I TI - MISSOURI MEDICINE FL - 50,1953-- PL - ST. LOUIS MO GN - CONTINUES JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION IS - 0026-6620 CA - WI MIS78 UI - M39000000 719 Repritited froin pa, s 719 to 758 of the Seple?ytber, 1968 'i\lissouri iN,lrDiciNF ,e I s s 0 u "fit I e( @eine JOURNAL OF THE MISSOURI STATE MEDICAL ASSOCIATION COPYRI(;HT, 1968 By MissouRi STATE MEDICAL ASSOCIATION-. ALL POGIITS RESER%'ED. VERNON E. WILSON, M.D., Coltirnbia Vice-Presi(letit for Aca(le7nic Aff(tirs Uitiversity of Hissottri Missouri Regional Medical Prograiii An Overview DuRiNC THE LAST YEAR AND A HALF numerous articles have appeared attempting to explain tl-ie role of the Missouri Regional ',\,Iedical Program and its relationship to the physicians in the state. The most recent appeared in illissottri Faiizily Docto), in April and May and are recommended for detailed statements of goals and philosophies. The purpose of the present paper is to clarify those points -,vbich seem to be most often misunderstood and to propose a basis for productive en- deavors during the next several vears. In its future development, the Missouri Regional Medical Program is expected to continue its goal to facilitate communications bet\,veen the physician who cares for patients and the sources of information that can help him provide the best possible care for those patients. Else,vbere in this issue the various projects whicii are presently underway in the Regional A comprehensive description of the Mis- Medical program are identified. All but two of souri ]Re-ioiial Medical Program, its pur- the projects which have been operational during and its pose, its coiiii-nuiiity.based projects the past year are so-called "core activity proj- goals for the future. Doctor Wilson speaks ects." These were designed to provide assistance of the University's involvement in and itti- to any physician who desires them, anyNN,Iiere in tudes toward the Program and this unique the state. Their purpose is to assist the physician effort to facilitate communications between in selecting from the great arrav of scientific ad- the physician and the vast sources of in- vances, which continue to become avai!ay?, formation now available to assist him in pro- those parts most applicable to his paqents in nis viding best possible patient care in the area community. of heart disease, cancer, stroke and related The Smithville and Springfield projects ar@ diseases. He states that the ultimate suc- demonstrations of this approach in action. An ccss of the Program depends entirely upon new projects for %vhicli applications have been the initiative of the physicians of the state at least tentatively approved are similarly c@m- and their response to this cliallcn-e to par- munity-based; In every instance, the project capitalizes oii close communication with the Ulli- ticipate in the design of improved health versity and the central staff of the RMP pro- care patterns for the future. gram. 720 AIISSO[7111 REGIONAL IIEDICAL ]'IZO(;R@llf-117ILSON Si@i'lil@\11,1:1". li)68 Perhaps a good subtitle for this article iiii(rlit is in accord \N7itli the oi-i(riiial intent of' tli(@ i)a- be "This Is Your l,ife," I)ori-o\%,iii(,, from the re- tioiial act. ceiit]N,-poptilai- radio and television pro(,-i-ain. Re- The pr(@sciit]Nl-opoi-ative p)-ogi,aiiis gioiial Nlcdicil Pro(,r@iiiis are a coiigi-essioiiallv- cated to a number of i-clatiN?el), siiiil)](@ OI)jccti%-Cs illiple)l-lented, but pliNsiciaii-giii(led, i)atioiial ex- iitiliziii(T kiio\\,ii but too iiifre(Iii(,iitl\- applied pressioji of the (,i-o\\,iiig public (lei-naiid to lia\,c principles. First, tliev arc based iil)O'll the IS- the advantages of the latest technologies brought stiiiiptioii that there is a coiisi(](@i-iil)lc, I)o(l\- of to the community, wlierever its location. iN4oi-e health care need as @,et iiii(lisco\7ei-(@(I the ii-nportantly, llo\N,ever, it is the one large, clearly formal health care si,steiii. The Regional -\l(@(lical visible and geiiuiiie effort oil a nationwide basis Pro-rai-n within lieii-t, stroke and ciiic(,i, con- to place the respoiisibilit), for health planning cerns has dedicated itself to fiii(iiii(il iii iiiipi-o\,e(i,@ squarely in the conijntiiiit\l \N,itli the physician Nvay to get patients to physicians iii(I into proper in the key leadership role. It has as a running and ethictl health-care systems. niate the comprehensive health planning en- Secondly, these projects ,ire direct(-(] to\\,,ir(i deavor, -,x,liicb, at least in ,Nlissouri, thus far has finding wa@,s of iiiiproviii(t resources ii\-@tilitl)le had minimal participation by the medical pro- to the physician. These ran e from -.I li,,tii(il.)ook 9 fessioii in the design of its policy or in the im- of resources to c]on,elopiiieiit of iic\N, t(@cliiii(Ities plemedtation of earlv planning. Comprehensive and distribution of iic\N, methodologies. Tliev in- health planning here has been structured to clude improved training for aiicill@ii-N7 ,i-otips and give the consumer and the supporting groups some types of "automated consultation." the major role in the design of health care. This The latter involves back-tip for pli\,sici@iiis in difference in postilre and plan is of crucial im- communities which do not lia\,e access to ti -to- p portance. date or coi-npi-cheiisiN,e medical center resources. Regional @Nledical Programs at present are by Stich techniques include "(Iial-a-lecttii-e" series, far flie most favorably financed for planning and autoi-nated computer interpretation of clectro- dei-nODstration. Nevertheless, ',\IRNIP will fail or cardiograms and the CO]III)Llter fact bank. Each succeed as a result of the support it receives is designed to provide for any iii(]iN,i(iiiil N,,,itli a from the practicing profession rather than the telephone the opportunity to obtain pertinent amount of finances poured into it. Insofar as information immediately. N,17]iile such "auto- IN@IRMP activities ire the result of initiative iiiate consultation" is still a research endeavor, tal,en by local physicians who exert their interest its enthusiastic receptioi-i suggests iii active fit- and energies in their behalf, they will fulfill the ttire. Ii-i general, these kinds of activities first dreams of those who brought this program into will be tested internally and then NN,itli medical being. If this is misunderstood, opposed or sim- students and faculty of The University of '.\Iis- ply ignored, the program will play into the souri Medical Center. Following this they will bands of those NNIio have always believed that be tested in hospitals affiliated Nvitli the Uiii- improvement must come from a central direc- versity's School of NIediciiie. AfterNN,ai4ds, such tion for the enliglitment of those on the pe- programs can be tested in the offices of precep- ripbery. Competition of ideologies is always a tors throughout the state and in demonstration sound basis upon which to initiate change. The areas, Stich as Smitliville and Sprilicrfield. They ideology of RI\IP is clear, namely, that the medi- then will be available for those NN@llo have an cal profession has been in a leadership role and interest in trying such devices "on the fil-iiig line" deserves to contini-ie in that role. without the protection of prearran,,ciiiciit. We From the beginDill , the Missouri Regional believe that this tv e of assistance will be par- 9 p Medical Program has been based upon grliss tictilarl), useful in Stich places Is poison conti@ol roots participation. Its Advisory Council is com- centers, but that it also has applicability far be- posed of citizens from outside full-time state di- yond such highly specialized needs. visions and the University and includes six pby- Other resources which will be ii)a(le iN@ailable sicians. Members of the Council are appointed to physicians include iiiipron,ed postgraduate bv the Governor, serve rotating terms and for- education prograi-ns tbrou 11 leised telephone- 9 mulate the policy upon which the pro,,ram is reaching circuits origiiiatidg at the UiiiN-ersity of 0 based. Their continued insistence has been that 'i\,,Iissouri Nledical Center. The "dial-a-iccttire" all projects undertaken at the community level program will be designed to pron,idc immediate should ultimately develop economic self-stiffl- and direct response to needs as detailed bv local cieiicy and that any changes in the health care medical staffs. Initial lecttires will be developed system should be of an evolutionary nature. This around questions asked most often. @17]iile this is VOLU)IIE 65 Nui.ij3En 9 illISSOURI REGIONAL IIEDICAL PROGRil.11-WfLSON 721 a more traditional approach, bv its very nature of i@,lissotiri Rc(,ional i'vlcdical Program has been it is more easily handled and helps to fill in the its effort to achieve a balance between resources spectrum of aids which are easily accessible for dedicated to central or supporting facilities and the physician's continuing education, those used for field activities, as in Sprinctfield One might appropriately ask why a university and Siilitliville. A few principles of approach re- and its medical center should have this kind of gardin(i this division have now been accepted involvement in ii-nprovement of health care. Cer- and implemented. The University provides only tainly those of you who are acquainted with the those service activities which cannot be per- tradition of land-grant colle,,es Nvill have no diffl- formed by others or those in need of immediate culty in perceiving the relationship between this and iiitimate research which can be carried out kind of medical experiment station and the only in the University with its multiplicity of types of activities conducted for many years in faculty and facilities. Each time the University the agricultural and enaineerinr experiment sta- takes on a service activity, it does so Nvith the tions. These stations have been established to intent of working itself out of business so far as respond to needs as perceived by the communi- service is coi-iceined. ty. Their purpose is to rapidly translate tech- However, a strong central resource unit is im- niques and research results, available through portant for a number of reasons. It can provide the university, into action in behalf of commuiii- unique assistance, such as prompt access to in- ties in the state. In the medical experiment sta- formation not otherwise available, research ca- tion concept, as conceived tbroti,-h the Missouri pability in problems of interest to those in the Regional Medical Program, the intent is to pro- field and coordination of effort which cannot be vide similar issistance primarily through the provided from the periphery. This kind of unit practicing physician, giviiil to him these ad- also furnishes highly sophisticated equipment vantages and hopefully belpiiia him to under- and personnel, ,vbicli are needed only rarely but stand at the earliest possible date the potential can be found in a university community because of newly discovered techniques. their time can be divided between several depart- One of the responsibilities agriculture and en- ments. The i-ii@it also serves as -t link betxveen the gineering have always had in relationship to local regional medical program and similar pro- these activities now shared by Regional Medical grams being conducted in conjunction with uni- Programs is that of measuring and demonstrat- versities elsewhere in every section of the U. S. ing the positive or negative impact of these ac- Obviously, the most important activities in the tivities. While no one as vet has measured nor, Missouri Regional 1\ledical Program are those in fact, defined "good health," a substantial effort which take place at the bedside or in the physi- in the Missouri Regional Pro,,-ram is dedicated cian's office in Siiiithville Springfield and t e toward evolving such a definition so objective many other communities to be included in these measurement can be carried out in a manner activities in the future. Quite as important will helpful to all concerned. be the maintenance of some 'kind of central ser- Meanwhile, traditional approaches are being vice and coordination so each of the projects - can proceed with full knowledge of lessoiis utilized to help set up standards that can mea 0 sure to some degree the impact of changes now learned elsewhere and of new information being beiii(-r proposed and tested. One such activity is assembled. Certainly, at the present time, no "Operation leepick-," Nvliicli was initiated by the one would claim to have discovered -%Nbat the Missouri Hospital Association in cooperation optimum balance will prove to be. It is our in- with the Division of Health and is now co- tent, however, to continue the majority of activi- sponsored by MRMP. This program provides for ties at the bedside, %vhile maiiitainina strong the collection of statistical idfol-niation from lios- central services at a level necessary to provide pitals throughout the state ind will 6ake pos- response to needs found in the field, and to pro- sible compilation of baseline data. In terms of vide a stable and desirable basis for comiiiiinica- disease incidence, it will indicate bow many tion between the field and the University, as people receive care, for what reasons and -,-,,Iicre well is betnveen the several units within the tbev receive that care. Other basic quantitative field. information about the state's population and SU1%1,-,IABY present health patterns and li,,ibits is being ob- taiiied through surveys conducted by the PopLi- We lia%,e attempted to answer two or three lation Study Group of N:IR'\IP. issues now before the medical profession and to Perhaps the most troublesome responsibility (Contintied on pa-@ 727) 722 GEORGE E. WAKE[ILIN, AT.D., Coltiitzbia Director for Plaiiiiiiig, 31[?MP Planning for the Missouri Regional Medical Program (MRMP) THE PRI'-\fARY COAL of the i\lissouri Regional standing that it will be continually revised and Medical Program (.@\4RiN@IP) is to facilitate flil- updated. Cpl)ies of the Plan have been sent to fillinent of the promises of modern medicine for the Division' 'of Regional Medical Programs and all people of tbe.L\4issouri Region with particular distributed to the coordinators of all RNlPs. The reference to bringing the newest and most com- essentials of this document, as summarized be- petent services in heart disease, cancer, stroke low, describe t]-ic current state of planning for and relited diseases as geographically close to INIRMP. the patient as possible. The final focus is on optimum health for the individual citizen of the COOPERATIVE ARIIANGENIENTS '-.\Iissouri Region NN,itli emphasis on assistance to In keeping with one of the prime purposes of the local practicing physician -Nvbo is strategical- the RN,@IP Law, N4RNIP has effected cooperative Iv sittiated to provide medical care and health arrangements among the University of Missouri guidance to his patients and to the community. School of Medicine, other University of Missouri Planning for ',\IRMP is directed by the'Ad- schools and colleges, other educational and re- visory Council and its committees and by Ar- search institutions of the \Iissouri Region, bos- tl-itir E. Rikli, i\,I@D., MRINIP Program Coordina- Pitals (including community hospitals), practic- tor. It is staffed by the MRMP Planning Divi- ing physicians, health profession organizations, r Wilson, fon-nerly Coordinator and appropriate voluntary health agencies, official sion. Docto now Vice-President for Academic Affairs for tile healtl-i agencies and consumer groups. Through University of i\,Iissouri, still maintains an active representation on the MRMP Project Review interest. MRMP is one of the responsibilities of and Liaison Committees, 30 Missouri organiza- his new office. tions, institutions and agencies have an active The Planning Division Staff of MRMP in- role in the NIRMP planning and operation. cludes the Director; Warren P. Sights, '.Nl.D. and MRI\,IP leadership and staff regard coopera- Yeu-Tsu N. Lee, M.D. of Columbia, Associate tive arrangements as a long term, continuing re- Directors; Richardson K. N6back, i\,I.D. and Mr. sponsibility and a sitie qua izon for success of the Albert P. N;Iauro, Associate Director and Assist- Program. ant Director for Planning, respectively. in met- HEALTH RESOURCES AND NEEDS ropolitan Kansas City; Stanley S. Pete;@on, M.D. and Mr. Bacil Steed of Springfield, Consultant In order to facilitate planning and later evalu- and Administrative Assistant, respectively, for ation of the,\4issouri Regional Medical Program, Southwest Missouri; and Mr. Lee G. Cochran of the Program Evaluation Center is gathering in- jacl,son, Consultant for Southeast Missouri. formation regarding health and bealtb-related The Program Evaluation Center of the Uni- resources of the 'Missouri Region, as well as mor- versity of Missouri School of Medicine, directed bidity and mortality figures for heart disease, by David J. Jones, -N4.D., is responsible for gatli- cancer, stroke and related diseases. Moreover, ering data regarding health and health-related five i\,IRiN4P pilot projects now in operation will resources of the Missouri Region -,ind for devel- directly produce important infon-nation relative oping methods for evali-iating the effectiveness to health resources and needs of the ',\4issou- of MRI\,IP in achieving its goals and objectives. ri Region and, at least, five other projects will An overall Plan for \IR'I\IP was prepared in tangentially supply helpful information. As more 1967 and thoroughly revised in early 1968. The data become available, 'i\4RMP will be able to Plan was approved by tl-ie MR.\4P Advisory plan, implement and evaluate on an increasingly CoLiiicil and its Committees %vith the under- firmer basis. VOLUi.iE 65 Nui,iiBt:ft 9 PLANNING FOR I'IIE IIR.IIP-IVAKERLIN 723 PPJORITUES Since the primary focus of ',\IRMP is on the In summarizing the overall Plan for delivery of optimum health care to the patient MRNIP as prepared in 1967,ind revised early as close to home as possible, top priority is given this year, Doctor Wakerlin explains the to pilot projects Nvbicli will directly strengthen need for and development of cooperative ar- the health care system of the 'Nlissouri Region. rangements with involved groups through- Prevention and early detection, continuing edu- out the state, the priorities extended when cation and public education-inforrnation may be considering new project proposals and the looked upon as parts of the health care system. guidelines that liivc been developed to as. They also are given high priorit%l by MRNIP. sist local physicians and groups in submit- ting proposals to NIRNLP. He also discusses Increasing attention is given to rehabilitation, ambulance services, school health, home care such pertinent subjects as planning for the and rheumatic fever prevention as well as to future; NIRNIP and continuing education; manpower, health careers and emergency medi- prevention and early detection of heart dis- cal and dental services. Indeed, when they are ease, cancer and stroke; community health part of a proposed comprehensive health care services; and public education and informa- project, they are given high priority by MRMP. tion. MRMP leadership holds all areas of concern under continual scrutiny and subject to change in priority as the Program unfolds. cancer and stroke will become increasingly effec- 0 CO,NTINUI,NGEDucATio-, tive. In the meantime, increased prevention and The University of Missouri Medical Center early detection require more continuing educa- recently initiated an MRMP-supported telelec- tion for physicians and allied health professions ture project for continuing education of -obvsi- and more public education. Thus, in the Mis- souri Region, full application of present knowl- cians and allied health professions. MRMP also encourages other organizations active in these edge would mean a yearly saving of 250 lives fields to submit project proposals, particularly from death by rheumatic heart disease, 1,000 ones involving cooperative effort. One MRMP from cancer, possibly as many as 2,000 from cor- project now under way-the Computer Fact onary heart disease and an undetermined num- Bank-is primarily concerned with continuing ber from stroke and from hypertension. 0 Early detection of heart disease, cancer and education for physicians, and eiaht other opera- 0 stroke will be facilitated by tl-ie findings of six tional projects include important continuing ed- MRMP pilot projects now under way. ucation components for physicians. MRMP will assist communities of the Region Continuing education for the allied health in developing screening project proposals when profession list parallel in coverage and effec- requested by local physicians and other bealtl-i tiveness pro,-,rams for physicians. Six pilot pro' I- leaders. Such project proposals should prefer- ects nonv in operation provide important contin- ably include a new or unusual feature such as uing education for nursing an other allied custom-designed screening or an innovative ap- health professions. oacl-i to more effective follow-up. MRMP encourages continuing education pro'- Pr I Ultimately, every physician's office should be- ect proposals for physicians based in community come, in part, a prevention and early detection hospitals, as well as similar efforts for the allied center for heart disease, cancer and stroke. health professions. NIRMP also encourages proj- 0 ect proposals for the retraining of allied health HEARTDISFASE C) professionals reentering the health fieldi MRMP projects are ordinarily of a develop- There is need for wider application of knowl- mental and experimental nature and, therefore, edce ibout the surgical correction of congenital supported for a limited period of years ,vitli the heart disease, rheumatic heart disease, peril)h- understanding that those provina successful will eral vascular disease and cerebrovasctilar insuffl- be continued under local or other funding and, ciency due to extracranial arterial disease, as hopefully, implemented in other communities. well as for knowledge relative to diagnosis and PREVEN-nO-% AND EAnLy DETECTIO-, treatment of hypertension and follow-up of con- gestive heart failure patients. An estimated 1,000 As biomedical knowledge advances, primary lives could be saved per year in the Missouri prevention of the various forms of heart disease, Region by prompt application of cardiopulnio- @Nlissoulu NliEl'ici,,;F 72.1 I'LANNING FOR TIIE ,IfR.IIP-117AKERLIN SE:I@TFNIBER, 1968 nary resuscitation and by making intensive cardi- Nvliich (lia@liiose and treat such patients in -,Nlis- ovascular care or coronarv care units available souri. in comi-nunit), hospitals for all heart attack@ pa- Elimination of ci,-.irette smoking sigiiifi- tients in need of sucl-i care. cintl), reduce the incidence of lung cancer. The According]%,, NI@NIP emphasizes the need for effectiveness of public education toward this ob- additional intensive cai-dion,aseular care and/or jective is expected to be advanced by @NIRNIP coronary care units in Missouri Reclion hospitals Communications Research Unit project findings including community hospitals, as well as for and by increased utilization of University Exteii- establishing training centers for such units. At sion Division facilities, including 4H clubs. least ten -NIR.NIP projects now under way relate Early detection of cancer Nvill be facilitated to the care of heart disease patients. Tlie@, in- b@, such NIR',,\4P pilot projects as Multipliasic cltide an intensive cardiovascular care unit in Testing, '-,\lass Screenin(,-Ra iology an Auto- one community hospital (Springfield), a coro- i-nated Patient History, as well as several project nary care unit in another (Si-nitliville) and a proposals piow under consideration (if illiple- coronary care unit at the University of Nlissouri merited). Nledical Center. '.\ilR'\,IP also is authorized to '\IR.NIP places strong emphasis on more effec- initiate a prograi-nmed cardiovascular care unit tive prevention of early detection of cancer in at Kansas Citv General Hospital and Medical the '.\Iissotiri Re"ion and pledges -,wholehearted Center (KCGH'\IC). Three of these also will cooperation with efforts directed toward this ob- serve as training centers. jective. STROKE CO.\IPREIIENSIVE HEALTH CARE The great majority of strokes involve either The most important i@,,IRi\IP project involving hypertensive cardiovascular disease or atbero- comprebedsive health planning now in opera- sclerosis or both, but data are still imprecise and tion is the Comprehensive Health Services Pro- more long term studies of etiology and p@itbo- gram.at Smitliville, since it exemplifies in micro- genesis are needed. Identification of the stroke- cosni the essential aims of 'I\IRMP for communi- prone individual offers increasing promise, but ties of the 1\4issouri Region and of all RMPs for much remains to be done. The MRMP Bio- communities of the United States. engineering project and the Ultrasound-Radiol- ',\,IRMP encourages the development and im- ogy project offer prospect of detecting altered plementation of a comprehensive health services blood flo%-,, patterns. The '@\IRMP-sponsored In- program in two or three other comi-nunities of tensive Care Stroke Unit at the University of the Missouri Region. As steps in this direction, Missouri '-\@ledical Center is concerned with im- -NIRN4P also encourages project proposals for proved diagnosis and treatment of stroke and (a) further improvement in the care of heart will provide training for the staffs of other medi- disease, stroke and/or cancer patients, (b) corn- cal centers and hospitals. The Nortl-ieast Missou- muiiity health centers (preferably associated ri Cooperative Stroke Project centered at Kirks- with community hospitals) and (e) coronary ville emphasizes rehabilitation and its early im- care unit demonstrations pointed toward solu- plementation. A number of other MR'@\,IP pilot tibn of the problem of such units in smaller corn- projects also assist in providing better care for munity hospitals. stroke patients. All MRNIP projects now under ,N,ay ultimately '\IRMP encourages the submission of project relate to comprehensive health care and several proposals for two or three innovative communi- involve collaboration with the Sii-iithville project. ty stroke programs. The programs may be hos- RELATED DisEAsEs pital-centered, based on home care or traveling clinics or a combination of tl-iese as deten-nined The Regional Medical Prograi-n Laxv specifies locally and should give appropriate emphasis to heart disease, cancer, stroke and relatetl dis- long term treatment. eases. MRNIP interprets the last to include dia- betes mellitus, renal disease, precancerous con- CANCER ditions and pulmonary diseases producing cor The i'%Iissotiri Cooperative Tumor Registries pulmonale. project is supported jointly by the Bi-State (St. During its regular 1968 session, the Missouri Louis-Soutliern Illinois) RMP and MRMP. The Legislature voted an appropriation of $100,000 project will provide centralized information to be utilized bv MRiN4P during 1968-1969 for about cancer patients from hospitals and clinics the development of a chronic renal disease-renal VoLui,tE 65 iliRLIIP-IVAKEIILIN 725 NUZ.ISEYL 9 PLANNING FOR TIIE dialysis proa am. This is the first appropriation Association and 'Nlissouri Interagency Council oil by a state legislature to an RMP for operational Smokiny and Health, much remains to be done purposes. At a special meeting on July 1, 1968, through public education toward achieving max- the MRNIP Advisory Council approved an imum application of existin,, knowledge regard- award of $60,000 to the Kansas CitNr General ing prevention, early detection and care of heart Hospital Medical Center to help finance its disease, cancer and stroke. Thus, one third of chronic renal disease proaram. The remainiiic, current cancer deaths could be prevented if the $40,000 will be allocated at a later time. seven danyer signals of early cancer were better Project proposals aimed at the foregoing 're- known and heeded promptly. The public needs lated diseases" are invited bv MRi\l to be more aware of the importance of self- examination of the breast, Papanicolaoti smear COM'.%IUNiTy HEALTI[I SERVICES and other procedures for early cancer detection. Community health services considered in this Likewise, the carcinogenic effects of cigarette section include rehabilitation, ambulance ser- smoking, especially for lung cancer, require con- vices, school health, home care and rheumatic tinued emphasis. There also is great need for fever prevention. more public knowledge of the benefits of rheu- There is need in the Missouri Recrion for sev- matic fever prophylaxis, stroke prevention, con- 0 trol of asyniptomatic hypertension and reduc- eral demonstration rehabilitation units in appro- tion of the risl, factors of coronary heart disease. piiate community be 'tals. When necessary, Indeed, reduction of these risk factors (dietary sp' every physician in the Region should be able to saturated fat, obesity, cigarette smoking, phvsi- refer his cardiac patients to a reasonably acces- cal inactivity and hypertension) has more I po- sible work evaluation unit. Also, the benefits of tential for reducing morbidity and mortality in rehabilitation for heart, stroke and cancer pa- the United States than any other health mea- tients must be repeatedly emphasized bv con- sure now available. tinning education of the health professions anci To facilitate cooperation of official, voluntary by health education of the public. One community of the Missouri Region is de- and professional organizations active in public education-inforniation in the Missouri Region, veloping an ambulance service project proposal MRMP established a Public Education Commit- which may well serve as a model for other tee consisting of representatives of these organi- urban-rural areas. zatioiis Nvliicl-i recomi-nended that initial health With reference to school health, the Missouri Heart Association has submitted a 'Pilot project education emphasis through University Exten- proposal involving earlv detection of heart dis- sion be given to smoking and health. c 1 MRI\IP now supports a Communications Re- ease in school children. Home care services need strengthening in search Unit-School of journalism pilot project metropolitan areas of the Missouri Recrion, but which aims to increase the effectiveness of C) i d procedures. especially in rural areas. Such programs are best health education materials , n I For many years, the University of Missouri developed in relation to community Hospitals. Extension Division has emphasized nutrition Home care also is an important coml oneiit of and home economics and one of the 4Hs is several current and pending.\,IRNIP projects. "Health." The Extensioi-i Division @nd MR.\,IP Rheumatic fever prevention and the need for , look- fornvard to significant collaboration in pi- more continuing education of physicians anci oneeriiig effective health education about heart other health professions as well as more public disease, cancer and stroke via Extension facili- education have alread@, been emphasized. Re- ties. cently, the Missouri Heart Associatipn imple- MRMP welcomes health education project mented a pilot project ,vliich will enhi@nce rlieu- proposals particularly when thev involve collab- matic fever prevention in the Missouri Reaioii. oration of voluntary, professional and official Missouri agencies already active in this field. PuBLic EDUCKTION AND INFOII-.%IATIO-% Despite the excellent efforts of the '@\lissouri MANPOWER Division of the American Cancer Society, '\,Iis- The subject of Health Manpower is signifl- souri Heart Association, Missouri Tuberculosis cantly related to every phase of '.@\IR',\IP. There and Respiratory Disease Association, '%,Iissotiri will always be a relative shorta(le of health per- Society for Crippled Children and Adults, '.\,[is- sonnel which precludes %vaste of this resource souri Division of Health, Missouri State Medical due to insufficient information or lack of i-inder- .,IISSOURI NIED'Cl,';E 726 PLANNING FOR I'HE IIR.IIP-IIIAKERLIN SEPTE"IBI-@R, 1968 standing of the skills and abilities of professional formed are invited to request speakers from irroups. ,NIRMP, through the Proyrain Evaluation Cen- This information task is. open-ended since, ter, has begun a Health -NlanpoNN,er StudN, which once the health professions and the public are should continue throughout the life of the Pro- informed about NIR.NIP, they i-niist be kept ap- gram. ',\Iaterial from previous studies is being praised of progress to stimulate development of collated to provide a baseline upon -%NIiicll to DONV pilot projects and to insure understanding build a new i-netliodology for the approach to and full utilization of health care adVlDces cat- liealfli manpower data. Such data stored on aINIzed by N,IRNI)P. magnetic tape will be essential in cstablisliin(i a 0 INTERREGIONAL COOPERATION continual communication netnvorl, %N,ith the vari- ous health professional groups. The Kansas R\,IP and i\lRiN4P already are en- @\IRMP encourages the development of train- gaged in joint planning and operation with re- ing courses and prograii-is for all levels of health gard to @Nletropolitan Kansas City, as well as care and public health management personnel on Regional bases. Appropriate interrelations and would cooperate with academic public have been developed with the @Nlempbis Region- health and i-nedical care administration pro- al '\Iedical Pro(Tram ,Ind the Arkansas R.'VIP, grams of the Universitv of N4issouri and other and cooperative arrangements are under way graduate schools by serving as one of the in- with the BiState (St. Louis-Sotitliern Illinois) service trainina sites for such programs. Prourai-n. Negotiations are in process for more C) zn HEALTH CAREERS active cooperation N17itb a number of other R'.\IPs, particularly the remaining six R',\,IPs bor- The,,Nfissouri Council on Health Careers, i\4is- dering on the Nfissouri Region. sotiri Hospital Association, Missouri State ',\Iedi- DEVELOP@%IENT AND SUBNIISSION OF cal Association, @N,Iissouri Nurses Association, PILOT PROJECT PROPOSALS Missouri League for Nursing, Future Nurses of Nliss6uri, Women's Clubs and Rotary are active NIR.-N,IP believes that ill health and health re- in recruitment for liealtl-i careers in the Nlissouri lated institutions, agencies, organizations and Region. The Missouri Health Council has pre- leaders of the Missouri Region should be aware pared a Manual on Health Careers in Missouri of their opportunity to develop and propose tinder i\/IRMP auspices. Thei%,Iissouri Council on projects to 'i\.IRMP for tl-ie benefit of their re- Health Careers and '@\lissouri Hospital Associa- spective communities. tion are developing a recruitment project pro- Guidelines have been prepared to provide posal for MR,\IP consideration. communities, organizations, institutions and oth- ,\IRMP encourages all organizations of the er !zroups with information concerning bencli- Missouri Region N-,,itli health careers potential, marks used by the I\,IRMP Advisory Council including the Universitv Extension Division, to and its committees in judgina the merits of pro- strengthen their efforts and collaboration in re- posed pilot projects ,ind determining priorities cruiti-nent of young men and women. for transmittal to the Division of Regional Medi,- cal Programs. E-@\iEYtCE-,CY iNfEDICAL SERVJCES Inquiries may be addressed to Dr. George E. Heart attack, stroke and motor accident pa- Wakerlin, Director for Planning, Missouri Re- tients are most acutely in need of emergency gional Medicil Program, Lewis Hall, 406 Tur- medical services. Hence, the concern of '\,IR',\4P ner Ave., Columbia, Mo. 65201. The I\IRMP for such services. Planning Division Staff will be pleased to advise INFOrt@\II-ZG TIIE HEALTII PROFESSIONS with reference to the preparation of project pro- AND THE PUBLIC posals. Indeed, early involvement of the Staff in project planning is likely to facilitate develop- All but four county medical societies of the anent of the project proposal and fon-nal submis- e i\lissotiri R gion have been directly informed of sion to MRMP. i\IR.\,IP. The remaining societies will be in- Inquiries from Metropolitan Kansas City, formed during tl-le fall of 1968. Osteopathic phy- South'%vest '\Iissouri or Southeast Missouri may sicians bav& been informed, as have members be addressed respectively to Dr. Richardson K. of the nursing profession. All health professions, Nobacl-, Medical Director, Kansas City General health related agencies and interested lay Or- Hospital and i@,ledical Center, 24t]i and Cherry gaiiizations of the '\Iissouri Region not yet in- Kansas City, '@\,Io. 64108; Dr. Stanley S. Peter- VoLu3,tF. 65 NUN[BFR 9 PLANNING FOR TIIE ilIRLIIP-1l,AKERLIN 727 son, 1835 South Stewart, Suite 105, Springfleld, pears to be its main thrust today-to serve as lvlo. 65804; and Mr. Lee G. Cochran, Jackson, catalyst for and to facilitate those winds of Mo. 63755. change which blow in the right direction."' FUTURE Achievement of the primary goal of MR',\IP over the next decade (as stated in the first para- The national climate is increasingly favorable graph) will require continued and effective co- to RMP. Thus, in January, 1967, Charles L. operation and participation of the medical and Hudson, M.D., nonv a Past-President of the other health professions, laymen and consumer American Medical Association, urged practicing groups, healtfi and bealtl-i related organizations physician concern with prevention and early de- and institutions, government agencies and com- tection, health team leadership, community munities of tl-ie Missouri Region. health services and community health plan- ning.' In January, 1968, Dwight L. Wilbur, BiBLiornApiiy M.D., now President of the A',\IA, stated that 1. Hudson, Charles L.: The Changing Medical Climate of RMP 'can m-,tl-e a real contribution to personal America. Missouri Medicine 64:965-969, 1967. 2. Wilbur, Dwight L.: Quality and Availability of Health Care health services ifit continues to pursi-ie @vbat ap- Under Regional Medical Programs. JANIA 203:945-949, 1968. Missouri Regional Medical Prnoi-cim (Contd) delineate the challenge mbicli appears to exist. eases. While we do not maiiltain,tliat we ve We believe that the University should be in- found the perfect balance between supporting volved and that it has a specific and unique service and peripheral activities, these relation- contribution to mike in assisting the physician ships are under constant stlidy.and will be sub- with the problems which confront him in his ject to continual revision as a great variety of in- particular practice. NN7e believe that the Regional dividuals assisting us throughout the state bring Medical Program stands alone in offering the to bear their advice, consultation and construc- profession both the opportunity and the cl-ial- tive criticism. The success of Missouri Regional lenge to participate in the design of improved Medical Prograi-n activities is totally dependent health care patterns for the future, even though upon the initiative and the response of pbysi- the present area of activity is categorically cians ii-i tl-ie state. This, we believe, is exactly as limited to heart, stroke, cancer and related dis- it should be. The Advisory Council of the Missouri Regional Medical Prooram has award- ed $60,000 to the Kansas City General Hospital Medical Center to help finance its chronic renil disease program. These funds are part of the $100,000 appropriated by the Missouri Legisla- ture last March to MRMP to initiate patient care and research in kidney disease in the state. The remaining $40,000 will be allocated at a later time, accordi-i-ig to Nathan J. Stark, Council Chairman of Kansas City. The Ktnsas City Program began its second vear of decreasing Federal support on July 1. The U. S. Public Health Service is providing $'-)87,000 of a $359,000 total budget for the program of the remaining $72,000, KCGliMC is providing $12,000 and the balance was made up by action of the MR'I\,IP Council. 728 ARTHUR E. RIKLI, ill.D., Cotteiiibia Director for Operatioyis, ilIRMP Operational Program for Missouri Regional Medical Program (MRMP) stroke and cancer patients in receiving better di- The Operations Division of NIR',\IP is agnostic and therapeutic measures from their responsible for implementing more than 20 traditional sources of health services. projects developed by the Planning Divi- nEFINI,\G AND MEASURING sion. Doctor Rikli rel.)orts that the three basic types are (1) projects that define The first group of projects defines the nature heart, cancer and stroke problems and eval- of heart, stroke and cancer problems in Missouri uate impact of '@\IRMP; (2) projects that and seeks to measure the effect of the iNIissouri assist in preventing or detecting these dis- Regional ;NIedical Program upon these problems. eases; and (3) projects that aid physicians For any health program to be effective, it is es- in providing diagnoses, therapy and pre- seiitial to know who has or is proiie to have a ventive measures. disease. In A,bat kind of an environment are thev living, what health services do they need and which ones are they demanding and receiv- THE MISSOURI REGIONAL MEDICAL PnocRA-,,f ing? The "Population Study Group Surveys" rep- seeks to provide optii-num health for the greatest resents Missouri Regional Medical Program's number of people by accelerating the applica- effort to deten-nine the nature of the heart, stroke tion of effective preventive and therapeutic and cancer problem in this region. This project measures for heart stroke and cancer patients will be supplemented by the "Automated Hos- or those with related diseases. pital Patient Surve " when we find appropriate y The '.\Iissouri Regional Medical Program Op- staff to assist Missouri hospitals in assessing the erations Division is responsible for implementing services used by heart, stroke and cancer patients. those activities that have been developed by the The physicians office is where most patients Planning Division through the'i\@lissouri Regional gain access to the services of health workers and 'i\rledical Program review groups and is given fi- related resources that make up the health de- nancial support by the Regional Medical Pro- livery system. Analysis of this system to aid in gram National Advisory Council. determining rational innovation is the responsi- These financlillv-supported projects may be bility of the "Operations Research and Systems divided into the following three groups: Design" project. This project is using its skills to 1. Projects that define the nature of the heart, analyze the forces at play within the Missouri stroke and cancer problems and the effect of the Regional Medical Program and is proposing Missouri Regional',\Iedical Program. more effective use of resources. 2. Projects that aid in bringing heart, stroke As we acquire information germane either to and cancer suspects into the health delivery sys- a specific problem or to a solution, we attempt tem. to simulate the anticipated effort through model 3. Projects that aid physicians in providing development and testing. This work is carried effective diagnostic, tl-icrapeutic or preventive out by the "Data Evaluation and Coi-nputer Sim- measures to those who need them. ulatioif' project. It is the Missouri Regional iNIedical Program The most difficult task in introducing an in- plan to help close the time gap between discov- novation into the health delivery system is to en7 and application by introducing innovations foretell the effect or value of the innovation. To- into the Nlissouri health delivery system on a day's health delivery system is the product of in- demonstration basis and, in this way, aid heart, numerable variables that have been introduced VoLui,iF, 65 729 NuNiBEn 9 OPERATIONAL PROGRA.11 FOR AIRIIP-RIKLI by botl-i the consumers and producers of health methods are beingblended so that they will be services. Most changes have been made upon an readily accessible to the inquirer as be considers nostic possibilities su,,,Yested by empirical basis rather than upon a carefully cal- various diag on culated cost-benefit basis. As therapeutic mea- sians and symptoms in a patient. Physicians now sures develop (such as renal dialysis and organ mav acquire answers to such questions by time- transplants Nvbich can prolong a productive life consuming iiiq'uiry into the medical literature. at costs that no individual or his family can It is the mission of the "Computer Fact Bank" afford), there arises t critical need for method- to provide this infon-nation much more rapidlv ologies to evaluate the practice of such extraor- and pertinently than would be available in any dinary measures. This is one of the responsibili- other way. ties of the "Program Evaluation Center" project. The second project in this group, and one of The "Communications Research Unit" has set the best models reflecting the use of modern in- out to detemiine and measure the elusive factors fon-nation-bandling devices to serve the health in communication which cause people to react needs of persons with heart disease, is the "Auto- or not to react under varying circumstances. The mated Electrocardiograph " project. It is pro- y medical profession has had little real success in viding physicians with computer interpretation .'selling" the principles of well-being to the pub- of electrocardioaranis at six different locations. C) he. Our 'Communications Research Unit," for The system has been developed during the past the first time, is delving deeply into this crucial ten years and is now beincy field tested by the problem on a scientific and closely controlled Missouri Regional Medical Program. It is antici- basis. pated that, in the near future, computer inter- pretation of electrocardiograms will be as readily DETECTING Oft PRMICTING available to physicians in Missouri as their tele- The second group of projects involves our ini- phones. This method could be used with pbono- cardiograms, electroencephalograms and mtny tial efforts to determine the most effective meth- other diagnostic signs. Computers are finding ods for detecting persons -%vlio either have or are their place in the practice of medicine as a diag- prone to have heart disease, stroke or cancer. nostic aid to a physician. Although there are many forces that influence Computers, however, are merely tools for the ways by which a person may gain access to lielpina the diagnostician or the practicing pbv- the health delivery system, the '@\lissouri Region- en C, C, al Medical Program is directing its primary effort sician. They neither can, nor probably ever will, 0 supplant the basically vital "doctor-patient" re- toward means of detecting signs of disease. The I.ationsliip that is the keystone of effective niedi- names of three of these projects are self-explana- cal practice. tory. They are, (1) Multipbasic Testing, (2) What we do -with these machines, or, indeed, Mass Screening-Radiolocy and (3) Automated Patient History. C> with any of the products of medical research is The fourth project, "Bioenctineering," provides being studied with uti-nost care, and their appli- 0 cations are being introduced into Missouri's support to several projects through the develop- health delivery system with careful restraints ment of new or different kinds of electronic and We look ilipon.all such activities as critical ex- mechanical "packages." One such development, C, perit-nents and we are carrying them out in two for example, has involved the design and build- carefully selected communities under limited, ing of a 'diagnostic chair" that lools like an ordi- controlled conditions and only with the closest nary, comfortable reclining chair. In less than collaboration -,vitli professional and adiiiinistra- two minutes and without the need for attached tive personnel in those comn-iunities. We are terminals however, it can produce tbree-lead proceeding with caution because we believe that electrocardiograms. Other measuring devices are C, the future of the Missouri Regional Medical Pro- being built into it at present. gram depends upon our ability to learn how to CLOSING A GAP carry out experiments like the "Smithville" proj- ect and the "ComprebensiN,e Cardiovascular The third group of projects l@ ends to stimu- Care UniC' in Sprin(ifield in a way that will re- t 0 late the flow of information from its research sult in the heart, stroke, and cancer patients in source to the physician who needs it in order to these communities enjoying an improvement in provide the best possible diagnostic or tberapeu- their health services after these projects are corn- tic services to his heart, stroke or cancer patients. pleted. Modern information storatie and retrieval (Coritiiitied on page 733) 730 GAIL BANK, 31.S. aii(i WILLIA@ll D. 31itYER, 31.D., Coliitttbia* Associ,(ite Project Director ati(I Project Director,,IlRjllP Continuing Education for the Health Professions ALTHOL,GH nIE LEVFL OF HEALTH CARE in the education based upon tl-ic prei-nise that learning United States is considerably higher than that in should be a lifeloiia activity, the ultimate goal many other nations, it has a potential of being being tl-ie improvement of health care. This con- even higher. How rapidIN7 we approach this po- cept envisions a time when health professionals tential level will depend to some degree upon will have at their disposal mechanisms with the extent to which provisions are made by edu- which to engage in learning activity at any cational institutions for continuing education for time, at any place and at whatever breadth or physicians and other health professionals. Even depth desired for their own self-learning and for more important is the extent to which those cur- the needs of their patients. To help accomplish rently in the health professions and those who this, access to great libraries, other clinicians, will enter the professions will involve themselves researchers, teachers, consultants, teac iing- in the process of continuing study of each learning materials and all manner of pertinent otlier's professions throughout their years of data and information will be immediately avail- practice. In these days of rapid growth in bio- able. In this concept, continuing education is medical knowledge, continuing education be- both a means to ,in end and an end in itself. comes the bridge between Nvbat is known and The concept of lifelong learning has brought what is applied. about cl-ianges in educational activities for prac- It is estimated that knowledge currently ap- ticing professionals and also has been an in- plicable in medicine is twice as great as it was a fluence upon the teaching programs within pro- decade ago and that it will double again in an- fessionil schools. There has been a shift from other decade. This staggering volume of infor- emphasis upon the acquisition of information to mation makes it impossible for a physician to selection, organization and evaluation of infor- learn during his professional education every- mation. At the '\Iedical Center, for example, thing necessary for a lifetime of practice. Elim- multidisciplinary laboratories and teaching- iiiating or even slowing down the development learning centers are being introduced. These fa- of new knowledge or lengthening the time re- cilities will make it possible for students to inter- quirements for professional school education are act ,vitli the basic material and, also, with many impractical alternatives. Thus, it becomes im- additional sources of information. Students, perative for those in the health professions to thus, can progress as rapidly as they wish with take increasing responsibility for continuing the aid of texts, recorded lectures, films, video studv in tl-ieir career lines and for educational tapes, computers and other devices. Developing institutions to provide increased opportunities self-learning habits early in the students' profes- for continual learning. sional education better equips them to direct Since its beginning, the University of '.L\Iissou- their own continuing education activities follow- ri '\Iedical Center has supported the view that ing entry into practice. continuing education needs to be an integral There also has been a shift from isolated pro- part of the day-to-day, week-to-week practice grams for different health professions to bring- of health professionals. Present and future activ- ing the professions to-etlier in patient-oriented ities are directed to%vird making appropriate education activities. This reflects an increasing contributions to a totally integrated system of interdependency among the professions in the *?%fr. Bank is Executive Director of Continuing 36fedical Edu delivery of health care. It also prepares them r and Docto -e participation in interdisciplinary con- ,.t,on and Associate Prof(,ssor of Extension Ediic-.ition;for futui Nia@v,erdis Dean and Director of the University of Nlissotiri School of c icine. tiniiing education activities. VOLUNIF 65 Nu%tDER 9 CON7'INUING EDUCA7'ION-BANK AND IIA)'ER 731 The Universitv Medical Center, reco(yiiizing these needs, established an office of Continuing Continuing education contributes to the Medical Education to develop and carrv out elevation of health care by reducing the various educational programs. Faculty supervi- time between biomedical discovery and its sion is provided tlirouali the Committee on Con- application. The authors also state that it tinning Medical Education and includes repre- should be an integral part of the day-to-day sentatives from the clinical departments of the practice of health professionals who have Medical Center, tl-ie basic science departments, educational linkage to practitioners in of- and nursing, medical technology, physical tber- fices, clinics and other local settings through apy and other health professions. Liaison and local health care facilities. They tell how, advisory arrangements with various professional through appropriate cooperative arrange- groups are activelv maintained. Thus, the edu- ments, the Missouri University Medical Cen- cational needs of many health professions are ist and support the educational ter can ass coordinated and the interrelationships of the function of local health care facilities. various health professions are incorporated in the educational activities. Many educational opportunities have been developed for different health professions. Con- al linkages with practitioners in offices, clinics or ferences and worlshops have been presented at other local settings, and the '@\ledical Center can the Medical Center, as well as at various loca- assist and support the educational function of tions in the state. Efforts are made to involve local health care facilities. the audience in each of the conferences rather An important start has been made in this di- than to rely on lectures alone. Panel discussions, rection. Regularly scheduled, illustrated lectures with opportunity for audience questions, are and discussions vii amplified tN,,,o-way tele- frequently employed. Other techniques include phones to a fenv hospitals in Missouri are being small group discussions; live case presentations; made on a test basis. Presentations are by i\led- presentations directlv from the clinical areas via ical Center faculty and various practitioners in closed circuit television with direct questioning the state. The speaker is beard simultaneously from tbeaudience; workshops in which the pro- at ividely separated locations and his slides and fessloiial learns skills and techniques; extensive other visual i-naterials are projected locally for use of audio-visuals; an presentation of silim- instantaneous viewing. Questions can be asked mary materials, bibliographies and reference and answered, and discussion from many dis- materials. tant geographic points is possible. Proarami-niiig Recognizing the difficultv professionals in tl-ie is arranged at hours when most physicians are health care fields have in leaving their practices normallv at the hospital and are not required to to engage in scientific procrran-is at distant absent themselves from their patients and prac- points, the Medical Center has helped to pro- tice. vide scientific programming at hospital staff Telephone activities to date represent only a meetings, at meetings of medical societies and be(,,innina in the development of this tech- other professional associations. This is accom- niqueIs potential activity. While proarai-nming plished through a Speakers' Bureau. Programs has been limited to only a modest nui-nbcr of for meetings arranaed through this service usu- physicians, requests from pbvsiciai-is at other ally til, - computer systems tbrouahout the next two vears cut with age undetermined 0.10 MV in 2 leads V2-5 in order to be able to recommend the very best infarct-anterior system for this region. Small or absent R and ele- R Wave criteria as above FUTURE PLANS -,,ated ST 2 leads N'2-5. Con- and STO > 0.15 MV in 3 sistent Avitb acute infarct- leads VI-5 We motild hope to serve a maxiii-ium number anterior of comn-iunities. To do this, it may be necessary ORS peak to peak must be to reprogram the existing system in order to use 0.20 '%IV more efficient, more modern computers .3 Alter- nativelv, collaborators may be able to work with Questionable Co_, 2 leads 1, 1) Q at least 0.04S C and us and Doctor Caceres to improve and render AVL, V5-6. Possible old in. 1/4 R amplitude the existing system more efficient. Caceres is per- farct-anteriolateral 2) Another Q at least 0.03 sonally iiivesti(rating the possibility of produc- (OR) 1/4 R amplitude tion by private industry of small, special purpose 3) QRS peak to peak at computers to be dedicated only to interpretation least 0.20 '.,%IV 2 leads of the electrocardiogram. If these prove to be 1, AVL, V5-6 sufficiently inexpensive, we inav be able to test I @\'OTE: _< means e(jual to or less than; >_ means eqttal to or them in selected communities -,vhich would then greater than. be totally independent of the Columbia corn- ptiter center. Fig. 3 Examples from the computer program de. Amlinger and Carlson 4 are testing a preproc- velopcd by the Nledical Systems Development Labora- essing circuit which may be able to reliably tory of USPHS: Version of Jan. 31, 1968. classify a tracing as "nori-nal" or "abnormal" NNitliout use of an expensive general purpose muiiity; and a medical group in a medium-size computer. This would radically reduce f ie cost town. DailN, operation has revealed several of processing and increase the number of corn- classes of problems Nvbich were largely unex- munities we could serve. pected by us. Solutions, so far, have been satis- Engineering collaborators in the Missouri Re- factory. Additional data carts have been ordered gional Medical Progrim are exploring the prob- and additional medical settings are being exam- lem of mass screening data acquisition devices. ined. Cox at NVasbington University, working inde- Brief experience with the system so far con- pendently, has been investigating the use of a firms Caceres' previous claims.' Specifically, the special computer for on-line processing of vari- systei-n is 100% correct when it classifies a tracing ous physiological signals, including the electro- as "normal." It is incorrect less than 15% of the carldograrn. This work has focused on the prob- there in its abnormal interpretation. Many (about lem of the intensive care facility. 5@c) of these instances constitute minor and/or All present systems fail to provide for a large insignificant deviations from the interpretation data file to store concisely the results of previous of reference cardiologists. electrocardiographic signals and interpretations. The simple provision of an electrocardiogram We plan during future years to be able to con- VOLUNIE 65 UN N .fliER 9 ELECTROCARDIOGRA.11-LINDBERG AND A.IILINGER 745 PHS-Caceres Mayo ClinicIlBill' Mt. Sinai Ilospitat Queens Urtiv. Does NID get Yes Yes Yes Yes 12 lead tracing Computer interpretation Yes No Yes Yes based upon 12-lead scalar system Computer based on 3-lead No Yes No Planned vector system Computers utilized CDC 8090, or CDC IBM 1800 (IBM 1401) PDP-8 and IBNI 160A IBM 360/40 360/50 Published medical evalua- See note I See note 2 See note 3 Not yet completed tion Data Carts cic IBM (Computer Instru. '.%Iarquette Experimental cic ments Corporation) Electronics Data Console Telephone connections Hartford Hosp: Private ]eased line In-house connections Un etermine Private leased line Missouri: ordinary "dial up" Dr. Robert A. Stratbucker of the University of Nebraska also is utilizing the Mayo/IBNI System. Note 1. Computers, Electrocardiography and Public Health, A report of Recent Studies From the Instrumentation Field Station, Heart Disease Control Program, Div. of Chronic Diseases, U. S. Public Health Service, Dept. of Health, Education and Welfare, Wash- ington D. C. Not@. 2. Smith, R. E. and Hyde, C. Ni.: A Computer System for Electrocardiographic Analysis, Third Annual Rocky %fountain Bio-Engineering Symposium, Univ. of Colorado, Boulder, Colorado, May 2-3, 1966. Note 3, Pordy, M. D. et al: Computer A-.tnalysis of the Electrocardiogram. journal of the ',vtount Sinai Hospital, ',Iol. XXIV, No. 1, January, 1967. Fig. 4 Features of selected systems for interpretation of electrocardiograms by computer. tribute this feature and, also (with collabora- inspection. This is an exciting time. The next five tors), to encode the requisite rules for compar- years will see major changes and improvements ing within the computer new and old tracinas in electrocardiography. from the same patient. BIBLIORRAPHY All of these efforts have been based upon "the expert cardiologist' as the reference against 1. Dobrow, Robert J., Caceres, Cesar A. et al: Transmission of Electrocardiograms From a Community Hospital for Remote which any nenv system is measured. In the mean- Computer Analysis. The Amer. J. of Card. 21:687-689 (May) time, other aroups of mathematicians and bio- 1968. C, 2. Lindberg, D. A. B., Rowland, Larry and Morrison, G. E.: statisticians are looking toward new techniques Automatic Message Center. In preparation. 3. Lindberg, D. A. B.: Pattern Recognition, Chapter Xii' in with which a computer system could extract from The Computer and Nledical Care. Springfield, Ill.: Charles C Thomas, Publisher, 1968. the electrocardiogram information which the hu- 4. Amlinger P. R. and Carlson A. J.: Proposal to Develop an C) Electronic E@d Pre-Processing bevice. Submitted to MRNIP, man viewer cannot see by present methods of Dec. 1967. Bioen,gi'neei-iiig (Contd) and minimum artefact. wave, but only that it is there. One suggested -A rapid portable system of taining six use of the phenomenon is monitoring without at- EKG leads simultaneously. tachment of aad(letry to patient. As might be expected, serendipity is bound We are prepared to dream and to inia-ine, to occur. In the case of biocnaineerina, we have but we are prepared throLi(yh basic knowledge stumbled onto an electrostatic wave surround- in medicine and engiiieeriiic, to convert dreams ing the human body with tip to five times the and imagination into useful hardware and sys- voltaae of an EKG si,,nal. It pulses at the heart tenis of an advanced nature to provide more ac- rate with its own peculiar wave form, We don't curate, reliable, durable, economical and simple- know the ori(-riii or method of modulation of the to-use eqtiipi-nent for patient care. 746 GLENN 0. TURNER, 31.D., SI)riiigfield* Project Director, illSillP The Community Approach to Reduction of Cardiovascular Deaths third of lieaj@ attack admissions who were saved A preliminary summarization of the unit justifies a i-najor coniiniiiiitN, expenditure in im- recommendation of the Project Staff of the proving corolitry care. Add to this the potential ,NIR'i%lP Comprehensive Cardiovascular Care lifesaving from bringing about, b), earlier recog- Unit in Spriii,,field as expressed by Doctor nitioi-i of and attention to warning si(iiis, bospita Turner in collaboration with Dr. Cecil R. admission of some of the 250,000 who now die Aiiner, Associate Director and Dr. John J. each \,ear at home or at .N-ork, and ODe is even d. Heart damage and deaths in i\IcKinsey, Advisory Comniittee Chairman. more iiiipresse The author details the need for and the those tcliiiitted ilso can be reduced by earlier development of a coiiimunity-supported entry of all coronirv patients. Additionally, ap- Comprehensive Cardiovascular Care Unit pIN-iiig intensive treat-nei@it methods to other high with specific reference to his experience in ri@l, cardiovascular patients ,N,ill swell tl-le total of Springfield,'%Vbere such a unit is well under- lives saved. Ultimately, actual prevention of Nvay under the aegis of MRMP. heart disease through attention to "Risk Factors" is now foreseeable. The Proiect Staff of the Ozarks Regional WOULD YOU BELIEVE that there is within our Comprehensive Cardiovascular Care Unit in grasp a medical advance, the most important in Sprin,field is undertaking these objectives on a a decade, that could save as many lives per year regional basis under a grant froi-n i\,Iissoi-iri Re- as were lost each year of World Wars I and II? gional '-\Iedical Program. Incomplete, capsulized Corday' draws this comparison, even if only half results of the flrst ),ear of this study are as fol- of the 100,000 potential reported by Wakerlin2 lows: 1. Pi-oi?iptiiess of i-eco-nitioti aiid 7iospital ad- is actually achieved. The means to tl-iis end is t, the application of the Coronary Care Unit Con- I)lissioti of heart.,tttack suspects is the prime con- cept in all our hospitals. sideration. In the Ozarks an initial effort to teach Fox3 reported that 350,000 of the nearly 600,- the people the early warning signs by the Greene 000 who die annually in this count-v from heart County Division of the Missouri Heart Associa- attacks arrive at the hospital alive 1(250,000 die tion by i-nass media communications led to a pro- NA,itbout benefit of hospitalization). The Coronary posal for a pilot public information program un- Care Unit can reduce the inliospital death rate der Missouri Regional Nledical Pro,,-ram. Such a from a proxii-natel), 30% to about 209c' resulting procrtm also should stimulate physicians to re- p I zn in tl-ie saving of rou-bly One third of the 350,000 spond more promptly and more definitively to 0 -,vho are still alive upon arrival. Using these early heart attack manifestations. Pain in the sub- figures, Corday's estimate of a possible 50,000 sternal region, back, jaws, arms or combinations lives saved per vear is, indeed, modest. of these areas and otherwise unexplained dyspnea Fox reports that, as of June, 1967, onlv 300 of or sweating frequently can be interpreted accu- the nation's 7,000 hospitals had coronary care ratelv enough by telephone to justify immediate units in operation. Even doubling or tripling this admission as a heart attack suspect and, often, to number of units during the past yeir would have peii-nit b),-passina outpatient facilities. Systems left more than 61000 hospitals without such rriod- of more rapid ambulance transport of patients ernized service@ Extendina this improved care tD with emergency care capability en route should into these remaining hospitals presents the great- be developed. est challenge the American health team has yet 2. Bed iieeds foi- t7ze estab7is7iiiieiit of a cardio- faced. vascular care unit can be determined most Preservation of future earnings of this one simply bv a patient count and classification of Doctor Tumer is in the private practice of medicine. the entire hospital population. This can be done VoLvkiE: 65 Nu.kfBER REDUCTION OF CARDIOVASCULAR DEA7HS-TURNER 747 by one physician in less than a day and can be physicians for admission of their patients to this repeated on other days by other physicians for newly-created division. This count (Fig. 1) can confirmation. The Springfield group feels that be carried out in any hospital with the anticipa- all high risk cardiovascular patients should be tion that roughly 10% to 25% could be classified tallied for probable inclusion in a specially as benefitting from arouped, specialized care. staffed and equipped cardiovascular division. 3. A progressive care system with three zones, These include proved or suspected acute myo- acute, intermediate and convalescent should be cardial ischemia and infarction, congestive fail- provided in one common area. The acute zone ure, arrhytbmias, pulmonary embolism, thrombo- should include intensive and "observation" beds. pblebitis, hypertension, cardiacs with other medi- -The ratio of beds needed in these areas can e cal and possibly suraical problems and, perhaps,. determined from the patient tally. Underestima- acute stroles. Pulmonary insufficiency also de- tion of needs as utilization increases Nvas one of serves similar care. Not only can this grouping the most common deficiencies noted elsewhere reduce the number of emergencies that arise, but by Springfield teams. resuscitation efforts also can be enhanced bv 4. A cardiovascular hall or division, including doing away with the 11 allopina, exercise that an intensive unit, can be established in almost 9 ends in failure." In February, 1965, the initial any hospital to accoi-nmodate these patients, such count in St. jobn's Hospital showed 75 of once bed requirements are ascertained. Existing the total 450 patients to be in such a high risk construction usually can be used. One device for cardiovascular category. This one count alone provision of intensive care is to knock out por- led to the restriction of an entire 40 bed ball, tions of walls between rooms and to install a door by rigid admitting policy, to these patients. and large windows extending down to or below Validity of the count was immediately shown by bed level to give easy access and full visibility. the inadequacy of this number of beds in meet- 5. Subdivision of the intensive care unit into ing the needs as reflected by requests of staff "quiet' and "noisy" areas will permit reception CARDIOVASCULAR DISEASE CENSUS, ST. JOHN'S HOSPITAL, BY DIVISION FEBRUARY 5, 1965 4N INT 5iq 4@4 3w Z TOTAL 1. Acute Myocardial Infarction and/or ischemia 6 1 2 1 3 4 1 2 1 21 24 Chronic Coronary Disease 3 1 2 6 3. tohgestive Failure 2 1 1 1 1 3 1 1 11 4. Stroke 3 3 1 1 8 5. Seizures, miscellaneous 1 2 1 4 6. Chronic Cor Pulmonale 1 1 1 3 7. Pulmonary Embolism a) Complicating leg fracture 3 b) Complicating abdominal surgery 1 C) Complicating Phlebitis, without surgery 2 Total Pulmonary Emboli 6 8. Arrhythmias, acute I 1 2 9. Arrhythmias, chronic I 1 10. Hypertension 1 11. Cohgenital Heart Disease 1 1 12. Acute Rheumatic Fever 3 3 13. Pericarditis 1 14. Bleeding Esophageal Varices 1 1 15. Ruptured CNS Aneurism 1 16. Chronic Coronary Disease, in for Surgery 1 2 5 Total 18 2 8 11 0 4 9 6 6 5 6 75 Fig. I Patient Survey. This rough tabulation of high risk cardiovascular patients in St. jolin's Hospital on Feb. 5, 1965, led to establishment of pilot 40-bed comprehensive cardiovascular care unit. @IIISS( LIll NIE:DICIN-E 1 748 REDUCI'ION OF CARDIOVASCULAR DEATIIS-TURNER SEI@)fF.',IBtll, 11)68 a. Direct visual surveillance, in addition to electronic. b. Recessin,r of griiesoi-ne monitors and other 5 gear. c. Outside windows NN,itli low sills. SLID-Ml GL&55 7 NN7 Doo ts o@EIJ7 d. Bathrooms, which do awaN ith that mon- -iode. A couple of steps strositn, the coinn into the bathroom is stirely less stressful than the comi-node or bedpan. e. Carpetiiia and acoustical ceilings for noise control f. Power drape operation-cost is about $70 per room. An abundance of electrical outlets, includ ing at least one 220 volt line. 6. Bedside (lefibrillator provision for each pa- tieiit is ideal. Savina the life or brain function of just one Nx,age earner by this means of cutting off that precious fraction of a minute would pay for numerous defibrillators. Fig. 2 Niodel Room Floor Plan. Floor plan of "saw. '7 tooth" design of one of 14 rooms in round unit for ob- .. The following ancillary services ideally servation of less complicated acute patients (six-bed should be in or near the cardiovascular division: intensive unit is separate). a. Department of electrocardiography, bearing of patients of varied requirements. This arrange- in mind possible later application of central ment also lends itself to a combination with recording and of coi-nputerization. general medical-surgical I.C.U. Staffing problems b. Inhalation therapy department. will be less with this coi-nprehensive grouping c. Cardiopulmonary laboratory, including than with pen-nitting these zones to be scattered blood gas analysis, where feasible. throughout the hospital. Nurse instruction is d. Procedure room for cardioversion and pace- simplified and there is better back-up for anv maker placement. e. Exercise tolerance evaluation. overloaded component. Patients can be shifted within the division with ease as they ii-nprove S. Radiographic service should be intensi or worsen. The Springfield -roup agrees with Meltzer4 In new construction, one can incorporate into that congestive failure, the second most death- the "observation" or uncomplicated acute care dealing complication of acute myocardial in- area the following desirable features (Figs. 2 farction, can be treated more effectively if recog- and 3): nized earlier through frequent cbest x-raying. Furthermore, even low output portable equip- ment can be successfully used by well-trained technicians to obtain six foot sitting PA films for determination of heart size and pulmonary vascularity (Fig. 4). Radiologists are urged to r outinely record heart size on films and re- ports in cardiac roentgenography. A difference of one cm. or less may be significant on serial study. Also, there should be a greater index of suspicion in looking for early increases in vascu- larity. 9. Telephone EKG t?-aiis?iiission, preferably utilizing bedside magnetic tape recording ,vbich permits sending a number of tracings with one phone call, will give same-day reporting and will. Fig. 3 Niodel Room. Photo of room represented by eliminate one of the most serious deficiencies in floor plan sketch in Fig. 2. Over-the-bed auto-headlight- type, recessed reading light and oxygen-and-suction out- hospitals NN,itbout an electrocardiographer. lets have not been installed. 10. Radio telemetry will expand EKG surveil- VOLt;NiE 65 Nu.%tBER 9 REDUCTION OF CARDIOVASCULAR DEATHS-TURNER 749 Fig. 4 X-Ray Photo. Comparison of conventional versus ICU portable techniques to show significant altera- tion in heart size and pulmonary vascularity (latter is more obvious on original films). Monitor needle electrodes are in place. lance into intermediate and convalescent zones. and with time for travel to community hospitals, Length of stay in the acute care zone can be can organize local teaching programs. Instituting diminished, perhaps, by this means. this system of consultation in Missouri is the 11. Financing of instrumentation and possibly ambition of the Springfield group. These nurses meeting other costs should be actively sought are the key to the entire program and must be through civic groups, particularly hospital ladies' given special recognition and encouragement. auxiliaries. This can reduce dailv rates by several Physicians will find that they can learn a great dollars. deal in the specifics of cardiovascular unit opera- 12. Nursing stag, relatives' lounges and teach- tion from them and also will be stimulated in ing and conference rooms should be better their own study. planned. 15. Physician education will accelerate as the 13. LPN and nurse aide i(tilizatioti can be potential and mecliai-iics of the entire program very effective in cardiovascular care units, in- are made more clear. Workshops and confer- cluding reading monitor scopes. In addition to ences designed for the community hospital, holding costs down, they permit expansion of ideally cosponsored by Regional Medical Pro- services into the areas of RN shortage. grams and the Heart Association, will best ac- 14. Defibrillatioti by nurses is mandatory for complisli this goal. The Springfield MR'\-IP maximum service to the patient. Not rovidin(i Project Staff and the Missouri Heart Association p 0 this capability may soon be le@ally 0Indefensible. are now planning such a workshop for October, Specialized cardiovascular training for nurses 1968 to be offered statewide. must be expanded. Under Missouri Regional 16. Hospital administrator and governing Medical Pro,-ram and other interested groups board participation in unit development is an and agencies, an early objective should be the obvious necessity. The latter serves as represen- provision of trainin,, facilities to enable each tation of the taxpan ler and of the purchaser and hospital in the Missouri Region to have one or consumer of health services. more such specially trained nurses. These nurses, 17. Alliance tvit7i health agencies, both (lov- under continued auidance of nursing instructors (Cc)tttiritie(I ott 1)a.-e 753) 750 HENRY 31. HARDIN'ICKE, ,)I.D., Coltinibia* Project Diret-tor, ilIRMP The Smithville Project An E, valuation The S-,,IITH-,'ILLE P.ROJECT of the Nlissouri Recrion- sive care to a community. It did not set out to al '.kledical Program itteiiipts to measure the as- direct the doctors in flie manner in which they sumptioia that if comprehensive care \,.,ere made were to provide ii)edical care to their patients, available to the people of a given medical service nor did it set out priinariIN7 to lower morbidity area, the people of this area would (a) profit or ii-iortalitv or absenteeism within the medical from the extended medical kiiowled-e available service area chosen. to them, (b) dei-nonstrate acceptance of coiiipre- The Smitbville Project did set out to prove hensive medical care which would be meaning- what we believe to be a valid asstilliption-if ful in their lives, (c) exhibit less ai-nbivalence physicians were given the equipment and, the in cooperating with the I:)I-iysicians' directives, backup personnel which, for financial reasons, (d) develop an iniiate motivation toward in- they cLii-rentlv did not have available but -,vliich creasing their own productivity and lowering they felt %N,ere needed, these same physicians their own morbidity and, in addition, that (e) would proceed to give the very best quality the coinprebeDSiVe care, having been made avail- medical care that tl-iey were capable of giving able to a medical service area, will inculcate in the most comprehensive manner that their within the CODsumers of this care the type of patients would accept. discipline Nvbich makes the care most effective. The Smithville Project also set out to measure SELECTIO.N OF THE NIEDICAL SERVICE AREA the degree to which physicians in practice with- Smitliville appeared to be ideally structured in the given medical service area would avail for conducting research of this type. The Smith- themselves of the totality of comprehensive care. ville Hospital, an economically self-sufficient unit It also attempted to measure the extent to which serving approximately 75,000 people and staffed physicians, given an appropriate time for learn- ' with some 38 doctors, was currently providing ing and for familiarization with comprehensive the best medical care that equipment, training care, would accept it as a -,vay of medical prac- and time permitted. tice. Smithville, as a medical service area, also was The purpose of the Smitbville Project was, unique in that Dr. Arcb E. Spelinan bad founded therefore, to determine and to focus upon those the hospital, bad developed a clinic adjacent to C , Medical Director of the Hos- inadequacies of current practice of Nvbich the it and had a ted,, s physicians were aware. Once these inadequacies pital and the Clinic NN7itliout beiii so named. 9 bad been determined, the purpose was to SUPPIV His personality was dynamic, his knowledge of the equipment and the necessary backup per- medicine tremendous, his interest in people un- sonnel so that inadequacies would no longer endin(r. For many years prior to the initiation of exist. The aim of the Smithville Project was, the Smithville Project, Doctor Spelman had been consequently, to shorten in one dimension, interested in studying the complexities of a pa- namely, time, the rogress which physicians in tient's illness. Helwas acutel), aware of the role p the area were currently making toward provid- that environment, economics and emotional sta- ing their patients with a total kind of care to bility played in the well-being of his patients. which they were receptive. He also was aware of and bad studied rather It is important to point out that the Smitliville intensely the effects that sudden illness bad up- Project did not set out to provide comprehen- oii the stability of an entire family. He, in shoit, 0 Doctor HaTdwicke is Assistant Professor of Phy ical Ntedicine bad developed the habit of practicing medicine and Behibilitation at the University of Nlissouri School of lledi- eine. in depth. His work and his records will prove of VOL.I%'.fE 6.3 THE SIIITIIVILLE PROJECI'-HARDIVICKE 751 NU%[BEFI 9 great value ,vhen the final story of the Smith- This evaluation of pro,-ress made durin- ville Project is written. Smithville is a "rtirall)olitan@' area. The medi- the first year at the iNtRiNIP project in Smith- ville includes a review of the basis for se- cal service area contains both well-established agrarian families N-,,I-iose roots are deep in the lecting this medical service area, the iiiitia- soil and whose mores and traditions are strong tion of the project and the implei-nentation of and a large number of suburbanites who bad the proaram. The author emphasizes that moved into the Smitliville medical service area the NIR'I\IP is not attempting to change the from Kansas City where they still maintain em- practice of medicine in Smithville. The goal ployment. This area, therefore, offered an inter- is to establish a model which, having been esting cross-section of the American scene. The developed by the pliysicans practicing in interplay of social forces are inevitable under that community, may be utilized with effec- these circumstances, tiveness in other interested areas. INITIA'NON- OF THE PROJECT Project was self-limited; that at the end of two The scope and intent of the Smithville Project and half years all financial support for person- were presented to the Board of Directors of the iiel or additional equipment would be -,vith- Smithville Comi-nunitv Hospital at their regular drawn; and that equipment purchased for the monthly meeting in F, ebruary, 1967. After a per- Smithville Hospital, which had been used suf- ceptive discussion of the proposed project by ficiently to justify its continued existence, would the Board, it voted unanimously to submit the be left there. At the end of the second meeting, Project to the staff for its approval. The Board the staff voted to recommend to the Board that further voted that if the staff approved the Proi- it accept the Smitliville Project. ect, the Board would endorse and sup ort the Project. p II%IPLEMF.NTATION OF THE PROGRANF Two meetinas were arranaed with the active Implementation of the Smithville Project has 0 eD staff. The first took- place -,vithin the first weel, been extremely difficult. Personnel had to be of March, 1967. The meeting, interestingly was found in all areas that were lacking within the held at a hotel in Kansas City, the place of the Smithville medical community. Research-ori- meeting being established by the active staff. ented individuals were needed to implement the At the first meeting with the staff, the Project repeated necessary surveys of the community. was presented for their comments and consider- These surveys were designed to continually test, ation. This meeting was devoted, for the most on a random samplina basis, the people'@ atti- c, part, to a discussion bv the staff of their deep tudes about medicine, their willii-igness to utilize feelings concerning federal funds being brought the medical resources of their community, their into the practice of medicine. It could well have mores or traditions that might interfere with been classified as a psychotlierapeutic group their appropriate utilization of medical science. meeting. It was our feeling that a great deal As time went on, surveys would remeasure these was achieved since the foundations for an honest same things so that changes for the better or for exchange of views were well laid. It was evi- the worse miaht be recorded. dent, however, at the end of the meeting that a Personnel had to be found who would offer second meeting to discuss the Project itself expert services in the fields of physical therapy, would be in order. medical social work, home care nursing, reliabil- A second meeting was held Nvith the active itation nursing and intensive coronary care nurs- members of the staff in the latter part of March. ing. From a purely professional level, resources With some expressed reservations, the staff at which were not then present in Smithville had this time agreed to participate to the extent that to be recruited in the fields of psychiatry, in- they felt their patients would benefit from the ternal medicine and physical medicine. Project. Their reservations all related to the fact It also was necessary to set up administrative that they anticipated that once thev had stic- devices which made it possible to cost-count the cumbed and become part of the Project, repre- operation of the extended care facilitv -,@,bich sentatives of the federal government would then ,N,as to be developed within the existing hospi- move in and I)ecyin to dictate in .vbat fashion tal, of any ome care program kvbich was to be C, - started, and of all other pro(,,rams to be initiated they should practice medicine. They were as t) sured that this would never happen. Tllev also for the physicians in their use of the extended I were reminded at this second meeting that the care program. Nlissoulit NIEDICI.ITE 752 TIIE S.IIITHVILL,E PROJECT-IIARDIVICKE SEI-TE',114E:R, 1968 Slowly, but steadily, administrative mechanisms since the death of Dr. Spelnian six months ago. were developed and personnel were recruited in Interestingly, the qtialit-\, of care has not deteri- the several areas. It Nvas impossible to recruit orated, the patient load in the hospital has not trained intensive coronary care nurses, so it was decreased and the attention which physicians necessary to recruit nurses who would be Nvilling pav to their patients and their dedication to their to leave for training at recognized training ceii- patients' welfare has not been altered. ters. Professional persODiiel are difficult to recruit A neNN, staff organization has begun to emerge, at best. When they are recruited tinder special the stroii(,, have begun to take leadership, the conditions and at salaries usually lower than pieces of the puzzle have begun to fall into those paid by hospitals less than 15 miles aN%,av, place and the Smitliville Project has begun to recruiting becomes extremely difficult. move ahead. A nenv adi-niiiistrator is being ac- It was possible by June I to maii-itain in the tive N, sotig t N, t e Boar o Directors. ost hospital 15 beds ,-.,bich were devoted to ex- accounting svstems NN,Iiicli are meaningful are tended care. It was possible to recruit and train bei'n- inaugurated. The management of the H p'tal is beginning to assume more definite a rehabilitation head nurse who was responsible os i for the training of aides and other nurses on her shape and pattern. ward. It also was possible to recruit a physical A new extended care pavilion containing 50 therapist who was registered and had had experi- beds and a large rehabilitation and occupational eiiee in professional physical therapy. After great therapy area is under construction. Plans already difficulty, the services of two well qualified in- are on the drafting board for a 250-bcd acute ternists and two physiatrists were made avail- hospital which will serve as an addition to the able to flie group at Smitliville. present hospital. The nursing home, -,vliich was Things were moving ahead in accordance with partly finished when the Project began, will now schedule. be finished; funds have been raised for its com- Suddenly, on Oct. 7, 1967, Dr. Arch Spelman, pletion. Plans have been altered so that the home the prime mover of the program, the prime su I will be more usable than its original design p- porter of comprehensive care in the Smithville would have permitted. It now appears that the area and the founder, builder and developer of Smitbville, hospital will begin to assume its the program, died of a coronary. An immediate proper responsibility for the personnel provided hiatus of no small magnitude ensued. The staff by the Regional i\,Iedical Program. Six months was disoriented and without leadership; the ad- later than anticipated, the pattern is reassumed ministrator found himself somewhat inadequate and the program continues. to the man tasks that fell upon him. The mem- There has been a groNN7ina acceptance by local y hers of the University of Missouri Medical Cen- physicians of the role that intensive coronary care ter faculty, who were assigned to Smithville to facilities and rehabilitation and extended care assist, felt it incumbent upon them to rei-nain can play in the lives of their patients. An in- .sicians are no aloof from the organizational problems that ex- creasing number of phN t only ad- isted. Any direct participation by members of mitting patients to both services, but are super- the team from the University of Missouri prob- vising their medical care after they are ad- ably would have delayed the final resolution of mitted. Consultation is requested only ,vhen the these problems and might well have placed a physicians feel they bonestly need it and not as bias upon the whole study Nvhich could not have a matter of routine. The home care program is been tolerated. There actually ensued a period growing quite rapidly and very satisfactorily. of approximately four to five months in %vhich There is evidence now that each of these pro- no real concentrated work was done on the pro- grams will be self-supportiny in the near future. gram by the members of the active staff of the It is probably true that the one aspect of the Hospital. All the related work was done indi- program that offers the areatest difficulty from a rectly by representatives from the Missouri Re- financial point of view is the intensive coronary gional Medical Program. Their task was to main- care unit. It is the most expensive to operate, tain as much cohesion and progress as possible the one least frequently covered by third party under the circumstances. carriers, and the one NN,Iiich those who do not This was an unexpected complication which, have insurance are least able to afford. in the long run, probably will move the entire It ,,k,otild appear that the research unit has project to quicker consummation than other-,vise done its Nvorl, quite well. An original survey rep- could have been achieved. resentative of the entire 75,000 people in the The staff has learned to relate to each other medical service area has been completed. The VOLV',IE 65 TIIE SIfl'I'IIVILLE PROJEC7'-IIARDIVICKE 753 NU'.IBER 9 second survey is no-,,., underway to measure, if By the end of 1968, there should be a stifficif-@iit possible, any chan(re in attitude on the part of number of people in both categories to make the recipients of medical care in the area during such a study meaningful. the past year. Physicians on the staff are now Within the next six months, it is hoped that planning actively to become part of a lay edii- the home care prouram will prove self-sufficient cational proaram and to conduct lav educational both economicall and from the service point of y meetings. view. It also is hoped that the intensive core- nary care unit will prove to be self-supportina PARTICIPATION OFHEALTHAGE-SCIES during this same period of time. The balance of the programs appear to be moving in this direc- Concentrated efforts have been made to uti- tion quite rapidly. fize the public health department and voluntary health agencies located within the medical ser- SUil-,fAftY vice area. Efforts to infonn these groups will be continued as opportLinitv pen-nits. In spite of unexpected difficulties, unexpected sorrows and the expected antipathy and distrust of the practicing physicians toward any program EvALu.4,TjoN connected to possible federal control, the Smith- It is hoped that bN, the end of 1968 it will be ville Program has moved along in satisfactory possible to institute a retrospective study of fashion. A great deal of work has gone into the those patients who have come under the influ- Program, both by people interested locally and ence of the extended comprehensive program by those representing the Missouri Regional offered through the '\Iissouri Regional Medical Medical Pro-ram. This work seems to be well Program conducted b-,, the physicians in prac- justified at tl-iis time. We are hopeful that the tice, and to compare this progress with patients outcome will be especially rewarding to the re- who have not come under the same influences. cipieiits of medical care in the Smitliville area. Commtini'ty,41-)I)roacli (Contd) emmental and volunteer, provides broadly based arrhytbmias, unresponsive congestive failure and support and vast resources of skill and expe- intractable pain and to uncertainty of diagnosis. rieiiee. There should be better utilization of SUMMARY USPHS systems development. Partnership with the Heart Association is a key factor. The Missouri Regional Medical Program has 18. Local medical society approval can pro- provided in the Ozarks the best mechanism yet vide cooperation of all physicians in the corn- available to meet the greatest health challenge niunity extending beN@ond any one hospital staff. ever faced here by creating a forum for as- g sembling a vast array of people and resources 19. News media itivolveinent, throuch s arm 0 of plans and objectives from t e outset, will to bring about a reduction in cardiovascular C, probably assure unprecedented public interest death and disability. and support, as exemplified in Sprincfield. 0 BIBLIOGRAPI-IY 20. Limitatiotis of Units will vary with the 1. Corday, Eliot: Address, National Coron,,iry Care Unit Plan hospitals and must be stressed. If full profession- ing Confer@nce, Washington, D. C., June 24-,25, 1967. 2. akerlin, George E.: Address, Annual Nlceting, I%Iissouri al and hardware capability is not at hand, ileartwassociation, Columbia, @Nio., ?,lay 18, 1964. 3. Fox, Samuel bl., III: Address, Nation,,tt Coronary Care Unit prompt referral or consultation when needed is Pitinning Conference, Washington, D. C., June 24-"-15. 1967. obligatory. This particularly applies to pacing H 4. Nfeltzer, Lawrence E.: Panel Discussion on "Congestive eart Failtiie." National Coronary Care Unit Planning Con- catheter placement, to management of serious ference, Washiniton, D. C., June 24-25, 1967. 754 NN,'ILLIA31 STEPIIENSON, Pli.D., Coltittibia* Project Director. MRMP Communication Research topics, somehow, have an intrinsic "demand" By "pre-testin-," the impact of health character of their own, iiid this tlirow-a,,vay bit pamphlets, posters, brochures, films and ra- of paper in no way satisfies it. '.\Iany examples dio-TV spots being developed, the Coinmu- of this kind could be given in which good inten- nication Research Unit of MRNIP is able to tions, fine photography and expensive films improve their effectiveness before general make serious COMMUDication mistakes -,vliieh - could have been obviated by prior copy-testing. distribution to the public. Doctor Stephen son shows how "pretesting" and "facilita- Second, CRU adds to pre-tested materials tors" applied to medical publications on certain "f@qcilitators" which aim at changing be- preventive health measures result in bavior not by "persuasion," "education" or "in- "changing behavior directly' and facilitat- jtinction" (Stop Smoking!), but in some sense ing desired action and response. directly. The best analogy here is "programmed learn- ing" by which materials can be learned very THE Co--\iNiu-,icAno-,, RESEARCH UNIT (CRU) effectively when each step in the earning is has as its objective the development of communi- 11 rewarded." Children will learn very effectively cation which serves not merely to infonn, but to and happily if they are paid to do it. Poor wom- bring about immediate change. Its concepts are en will readily look at a television program on communication-facilitation, communication-ac- birth control if paid to do so. Mass advertising tfon and the like; its affinities are with advertis- for consumer goods wouldn't be successful with- ing and public relations programming rather out the facilitation of supermarkets where than with education and information dissemina- housewives ,vho are shopping can see again the tion. items they saw on television and, thus, be re- First, CRU has devised methods for 'copy- minded to act. Each of us, upon hearing some testinle' news releases, pamphlets, radio and tel- news about which we feel strongly, may intend evision spots, posters, documentary films and to %vrite to the editor or to one's congressman, movies and any or all of the materials produced but bow often do we do so? CRU sets out to for public consumption. It is important to be facilitate action. Given pre-tested materials, how able to do this because few, if any, of these in'a- does one cause people to act? terials are "pre-tested" today. Costly films are An example of CRU at work in this matter is produced and pamphlets published without T)ri- seen in connection with the Smithville Project or copy-testing to find out how far people ide-nti- of MRXIP. Can women be persuaded to exam- fy with them. The result is that many are doing ine themselves regularly for early signs of breast more harm than'good. One pamphlet on cancer, cancer? for example, is calculated to alarm women and CRU studies show that women are worried not at all to assuage their anxieties about can- about cancer. As one physician has said, "There cer. are two major diseases today, cancer and worry Copy-testing sbovn,s that women react highly about cancer." How, then, assuage the anxiety negatively to this kind of leaflet, in spite of the and, at the same time, get women to examine bappy-looking graphics. It is not merelv that themselves? First, cancer experts devised the they dislike having their attention drawn to the self-examination procedures. Next CRU under- grave consequences of leukemia. What disturbs took some outstanding photography to illustrate the women is the triteness of the treatment- the self-examination by using a beautiful model the scrappy bit of paper for so grave a matter with restrained, clignified poses (Fig. 1). An ex- is totally out of place. As one woman said, "Ies pensive-looking pamphlet was then -,vritten and designed bv a creative advertising expert whose like printing the Bible in a comic book . Serious work had won many awards for excellence na- Doctor Stephenson is a Distinguished Research Professor of tionallv and at tl-ie 12tli Festivil International journalism at the Universit), of Missoun. VOLU.NIF. 65 SEARCII-SI'EPI]ENSON 755 Nv%iBFR 9 COAIlt[INICATION RE lowing basic principles, CRU doesn't seek' to persuade, enjoin or inform anyone (although these benefits may occur incidentally). Instead, the object is to chance behavior directly. Again, resort has been made to a pamphlet written from the standpoint of a "do-it-yourself" kit. It doesn't tell anyone to stop smoking. It rely says that if you want to quit smoking, me ientific way to do it by "switching" there is a sc the smoking habit for another habit. The meth- theory (re- od is based upon a modern learning enforcement of a low probability habit by a high probability habit). If you want to switch Fig. 1 This model was used for the many photo. 11 chewin,, gum" for 11 smoking," the trick is to re- graphs required for the pamphlet. Note the restrained, inforce the one at the expense of the other. quiet dignity. Thus, the reader finds that the next time he wants to smoke, he "chews crum" for five min- C, du Film Pubheitaire in Cannes (1965). All of utes and then has a smoke. The latter begins to this material is copy-tested. Men like looking at reinforce the former. Soon he finds himself en- it as much as their wives. Finally, comes the fa- joying the gum, and forgetting the smoking. It cilitator. The responsibility for putting the sounds like expecting a snake to eat itself tail- end inwards, but it works. Aaain, the pamphlet pamphlet into the bands of %,.,omen in Smithville C) rests, of course, with their physicians. Once it on "How to Cope With Cigarette Smoking" is in the homes, however, will the women under- (Fig. 2), is expertly produced. It tells no one take the monthly examination following, MCIL- not to smoke. CRU tests how far behavior is struation as advised in the pamphlet" How can changed this way. The attitudes, no doubt, this be facilitated? CRU hit upon the idea of change par! passti. asking the women to bang the pamphlet in the bathrooi-n, just as cookbooks are kept in kitchens. Fig. 2 This poster, So, this medical booklet has to find a place in a through graphics bathroom. People read there. The booklet is ex- alone, alerts high pensi-v,e-lookina, and worth keeping; it is pro- school students to the dangers of smoking. vided with a silk loop so that it can be hun 9 The above-mentioned from a hool,. A newspaper campaign is used to folder explains how impress upon women the idea of keeping the they may then handle booklet (and other MR@NIP -do it yourself" bool,- their smoking prob- lets) hanging near a seat in the bathroom. Such lem. They will find copies in the school is a facilitator. library. It is scarcely necessary to add that husbands act as facilitators, too, in the above case. Put a COPY of Playboy in a man's bands and his in- terest in breasts is obvious. The pamphlet on It should be clear, then, that CRU is directed 'How to Make a Self-Examination" interests to changing behavior by communication, and men as well as -,voi-nen, and husbands influence not simply to comi-nunicating information to peo- their wives in the matter of regular self-examina- ple. Where information is involved, it is inci- tion. The beauty, the elegance of the production dental to the main purpose. In particular, it is is anxiety-reducing-a matter CRU puts to test. nowhere assumed that "educating" or informing Consider cigarette smoking. Everybody knows people leads ipso facto to desired actions, nor is that lung cancer and cigarette smokina are it anywhere assumed that messages themselves linked. Smolers, however, meet the situation mav be 'persuasive" and that tli duce be- ey in that account. Instead, action requires with reactive indifference. How, then, can we bavior on chan-c their behavior? action. This is the basis of CRU's worl,. c C, urrent advertising caiiipaitins by the Ai-neri- Is it not interesting that where matters of can Cancer Society stress the risks run by opinion arise, CRU may have a place? This fol- smolers and call on smokers to stop smoking. lows from the body of tlicorn, at issue.1-3 When CRU offers no such categorical injunction. Fol- one thinks of theory in the communication fields, I%IISSOVI I NlEl)]CINF 756 COlfAIUNICzITION RESEA]iC]I-Si'EPI]ENSON 1968 one thinks of it in relation to infoniiation science N\,Iiat operant coiiiiiiiinicitioii (\\,])icli is CRU's (such as enters into library science, cybernetics principle conceri)) really is. However, examples and co)nputerized networks generally) and to can liell). Consider, for example, bow CRU mass COMIIIUDication, interpersonal coini,niiiiica- mi(,rlit enter into i-niiltil)basic testing. N17liere does tion and organizational networks and so on. opinion enter here? No doubt, there may be There can be little doubt, bonvever, that what is differences of opinion ii-noiig biomedical re- common to these areas, upon -%N,Iiicli so much searchers about this or that in the nitiltipbasic effort is being expended in the applied sciences test battery. OrdiniriIN", this would Dot become today, is information theory in the Shannon and a problem for CRU unless these scientific differ- Weaver sense.4 The concern is NN,itb si nal trans- ences took oii considerable, almost ideological 9 mission expressed as entropy, redundancy, net- proportions. Or if automated nitiltiphasic testing works, noise, collipling, channel capacity and the can drastically reduce costs for tests in general like. From this standpoint a regional medical hospitals, there might be differences of opinion program is a network involving the lay ptiblic, regarding the desir,,ibilit37 of instituting these re- hospitals, general practitioners and \IR',\IP re- ductions, at least until hospitals have found a search and development projects. One would ,N7ay to recotip tl-iei-nselves for loss of ii)come that study, from this standpoint, Nvliich parts of the this i-nore efficient testing kN,ould occasion. Again, network have the greatest information input, it is unlikely that CRU would find much of a output and couplings. One might inqtiire about problem here that wouldn't be solved more channel capacities. If information is fed to the easily in other ways. What of the publie's body public at increasing rates and volume, is there a of opinion about such testing, sucl-i as attends maximum capacity for its absorption? What of the Kaiser Foundation Health Plan in California, the couplings between lay public and pricti- compared with the NN,ider i-nedical profession's tioners, public and MRMP and practitioners and standpoint? It is here tl-iat CRU can find its MRINIP? Who channels ,vbat information in problems. these couplings? What is the fldelity of the mes- One could illustrate the matter for every proj- sages they receive? What distortions occur? Who ect of every regional medical program. Enough passes on what to NNIiom? How repetitious (re- has been said, it is hoped, to introduce the pur- dundant) do messages have to be in order to pose of CRU, Notbing has been said about the communicate? Is terse and simple writing the technical resources it has at its command, such best for information flow? These and similar as in depth-type interviewing, Q-sorting, "copy- questions illustrate very well to what iiiforma- testing" pamphlets, television spots, posters and tion theory leads. TI-ie questions, no doubt, are ii-i programmed fictor analysis and the like. Its all important ones requiring answors by scien- staff are journalists with beliavioral-science (as tific means. The concern, however, is with in- well as information theory) perspectives and in- fori-nation and the afore-mentioned flow, cou- cludes Communications Director, William Ste- plings, networks, redundancy, entropy, channels phenson, Pli.D.; Associate Director, Normand and t]-ie like. All enter, no doubt, into mass in- DuBeau; Associate, Donald J. Brenner, Pb.D.' terpersonal and organizational communication, Technical Consultant, Terrill Rees, Jr.; Adminis- but none leads to action as such. Indeed, there trative Assistant, Elvera Scroggs; and Research is an assumption in information theory that mo- Assistants, Cathryn Buesseler, Richard Carlson, tivation is either nonexistent or of maximum Thomas Drese, Robert Dunham, William Ingen- and constant impact upon the systems under tbron, Leah Krawetz and Arlene Stewart. consideration. CRU can accept no such assump- tion. On the contrary, it sets out to study these BIBLiornAptiy motivations in the form of operant behavior, 1. Stephenson, W.: Definition of Opinion, Attitude, and Belief. The Psychological Record XV: 281-288. 1965. first as attitudes (Nvbetber before or after 2. Stephenson, W.: Application of 0-metbod to the Measure- ,n,,nt of -Public Opinion. The Psychological Record XIV: 265-273, events) and, then, as changed behavior. This 1964. 3. Stephenson, W.: Evalu,,ttion of Public Relations Progra to in no Nvay denies importance to information de Scienze Econo., ""; . I be published in RiN,ista Intemazionale i,:h theory. We use it iii CRU whenever necessary Co)-nmerciali, Milan ( 1968). (Copies of the paper are available on reqiihest to the author to get at facts. 4. S a non, E. E.')and Weaver, W.: The Mathematical Tlic!o@l of Comintinication. Urbana, The University of Illinois At first, perhaps, it is a little difficult to grasp Press 949. 757 CIIES'l.'Ell G. STARR, Coliirtibi(i* Project Director, ilIR31P Manual of Medical and Paramedical Services in Missouri FOR A NUNFBEII OF YEARS in '@\lissouri, a demand for a statewide director-%- or manual of the vari- A description of The Matitial of Nledical otis health facilities and personnel has been ex- and Paratizedical Set-vices in Alissouri which pressed at meetings and conferences of pbysi- consists of two volumes and was developed ciaiis, nurses, hospitals, nursing home staffs and by MRNLP in response to the demand for a public health, welfare and voluntary health or- statewide directory of various health ficili- ganization personnel. The Health and Welfare ties and personnel in Missouri. The first vol- Council of Greater St. Louis and the Regional nine offers a county-by-county breakdown Health and NVelfare Council of Kansas Citv have of all health facilities and services. The published directories for their areas. Also, nu- second is a supplementary report on all as- merous voluntary health associations have pul)- pccts of employment and training of health lished special boollets and brochures on the spe- manpower in Missouri. The iuthor discusses cific diseases in .vhich theNr are interested. distribution of the books and invites inter- At the inception of planning for the Missouri ested persons to send for copies. Regional Medical Proaram, the Missouri Health Council, a federation of some 35 statewide and regional health organizations, presented a proj'- 0 i)artment of Education and the State Crippled ect to collect ind arran-e information concern- iaiildren's Service are described in regard to ing the entire state and to make this infoniiation functions, district or area territories, hospitals available through publication. The project was treatment centers, clinics and other health ser' approved by the National Advisory Council for vices. The principal professional health organi- MRMP and the Missouri Health Council as- zations are listed with location, permanent sumed responsibility for its implementation. branch offices, officers, membership and other As the project progressed, it appeared that C, pertinent information. The voluntary health or- two publications would be more useful. As a re- ganizations are included with location of prin- sult, one was developed on facilities and ser- vices and the other on the health manpower cipal and branch offices, field representatives, situation in Missouri. executive directors and the services offered. HEALTII NIANPOWER IN N'IISSOURI THE M.C-,'UAL The supplei-nentary report on health man- This publication is a book consisting of i-nore power in Missouri is a much smaller publica- than 400 pages with particular emphasis on tle tion of approximately 60 pages. Current em- health facilities and services available in every ployment or practice of the various principal county in Missouri. The-%, include hospitals, nurs- health professions, current needs in the various ing homes, medical laboratories, clinics, treat- disciplines, the number of specialists in medi- ment centers, pharmacies, public health services, cine, dentistry and nursing, salary ranges and permanent local offices of voluntary health as- schools for education and training are presented sociations and societies, field representatives of on a statewide basis and, also, for each county various health organizations and local clubs or in the state. The counties are represented in a groups that furnish some type of medical or series of charts that are self-explanatory. Each paramedical service. discipline is described and schools are liste The official health aaencies of the Division of with location, admission requirements, length of Health, Division of Welfare, Division of Mental study, costs and degrees given. Twenty-two Diseas es, Vocational Rehabilitation of the DO- health disciplines are represented in the book. Staff is Secretary of the Nlissouri Health Council. The Health Manpower in Missouri Report is NIISSOUFU NILDICI'I'E 758 PARAIIEDICAL SERVICES IN illISSOLIRI-STAIIR SEPTE%(FlEft, 1968 especially ada ted for use bv the disciplines in sociatioii of- Osteopathic Physicians and Sur- p recruiting young persons for health careers. geoiis plan to distribute copies to all of their county and district societies and organizations. DISTRIBUTION The Missouri Dental Association is placing copies in each of its area districts. Many hospi- The circulation of the two books will reach tais and nursing homes have requested copies personnel of the Division of Health, Division of also. Welfare and Division of Mental Diseases. The Any person who is interested in the informa- voluntary health organizations plan distribution tion contained in the books May secure copies to their county and area districts. The Missouri from the infissoi-iri Regional Medical Program, State Medical Association and the \,Iissouri As- Lewis Hall, Columbia, Mo. 65201 National Manpower Conference To Be Held in Columbia One of the most urgent problems facing the nation's health care systems is the critical and ever-growin(r need for health manpower-the right numbers and kinds of people in the right places. About 2.8 i-nillion people were employed in health occupations in 1966; estimates are that another million will be needed by 1975. In order to help meet this serious challenge, the iNIissouri Regional Medical Program and the University of ',\,Iissouri Medical Center has announced that a national conference will be held on Sept. 25, 1968 at the Medical Center Auditorium to discuss "Manpower: Does Health Get Its Share?" The one-day conference will include presentations by Dr. Vernon E. Wilson, Vice-President of the University of 'i\lissouri for Academic Affairs; Dr. Leonard Fenninger, Director of the Bureau of Health ',\Ianpower, NIH, Bethesda, Md.; Dr. William L. Kissick, Executive Director of the National Advisory Commis- sion on Health Facilities, Washington, D. C.; Dr. James P. Dixon, President of Antioch College, Ohio; and other prominent figures from across the nation Nvho are deeply involved in health care planning. The conference will be unique in considering manpower needs, supply and re- cruitment for the health and competing professions, such as law, engineering, finance, industry, etc. Key officials from Regional Medical Programs from all over the U. S. ire being invited to attend and participate in the conference and panel discussion which will follow, as well as representatives of medical schools, educational institutions, hospitals, health professional organizations, voluntary health agencies, official health agencies and consumer groups. Health manpower needs are a national cballena,e, and a nationwide sharing of ideas is needed to find solutions.