D E P A R T M E N T 0 F H E A L T H, E D U C A T I 0 N A N D W B L F A R E National Institutes of Health Division of Regional Medica I Programs National Advisory Council on Regional Medical Programs Minutes of Meeting August 28-29, 1967 ..Iiational Institutes of Health Conference Room 4 tuilding 31 DEPARTMENT OF !IEALTI-1, El:,UC@,.T-J.ON AND WELFARE rul:3LIC HEZ@LTli SERVICE NATIONAL ADVISORY CON.'CIL 01@ REGIONAL MEDICAL PROGRAMS Minutes of Nintli Meeting I/ 2/ August 28-29., 1967 The National Advisory Council on Regional Medical Programs convened for its ninth meeting at 8:35 a.m., on Monday, August 28, 1967o in Conference Room 4, Building 31, National Institutes of Health# Bethesda, Maryland. Dr. Robert Q. Marston, Associate Director, NIH, and Director, Division of Regional Medical Programs, presided for Dr. William H. Stewart, Surgeon General, who was unable to be present at the meeting. The Council members present were: Dr. Leonidas H. Berry Dr. Clark H. Millikan Dr, Michael E. DeBakey Dr. George E. Moore Dr. Bruce W. Everist Dr. Edmund D. Pellegrino Dr. John R. Hogness Dr. Maclt 1. Shanholtz Dr. James T. Howell The Council members absent were: Mr. Charles J. Hitch Dr. Alfred M. Popma Dr. Cornelius H. Traeger Public Health Service members attending some of the sessions included: Dr4 Gilbert R. Barnhart, Bureau of Health Services Dr. Ronald G. Basalyga, National Center for Chronic Disease Control Bureau of Disease Prevention and Environmental Control Dr. Lionel Bernstein, Veterans Administration Dr. Burnet M. Davis, National Library of Medicine Dr. Gerald Escovitz, Bureau of Health 'manpower Dr. Frank Freeman, Bureau of Health Services Dr. M. H. Gordon, Office of the Surgeon General Dr. E. P. Offutt, Office of the Surgeon General Dr. James A.,Shannon., Director, NIH Proceedings of meetings are restricted unless cleared by the Office of the Surgeon General. The restriction relates to all material submitted for discussion at the meetings, the agenda for the meetings the supplemental material, and all other official documents. For the record, it is noted that members absent themselves from the meeting when the Courc-'-.l is discussing applications: (a)-from their r i., only when the application is under individual discussion. -2- Liaison irc-mL@ers attending Dr. Murray M. Copeland, NCI Council Dr* Edward W. Dempsey, NICT@,S Council Dr. John B. Hick@iia, Nill Council (absent) Dr. A. Earl Walker, NINDB Council Others Attending- Dr. Philip Anderson, NIH-OD Dr. J. H. U. Br@,,7n, NIH-NIGTI.S Dr. D. C. Murphy, NIII-DRG/GA Dr. R. L. Ringler, NIH-Nill Dr. Mathilde Soloway, NIH-NIIIDB Miss Pauline Stephan, NIH-NCI Dr. Richard Stephenson., NIH-OD DRMP Staff- Mr. Stephan J. Acke an rm $ Chief, Planning & Evaluation Branch Yiro James Beattie, Chief, Grants Management Branch Dr. Robert 11. Bucher, Office of the Director Mr. E. M. Friedlander, Asst. to the Director for Communications and Public Information Mr. Charles Hilsenrothp E%ecutive Officer Mrs- Eva M. Handal., Committee Management Officer Mr. James Lawrence, Financial Management Officer.' Mr. Maurice Odoroffp Assistant to the Director for Systems and Statistics Mrs. Martha Phillipst Chief, Grants Review Branch Mr. Robert L. Quave, Administrative Officer Dr. A. M. Schmidt, chief, Continuing Education & Training Branch Dr. Margaret H. Sloan, Chief, Program Development & Assistance Branch Mr. Karl D. Yordys Assistant Director Miss Rhoda Abrams,'Planning & Evaluation Branch Mr.'Ira Alpert$ Program Development & Assistance Branch Miss Sheila Beach, Committee Management Office Mrs. Marilyn Buell, Grants Review Branch Mr. Peter Clepper, Grant-s Review Branch Dr. D. J. Corollo, Program Development & Assistance Branch Mrs. Elizabeth Fuller, Office of the Director Mrs. lq. V. Geisbertf Resource Support Section Dr. David W. Golde, Continuing Education Branch Dr. J. H. Hall, Office of the Director Mr. Lauren Hellickson, Resource Support Section Mr. Arthur Hiatt, Planning & Evaluation Branch Dr. Frank Husted,-Continuing Education Branch Mr. Robert Jones, Gra nts Review Branch Mr. J. S. Kakalil-1, P'.aniiing & PNralti,)ti..on Branch Kooatz, Mr. Ro G. Lindee, Office of the Director -3- Miss Elsa Nelson, Continuing TOucation Branch Dr. R. F. Manegold, Office of the Director Mrs. Erii.ly 14acAfee, Continuing Education Branch Dr. Hurl)ert Mathewson, Continuing Education Branch Mrs. Patty McDonald, Grants Review Branch Dr. Ian A. Mitchell, Proaram Development & Assistance Branch Miss 11. L. Morrill, Continuing Education Branch Dr. R. M. O'Bryan, Program Development & Assistance Branch Mrs. Suzanne Pau.1, Planning & Evaluation Branch Miss Leah -@nick, Systems & Statistics Branch Mrs. Rebecca Sadin, Continuing Education Branch Mrs. Jessie F. Salazar, Grants Review Branch Dr. J. Schneider, Continuing Education Branch Mr. J. T. Simeone, Grants Ilanagement Branch Mrs. Judy Silsbee, Continuing Education Branch Mr. A. Strachocki, Program Development & Assistance Branch Miss Charlotte Turner, Continuing Education Branch Mr. Stephan Walsh, Planning & Evaluation Branch 1. CALL TO ORDER AND OPENING REYIARKS Doctor Marston called the meeting to order at 8:35 a.m. II. ANNOUNCEIENTS Doctor Marston made general announcements about the Service Desk and called attention to the statements on, "Conflict of Interest," and "Confidentiality of Ileetings." He announced that there would be an Executive meeting of the Council at noon on Monday when the Council would be joined by Doctor Shannon, Director, NIH, and the liaison members. Doctor Marston then discussed the reorganization of the Division of Regional Medical Programs, and introduced additional staff recently recruited to the'Division, including Dr. Richard F. Manegold, Associate Director for Program Development and Research; Dr. Alexander M. Schmidt, Chief, Continuing Education and Training Branch; Dr. Richard B. Stepit@nson, Associate Director for Operations. Doctor Marston also introduced Drs. Robert M. Bucher and Jack H. Hall who have joined the Division to work-in the areas of operations research and systems analysis; and Mr. Robert G.Lindee who will spend several months with the staff focusing on the revision of the "Guidelines." Dr. Lionel M. Bernstein, Director of Research Service, Veterans'Administration, was introduced as the new Veterans Administration liaison representative. Dr. George 9. Moore was congratulated on his appointment as Director of Research for the New York State Health Department. Doctor Mdore's office remains at Roswell Park. The Surg@on General'-- P-@,ort to ti-,,- Cop-r-,res,,i T,7as 111. CONSIDER-,ATION OF FUTURE The Council reaffirmed the following-dates for future meetings: November 20-21, 1967 8:30 a.m. NOTE LOCA-ilOlq: Conference Room "C" Stone House February 26-27, 1968 May 27-28, 1968 August'26-27, 1968 November 25-26, 1968 All of the above will be held in Conference Ro beginning at 8:30 a.m. IV. CONSIDEIUTION OF MINUTES OF MAY 1967 MEETING The Council unanimously recommended approval of the Minutes of the May 22-23, 1967, meeting as written. V. COI-IFiEi\rfS FROM LIAISON ATIZERS None of the liaison members had comments to make. VI. REPORT ON APPLICATIONS WHICH WERE COI%TSIDERED AT THE MAY COUNCIL 14EETING APPLICATION NO. REGION .AWARDED 3 S03 RII 00015-OIS1 Intermountain 3 S02 RM 00019-OlS2 California 1 S03 Pd4 00037-01 Wisconsin 1 S02 @l 00042-OIR New Jersey I S02 RM 00057-OIR Mississippi 1 S02 RM 00059-01 Susquenhanna Valley I S02 114 00060-01 North Da ota I S02 101 00061-01, Illinois RETURN FOR REVISION 3 S02 PM 00006-02SI North Carolina l.SO2 Pkl 00062-01 Massachusetts New Hampshire and Rhode Island DEFERRED 3 S02 Pd@i 00003-OIS2 Northern New England 1 S03 RM 00003-01 Northern New England DISAPPROVED -5o VII. PROPOSED COtq,',CIL DELEC@KTION TO DRMP STAFF FOR AD14INISTLRATIVE CIIJ@NGES IN ON-COING GIUNTS DeleRati.on for Administrative ChaLi -, in Amoti ts of On-G,,l rants After discussion the Council unanimously approved the following delegations of authority: "It is proposed that the Council delegate authority to the Division staff to approve increases in amounts for active grants for the following purposes: 1. Iiistitution-uide salary increases, social security and other mandatory employer contribution adjustments. 2. Extension of grant period with additional funds, at a rate not to exceed the current rate of support, for a period not to exceed six months--in order to prevent hardship to personnel or loss of investment already made under the grant, to provide additional time for preparation, review, and approval of a renewal application, or to provide for orderly termination of t e grant. Such extension would be reported to the Council. 3. Increases of an administrative nature which do not represent an expansion of the program or change in any significant manner the nature of the program, such as increased costs for equipment, personnel, travel, rental, and alterations and renovations. Sue increases would be limited to 15 per cent for any budget category and all increases would be reported to the Council. 4. Rebudgeting of allowable indirect costs to direct costs expenditures with an-equiva,lent reduction in the indirect costs allowance (an increase in direct costs only, not in total grant amount). In requesting such increases, grantees would have to include in their justification reasons why the increased costs could not be covered through rebudgeti.ng within the current grant. DeleRation for AdministrLLivq_4TIp;@@l of Minor Expansions in Activities U der A_p2r@v-@@er4t_L Re ional Medical Procrams Staff may approve reques4.-s for expansion of approved activities or initiation of activities ancillary to the Regional Medical Programs--up to 5 percent of the total direct costs awarded for the current budget period, but not greater than $50,000 (plus indirect costs). This annual limit would apply whether it is reached in one or more individual requests. each Cou-acj.'t acL-1011 approval of an operational grant application. Requests must be approved by the Regional -6- Advisory Group and should justify why the increased costs cannot be covered through rebudgeting within the current grant. VIII. PROGRESS REPOIIT ON CONTP@ACTS FOR TRAINING OF EDUCATION RESEARCH PERSONliEL . . . . . . . .Doctor Schmidt At the November Council meeting, it was agreed that it was necessary to document as precisely as possible the beneficial results of educational efforts of the Regional Medical Programs by producing data concerning improved levels of patient care, improved levels of knowledge of health workers, etc. Also, it has been necessary to insist that the regions produce data for themselves on their various educ'ational needs, goals, and methods for achieving the goals, results of pilot projects, etc. Without this information, successful regional programs cannot be designed. It has become evident that the person who can ask the proper questions, design training methods that will allow the answering of these questions at the end of the training effort, is in short supply. Doctor Husted of the Division staff, has had requests from regions for more than 11,000 man-days of consultation regarding methods concerning evaluation procedures. In addition, this past Janqary, when planning and operational proposals were examined, it was found that there were 95 unfilled Regional Medical Programst staff positions for medical educators. Also, 55 senior staff positions were identified for educational media people, these also being unfilled at that time. The consensus last November was that the need for these people was critical, and that it was not being met. A modest beginning had been made in this area when the contract was made to Dr. George Miller and his group at the.University of Illinois which provides for training of physicians as medical educators. This contract has been expanded to include training physicians to the level of a Master's degree in education. The University of Southern California will soon be involved with the training of physicians in educational techniques, as well as involving professional educators in medical education. Another contract is being negotiated with Ohio State which will bring educators into medical education. Beginning in September 1.967 the Medical College of Georgia, Michigan State) aiid Albany Medical College will have programs to which the Regional Medical Programs can turn for their.needec-I educational specialists. The various inputs into these programs deal with the bringing in of.both physicians and professional educators. Physicians will learn about education, and the professional educators.viill learn S r@_.,, Ti- c -7 - for more programs is evident. The Division has now committed $534,000 for contracts for these purposes, and expects this to be increased to about $750,000 during the next fiscal year. This stl,-a will support six excellent programs, well distributed, and producing a commodity which the Regional Medical Programs cannot do without. IX. SALARIES OF PROG@-M COORDIN-KTORS Doctor Marston reported that the Division is encountering problems concerning salaries of program coordinators, and are checking carefully on the salaries requesting niore than $35 3' 000. The Division has not issued specific guidelines on this, but have requested the Office of the Director, NIH, for advice. A ceiling on salaries has not been considered to be appropriate since,it might give the impression that all Program Coordinators should receive the same salary. The Division hopes that a policy can be reached on this matter in the near future. Xs CRITERIA FOR REGIONikL DA@A . . . . . . . . .Doctor Howell Doctor Howell read a statement on the quantitative evaluation of the effectiveness of regional medical programs. His presentation covered the following essential points: "*,,to document statements of progress quantitatively ... the Council must have available to it reliable data. To establish the proof that the effort did in fact close the gap...the council ... needs the support of hard data. We shall try to make it clear that. each region must be prepared to quantify and to evaluate its own efforts...." "Each region should know from the National Advisory Council, soon, that we require in the operation phase, quantitative evaluation of its effort. The intent of the law is to foster local initiative in developing programs that fit local needs. Hence the evaluation. process too must fit the regional "It seems mandatory, therefore, that each regional operational program have the capability of measuring its activity. At first this may be quantitative or,.I@ iii.form of counts and in the form of records kept of regional activities, but there must be the potential of furthering the measurement of qualitative factors which are difficult to quantify." "If acceptable as a preliminary objective, the Council, through the review mechanism, can require each region to avail itself of quantitation competence including systems analytical and operations research capability. It is upon competence in quantifying, especially Systems Analyses (SA.) rri Oper@,.tion-, in reliability of regional. data and, in turn, for proper evaluation... SA and OR people have the knowledge and the techniques for studying effectiveness and the means of developin- the requirements for records and data. There are other benefits which will accrue fiom SA and OR professionals, not the least of which will be a clear definition of the purposes and objectives of the regional medical program, tliere are two main objectives of-, the RIIP which may be termed outputs of the local system: 1. To improve the gamut of health manpower. This may be measured by: a. training programs conducted or participated in; b. practical testing to ascertain that the skills taught can indeed be performed; and c. records of the utilization of the developed manpower. 2. To afford the physician the latest advances in diagnosis and treatment in the care of his patients. This may be measured in many ways: a. the number of patients managed in the program; b. the number of technical procedures used in the program including the frequency of observations, and c. the management of the patient, including correctly referring patients to proper medical points and other signs of cooperativ6.arrangements. The inputs for a RMP may be assumed to be two in number also: 1. The region presents a series of cooperative arrangements; 2. There is an input of dollars from Federal and local sources. Evaluation may then be defined as the amounts of the two outputs obtained for the expended amounts of the two inputs. "The different quantitative approaches in the several regions will be developed locally and may well be innovative. Compardbility will grow out of demonstrations rather than being set at the National Advisory Council or NIH level. Two other important factors would be realized: 1. National Advisory Council perception of the progress of the 2. The evaluation process would re=in in the core of each R@LP and not suffer from delegation. -9- A sample listin- of measurements which riigtit be employed would 0 perhaps be helpful in initiating regional evaluation: 1. The number and types of cooperative arrangements; 2. The changes that have occurred in health manpower; 3. The expenses related to training programs, laboratory developments,, etc.-, 4. The rates of contacts of the program with patients hospitals, diagnostic and treatment units, etc.; 5. The penetration of the program: geographical location of doctors involved; geographical location of patients, of hospitals particpating, of training, and degree of depth of penetration in these areas.it "This list could be augmented by each MIP. Records would thus begin with the operational phase. One can surmise that such records would contain important sociological, financial, medical information and feasibly be transmissible within or even without the region. Time, experience, and technical growth would logically give rise to a more complete medical record giving better indices of the health status of persons in the region. "To prescribe a fixed medical record is probably to stultify regional development; thus it would seem that record development ought to remain an investigational project within the program. "The quantitation. or SA and OR capability in each operational region would insure the maintenance of proper records, guiding the effort of the RIIP, and anchor the responsibilities of the National Advisory Council to evaluate the progress of a program." RECOIZIENDATIO',\'S "In view of certain capability and willingness exhibited in some site visits, such as, Utah, Wisconsin, and Vermont regions: 1. @Te should ask these regional programs to develop analytical projects to measure quantitatively the effects of their programs in terms of the intent of P.L. 89-239; 2. These should represent experimental programs in evaluation and should be funded for SA and OR people to carry out the projects; 3. The staff should visit with these programs encouraging them to do so; si-iould @i v E,, o pLit@ ii: SA an(i Ok, capability in conjunction with the University staff with which they are affiliated." XI. E):ECUTIVE !,IPETING me t in -4ison Council members, and Director, NIH, The Council, Li@ Executive session with Doctor '@iarston from 12-00-2:00 on August 2'0 to discuss the transition of individual Programs from planning to operational. stages; and, the concern of Regional Medical Programs with metropolitan areas and the related urban health problems. XII. CONSIDERATIC,'-@q C LICATIO@TS' I S02 Pd4 00024-Olr,2. Flor ProRram The Council felt that the medical schools should be more actively involved in the development of the program. They noticed that the Regional Advisory Council is largely composed of people.from the applicant organization and, as a result, might not be able to function freely in.reviE@-,ii,ng the proposed activities. The adequate representation of minority groups is still only very minimal. The organization of the program was criticized for being overly complicated. The mechanism for planning seems much too decentralized and vaguely presented. Finally, there was considerable question regarding the justification of the budget. The Council recowended that some support for pre-planning be given to the Florida region to assist them in formulation of a more reasonable approach to planning for a Regional Medical Program and eventual submission of a true planning proposal. The Council reccalnends approval in the amount of $200,000 for direct costs for each of two years provided that: (1) the Regional Advisory Council is made more representative and functional; (2) a more definitive planning approach is developed; and (3) a more realistic budget is submitted. The amountsrequested'vera: $639,753, first year; and $412,525, second year, plus appropriate indirect costs. 1 S02 Pll 0006 d Medical Care The Council recommends conditional approval of an award not to exceed $3000000 for each of tv7o years contingent upon a satisfactory site visit to resolve questions on the structure and function of the applicant organization, as well as the degree of active involvement and representation of regional organizations and institutions. Although this revised application shows improvement the program does not show community support or adequate representation of those 'eateft,orical ilriDtitutinn.s i@-liase supi)()rt i.s essential.. O., the otbe Ca L staii may encourage. The Council specifically rec(x.-,,.nendz:, t@at the site visit include representatives, not only of the Trustees and the group officially involved in the present application, but also of the organization named which is not effectively -'Lnl.7i-.)Ived. The amounts requested were: $80'/,599, first year; and $1,870,276, second year. Indirect costs were not requested. 3 S02 Rll 00003 02SI, Northern New Eri'@,land Re 1-onal @ledicLI ram The Council recommends conditional approval in line with the recommendation of the Review Con@mittee. Support is to be extended with the deletion of the following: 1. Subcontracts for special studies; 2. Four staff positions; 3. Renovations and alterations (not allowable in a planning grant). The Council also recommends providing additional support up to $50,000 for extension of the Professional Activity Study (PAS) coverage if, after negotiation with staff, such extension is feasible and desirable. The PAS proposal was considered to be an excellent opportunity for this system to demonstrate its fullest capability at a moderate investment. The amount,, to be negotiated by staff and based on the Councills recommendations will be approximately $267,000; plus the additional amount for PAS; plus appropriate indirect costs. 3 S02 RM 00006-02SlR. North Carolirli Rep-ional l@4edical P am Council recommends approval in the amount and time (one year) requested. The additional core staff positions Are well justified, with clearly defined functions and responsibilities. Recent information concerning readiness to submit an application for an application for an operational grant made it clear that planning activities are meeting their objectives. The approved amount is: $253.,976, plus appropriate indirect costs. 3 S02 al 0001.,@,-02SI, Tennessee llid-South Council recor-miends approval (one year), subject to an amended award date, because it believes that the added core staff requested in the application are well justified and are an appropriate increase for a region about to assume large operational responsibilities. The requested amount is: @106,000, plus appropriate indirect costs. The Council recommends approval in the reduced amount after their concerns are communicated to the applicant. As in previous requests, -12- it was felt that the development of the new medical school concurrently with the regio--t;,,l medical program is.a real strength upon which to build mutual interests. There was the consensus that the request is "pre-planning" rather than planning; and approval in a reduced amount will enable this area to acquire staff and to develop a program. The amounts requested were: $125,000 for each of two years., plus appropriate indirect costs. lir. Lindee absented himself. 3 S02-RM-.-OQQ!9-OlS4.. California-Stanford Council recommends approval in the amount and time requested. Although this area was somewhat late in requesting active participation in the California Region, it appears they are now ready to go forward. They have the organizational framework for planning, and plans for developing programs in manpower, education, and evaluation of medical services. The amounts requested were: $223,545, first-year; and $217,673, second year, plus appropriate indirect costs6 @Ir. Lindee absented himself. 3 S02 Pl@l 00035-OISI, South Carolina The Council recommends approval in the time and amount (the remaining four months of the calendar year) and agreed that the applicant should be encouraged to acquire competent assistance with the design and implementation of the proposed sociologic studies. The amount requested it: $51,683, plus appropriate indirect costs. 3 S02 Rl!l 0003" 02Sl. lJashington-Alasla @q- The Council recorimcnds conditional approval for two years in an amount to be determined which will include not more than $250,000 direct costs per year for additional core staff, plus the I full amount requested for the myocardial infarction registry. Indirect costs will be added. Sinc,- certain new positions would relate primarily to operational p-@ojects, it was suggested that such positions not funded under this recommendation could be included in a subsequent operational grant application. The amounts requested were: $79UO,412, first year; and $700,418, second year, plus appropriate indirect costs. Doctor liogness absented himself. -13- 3 S03-R).','r,. 00037-OISI, v7i.scor)sill It was the consensus of the Counci.1 that this proposal is consistent with the objectives of the Regional lied:';-cal Program, and that it merits support. The request for funds to support the purchase of urokirkase x,,as deleted at the request of the applicant. The amounts requested were: $75,067, first year; and $55,404, second year, plus appropriate indirect costs'. Doctor liogness abstained. Xllli ADJOTJPL@TIIENT The meeting was adjourned at 12:05 p.m. on August 29, 1967. I hereby certify that, to the best of niy knowledge, the foregoing iiii.riutes and attachment are accurate and complete. Robert Q. Marston, Yi.D. Associate Director, NIH,'and Director, Divir>icpm of Regional Medical Programs Eva 161. I-landal, Recording Secretary Council Assistant, DPDIP N @TION A L ADVISORY COUI%TCIL ON PEGION'KL IIEDIC,@L PROGR-V..S Lo-on,tdas H. Berry, M. D. (67) J'.mes T. Howell, M. D. (68) Professor, Cook County Graduate Executive Direct or School of 1,1,,dicine, and Hcnry Ford Hospit'il Senior Attending Physici.in D!-!tro,.t, Michigan 48202 Michael Reese Hospital Chicago, Illinois 60653 Clirk H. l@lillik n, M. D. (68) Consultint in Neurology Mailing address. M yo Clinic Rochester, Minnesota 55902 412 East 47th Street Chicago, Illinois 60653 G(iorge E. Moore, M. D (68) Director of Ro-sea-ech for the @lichael E. D@-Bik@-y, M.D. (68) New York Stite H-2alth D@pirtment Professor ind Chai-tmln Roswell Park Ilic@moriii Institute Department of Surgery 666 Elm Str@,et College of @ledici-nc, Buffalo, N,,,117 York 14203 Baylor University Houston, To),,is 77025 Edmund D. P@llegrino, 11. D. (70) Director of the Medical Cent-@r Bruce @l. Evf--rist, 1,1. D. (71) Stat-- University of N--xq. York Chief of Pediatrics Stony 'Brook, New York 11790 Green Clinic 709 South Vienna Street Alfred M. Popma, M. D. (70) Ruston, Louisiin-3. 71270 R@gional Director R@gional I-,i.?dical Progrim Mr. Charles J. Hitch (71) 525 1,7@st Jefferson Straet Vice Prcsident of the University Boise, Idaho 83702 for Administration University of California Mick I. Sh,-anholt;?, M. D. (70) 2200 Univ@rsity .,Ivcnue State Hf-l-ilth Commissioner, Berkeley, California 94720 St,-ate D@@,p,:Irtment of Hc2nith Richmond, Virginia 23219 John R. Hogness, M. D. (70) D2,in, School of Yiedicine Cornelius H. Tracger, M..D. (67) Univorsity of W-tsliington 799 Pnrk,Avenue Sc2ittle, @l@shington 98105 New York, Now York .1002-1 Ex Off ic io Member Dr Williim H. St@@wart (Chairmin) ;Urgeon Cr,@neril Public H.-@,,iltli S:.@rvic(, 10000 Rockville Pike Bethcsdi, Yilryl-ind 20014 7-24-67