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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 grow

I ing 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

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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.



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.


The development of such a device requires an intimate involvement of engineers and non-medical scientists not heretofore required in the biomedical field. The development of an artificial heart probably requires a technical management approach not unlike that required for engineering developments in other fields. First and foremost, the decision must be made that the state of fundamental knowledge is sufficient to warrant the development. However, it must be kept in mind that a device, no matter how well engineered, may have very little effect on the basic goal of the betterment of human life. The ultimate cost for utilization may be too high or the conditions for utilization too limiting. These are subtle but essential judgments that must be made. We don't have to look hard about us to see many costly engineering developments with little practical value.

If the go ahead decision is made, the government must study alternative feasible approaches, comparing the technical risks, the costs and payoffs of each. The government must decide what type of organization would be most suited to pursue the development, then solicit proposals and select contractors, specify and negotiate contracts and continuously monitor the work as it progresses. It must decide where and to what extent alternative efforts should be sponsored and when a seemingly fruitless program should be terminated. I do not want to imply that we are now ready for an all-out program of development of an artificial heart. I do not have the competence to judge this, but am using this example to point up a type of activity which the medical community in general and NIH in particular are probably not prepared to handle efficiently.

Why are they not prepared ? “Big medicine” is just beginning so there has not been a confrontation with such problems. Physical scientists have learned to live, not always happily, with big science and big developments and have adapted to them. They started out regarding “managers” very suspiciously but now, at least as a scientific community, they accept managers and even encourage those among the scientific group who have management interests and talents to exercise them. Presently, the medical community provides high status to people in direct medical service and in medical research but low status to the medical administrator or manager. Within the government structure pay scales are low for people in medical management" roles, and in the medical field as a whole there is very little encouragement for people who might think about medical administration or medical project management. This results in a crucial shortage of people with the technical background, experience, and temperament needed to assume the responsibilities of program management in the biomedical area.

Also, the medical community has by and large been aloof from other applied scientific fields. Physicians have traditionally worked individually and have only recently begun to work in teams in group practice or on research projects. They are not used to working closely with chemists, engineers, and other technical experts within a structured group. Currently one may find situations where engineers and physical scientists provide services for physicians or where physicians are consultants to an engineering group working on medical instrumentation but these are not the team efforts I am referring to.

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