I believe our experience in Michigan is not atypical. I do think it is important for us to understand the soundness of the program which is under way, the marshaling together of resources, the innovation which characterizes all of the planning activities in the foundation for the program which is being well laid at this point in time.

To help these programs, I would certainly hope that a great deal of emphasis will be placed on the need for the efforts under comprehensive health planning programs and the cooperative regional arrangements developed under the Regional Medical Program Act, to be compatible and in conformity.

I think they are complementary with respect to goals and activities, and I think at the local level we must do everything possible to be certain that these are not in conflict, but in fact do cooperate and support each other.

I do believe there is a real need, as the statement indicates, for limited construction funds, and I would hope that as a part of the introduction of my formal statement in the record that you would also include the appended article entitled "Hospitals and Regional Medical Programs, a Plea for Coordinated Action," which was in the December 1967 issue of Hospitals magazine. This was written by my good friend, Dr. Robert Evans, and I think amplifies eloquently on the point that I would make, that there is a real need for limited construction dollars. Mr. Chairman, I certainly hope that this bill will be supported by your committee and will be adopted. I think the progress so far is sound, because we have gone cautiously. I believe the operational programs will speed the day that we will get to every area in Michigan, to every citizen in Michigan the benefits that this program was designed to bring.

I should be pleased to answer any questions you might have. It has been a pleasure to appear.

(Mr. Sibery's prepared statement follows:)

STATEMENT OF D. EUGENE SIBERY, EXECUTIVE DIRECTOR, GREATER DETROIT AREA HOSPITAL COUNCIL, DETROIT, MICH.

Mr. Chairman and members of the subcommittee, I am D. Eugene Sibery, executive director of the Greater Detroit Area Hospital Council. I also serve as chairman of the American Hospital Association's Council on Research and Planning, and I am the president of the Association of Health Planning Agencies. I was the acting coordinator of the Michigan Regional Medical Program during its initial, organizational period, and now serve on that Program's Regional Advisory Group.

I am here today to speak in support of Title I, H.R. 15758, to extend the authorization for Regional Medical Programs for heart disease, cancer, and stroke. As a health planner involved with the coordinated planning activities of a hundred hospitals in one of the Nation's most heavily urbanized areas, I am strongly attracted by the potential of Regional Medical Programs and impressed by their progress.

The strength of these Programs stems from the spirit of voluntary cooperation which underlies them, and which was written into the law largely by your committee three years ago.

This voluntary, cooperative approach to problem solving isn't as swift as a more directive approach might appear to be, but I hope that you will be persuaded that it is far more sure.

Regional Medical Programs are becoming strong and successful forces in our society because they challenge the ingenuity of the participants. They are becoming strong and successful forces in our society because they exist to meet specific local problems, not problems that have been rendered sufficiently vague to be

labeled national problems. And finally, Regional Medical Programs are becoming strong and successful forces in our society because they are based upon plans and decisions made by those who must carry out the plans and decisions, and by those who will be affected by them.

This last point-broad-based involvement for cooperative planning and actionis the paramount reason Regional Medical Programs will ultimately succeed in the inner cities of America. It is a program that health planners have long awaited, a program to draw together the hospitals, physicians, public health agencies, and all of the other elements necessary to provide efficient, effective, and economic health services.

It is also a program which must incorporate the opinions and thoughts of the public to be served by these health resources, and this too is a terribly difficult task. The population of our inner cities is depressed in mind and spirit, handicapped by lack of education and opportunity, and all but overwhelmed by poverty and need. This must not deter us. Without the cooperation and support of these people, no program can succeed.

The development of Regional Medical Programs has seemed slow in the inner cities, but there has been progress. It's not unlike the construction of a building. Until the foundation is laboriously dug and built, and the main structure begins to rise, progress is not apparent. Regional Medical Programs have been digging their foundations with à process of careful planning, and the structures beginning to emerge the operational programs-will be all the sounder and stronger for this early effort. Briefly stated, from the national view, the progress of Regional Medical Programs has been dramatic: Less than two years ago, there were no Regional Medical Programs; today there are 53 organized and at work. There is one further reason why I view the period of planning as so essential. The experience gained in this program for heart disease, cancer, and stroke can serve as a guide to make it far easier for other health programs to meet the needs of our country's entire population, including our urban areas. Significant changes in the traditional methods of delivering health care must be effected. I believe with active and meaningful involvement of all health professionals, the Regional Medical Programs will provide the mechanism for the health professionals to markedly improve the patterns of organization and distribution of health care.

I believe our experience in Michigan is not a typical. With the $1,294,449 grant awarded the Michigan Regional Medical Program almost a year ago, the Federal Government has essentially bought a blueprint for the initial stages of action. Most tangibly, this initial blueprint is a 504-page document, our first operational grant request, which defines what we must do and commits us to doing it. It is not a sterile plan devised in some ivory tower. It represents a realization that previously fragmented health resources can unite to provide the best possible patient care for heart disease, cancer, and stroke, a realization held by the scores of men and women who live in the real world and who have contributed and will continue to contribute to this planning task. It represents our entire Michigan countryside.

From my point of view as a health planner concerned with the total health needs of my metropolitan area, one of the most important facets of this Michigan Regional Program is the series of linkages which have been made with a great number of groups and institutions engaged in health planning and providing health services in our Region. I hope that the staffs and Advisory Groups of all Regional Medical Programs share my zeal for coordination of activities in this regard. Specifically I believe Regional Medical Programs and Comprehensive Health Planning programs, both authorized by legislation enacted by the 89th Congress, are quite complementary and mutually supportive of their activities and goals. Every effort should be made by the staffs of these two programs, at the local levels, to ensure this cooperation and coordination exist.

To help make these Programs more effective, I urge your approval of Title I, HR 15758, with one change: Give the Regional Medical Programs limited authority for construction to meet regional needs as stated in the Surgeon General's Report on Regional Medical Programs to the President and the Congress, and as eloquently amplified in an article entitled, "Hospitals and Regional Medical Programs: A Plea for Coordinated Action". This article appeared in the December 16, 1967, issue of Hospitals magazine. It was written by my good friend, Dr. Robert L. Evans, Director of Medical Education at the York (Pennsylvania) Hospital, and immediate past president of the Association of Hospital

Directors of Medical Education. Dr. Evans assisted me in preparing my testimony for today, Mr. Chairman, and I would like to request that his article be inserted in the record of this hearing. I hope, gentlemen, that Dr. Evans' article will convince you of the need for Regional Medical Program construction authority.

Thank you; that concludes my statement.

[From the Journal of the American Hospital Association, December 1967]

HOSPITALS AND REGIONAL MEDICAL PROGRAMS: A PLEA FOR COORDINATED ACTION (By Robert L. Evans, M.D.1)

To say that in the last three years our medical care system has been subjected to close scrutiny, deep concern, and an incomprehensible quantity of advice is both trite and insufficient. Since early 1965, our medical care system has existed in a holocaust of suggestion, pressures for change, and internal and external examination, which has involved the President of our nation on one hand and volunteer drivers of our neighborhood ambulance clubs on the other.

Organizations representing every level of medical care and medical education in our voluntary system and virtually every executive and legislative branch of our national, state, and local governments have had their say-and are still talking. Beginning with the Coggeshall report in 1965 and progressing through the DeBakey commission, the AMA task forces on education and care, the Millis commission, the pending reports of the National Advisory Commission on Health Manpower and a similar Commission on the Cost of Medical Care, our system, its voluntary hospitals, organized medicine, medical colleges, and the role of our federal and state governments have been studied by so many groups and individuals that often there have seemed to be more bacteriologists than bacteria composing the culture. There are no indications that this trend will stop. There should be no desire for the cessation of these activities unless they are threatened with the mumps of minisculity, from which they may emerge sterile.

Good health is now a fundamental right, together with life, liberty, and the pursuit of happiness. Examination of the system that ensures this health is now in the public domain.

LEGISLATIVE ACTIVITY

Complementing the studies and investigations has been a host of bills repre senting the greatest activity in social legislation our nation has ever experienced. This began with the legislation encompassing hospital and medical care for the aged and indigent, followed by the various health career training acts, and more recently has included the programs for planning on a regional nonpolitical base and on a nonregional, political base (Public Law 89–239 and Public Law 89–749). This legislative onslaught is aimed at producing better health for the citizens of our nation, although in some respects it replaces properly aimed rifle fire with poorly aimed shotgun charges. No one can predict with any degree of accuracy the eventual effect of the activities of the mid-1960s on our voluntary care system-indeed, to attempt an intelligent appraisal is a staggering and incomprehensible task. This paper is concerned with only a small and comprehensible portion of the studies-the planning legislation-that portion concerned with the Regional Medical Programs of the National Institutes of Health, continuing education in medicine, their relationships to our hospitals and medical colleges, and their governmental support system.

Beginning in the 1930s, but accelerated productively by World War II, two parallel governmental funding systems have had a vital impact on medical care and knowledge: (1) billions of dollars of federal support and additional millions of voluntary foundations support have gone into basic biomedical research, and (2) additional billions have gone into hospital and facility construction.

While expenditures for research were producing almost indigestible quantities of new knowledge designed to be productive in the prevention, diagnosis, and treatment of disease, other monies in smaller quantity were developing a voluntary system of hospitals and other community facilities that are structurally

1 Robert L. Evans, M.D., is director of medical education, York (Pa.) Hospital, and president of the Association of Hospital Directors of Medical Education.

modern and usually competent. New medical knowledge has been produced largely in major medical college research and teaching hospital complexes, but the majority of health care has been delivered to our people through a distinctly separate system of community medical institutions.

Communication between medical education and research centers and community health care delivery centers began to deteriorate before and during World War II. It has become increasingly ineffective through the 1950s and 1960s.

Unquestionably, the federal system of research support has been productive in terms of knowledge, but it has served, through the tender trap of "soft money," to enhance greatly the difficulty in communication between the teaching and research centers and the community hospitals. Patterns of human behavior dictate that an individual infected with the virus of discovery-whether through financial or personal suasion-and whose job and family support are functions of continuing success in discovery, will lose interest at a rapid and predictable rate in the more mundane functional application of his discoveries, except as such application might further prove his theses. Understandably, as the Midas touch of research support produced more full-time faculty members who received their major support from investigation rather than teaching, less and less of their time became available to transmit and validate information from the medical college to the functional arm of the medical care system. These attitudes are both inevitable and defensible within the system that has produced them.

At the receiving end of this sclerotically deteriorating pipeline of communication between educational centers and care centers, other disruptive forces were at work. Most of the governmental support to our voluntary medical care system, as represented by our community hospital, is directed at bed needs. Provable demographic studies, leading to indicated increases in bed capacity, produce the highest priority of funding in hospital construction. Very little support has gone into the creation of diagnostic or treatment facilities unless they are immediately defensible by bed capacity. Almost no support has gone into nonpatient care and supportive facilities of an educational, evaluative, or analytic nature. Accrediting bodies stress in ponderous manner the necessity for smooth operation and recording of the administrative and business functions of a hospital and its medical staff, but pay almost no attention to the actual quality of the staff, or to any system of assuring the continued quality of the staff in terms of updating of knowledge and techniques.

The exceptions to this insistence on administrative and directive function have occurred in relation to two active forces: (1) incidental to approval of graduate programs (internship and residency), the American Medical Association's Council on Medical Education does insist on minimal standards of graduate education and on evidence of departmental educational activities in those departments operating approved programs; and (2) the American Academy of General Practice for some years has had an established minimum requirement in continuing education for its membership, which the academy itself recognizes as a minimal figure.

EMPHASIS ON BUSINESS FUNCTION

The predominantly lay boards and lay administrators of our voluntary hospital system frequently have contributed further emphasis upon bed capacity and direct bed support. It is a paradox that individual hospital board members, who are involved in corporate structures that place tremendous emphasis on continuing education in management techniques, psychology, and evaluation for their management personnel, neither insist upon, nor are oriented toward, the same emphasis on comparable continuing education activity in the medical staffs of the hospitals that are their community charge. The development of this orientation is again both understandable and defensible within the system that has produced it.

Businessmen tend to regard hopsitals as businesses and to stress their business function to the administrative group. Government and accrediting bodies understandably have been reluctant to impose continuing education requirements on the medical profession. Many examples around the country show that when the necessity for continuing education and its basic purposes in relation to medical practice are explained in a clear and knowledgeable manner, most board members and administrators are quick to recognize its import, but still may assign

it a low funding priority in an overall system that directs insistent light upon bricks, mortar, systems, and machines.

ATTITUDES OF MEDICAL STAFFS

Hospital medical staffs have been both active and passive in adding plaques to the sclerotic communications pipeline. The measurable shortage of physician manpower tends to confine their immediate thought to the care tasks at hand, which are all too time consuming. Physicians have tended to regard the medical colleges, which spawned them, as sophisticated purveyors of a type of intellectual exercise that is impractical in terms of temporal, physical, and emotional pressures in the community setting. With some justification, they look on medical college faculties and functions as consuming inordinately large numbers of physicians, in both intern and resident programs and staff positions. Their plea to the medical colleges too frequently has been based on what they believe to be a clearly demonstrated need for house staff in the operation of their hospitals and for passive spoon-fed, time-consuming continuing education programs. That these pleas have fallen on deaf and unsympathetic ears is understandable in view of the content of the pleas and the nature of the institutions and individuals to whom they are directed.

Although many other factors have contributed to a lessening of effective communication between the sources of our knowledge and the institutions of its application, those discussed would seem to be the most important and relevant to the effects of federal support on the individuals and institutions at each end of the "knowledge to application" transport system.

Suddenly, into this potpourri of understanding, misunderstanding, interest, and disinterest has come a tremendous force for motivating change. After decades of providing major fund support for both medical research and medical care institutions, the federal government, representative of the consumers of our product, recently has discerned that much of its investment in research has been unproductive because the information, techniques, and skills produced in the research centers have not been transmitted effectively to the operational arm of the medical care system-the community hospital and its medical staffs.

Whether the failure of effective transmission is due to simple lack of information transfer is open to serious question, even though it is a convenient theorem, Campbell Moses, medical director of the American Heart Asociation, identifies the real problem as validation of knowledge-that is, inability of the practitioner to accept and adopt new knowledge or technique until he has had the experience of "seeing" it used and using it under direction. Perhaps the "information gap" is really a "validation gap," but probably it is both certainly the therapy for either lies in continuing education.

Forces within government also are beginning to recognize that much of the support assigned to the construction of community medical care facilities has been less than totally effective in producing efficient and knowledgeable delivery of medical care. Funding instead has produced an overemphasis on inpatient care and medical staff direction and administration. to the detriment of a coordinated system of patient care involving logical division of inpatient and outpatient activities, and to the detriment of the continuing updating of physician knowledge, techniques, and skills.

With the recognition of its less-than-complete success in the past, the consumer group, represented by the Regional Medical Programs, the National Institutes of Health, and their parent body, the Department of Health, Education, and Welfare, have come up with a very efficient and almost certain to be effective mechanism to correct some of the past inadequacies.

A "SHOTGUN WEDDING"

Stated simply, medical care and medical education, the two ends of our sclerotic pipeline for the transmission of knowledge and understanding, are about to be subjected to one of our more common social relationships-the inevitable progression from the spurned proposition, to the proposal, to the engagement, and finally to the marriage. Considering the divisive factors above, this is certain to be a stormy junction, but it is just as certain that it will be consummated and productive, for it is a "shotgun wedding." The people of our nation are holding the shotgun. It is loaded with cash-the greatest motivator in our society. Of