He got six doctors and I got six engineers-electrical, mechanical, fluid mechanic, acoustics, and so on. We spent 2 hours discussing needs of the medical profession, and came up with one-a gallstone detector. The next day we spent 2 hours, and in that period of time we invented, on paper, three gallstone detectors. We tried all three eventually. We built one that worked. Yet the thing never got out into common practice among the doctors. No medical supply house wanted to risk the money to build 50 of them, teach salesmen how to sell them, teach nurses how to maintain them, teach doctors how to use them. More of these devices were sold in Russia than in the United States, because the Russians were willing to take a chance on it. This is the sort of thing that is needed the follow-on after the scientific research, getting the thing to where it is being used. And it involves not only building such devices, but the education in how to use them, maintain them, and so on. I think this is going to be very necessary, if we are to move these ideas into practical use as quickly as possible. This could be done by an in-house laboratory. It is what is done by the military laboratories, you see. Senator HARRIS. How do you assess the kind of support there is for this general idea among those in the engineering profession? What sort of feeling is there around the country? Dr. WALKER. I think there would be a great deal of support for it. In fact, most of our engineering colleges want to get into the biomedical engineering area, but they don't quite know how. They don't know enough about the biology. I think it is going to take some sort of departmental support similar to the kind of support that is given in other areas by the National Science Foundation to get this thing started. I think we ought to get it started in 20 or 30 or 50 engineering colleges in this country. Senator HARRIS. The suggestion also was made yesterday that such an institute, or the Government, through some other agency, might make institutional grants to projects which were sponsored jointly by a medical school and a school of engineering. This would be in addition to the in-house type of activity which you have described, and would hopefully build greater interdisciplinary understanding and cooperation at institutions around the country. What do you think about that? Dr. WALKER. I think it is a very good idea. One of the reasons it hasn't been done is that at the end of the last war, most engineering colleges were involved in research for the Department of Defense. In such situations, the easiest thing to do is to stick with the familiar. You know the channels. You know how to operate. And so you keep on working for the Department of Defense, even though your conscience says you ought to look around and work for somebody else once in awhile. And you never give up a winning horse in favor of one that might win. But if we had institutional grants that would enable us to take some man in my college of engineering and say, "Look, for the next few months you are to get people together to discuss these problems and propose projects that we have the capacity and capabilities to work on," we would get things started. But it is just this seed corn that we have to have, to start the thing rolling. Senator HARRIS. Very good. Do you have anything further that you would like to add, Dr. Walker? Dr. WALKER. No, thank you, sir. These are the two points I wanted to make, and I think you understand what they are. Senator HARRIS. And you have made them very well. Dr. WALKER. Thank you, sir. Senator HARRIS. We appreciate it very much. Thank you very much. Our next witness is Dr. Robert H. Ebert. Dr. Ebert is dean of the Harvard School of Medicine in Boston, Mass. Without objection additional biographical data concerning Dr. Ebert will be placed in the record at this point. Biographical Sketch: Robert H. Ebert, M.D. Dean, Harvard School of Medicine, Boston, Mass. Assistant, Assistant Professor, Associate Professor and Professor of Medicine, University of Chicago, Hanna-Payne and John H. Hord Professor of Medicine, Western Reserve University. Director of Medicine, University Hospitals, Cleveland. Jackson Professor of Clinical Medicine, Dean, Faculty of Medicine, Professor of Medicine, Harvard University. Chief of Medical Services, Massachusetts General Hospital. Consultant in Medicine, Beth Israel Hospital. Rhodes Scholar, Markle Scholar, Distinguished Service Award, University of Chicago. Director, Trustee and Member of many organizations. Senator HARRIS. Dr. Ebert, We are very honored to have you here this morning. We appreciate your interest in the subject matter of these hearings. We would be pleased to hear from you at this time. TESTIMONY OF ROBERT H. EBERT, M.D., DEAN, HARVARD SCHOOL OF MEDICINE, BOSTON, MASS. Dr. EBERT. Thank you, Senator Harris. It is a privilege to appear before this group. I hope that I can be of some small help to the Subcommittee on Government Research in its effort to evaluate the adequacy of Federal institutions for biomedical development. During the past two decades there has been an unprecedented expansion of knowledge in the field of biology. We have acquired an intimate understanding of life processes which profoundly affects our thinking about growth and development, health, and disease. One sometimes hears the criticism that too much money is spent on theoretical work and too little upon the application of what we know. I would like to address myself to this problem and explain to the subcommittee why I believe it is vital to continue support of fundamental research. One of the most exciting areas of modern science is molecular biology. We now have some understanding of how desoxyribonucleic acid, or DNA, transcribes genetic information in the nucleus of the cell and transmits this information via ribonucleic acid, or RNA, to organelles in the cytoplasm of the cell and how the RNA in turn acts as a template in the manufacture of proteins. All of this seems quite remote from an understanding of disease and certainly the treatment of disease, and yet the potential use of this knowledge is enormous. It is known, for example, that certain viruses contain only RNA and that such viruses must parisitize cells in order to replicate themselves. It is also known that certain experimental cancers are transmitted by such viruses. It is within the realm of possibility that methods can be devised to interfere with the metabolism of the RNA of the virus without damaging the RNA of the host cell. In other words, it may be possible to design specific treatment on the basis of a fundamental understanding of the biology of cellular metabolism. There are many "ifs" in this hypothesis but the point I wish to make is this: The more we know about the mechanisms of biological processes, the better prepared we will be to describe disease in fundamental terms and to define treatment on a rational basis. It is fair to ask, "Why not pursue more vigorously the application of the biological knowledge we now possess in the study of disease?" The answer is that such research is being pursued vigorously and that such research is greatly stimulated and enhanced by a continuing elucidation of basic biological principles. It will not be possible at any given time in the foreseeable future to say that we now have sufficient understanding of human biology so that we can afford to stop fundamental research and expend our medical research funds only on the application of what we know. These two aspects of research must proceed simultaneously if we are to obtain the greatest return from the investment of public funds in medical science. While on this subject let me comment on a popular fallacy. The statement is sometimes made that there is a long lag between scientific discovery and its application to patient care. The implication is that certain facts are known which could be applied immediately to the treatment of disease and the problem is a lack of communication between basic scientists and clinicians. This is a misrepresentation of the fact. There is almost no lag between discovery and application in those instances that application is immediately relevant. This is the business of university hospitals and medical centers. There is an inevitable lag between scientific discovery and application in those instances which require further research to determine the feasibility of application. I would like to make one final point about fundamental research. In the world of fantasy, a great discovery is made by a flash of insight and a few extra nights in the laboratory. In the cold world of reality, scientific achievement is the result of long hours, arduous, and often boring work by many scientists. Science is expensive, often frustrating, and fundamental research cannot be programed in the same manner as an engineering project. It is not possible to say that we will solve the problems of heart disease in the next 5 years because we do not have the fundamental knowledge to apply to the problem. Under the leadership of Dr. James Shannon a healthy balance has been maintained between the fundamental and applied research supported by the NIH. I would hope that this balance will be maintained in the future and that we will not be stampeded into the expenditure of huge sums on categorical disease programs at the expense of the fundamental research which will ultimately be needed for the solution of all medical problems. Modern biology is noncategorical and often seems remote from the problems of the sick patient. I would remind the subcommittee, however, that the principle of antibiosis seemed remote from the problems of the clinic until the introduction of penicillin. The notion that the rapid application of recent discoveries in biological science to the study of disease will solve all our problems is naive. It ignores the fact that our system of medical care delivery has broken down and very little is being done to solve this problem. Let me explain what I mean by "the system is breaking down." Because of the advances in medical knowledge and medical technology, the treatment of the patient has become a much more complex affair than it was a generation ago. No physician can practice in isolation, either from other physicians or from other members of the health professions. A spectrum of talent is needed in order to deliver the best health services but we have failed to devise new means of integrating these services for the benefit of the patient. The problem facing us today is not so much the lack of centers for open-heart surgery as it is entry into the health system so that a patient may discover that he does, in fact, have heart disease. In other words, there are too many people in this country, particularly in the cities and in the rural areas, who have no regular medical attention. While this is partly a problem of numbers of people in the health professions, it is more a problem of organization of health care. I was delighted to see in the President's message on education and health in America his proposal to establish a National Center for Health Services, Research, and Development. This represents perhaps the most critical need in medicine at the present time for if we are to apply effectively what we know we must have a workable system, or systems, in which to do it. Since universities and university medical centers are heavily engaged in the problems of biological research as well as clinical investigation, it is perhaps pertinent to highlight some of the effects of Federal programs on universities. It seems particularly appropriate to do so at a time when the universities are also being called upon to participate in the heart disease, cancer, and stroke program and will certainly be asked to participate in health services, research and development. Fundamental research, clinical investigation, and concern for the delivery of care to the community are all legitimate concerns of the university and the medical school but the medical schools and teaching hospitals have another vital function. Their primary purpose is the training of physicians, both at the medical student level and at the levels of internship and residency. Because of the manner in which medical schools are funded these primary functions sometimes seem to be of secondary importance. I would submit that some attention must be paid to the total integrity of the medical school and the teaching hospital if one is to avoid the development of a series of independent institutes and research laboratories loosely connected to the medical school. What is needed is direct funding of the medical school and of the teaching hospital in order to facilitate the pursuit of its primary function. Ultimately this will strengthen rather than weaken the various research programs for the fragmentation of the medical center will ultimately harm all of the health activities within the university. We need better coordination among the various agencies supporting biological research and demonstrations of patient care rather than 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 elinic, 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 |