a moment, the disinterested and apathetic governmental father of the research years has become the kindly, interested, but extremely firm, future father-in-law. (That he may become an overbearing tyrant is possible, depending upon the success of the courtship.)

The imminent wedding is complicated by the fact that we are not quite certain who is the bride and who is the groom. If educational ability, facility, and personnel are the measure of virility, then the medical college system must be the groom. It is doubtful that the father will listen for long to any disclaimers of ability of the groom to effectively support the bride without further prodding or promise to help with support. It also is doubtful that any disclaimers on the part of the bride (the medical care delivery system) as to her ability to assume educational or analytic duties in the household seriously will affect the future of the marriage.

Similes aside for the moment, let us consider this union between medical education and research and medical care and examine the factors necessary for its success. Three areas require close scrutiny: (1) the depth of the quality, the ability, and the personnel of our educational and research facilities; (2) the sophistication, the quality, the ability, the personnel, and the functional pattern of our medical care institutions; and (3) the question of facilities support and construction subsequent to a productive union of the educational and research institutions and the medical care institutions-perhaps recognizable as the eventual arrangements for housing the family.

The medical college system at present is rich in all three areas. Over the last four decades, it has built up a large cadre of educationally oriented individuals, in spite of research emphasis. The very nature and primary task of the medical college system provides it with adequate classroom, audio-visual, instructional, and other material aids to education. Its hospitals are equipped for the most sophisticated care-a significant portion of it on a research or research-connected basis-and are largely modern and relatively well staffed. Although the medical college certainly will need some additional support to help it in its new role as the resource of both content and some instructional ability for the transmission and validation of knowledge, it is relatively well equipped to cope with its role as educational breadwinner. The distaff side-the community hospital, which will consume and utilize the educational paycheck-is much less adequately prepared.

NON UNIVERSITY HOSPITALS

The nonuniversity hospitals divide into those that have graduate educational programs and those that do not. A recent survey conducted by the Association of Hospital Directors of Medical Education shows that although graduate teaching hospitals are much smaller in number, their total bed capacity and total number of staff physicians are approximately equal to the total bed capacity and total medical staff physicians of the hospitals that do not conduct teaching programs. The same survey indicates that even among those hospitals conducting graduate programs, less than 50 per cent have minimally adequate teaching facilities and less than 10 per cent have the services of trained educators, evaluators, or sociologists available, even by consultation.

There is little difference between the two types of nonuniversity hospitals in most of the important parameters we shall measure. The major difference seems to be that those hospitals conducting graduate programs may be a little further advanced in educational philosophy. Their staffs, however, frequently are composed largely of physicians who do not actively participate in the teaching programs, and their educational facilities, with a few notable exceptions, tend to be little different from those present in hospitals that do not conduct graduate programs. Consequently, for the purposes of this discussion, the two types of nonuniversity hospitals may be discussed as a common entity. The fact remains that the emerging strident necessity for the nonuniversity hospital is that it assume its proper role as the center of continuing education for the physicians and allied health personnel of its area.

Most nonuniversity hospitals are modern, quite sophisticated, and relatively well equipped to render medical care. When one compares them with the medical college hospital, the difference in the area of medical care is a difference between acceptable sophistication on the part of most nonuniversity hospitals and proper ultrasophistication on the part of the medical college hospitals. This is a tolerable and appropriate difference.

INTOLERABLE DIFFERENCE

The difference between the university and community hospitals in educational facility and ability, however, is so great as to be intolerable, even under present loads in continuing education in the nonuniversity hospital. These community institutions have their ultimate direction residing in the hands of boards and administrations who, in a proper and dedicated fashion, represent the voice of the community in the operation of its medical care facilities. Very few of the medical staffs and educationally oriented physicians in these hospitals have been able to impress upon their boards and administrators the overriding importance of continuing education to the competence and survival of our medical practice system and its hospitals. Some of the blame for this failure to impress directive bodies must reside in the medical staffs, who have not made a coordinated effort to educate and thus produce a change in the attitude and behavior of their boards and administrations.

Similarly, with fault resting in medical staffs as well as directive bodies, nonuniversity teaching hospitals have tended to look upon graduate (intern and resident) education programs as tolerable and interesting because they appear to raise the level of medical care, and because they provide additional hands with which to supply that medical care. However, even in relation to graduate education, it has been difficult to bring boards and administrators to spending patient care income on educational facilities, or to supply within the hospitals physicians whose base purpose is graduate or continuing education as opposed to the delivery of medical care. With the rapidly rising cost of hospitalization, and the clamor this rise has produced, one certainly must have sympathy with our hospital boards and administrators in their reluctance to utilize patient care funds for educational facilities and personnel, even though the dollars spent on education are the best purchase the patient might make. The concept is sufficiently abstract to make direct continuity of purpose and decision difficult to achieve.

PROPOSALS AND PRACTICALITIES

In addition to being the subject of studies and recommendations by various commissions and individuals, our medical care and education system has been exposed to many different proposals in relation to continuing education. One hears of universities with and without walls, nationwide closed circuit television, application of the national educational television network to medicine, two-way radio, television tape, and a host of other novelty approaches. When one digs beneath the veneer, he is forced to the inescapable conclusion that, in spite of all of these proposals and gimmicks, the only practical place to educate the practicing physician in a continuing and productive manner is in the milieu in which he works, treats his patients, and earns his living—his hospital. While it is true that in leading a horse to water, one may not force him to drink, the horse is a great deal more likely to drink if the water is under his nose constantly.

While the universities and their medical centers may be the central nervous system om continuing education and of the Regional Medical Programs, there cannot be must doubt that the nonuniversity community hospitals will be the muscle of these programs. No portion of the knowledge produced by the billions of dollars spent in basic research in the last 40 years can be productive until it is in the hands of the individuals who care for the majority of the people of our nation-the physicians of our community hospital medical staffs. The people of our nation-our consumers-in the form of Congress, have spoken in a loud and clear voice.

The basic purpose of the Regional Medical Programs is to translate knowledge into understanding and thence into medical care, in a cooperative, regional, and efficient manner. Thus, the basic and initial form of the activities of the Regional Medical Programs must be reparative education in bringing physicians and other health professionals up to date. This must be followed by continuing education to maintain their competence.

Once education is well under way, attention may be paid to providing the facilities in which the newly understood knowledge, techniques, and skills may be applied in a coordinated manner. It is senseless to build the facilities until the system of education that will assure their proper usage is established and functioning, with the explicit purpose of making the billions of dollars they have spent in research productive in the care of our people.

HOSPITALS NEED HELP

At this time, the educational muscle of the nonuniversity hospital system is so weak that it is difficult or impossible for it to handle its presently assigned tasks in education. If it is to become the cornerstone and functional arm of the Regional Medical Program, then the nonuniversity hospital needs a great deal of help. This help must be twofold: (1) an informational campaign that stresses the importance of an educational foundation to underlie all patient care activities so that the boards, administrators, and medical staffs of our hospitals assign proper recognition and importance to the educational activities of their institution; and (2) direct financial support to establish the skeletal framework of facilities and personnel necessary to support the educational functions. The first of the requirements for help to the nonuniversity hospital in education is well under way. The publications of the Regional Medical Program division of the National Institutes of Health place constant stress on this area. Programs within other portions of the government are designed to stimulate the medical colleges and organized medicine to a more active recognition of continuing education as unquestionably the most important portion of the spectrum of undergraduate, graduate, and continuing health profession education. Accediting organizations and institutional groups, such as the American Hospital Association, should play a more important role in the stimulation of interest in the educational function of hospitals; they are just beginning to evidence interest in this activity. The Association of Hospital Directors of Medical Education, composed of key individuals in stimulating and directing continuing education, continues to increase its voice, competence, and activity. Continuation and expansion of these initial activities on the part of all the interested groups and organizations will assure proper emphasis to a function that will produce more good patient care in the future than any other single area of endeavor.

The second need, that of funding support, becomes increasingly important as more emphasis is placed on continuing education. The initial direction of funding in the Regional Medical Programs and in the comprehensive community planning programs properly has been toward the commitment of monies for integrated planning of an approach to the problem of opening the communications pipeline between medical education and research and medical care. Once these groups have planned to communicate effectively, we still are faced with the problem of a bride and groom who are geographically separate, and who, therefore, must be provided with the means to communicate appropriate to their desire to do so.

FACILITIES AND EQUIPMENT

Funds must be provided for educational faciilties and equipment in nonuniversity hospitals. Facilities include most importantly, auditorium and conference room space and their accoutrements, library facilities and materials, audio-visual materials and departments, and areas specificlly designed for educational demonstrations in patient care. These require brick, mortar, and equipment funds, which most hospitals simply cannot supply from monies currently available in their communities, the Hill-Harris program, or as a result of their patient care efforts. These are the very basic facilities that all hospitals must have to adequately perform their task in educating their staffs and personnel. They are multiuse facilities and, thus, can serve for the continuing education of allied health professionals as well as physicians.

Design and construction of facilities may occupy a considerable period of time; thus, their funding should be of first priority. Concurrently, however, funding should be available to ensure proper and complete utilization of these educational facilities. To make these new facilities really functional will require two additional factors: (1) investigation and measurement to assure the most productive content of the programs they will house; and (2) adequate numbers of educationally competent personnel to assure the productive application of the identified curriculum content and the facilities.

Two of the greatest problems for individuals with practical experience in continuing education are curriculum design and content and the motivation of the practicing physician who is the student. These two factors are inextricably interwoven with a need to know patterns of medical care and physician func

tion. The area where need for information and the presence of misinformation is most apparent is in the field of function-the activities of physicians in the delivery of medical care and the identification of their needs and motivation in relation to continuing education.

There is sore need for support within the nonuniversity setting for the measurement and evaluation of continuing education to assure its efficiency and pertinence. Additional need relates to the measurement and evaluation of the physician's performance, so that he can be helped to become more efficient and productive in the delivery of medical care. In short, we should be attempting now to identify what we should teach and what changes in behavior we are trying to bring about through continuing education.

ESTABLISH REGIONAL UNITS

It would seem of great importance that within each of the Regional Medical Programs there be one or more nonuniversity hospital granted funds to construct and staff units to measure and devaluate systemically patient care and its delivery, thus to assist in determing need, content, and motivation in continuing education. These units should be staffed by physicians, educational personnel, and sociologists. Because each region by definition is singular in quality, it is probable that each region will have sufficiently different needs to require difference in approach and measurement techniques. To establish just one or two national institutions or units involved in this type of research would be inefficient and insufficient. This investigative function cannot be carried on in the university setting, for we are studying a nonuniversity organism.

Once identification has been begun of need, content, and pertinence in relation to continuing education, it will be necessary to ensure that sufficient educationally oriented, able and motivated individuals are present within each community hospital (or available to it) to ensure productive usage of the information gleaned and facilities added. This assurance, in the form of trained personnel, might vary across a spectrum encompassing highly skilled, formally trained educators in the larger and more complex hospitals, to individual staff members who have had the opportunity to receive additional understanding in educational philosophy, skills, and techniques in smaller hospitals and communities. One might regard these individuals as the "marriage counselors" of our simile. They are vitally important to a marriage that has little solid foundation in previously existent love or mutual respect between its partners.

Only after the establishment and support of competent and productive continuing education programs should attention be turned to large-scale support of patient care facilities. While such devotion to competence in continuing education, orientation, and ability would somewhat delay the construction of actual physical facilities for more omplex and sophisticated patient care, the delay would serve to ensure that these faciilties would be properly utilized by physicians. Some programs could be coordinate and concurrent. Caring for patients is, after all, the primary purpose for the existence of our entire medical care system.

A PLEA FOR ACTION

In summary, this presentation is a plea for a cogent and logical progression of activity in relation to Regional Medical Programs, perhaps the most important portion of the socially oriented legislation that has arisen in recent years. By simile, it is a request for good, sound premarital discussion and orientation by the groom and the father-in-law to ensure that the bride of our "marriage" has the knowledge and the necessary appliances and counsel to keep house properly.

Community hospitals and their health professionals must be properly prepared to accept and use the knowledge that will pour from the perviously sclerotic communications pipeline. The medical care system must have initial funding support for identification of educational need and provision of educational space and personnel. Such funding will prepare it for the proper and productive utilization of the health care system and facilities to be established in the future as the result of coordinated regional and community planning for the delivery of medical care.

To paraphrase Winston Churchill, "We are not at the end, nor the beginning of the end, but perhaps we are at the end of the beginning." It is of vital importance that we be sure that this "beginning" represents a solid foundation for a productive and functional future.

Mr. ROGERS. Thank you. We appreciate your being here.

Are we getting enough representation from hospital administrators, from local people involved with the delivery of services in the councils?

Mr. SIBERY. From my vantage point I cannot generalize. I would say that because of my American Hospital Association responsibility, I hear some say we do not have enough hospital involvement. Others say it is fine. Hospitals are certainly welcome to participate.

Generally, I believe they are eagerly invited to participate, so I don't have much sympathy for those who say they have not had an opportunity to be an integral part.

I think that our experience in Michigan might help you to see that this is not just a continuing education program for our medical schools, but in fact is a program that was designed to develop truly cooperative regional arrangements, and it took us many months to develop a working mechanism for the three medical schools to coordinate their efforts and communicate because they had never done this in a similar way before.

I think the very fact that I as executive director of a hospital council was asked to take the initiative in trying to draw together the program and develop the grant application is a good indication that in our State at least the hospital role was well identified. Thank you very much.

Mr. ROGERS. Thank you. Your testimony has been most helpful. This concludes the hearing for today. The hearings for tomorrow will be held, I understand, in the main hearing room, which is on the first floor, room 2123, and so the committee will now stand adjourned until 10 o'clock tomorrow morning.

(Whereupon, at 4:15 p.m. the committee adjourned, to reconvene at 10 a.m. Thursday, March 28, 1968.)