more Federal agencies concerned with health matters. In the best of all possible worlds I would like to see one agency with the responsibility for all medical research at the basic level and at the clinical level, another responsible for all experimental demonstrations in the organization and delivery of medical care, and the third responsible for all matters pertaining to the education of physicians. This is an impossible goal but the more we can do away with duplication of effort the better will be the end product.

In conclusion, I wish to thank the subcommittee for listening patiently to the convictions and prejudices of a medical educator.

That is the end of the formal statement. If I could be permitted, Senator Harris, I would like to make a few comments about engineering.

Senator HARRIS. Yes, sir.

Dr. EBERT. It was something that I had though of putting in this statement which will I think supplement some of the remarks that were made by Dr. Walker.

I believe, as he does, that engineering is an area in medicine which has not been developed fully. As he has stated, there has been relatively little communication between schools of engineering, or even departments of engineering in universities, and medical schools. Some work is being done in this area, but not enough.

I think that basically there are three areas in which one can see fruitful collaboration between engineers and physicians. First of all, at the level of fundamental investigation, it is quite clear that the engineer today has the methodology and the knowledge to do quite sophisticated studies on such things as flow. Yet the people working in physiology and cardiovascular disease have not availed themselves of this kind of knowledge to the degree that they might. This type of remark I think could be duplicated in many other areas.

A second important area is in the development of instrumentation. It is quite clear that much of what goes on in the hospital today in the study of the patient is dependent upon the development of sophisticated and economic instrumentation. As Dr. Walker pointed out, there is not a great deal of funding available for the development of this kind of instrumentation; yet it has a direct effect upon the quality of care given to the patient, as in cardiac monitoring, or upon the expense to the patient, as in the development of the autoanalyzer, which now makes it possible to do 15 tests on the blood as inexpensively as it does to do one.

The connection of these to adequate computer monitoring is also an area that needs to be developed. It is of interest, just continuing briefly on the private sector, that Lockheed has now a contract with the Mayo Clinic to look at the organization and the instrumentation. at that clinic, with a view not only to look at how they use their instrumentation, but how to save time and effort on the part of people involved.

This brings me to the third area, which I think would be most productive in collaboration, and that is in the area of systems engineering. There is the expert knowledge in the field of engineering which has been applied in things like the defense industry and in the space industry, which could clearly be helpful in the study and the solution of problems in the health field. I think it has many appli

83-470 0-67- -13

cations, but the one that interests me particularly is the help that systems engineers might give in the organization and delivery of care. This would be important, not only in making more care available for less money, but also I think it could lead to a much more efficient and effective use of our resources. Ultimately it could lead to comprehensive care for the individual patient.

Thank you very much.

Senator HARRIS. Thank you. That is a subject I was going to ask you something about. Dr. Starr and I were talking after he testified, and he made a statement (which I paraphrase) that with the growing interest of the Federal Government in the health of all its citizens, we simply do not have either the people or the resources to provide adequate health care for our growing population, if we continue exactly as we are today. This, of course, suggests innovation.

It seems to me that one of the innovations may have to be in the field that Dr. Walker, Dr. Starr and you have discussed. As a matter of fact, that was why he made that statement. He is in the field of bioengineering.

He went on to say in our conversation that many times the doctor doesn't realize that the engineering people might be able to do some new things that can't be done now in the practice of medicine. On the other hand, the engineer doesn't know that the doctor needs these things done.

Dr. EBERT. That is correct.

Senator HARRIS. And it is only when they get together that they might discover new ways, for example, that the patients' atmosphere might be controlled more precisely. If the engineer were given the specifics and if he knew what level would be acceptable, he would have something to work on. So I appreciate the three areas where you feel bioengineering or some collaboration between engineers and medical people might have some promise.

Also, it seems to me that in addition to that field, we are going to have to reexamine ourselves and our institutions and our programs, to see if, in addition to simple or complex mechanical aids, we might not have to do more to help the doctor. Through the use of subprofessionals of some kind, we might spread his abilities and knowledge around further. I wonder if you have any comment about that.

I agree with you that right now we can make the greatest breakthroughs in this country by better delivery of what we already know. Dr. EBERT. The point that you have just made is really in a sense a key one. When we look at the possible solutions to the problem of shortages, we really have only two choices.

We can produce a great many more people and we know that that takes time, and use them as we do now, or focus on the problem of increasing the productivity of the physician. If we could increase the productivity of physicians in this country by the use of other professionals and subprofessionals by let's say 30 percent, it would be the equivalent of adding another 90,000 physicians to the country. It would take 10 years to produce this number by graduating let's say 9,000 physicians a year.

The only way that one can really go about increasing productivity is to provide the physician with sufficient aids to what he does so that

he can be more efficient and more effective. It seems to me that this is going to be done in several ways.

It is going to be done by the use of these bioengineering devices at the level of both instrumentation and the systems kind of engineering. It is going to be done by developing teams of people who can work together, so that the physician does those things which he does well, and which only he can do. Other people in the health professions or subprofessionals can do many of the things which the physician now does because it doesn't take that much skill to do them.

I believe as you do that increasing productivity is by far the more rational solution. In order to do it, however, we must look into this whole area in a rational kind of a way, using certain kinds of engineering techniques to develop new methods. I admit immediately that these are not easy things to do. We have learned something about the manipulation of molecules. It is a little more difficult to manipulate social institutions, hospitals, clinics, doctors' offices, and their relationship to the community.

I think it is absolutely mandatory that they do move, because in the long run it is going to be in the best interests of all parties, it is going to be in the best interest of the physician, it is in the best interest of the patient and, really, in the best interests of all of our citizens to go forward in this kind of a manner.

Senator HARRIS. I think it is actually not so much a matter of choice between things we will do. I think especially when the war in Vietnam has ended, we will be able to do all of these things and that we must do them. The people are going to demand it.

Dr. EBERT. Yes, sir.

Senator HARRIS. And rightly so. It seems to me that the medical school is the one which is particularly going to have to take the lead. Dr. EBERT. Yes.

Senator HARRIS. On the matter of subprofessionals, and I know that there are certain deterrents to that concept, but are there plans being worked on in medical schools around the country to provide for other kinds of professionals and subprofessionals, as well as for physicians? Dr. EBERT. There is an increasing interest in this, Senator Harris. A number of schools are developing. Medical schools have really become schools for the health professions, this has been particularly true in many of the State institutions in Alabama, Kansas, and so on.

There is another way in which one can proceed in this, and one which we are interested in. That is to actually join forces with other schools in the area. Northeastern University is a near neighbor of ours, and has been extremely active in the development of people at all levels in the various health professions. They have traditionally used our teaching hospitals, and as a part, then, of a kind of consortium, we can use the medical school, the university, the community college, the teaching hospital, in an effort to provide the appropriate kind of educational environment for the use of all of these kinds of people. I think that this is something in which the schools in the country are interested in, and I think will go forward, but I think it clearly is going to need additional support in order to push forward.

Senator HARRIS. Thank you very much. Do you have anything further to add?

Dr. EBERT. No, sir.

Senator HARRIS. Thank you very much for your presence here and for your testimony. We appreciate it very much.

Dr. EBERT. Thank you, sir.

Senator HARRIS. Our third witness this morning is Dr. Jack P. Ruina, professor of electrical engineering and vice president for special laboratories, Massachusetts Institute of Technology. Without objection we will place a biographical sketch, concerning Dr. Ruina, in the record at this point.

Biographical Sketch: Dr. Jack P. Ruina

Professor of Electrical Engineering, Vice President for Special Laboratories, Massachusetts Institute of Technology, Cambridge, Massachusetts.

Background data: Instructor, Electrical Engineering, Brown; Assistant Professor, Associate Professor, Research Associate Professor, Control Systems Laboratory, Illinois. Deputy for research to Assistant Secretary, Research and Engineering, U.S. Air Force. Assistant Director of Defense Research and Engineering, Office of the Secretary of Defense. Director, Advancement of Research Projects Agency, U.S. Department of Defense.

Dr. Ruina, we know of your background and work, that it is in the general field of concern of this subcommittee. We compliment you for your record of achievement. We are pleased to have you this morning.

TESTIMONY OF DR. JACK P. RUINA, PROFESSOR OF ELECTRICAL ENGINEERING, AND VICE PRESIDENT FOR SPECIAL LABORATORIES, MASSACHUSETTS INSTITUTE OF TECHNOLOGY, CAMBRIDGE, MASS.

Dr. RUINA. Thank you very much, Senator Harris.

I appreciate your inviting me to appear before this committee. I presume your invitation to me stems from my role as chairman of an ad hoc committee on certain management aspects of NIH's support of directed research. This committee reported to the Secretary of Health, Education, and Welfare in March, 1966. As you may know, I am not a medical scientist but I have had a good deal of experience in applied research and the management of research and development in academic and government settings.

NIH has long been immersed in biomedical research and training and enjoys an excellent reputation. It has been very effective in its dealings with the research community and in serving national goals.

However, part of the report of the Secretary's ad hoc committee dealt with the problem of management that would be posed if, as is anticipated, there are to be large scale developmental efforts in the biomedical field. Examples of developments the committee had in mind are such things as an artificial heart, an artificial kidney, special prosthetic devices, and systems for computer-aided medical diagnoses. This would involve NIH in contract specifications and negotiations, assessments and decisions regarding tradeoffs in performance, costs, schedules and risks. Parts of the government such as the Department of Defense and NASA have had experience with large scale development projects but NIH has not had this experience. It is my opinion that more than simple changes in NIH procedures and staff would be required to prepare NIH to manage effectively such programs. There are deeper factors involved that relate to the traditions and values of the medical community which I will discuss later.

I believe that the degree and the kind of involvement that the government should have in its sponsorship of undirected research is different from that it must have in its sponsorship of large, directed development projects.

In undirected research a minimum of management and control seems best. Generally such projects revolve around the work of individual scientists or small groups of scientists. Initiative, stimulation, and standards come primarily from the scientific peer group. If management and administration are too involved, you are likely to find a demoralized scientific staff and an environment not conducive to retaining creative people. The role of the government is to decide the important areas of research, the proper allocation of funds, the choice of talented individuals, and appropriate institutions. This can be successfully done with minimum staff and usually with heavy reliance on advice from the scientific community. Scientists have a long tradition of judging their peers. They are regularly involved in judging the professional qualities of prospective staff and students, the quality of publications and the merits of research results. Government involvement in day-to-day activities is neither necessary nor desirable. Sometimes administrative rules and regulations are developed to protect against real or imagined transgressions. These safeguards can perhaps serve to protect the sponsor. However, they may also result in changing the environment of the laboratory from one which is conducive to scientific productivity to one which is administratively neat but scientifically sterile.

This is not to imply that the government should not periodically review progress in the field, reassess national priorities, and reallocate resources accordingly. However, the government would be doing its own goals a great disservice if it did not do everything possible to maintain the integrity of the research laboratory.

As we move into the areas of directed research and engineering development, the government's role becomes different. Here individual projects are large and the inevitable changes in direction, performance, and costs become day-to-day matters of concern. Outside advice becomes less important and cannot conceivably replace in-house government competence in handling the job. A different type of person with different skills is required to assume the role of government manager. People are required who are technically competent and who are temperamentally suited to live with the risks and responsibilities involved in their day-to-day decisions. It must be kept in mind that development projects are larger and therefore more visible. Because their goals can be more clearly specified, they can also be more clearly judged as successes or failures.

The possibilities of development of an artificial heart can illustrate some of what I am getting at. NIH, I am sure, has supported many investigations in blood chemistry and other fundamental, biomedical aspects of the circulatory system. I am sure that NIH has also sponsored investigations of different cardiovascular surgical techniques. Some of these investigations have produced very useful and relevant results. Others have uncovered unforeseen difficulties. All have helped train experts in the field and helped focus attention on the technical problems. In the last few years attempts have been made to develop a device which can augment or even replace the human heart as a pump.