (Figure 1). How do meant less opportunity for creativity, you define a region? How many regions fewer opportunities to develop diverse will there be? Who can appl@-? What answers appropriate to diverse problems, will be the responsibilities of the appli- and less assumption of responsibility at cant? What is the exact nature and role the local level. of the regional advisory group? Tell me After one year of experience, there is in specific terms what a regional medical considerable evidence justifying this program will do and how it will function. law's almost naive trust and faith in the The answers, or some would say lack of ability of formerly divergent medical answers, to these questions reflected the interests to cooperate on a voluntary 20 journal of Medical Edii(-atio7i VOL. 42, JANIIARY, 11)(i7 may AME -----O FI(@IJRF, 2 )asis in accomplishing impi)rt@ii-it health of the edic@il school faculty and @tdrniii- objectives. isti-ators feared that their n-iedic@it centers were being asked to assume the total i-e- I)EVEI,OPMENT spt)nsibilitv in their regions foi- medical REASStiRANCE ANL) I)EFINITION care in the fields of heart disease, eancei-, Experience with the program divide,; and ,,trol@e. Noniffiliated hospitals feared n,Lttirallv into several phases (Figure 2). that they would have no role to play in The first spans the period from the sign- the pi,o@Ti,,tm (Figure ',I). inl,y of the legislation in Octobei- until Ilowever, along with the fears and aiix- about February, 1966. During this time, ieties, thei@e was @t ground swell of iii- i-ntich of the effort of Di-. Sessonl,;, ti-ie tei-est in the Ilegional Medical 111-ogr@ims authors, tnd others was spent ii-i I)i-o- expressed by -,I very wide v@ti-iety of vi(iing i,e,@,stir@ti-tee to various medical health organizations. iiistitLiti(@n-,. @nd iii- i,yi-otip,; concerning the nature of this dividiitls. Meetings were held in i-elrioiis pi-ogi-,iyr. as (refined in the F(,i- some thi@o"ghotit the cotinti-v to discuss iml)le- still feared that the program would be meiitition of the program. The staff at ,i 1'e(iei@@tl medical system which would (ii- Nill W@LI; contacted bv litei-@tllv htiti(ii-e(ts vei-t patients to distant medical centers of i-ne(lic@il orgiiiiztti,,@ns z@ii(I ex- with no c(;iieei-n foi- the role of the pressing interest and support. The Re- I)i-@t(,ticitig phvsi,,iiii (ii- hospital. Some Medical Ili-ogi-,tnis @il)l)e-,ti-e(i as @t ,,I N'otio@i Stat-t.,; (i P@'oti)-a@@i Mat-stoii a@i,(l Yoi,dlf 21 ..... . ..... . ..... .. .. .. .. Uri . .......... FIGITRF :1 topic for discussion in the programs of Council as required by the law. -Nllembers @i iitiml)et- of majol- medic I professional of the Council and the ad /@oe consultants organizations, became incre@isinglv articulate in inter- In Deceml)ei@ the Division of Regional pi-eting tnd defining the program in Medical Ili-ogi@ams was established and its ;peeches, in their' own professional or- National Advisory Council held its first ganizations, and in the development of meeting. individual regional plans. ]?F@('.ITI,ATIONS, (.IJII)FLINES, AND OTJTI,INES ITECEIPT AND REVIEW OF APPLICATIONS The second phase of the program ex- The period from April through June teiide(i from Februai-v until April. Spe- constituted the third program phase. ci,il groups of consultants with expertise During this time, the emphasis changed ill Such relevant fields as continuing edL]- from reassurance, definition, and prep- cation, community health planning, and zii-@ition to the receipt of applications for hospital idiiinisti-atioii were called to- planning grants and the review of those l,rethei- to advise the Division on the I plicitio]IS (Figure 4). No deadlines implementation of the progi, m. Regul@t- for the receipt of ipplicationg were pub- tions were drafte and proposed. Pre- licized. Instead, it was the Division',,; lin-iin.ii-y guidelines for applications and the tpplication forms themselves were Stated intention to hold frequent review developed and widely distributed. Anothei- meetings so that applications could be meeting of the National Advisory Coiin- considered without Lindtie dell'v and with- cil was held tiid t process foi, the review out the development of @t crash program. of applications was developed, consisting Therefore, the National Advisol-v Cotill- of @i preliminary review by stiff and bv (,ii i-net to consider applications in April. @l 91-OLIP of ad lio(- consultants prior to lLine, tnd August, preceded each time the review I)v the Nationtl Advisoi-v I)N- t meeting of an ad lio(, inititi i-evie@v 22 Jo@urnal of Medical Education VOL. 42, JANUARY, 1967 w we him FIGURE 4 group representing a variety of back- in the actual review of planning-grant grounds in health affairs. These groups applications. were able to consider applications with varying approaches to the planning of a NEGOTIATIONS AND ANTICIPATION 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. Dur- October, concern was with (a) contin- ing this phase, 39 planning-grant appli- ued review of applications for planning cations were received-overwhelming evi- grants; (b) a rapid buildup of activities dence of the willingness of regional in continuing education; (c) preparation groups throughout the country to accept 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 was able to identify certain view groups found that a straight "yes" areas of emphasis and problems, which or "no" answer was seldom sufficient to were 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 educa- cuss with each applicant the action that tion as a major function of the Regional was taken and the reasons for that Medical Programs and the proposed action. It was felt that this interchange large-scale use of systems analysis tech- and discussion between the applicant niques in the planning of specific regional group and the staff of the Division would medical 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. sion on July 1 was based not only 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 Nation Starts a Program/Marston and Yoi-dy 23 recommended for approval and a grant pated in the development of applications. awarded. When the additional informa- 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 bers 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 was more substantial, the Council One of the most productive sources of deferred action on the application until information at this relatively early stage it could consider the additional informa- of the program has been the grant appli- 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 ap- 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, and other health agencies and in- and that in negotiating these revisions, stitutions have developed to date. the @ff of the Division would not re- Foity-three applications have been rec- quire. that applications conform to a ommended for approval or are currently standard pattern. The Council wanted under 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, multi-medical- been presented that the proposal, what- -enter urban areas have had particularly ever its proposed approach, could reason- difficult problems in developing the coop- ably be expected to result in a plan for erative arrangements essential to the Re- a regional medical program that accom- 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 and Congress, due June health interests that exist in these urban 30, 1967. Also during this phase, ini- areas. tial plans were made for a national meet- The applications which have been re- ing to be held January 16-17, 1967 in ceived indicate that the initial planning response to a number of requests for of the Regional Medical Programs will such a meeting and also because of the 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, opmentof ways to strengthen communica- primarily because increasingly large pro- tions and relationships among the health portions of audiences had actively partici- institutions and agencies of the region; VOL. 42, JANUARY, 1967 24 journal of Medical Education special- and (d) preparation of proposals for health manpower facilities, and operational projects. ized capabilities. Most of the applica- The approaches to the organization tions include proposed studies of the dis- and staffing of the programs vary widely. tribution of and needs for medical and In a majority of cases (26), the formal nursing manpower. They also give high applicant-the institution acting as the priority to problems associated with the "programming headquarters" or "agent" shortages of laboratory and other allied for the region-has been a medical health personnel. school; this situation is particularly Most of the applications include plans likely when there is only one medical for continuing education activities for school in the region and that institution allied health personnel as well as for phy- is part of a state university system. sicians, dentists, and nurses. There have 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 regions new Medical Programs through a variety of corporations have been established to be devices is planned. the applicant. It has been suggested that In view of the critical importance of these new organizations may be of con- cooperative arrangements in the pro- siderable significance for the develop- grams, the following delineation of the ment of @ore effective cooperation among membership of the regional advisory major health resources. groups may provide an initial measure of in addition to the applicants them- how effective the programs are likely to selves, well over 400 other cooperating be in engendering these arrangements: agencies or institutions are represented 1. Practicing physicians and medical in the applications, with hospitals, both center officials each make up about 20 affiliated and nonaffiliated, constituting per cent of these advisory groups. the largest group. Among the other key 2. Hospital administrators, representa- participants are medical societies and tives of the voluntary health agencies, state or municipal health agencies. It is clear from the applications that other health professionals, and public utilization of existing health personnel is health officials each account for about 13 planned; experienced senior health ad- per cent of the total. ministrators and educators are being 3. "Public" members, including law- sought and found to fill major positions yers, industrialists, labor leaders, and 'housewives, account for the remaining 8 It is also evident that many of the per cent. grantees will be looking to other disci- 4. The state governors have been in- plines and to other university faculties volved, in one way or another, in about for assistance. For example, there have one-half of the cases. been a number of proposals for the par- ticipation of such individuals as sociol- 5. The state health officer or a member ogists, economists, and communication of the state board of health f rom the specialists. In addition, applicants will staff of related health departments is a seek advice and assistance in areas such member of the regional advisory group as 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. planning agencies are members of about The surveys which are most commonly one-half of the groups. In all other mentioned in the applications are con- cases a representative of the appropriate cerned with the collection of data on hospital association is named. A Nation Stai,ts a Pi-ogramIMag-ston and Yordy 25 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 Sloan resulted to develop operational programs (Figure from a recognition of this need. Further, 5). While continued planning is a cru- applicants are being advised to make cial part of the programs, it is antici- free use of supplemental applications so pated that only a few new planning that their programs can more easily 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- nonfederal 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 are in preparation. calls for an integrating and synthesizing The Division has been deeply involved activity on the regional level, the Divi- in the development and clarification of sion has a synthesizing and integrating the review and approval processes which responsibility to the grantees. In some will be required for these applications. instances it is clear that specific proce- As a result of this study, it has become dures must await the opportunity to apparent that this process must estab- lish 3 new types of relationships: work 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 re- tional Advisory Council, and the grantees. gions. Basic to the goal of establishing The frequent meetings of both the review the decision-making mechanisms on the committees and the National Advisory local level is the assumption that differ- Council as well as the extensive staff ent priorities exist in different parts of 26 Journal of Medical Education VOL. 42, JANUARY, 1967 the country. However, neither the Na- law anticipates the use of research and ex- tional Advisory Council nor the Public periments, and the initiation of activities Health Service can delegate its funda- 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: grants numbers of meritorious and needed proj- will be received and reviewed by the ini- ects which could be supported. Suggested tial review committee; additional infor- criteria for 'setting priorities are as mation will be gained by site visits, follows: which in many instances will be con- 1. The degree to which the project ducted by members of both the committee would assist in the wise utilization of and the Council; and then there will be manpower. As one applicant noted, the a recommendation by the Council and the regional group is not interests in tying final action involving administrative de- up resources with fine projects for which cisions by the Public Health Service. the necessary manpower is not readily In addition to this regular process the available. staff will custom-tailor the review proc- 2. The degree to which proposed proj- ess tQ meet the particular needs of indi- ects involve multiple institutions and vidual grants. In many instances this types of institutions and, therefore, will mean obtaining additional informa- would lead to more effective development tion on scientific merit or other aspects of cooperative arrangements, particularly from the existing expertise in other in- in the initial steps. stitutes 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 insure 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 decision-making personnel. process in each region is a prerogative 5. The degree to which latent talent or of that region, and much time and effort unique regional resources might be uti- have already been devoted to this area by lized more effectively. the Division and by 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 easily identifiable or particularly larger program. A regional medical pro- pertinent: (a) The initiation of the first gram offers the opportunity to bridge steps in the operational program along gaps and to support new and innovative 'th continued planning should represent approaches which of themselves may be wi movements toward the fuller development only a small portion of much more ex- of the regional program. (b) On the one tensive activities. hand there will be a need to determine Finally, of course, the fact that this is the appropriate balance between depend- a broadly 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 that tiate activities which 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 Nation Starts a Program/Marston and Yordy 27 vised to select those activities which they that did not previously seem connected, can see clearly, rather than depending on sketches a more embracing framework, the development of some master plan in moves toward larger, more inclusive under- vague and unexplored areas. Therefore, standing. it is anticipated that many will choose The beneficial changes which have been those initial steps which will contribute effected by the program twenty years to further refinement of the basic deci- from now will depend upon the extent sion-making processes which they have to which it has stimulated creative per- established. formances which have contributed to con- As those who are involved in the pro- stant improvement in the quality of gram move along this not uncomplicated medical service in the nation. path, it is worth remembering the way a REFERENCES dean once described the problem of the 1. BOLT, R. A Man for All Seasons. vice president for health affairs in bring- London: Heinemann, 1961. ing together groups with nonidentical 2. COGGESHALL, L . T. Planning for Medi goals. After speaking to the value of Cal Progress Through Education. Evan- such activities, he raised a word of cau- ston, Illinois: Association 'of American tion in the following way- Medical Colleges, April, 1965. What do they do? In short they try to 3. DRYER, B. V. Lifetime Learning for hitch.' mules and cows to the same plow and Physicians: Principles, Practices and then drive the rig. What do they try to do? Proposals. J. Med. Educ., 37: June, They try to assemble the team, work 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 two JACOBSEN, C.(Eds.)."Medical Education thousand-pound beasts together without rec- and Medical Care: Interactions and ognizing that the objective of one is to pull Prospects." Reportofthe Eighth Teach- and the other to be milked could end with ing Institute of the Association of one going unmilked and the other sitting American Medical Colleges. J. Med. down. Both have highly and equally com- Educ., 36: December, Part 2, 1961. mendable objectives, but working together 5. WOLF, G. W., JR., and DARLFY, W. as a team neutralizes the effectiveness of "Medical Education and Practice: Rela- each. ti@o'nships 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 Teaching Institute of the Association health affairs, is to make the activities of American Medical Colleges. J. Med. of its members more effective in their Editc., 40: January, Part 2, 1965. pursuit of their own goals. 6. President's Commission on Heart Dis- ease, Cancer and Stroke. Report to the CONCLUSION President. A National Program to Coit- q?ier Heart Disease, Cancer and Stroke. The success of the Regional Medical (Volume I.) Washington, D.C.: U.S. Programs requires that medical schools Government Printing Office, 1964. as well as all other participants share 7. Gitideliiies-Regio?zal Medical Programs. authority as well as responsibility. Gard- U.S. Department of Health, Education, ner (8) made the following Statement in and Welfare, Public Health Service, his monograph, Self-renewal: The Indi- National Institutes of Health, Division vidual 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-Renewal: The bringing of order out of chaos. It brings Individual and the Innovative Society. about a new relatedness, connects things New York: Harper & Row, 1965, P. 39. I-C