for health in the region, scientific devices which are needed but lacking at present, a communication facility which possibly could be adopted for purpose of the program.

The research group functions as a medical experiment station drawing together the talents of all university disciplines which can contribute to the definition or solution of health care problems.

Of the 21 bioengineering projects now active, I should like to mention two. One result of this research has been the development of a diagnostic chair, which simplifies the taking of a heart tracing. The chair reduces the time required for an EKG from about 20 minutes to less. Another piece of equipment developed by the engineers and the physicians working together is an electrolytic unit which has proved extremely helpful in speeding the healing of leg and body ulcers for the diabetics or patients who must be in bed for long periods, and these compact units can be taken home.

An added feature is an alarm system which reminds the patient to keep the bandage properly dampened.

Future programs could be summarized as the design of more model delivery systems in cooperation with the public and health professional involving finally the entire region, continued concentrated study of appropriate services designed to be self-supporting, the assistance to programs in providing for treatment of disease and rehabilitation of patients suffering from these categories of disease, and last, a translation of new ideas into action on behalf of the patient or the potential patient.

This is indeed an exciting, though wearing, time to be involved in health affairs. The regional medical program, to my mind, offers one of the best means for achieving optimal health for all people, who are in effect the real beneficiaries of regional medical programs.

I would certainly urge the support and the continuation of this program.

Now I have here an organization chart of the Missouri regional program which I would like to offer for the record.

Mr. ROGERS. The committee would be very pleased to have that, and it will be made a part of the record at this point. (The document referred to follows:)

MISSOURI REGIONAL MEDICAL PROGRAM ORGANIZATION

1. GOAL SETTING

(a) Policy is set by representatives of the public and the practicing profession upon advice from:

Medical schools.

State departments related to health.

Voluntary organizations.

All health professional organizations.

(A total of more than 50 people read and comment upon each Proposal.) (b) Planning is for a selected population of people regardless of where they may ultimately receive their care. This permits maximum use of communication mechanisms already established between the many involved groups. (c) Planning and operations are kept administratively separate.

2. ORGANIZATIONAL PATTERN

The Project Review Committee consists of the head or his delegate from the schools of osteopathy and medicine, the Division of Health, Director of Welfare and Director of Mental Diseases. This committee serves as an advisory body to the Council on all proposals.

An Advisory Council, nominated by the Project Review Committee and appointed by the Governor, serves as the governing body. The 12 members serve staggered terms, no person's service to exceed six years. Members may not be drawn from University staff.

The Liaison Committee is composed of elected or appointed representatives sent by each state-wide voluntary or professional organization which has applied to and been accepted by the Council. The 24 members serve as a reaction panel on all projects for Council.

The University of Missouri serves as trustee for funds for the Missouri Regional Program.

3. SPECIAL URBAN ORGANIZATION

For the Kansas City area a special Metropolitan Liaison Committee has been formed. Members include five local citizens and two representatives from each of the Advisory Councils of the two regions (Kansas and Missouri) which overlap in the Kansas City area. This committee also serves in an advisory capacity to the two Regional Councils for all projects which fall within the six county urban area of Kansas City.

A special, local planning force has been assigned to Kansas City by the Missouri regional program.

No matter how a region is described, ultimately it must interact with other regions. Modifications of the Kansas City committee have been developed with three of the other adjoining regional programs and similar plans are under discussion with a number of other regions which also adjoin Missouri.

Mr. STARK. I submit for the record three separate publications of the Academy of General Practice as evidence of cooperative efforts between the practicing physician and the program.

Mr. ROGERS. We will receive those for the committee file.

Thank you very much.

Dr. Carter?

Mr. CARTER. I just want to compliment this gentleman upon the paper that he has delivered here today, and to say that I think it is a very healthy sign when men of his evident ability take part in such programs as this. Thank you.

Mr. ROGERS. I would like to second those sentiments. I think it is excellent, and we do need more and more people to involve themselves in the health field other than just the scientific community, and I wonder if you could give us an example-you say the design of more model delivery systems. What is your thinking there?

Mr. STARK. Two that I have specifically in mind: One would be the Smithville project located in a rural area about 15 miles from Kansas City where they are designing a program for the first time to give complete continuity of care from the time the patient is seen in the diagnostic stage through the treatment stage and then into the rehabilitation stage.

Another one is that taking place in Springfield, Mo., at the community hospital. A cardiovascular program is in force where they are treating the cardiac patient and also training nurses and doctors in the care, treatment, and rehabilitation of cardiac patients. This is a part of the current operational grant and is working out very well. There are six or seven programs in operation, or being proposed now, in community hospitals.

Mr. ROGERS. Thank you very much. We appreciate your being here today.

Our next witness who has a 4 o'clock plane, I believe, is Dr. Amos Bratrude. We appreciate your presence here today. Your Congress

man, Tom Foley, spoke to me on the floor and said he wanted to be here to personally introduce you to the committee and regrets he cannot be. He is in committee himself.

STATEMENT OF DR. AMOS BRATRUDE, WASHINGTON MEDICAL ASSOCIATION, AND ASSOCIATION OF GENERAL PRACTITIONERS

Dr. BRATRUDE. I was sent here today by the Washington Medical Association, and I have the blessing of the Association of General Practitioners.

I am Dr. Amos P. Bratrude and am in general practice in Omak, Wash. I have a common failing with all people who have moved West, and that is our adopted home has become very important to us, and so you'll excuse me if I give you a few words about Omak. It is a rather typical western community of about 4,500 people. The prime industries are logging, apple orchards, and cattle. The biggest single event of the year is the Omak stampede with what we consider, a world-famous suicide race. It is a nice community and my 9 years there have been very pleasurable. I am married and have four children, and as a father am beginning to experience the rigors of a teenage daughter.

I was raised in the Middle West. My father was a general practitioner in a small town by the name of Antioch, Ill. Upon deciding where to practice, there were several things I was sure that I wanted.

I wanted a community with a hospital in it. I have always been very interested in general practice but could see no reason to choose a community that was large enough to have a well established specialist group. I wanted to choose a community that I felt had some promise of growth so that I could eventually have the type of medical practice that I was interested in. This; namely, is a group of three, four, or five doctors who are quite interested in the practice of medicine, but also want to be free to pursue academic and recreational activities. I am now the senior man of a four-man group, and the reason that I can be here today is that I have three excellent partners that are covering for me.

Those were the practical reasons for choosing Omak. The emotional ones are that the country just immediately appealed to me. I enjoy hunting and fishing and being outside, and all these things were available. We have been 15 months in a new hospital with 32 beds, and a staff of seven physicians. Of course, four of these are of our group. It is quite interesting to me to go to various meetings and seminars and hear people discuss the problems of a small hospital. Invariably these people consider anything from 100 to 150 beds to be a small hospital. Consequently, their discussions of problems that might occur there have no bearing at all on what happens in a hospital of 32 beds. I had always been quite interested in the broader problems of medicine, and when the opportunity came to me from the Washington-Alaska regional medical program I welcomed it.

I would be the first to admit that I had a rather biased viewpoint when I joined the Washington-Alaska regional medical program board. I had been raised of fairly conservative parentage and had a decidedly jaundiced opinion of the role I thought Government was playing in medicine. It is quite surprising to find out at the first advisory com

mittee meeting that most of us had the same feeling. Then it was interesting to see the change in everyone as the meeting progressed. It seemed that most of us had very definite, but very erroneous ideas of what the regional medical program would be and how it would work. It was explained in the first session in May of 1966 that the regional medical program was not going to be a vehicle to transport the patient to "supercenters" but rather was going to be a vehicle to transport knowledge, technique, and assistance to the local level to improve patient care in places such as Omak. I, of course, was very suspicious that this was just the bait to lure us into the trap. I have now com pleted approximately 20 months on this committee, and I am convinced that at least the Washington-Alaska program has not altered from this ideal; that is, to attempt to improve the level of care for victims of heart disease, cancer, and stroke and related diseases into local communities. I was also prejudiced in another area as I approached the work on the regional medical program. I am in a very rural community. I think it is wonderful to have great research projects and a large amount of what we call ivory tower medicine. But I also feel there is a tremendous amount of medicine that has to be practiced on a day-to-day basis to help the people receive proper care.

I also had many preconceived ideas about physician education programs that I felt were fairly worthless. I have taken these prejudices and conveyed them into ideas for our group, and am afraid I have helped to sidetrack certain programs I felt had little practical value.

I do want to say that I feel there is a definite place for complicated research projects, and without them many of the advances we enjoy today would not be here. But I feel, as the only general practitioner on the Advisory Committee, that I have wasted very little time arguing for the aspect of medicine because many about me are. In regard to specific problems that were present in the practice of medicine in north-central Washington these are some.

There are certainly many other problems which deal with rural areas, and many of these would fall in the categorical areas of the heart, cancer, and stroke program. We are looking forward to taking advantage of the coronary care unit training programs that are currently being established by our RMP and are looking forward to many other benefits from it. I think the point that I would like to make so strongly is that the RMP has offered the first opportunity for local medical communities to feel that it is worthwhile to get involved and interested in because their opinions and problems are being sought.

There certainly has been a considerable change in stance of the average physician in regard to Government in medicine. Just a few years ago no cooperation would be offered, and if preferable no interference would be tolerated. Today we find the average physician understanding that the Government will be involved in medicine and that a cooperative venture of some kind would be most desirable. The RMP with its emphasis on regionalization has, I believe, caught the fancy of the medical communities of the United States. As I travel to various meetings with colleagues who are scattered across the country, I find that quite often they have many favorable comments concerning the aims and goals of this program. I think that if this pro

gram were to be significantly curtailed or even dropped, you would find a considerable disillusionment in the medical profession. I think most of us feel there is a strong chance that the RMP is going to offer all of us help and cooperation, not interference, from the Government on our local medical problems. I think that if it were possible to establish a long period, such as 5 years, the RMP could then do significant future planning and the medical community would know that the program was here to stay.

I have certainly enjoyed the experience of coming to Washington, D.C., and appearing before this committee.

Thank you very much for the opportunity.

Mr. ROGERS. Thank you very much, Dr. Bratrude. Your testimony is the type I think the committee needs to hear, from a practicing physician. We are delighted that you took time to present this testimony to the committee.

Dr. Carter?

Mr. CARTER. I certainly want to congratulate the gentleman upon his presentation. He is one of the men who applies the tools which have been given him, and in addition will evaluate and use what other tools are given him by our regional groups. I am impressed by his paper, and the depth of what he says. I am happy to have such a young physician before us today.

Mr. ROGERS. Let me ask you: You say you are the only general practitioner on the Advisory Committee for your region, or is this a subregion?

Dr. BRATRUDE. I am the only one for the Washington-Alaska meeting. We have six practicing specialists from various disciplines; in addition, of course, to many physicians in the universities.

Mr. ROGERS. But there are six out of 30 whom you would classify as practicing physicians?

Dr. BRATRUDE. Seven, counting me.

Mr. ROGERS. How many hospital administrators do you have?
Dr. BRATRUDE. Two.

Mr. ROGERS. Do you think this is a good ratio?

Dr. BRATRUDE. It is difficult to put everybody there. We have six or seven lay people, we have two nurses, we have a dentist; and by the time you are done, we really aren't heavily laden with the medical school people.

Mr. ROGERS. Would it be more of a problem getting away if you were not in partnership?

Dr. BRATRUDE. I would like to speak about this a bit. I think the concept of the practicing physician is changed somewhat. As we are trained today, we are totally convinced that we have to stay current; and I think, as we set ourselves into practice, many of my colleagues in our county are in independent practice, such as Bill Henry, one of the doctors there. He feels it is important enough, and has educated his patients enough that he gets away for courses. I believe that group or no group, this is the way it is going to be in the future.

Mr. ROGERS. You don't think it can be brought down to the hospital level?

Dr. BRATRUDE. I don't mean that. We have hospital staff meetings, and visiting professors who come for seminars, and the gentleman