A Nation Starts a Program: Regional Medical Programs, 1965-1966* ROBERT Q. MARSTON, M.D. ann KARL YORDY National Institutes of Health, Bethesda, Maryland - Preprinted from The Journal of Medical Education Vol. 42, No. 1, January, 1967 Printed in U.S.A. A Nation Starts a Program: Regional Medical Programs, 1965-1966* ROBERT Q. MARSTON, M.D.} anp KARL YORDY{ National Institutes of Health, Bethesda, Maryland This month [October, 1966] marks the first anniversary of P. L. 89-239, the Heart Disease, Cancer and Stroke Amend- ments signed by President Johnson on October 6, 1965. The legislation was hailed: by some. as a landmark in the history of American medicine. It was strongly criticized by others, both for what it said and what it did not say. Even “some of those who supported the legislation in principle still maintained a wary curiosity concerning the imple- mentation of such. general legislative language. The philosophical hopes and fears of a year ago have been replaced by actual events, real problems, and iden- tifiable progress. It, is appropriate at this time to report on the extent to which the Regional Medical Programs legisla- tion has been implemented. It is estimated that there will be 48 or 49 programs: 45 planning grant ap- plications or declarations of intent have been submitted to date. These programs will actually be defined in large measure through the activity of those people who will make them operative. It is this characteristic of the Regional Medical Programs that makes them a fascinating experiment in federal health policy. Obviously, experience with the devel- opment of these programs is still quite limited, and many of the difficult prob- * Presented at the 77th Annual Meeting of the Association of American Medical Col- leges, San Francisco, October 22, 1966. + Associate Director; Director, Division of Regional Medical Programs. f Assistant Director, Division of Regional Medical Programs. lems being encountered in implementing this legislation are influenced by large issues and historical trends which can be seen only incompletely at any one time and from any one place. While the historian of the future will focus on forces that we can perceive only dimly at present, reflection on the. possi- ble impact of the programs brings to mind a view of history presented by Rob- ert Bolt (1) in A Man For All Seasons. His theme is that an examination of the trends and forces will illuminate only a portion of any historical event. What is of interest is the way it happened, the way it was lived. “ ‘Religion’ and ‘econ- omy’ are abstractions which describe the way men live. Because men work we may speak of an economy, not the other way round. Because men worship we may speak of religion, not the other way round.” BACKGROUND There are a number of long-range fac- tors and trends which constitute a com- mon heritage for the Regional Medical Programs and which set the scene for the passage of the authorizing legislation. The most important of these factors is the impact of science on the nature of medicine and medical practice. The dy- namic growth of medical research in this country during the past twenty years and the resulting advances in knowledge form the scientific base which is the beginning point for the program. Following are some of the factors which contributed to the development of the legislation: 17 ne 18 Journal of Medical Education the forty-year discussion on regionaliza- tion of medical services; the evolution of the medical schools with the accom- panying development of great medical centers; and underlying social factors relevant to health concerns, including the rising expectations of the consumer of health services who is increasingly com- ing to expect that modern medical science will have the solutions to his health problems. The legislation was directly influenced by such publications as the Coggeshail Report, Planning for Medical Progress through Education (2); the Dryer Re- port, “Lifetime Learning for Physicians” (3) ; and the Reports of the Association’s Eighth and Tenth Teaching Institutes “Medical Education and Medical Care: Intefactions and Prospects” and “Medi- eal Education.and Practice: Relationships and Responsibilities in a Changing So- ciety” (4, 5). However, the actual im- petus for the introduction of the Dill was the publication of the Report of the President’s Commission on Heart Dis- ease, Cancer and Stroke (6), which focused on the relationship between sei- ence and service in medicine. The man- date of the President’s Commission did not include the drafting of legislation ; that task was performed under the leadership of Dr. Edward Dempsey, then Special Assistant to the Secretary of the Department of Health, Education, and Welfare for Health and Medical Affairs, and Dr. Dempsey’s Assistant, Dr. Wil- liam Stewart, now Surgeon General. The bill that. was sent to the Congress by the Administration contained the elements which have proved to be most important to the development of the program over the past year, including the emphasis on the relationship of academic medicine to medical practice, the creation of work- able cooperative arrangements among health resources, and the use of competi- tive grants rather than formula grants. Congress did not rubber stamp the VoL. 42, JANUARY, 1967 Administration’s proposal. Many changes were made in the original bill, primarily as the result of hearings before the House Interstate and Foreign Commerce Committee, chaired by Congressman Oren Harris. By its action, Congress made it clear that this program would be built upon cooperation among existing institutions and that local initiative would play a determining part in the de- velopment of the Regional Medical Pro- grams. The law emphasized the role of the required regional advisory group and the intent that this group be broadly representative of all health interests and include practicing physicians and repre- sentatives of the interested public. The House Committee was impressed with the potential contribution that the Regional Medical Programs could make to the more effective utilization of man- power. Therefore, it stressed the role of continuing education and training in accomplishing the purposes of the legislation. Although the bill as originally written provided authority for new construction, this section was eliminated before the legislation was passed. Finally, Congress authorized the pro- gram for three years and made clear its intent that this initial period be an. ex- ploratory phase which would constitute the learning experience on which future extension and modification of the jegis- lation could be based. Preceding the signing of the legisla- tion, the administrative decision was made that this new responsibility of the Public Health Service would be adminis- tered by the National Institutes of Health. This action emphasized the fact that the Regional Medical Programs concept focused on the relationship and interaction between the development of new knowledge and the provision of bet- ter medical care. In the period preceding and following the final approval of the legislation, Dr. Stuart Sessoms, Deputy A Nation Starts a Program; Marston and Yordy 19 Mo construction funds | How con you build “NEW Centers’? Whaté rally -p your shew? What is a Region? Ho eprint ? No masterplan ® FicurE 1 Director of NIH, was the focal point for NIH concern with this legislation, as- sisted by Mr. Karl Yordy. Much of the early implementation which will be de- scribed later in this paper occurred under the leadership of Dr. Sessoms, who bore the major responsibilities until February, 1966. On October 6, 1965 there were no ex- perts on regional medical programs, no master blueprints of how a_ regional medical program would work. During this period, questions from prospective applicants and other interested parties attempted to probe the flexibility of the legislation in order to determine whether or not there was a specific blueprint for implementation (Figure 1). How do you define a region? How many regions will there be? Who can apply? What will be the responsibilities of the appli- cant? What is the exact nature and role of the regional advisory group? Tell me in specific terms what a regional medical program will do and how it will function. The answers, or some would say lack of answers, to these questions reflected the fact that the flexibility of this legislation was deliberate public policy and that this flexibility is central to the concept of a regional medical program. | The legislation clearly prescribed that the program be carried out on a regional rather than a national basis. The law represents a vote of confidence in the willingness of the regions to accept the basic responsibility for devising the pro- grams to accomplish the purposes of the law. The flexibility of the legislative provisions highlights this transference of responsibility to the regional level. A clearly defined national medical program would have led to fewer questions. How- ever, even if workable, it would have meant less opportunity for creativity, fewer opportunities to develop diverse answers appropriate to diverse problems, and less assumption of responsibility at the local level. After one year of experience, there is considerable evidence justifying this law’s almost naive trust and faith in the ability of formerly divergent medical interests to cooperate on a voluntary 290 Journal of Medical Education VoL. 42, JANUARY, 1967 . CHRONOLOGY OF REGIONAL MEDICAL PROGRAMS (Pubic Law 89-238) October, 1966 iy oor, FEB. APL. UNE RAY AUR OCT.NOW-DEC. WAY JUNE ae oO PRESIDENTS MEETINGS OF THE NATIONAL ADVISORY, ECUNCIL | POMMISSION — CONGRESSIONAL ] : FERN PUBLIC LAW. REPORT TO! OTHER @ ENACTED THE, PRESIDEN REPORTS ANE SIGNED. BY THE AND TH (COGERSHALL) -PRESOENT _paeinany unrent ONGRESS| : PUBLICATION. OF GUIDELINES” GUIDELINES” PUBLISHED "© DIVISION DF REGIONAL FIRS. ANNIVERSARY: © MEDICAL PROGRAMS aL OF THE (AW | ne paning Sorta | wpordctober 186 : —— | mabecmmmmeiabaiil SUBMISSION AND REVIEW OF PLANNING APPLICATIONS® eres SUBMISSION. AND - REVIEW Fae pesky ret 4 bop peat ey 3 <7 ea prs NG) OF OPERATIONAL APPLICATIONS Hy Pee Peas Pass Peace ft : ie : Raat. = peas e ts a pees a eres é etigess st [es bas AU ee Ee Perec Cate so acbubneeas PTY AG, OCT NOV. UEC. FEB FIGURE 2 basis in accomplishing important health objectives. DEVELOPMENT REASSURANCE AND DEFINITION Experience with the program divides naturally inte several phases (Figure 2). The first spans the period from the sign- ing of the legislation in October until about February, 1966. During this time, much of the effort of Dr. Sessoms, the authors. and others was spent in pro- viding reassurance to various medical groups concerning the nature of this program as defined in the law. For some still feared that the program would be a federal medical system which would di- yert patients to distant medical centers with no concern for the role of the local practicing physician or hospital. Some of the medical school faculty and admin- istrators feared that their medical centers were being asked to assume the total re- sponsibility in their regions for medical care in the fields of heart disease, cancer, and stroke. Nonaffiliated hospitals feared that they would have no role to play in the program (Figure 3). However, along with the fears and anx- ieties, there was a ground swell of in- terest in the Regional Medical Programs expressed by a very wide variety of health organizations. institutions, and in- dividuals. Meetings were held in regions throughout the country to discuss imple- mentation of the program. The staff at NUH was contacted by literally hundreds of medical organizations and groups ex- pressing interest and support. The Re- gional Medical Programs appeared as a A Nation Starts a Program Marston and Yordy 21 They want fe tall us wnat re def § Complexes ? Sigh\ LW never see my petients x ean! Theyre hot Seng te Fel upl “S what , te woo Well pe swallowed | es PROSE, Vet works 7B You m ean > Commences ¢ Got te oe ta aus Sigh! for ever, erTHrG body 2 FIGURE + topic for discussion in the programs of a number of major medical professional organizations. In December the Division of Regional Medical Programs was established and its National Advisory Council held its first meeting. REGULATIONS, GUIDELINES, AND QUTLINES The second phase of the program ex- tended from February until April. Spe- cial groups of consultants with expertise in such relevant fields as continuing edu- cation, community health planning, and hospital administration were called to- gether to advise the Division on the implementation of the program. Regula- tions were drafted and proposed. Pre- liminary guidelines for applications and the application forms themselves were developed and widely distributed. Another meeting of the National Advisory Coun- cil was held and a process for the review of applications was developed, consisting of a preliminary review by staff and by a group of ad hve consultants prior to the review by the National Advisory Council as required by the law. Members of the Council and the ad hoe consultants became increasingly articulate in inter- preting and defining the program in speeches, in their own professional or- ganizations, and in the development of individual regional plans. RECEIPT AND REVIEW OF APPLICATIONS The period from April through June constituted the third program phase. During this time, the emphasis changed from reassurance, definition, and prep- aration to the receipt of applications for planning grants and the review of those applications (Figure 4). No deadlines for the receipt of applications were pub- licized. Instead, it was the Division’s stated intention to hold frequent review meetings so that applications could be considered without undue delay and with- out the development of a crash program. Therefore, the National Advisory Coun- cil met to consider applications in April. June, and August, preceded each time bv a meeting of an ad foc initial review 22 Journal of Medical Education VoL. 42, JANUARY, 1967 Weve got it madet Now aff wt jave To do is watt. FIGURE 4 group representing a variety of back- grounds in health affairs. These groups were able to consider applications with varying approaches to the planning of a regional medical program and reach a consensus on the merits of the proposals in terms of the purposes of the law. Dur- ing this phase, 39 planning-grant appli- cations were received—overwhelming evi- dence of the willingness of regional groups throughout the country to accept responsibility for the development of a planning program. In reviewing the first applications, the Division was able to identify certain areas of emphasis and problems, which were then reflected in the organization of the Division’s staff and development of Division policies. Examples are the consideration given to continuing educa- tion as a major function of the Regional Medical Programs and the proposed large-scale use of systems analysis tech- niques in the planning of specific regional medical programs. As a result, the guide- lines document (7) issued by the Divi- sion on July 1 was based not only on the intent of the Congress and the judgment of the National Advisory Council and other advisors but also on experience in the actual review of planning-grant applications. NEGOTIATIONS AND ANTICIPATION During the final phase of the first year of the program, lasting from June until October, concern was with (a) contin- ued review of applications for planning grants; (b) a rapid buildup of activities in continuing education; (c) preparation for the required Report to Congress in June, 1967; and (d) anticipation of ap- lications for operational grants. In considering the applications, the re- view groups found that a straight “yes” or “no” answer was seldom sufficient to communicate the intent of their actions. Therefore, the National Advisory Council requested that the Division staff dis- cuss with each applicant the action that was taken and the reasons for that action. It was felt that this interchange and discussion between the applicant group and the staff of the Division would contribute to a better understanding on both sides of the nature of the proposal. On many applications the National Ad- visory Council required that additional information be obtained from the appli- eant before the application could be A Nation Starts a Program/Marston and Yordy 23 recommended for approval and a grant awarded, When the additional informa- tion requested would not affect the basic ‘soundness of the proposal, the Council recommended approval, conditional upon receipt by the Division of clarifying in- formation. If the information to be pro- vided was more substantial, the Council deferred action on the application until it could consider the additional informa- tion supplied. by the applicant. On other applications the Council did not feel that it could recommend approval of the ap- plication until substantial revisions had been made in the proposal. In recommend- ing revisions, the Council emphasized the fact that it expected to see the revised application at its next review meeting and that in negotiating these revisions, the staff of the Division would not re- quire. that applications conform to a standard pattern. The Council wanted these applications to retain their unique characteristics; but it felt a strong sense of responsibility that the award of fed- eral grant funds could only be recom- mended after satisfactory evidence had been presented that the proposal, what- ever its proposed approach, could reason- ably be expected to result in a plan for a regional medical program that accom~- plished the objectives of the legislation. This phase of the program saw the appointment of a blue ribbon ad hoc com- mittee, which has now had 2 meetings to focus on the Surgeon General’s Report to the President and Congress, due June 30, 1967. Also during this phase, ini- tial plans were made for a national meet- ing to be held January 16-17, 1967 in response to a number of requests for such a meeting and also because of the need to get grass-roots opinion for the Report to Congress. At this time, a change in the types of questions which medical groups asked staff representatives became apparent, primarily because increasingly large pro- portions of audiences had actively partici- pated in the development of applications. Actually, many have now given in their regions the same type of talks staff mem- bers were giving a few short months ago. PLANNING-GRANT APPLICATIONS One of the most productive sources of information at this relatively early stage of the program has been the grant appli- cations themselves. They provide pre- liminary insights into the types of ac- tivities to be carried out on behalf of the Regional Medical Programs as well as a rough gauge of the extent to which “re- gional cooperative arrangements” among medical schools, research institutions, hos- pitals, and other health agencies and in- stitutions have developed to date. Forty-three applications have been rec- ommended for approval or are currently under consideration. They cover regions which contain about 80 per cent of the nation’s population. Certain of the major metropolitan centers account for most of the remainder of the population. As might have been expected, multi-medical- center urban areas have had particularly difficult problems in developing the coop- erative arrangements essential to the Re- gional Medical Programs. However, pend- ing applications and discussions with groups in New York, Philadelphia, Chi- cago, and Boston, for instance, have led to the conviction that effective ways will be found ef bringing together the many health interests that exist in these urban areas. The applications which have been re- ceived indicate that the initial planning of the Regional Medical Programs will generally include 4 major types of activi- ties: (a) organization and staffing; (b) studies to collect and analyze data on re- sources, problems, and needs; (c) devel- opment of ways to strengthen communica- tions and relationships among the health institutions and agencies of the region; 24 Journal of Medical Education and (d) preparation of proposals for operational pYojects. The approaches to the organization and staffing of the programs vary widely. In a majority of cases (26), the formal applicant—the institution acting as the “programming headquarters” or “agent” for the region—has been a medical school; this situation is particularly likely when there is only one medical school in the region and that institution is part of a state university system. There have been 4 applications from medical societies, 2 from existing private nonprofit agencies, and one from a state agency. In 10 of the 43 regions new corporations have been established to be the applicant. It has been suggested that these new organizations may be of con- siderable, significance for the develop- ment of more effective cooperation among major health resources. In addition to the applicants them- selves, well over 400 other cooperating agencies or institutions are represented in the applications, with hospitals, both affiliated and nonaffiliated, constituting the largest group. Among the other key participants are medical societies and state or municipal health agencies. It is clear from the applications that utilization of existing health personnel is planned ; experienced senior health ad- ministrators and educators are being sought and found to fill major positions. It is also evident that many of the grantees will be looking to other disci- plines and to other university faculties for assistance. For example, there have been a number of proposals for the par- ticipation of such individuals as sociol- ogists, economists, and communication specialists. In addition, applicants will seek advice and assistance in areas such as computer. technology and operations research on a contractual basis, either from universities or from private firms. The surveys which are most commonly mentioned. in the applications are con- cerned with the collection of data on VoL. 42, JANUARY, 1967 health manpower, facilities, and special- ized capabilities. Most of the applica- tions include proposed studies of the dis- tribution of and needs for medical and nursing manpower. They also give high priority to problems associated with the shortages of laboratory and other allied health personnel. Most of the applications include plans for continuing education activities for allied health personnel as well as for phy- sicians, dentists, and nurses. The strengthening of communications and relationships among the existing and potential participants in the Regional Medical Programs through a variety of devices is planned. In view of the critical importance of cooperative arrangements in the pro- grams, the following delineation of the membership of the regional advisory groups may provide an initial measure of how effective the programs are likely to be in engendering these arrangements : 1. Practicing physicians and medical center officials each make up about 20 per cent of these advisory groups. 2. Hospital administrators, representa- tives of the voluntary health agencies, other health professionals, and public health officials each account for about 13 per cent of the total. 3. “Public”? members, including law- yers, industrialists, labor leaders, and housewives, account for the remaining 8 per cent. 4. The state governors have been in- volved, in one way or another, in about one-half of the cases. ‘ 5. The state health officer or a member of the state board of health from the staff of related health departments is a member of the regional advisory group in almost every case. 6. Staff members of area-wide hospital planning agencies are members of about one-half of the groups. In all other cases a representative of the appropriate hospital association is named. A Nation Starts a Program/Marston and Yordy , 25 Planning Together wasn't so bad, Po we really have to work together ? FIGURE 5 7. The groups have representation from heart associations and cancer societies. OPERATIONAL GRANTS The purpose of the planning grants is to develop operational programs (Figure 5). While continued planning is a cru- cial part of the programs, it is antici- pated that only a few new planning grants will be submitted and that in- creasingly the focus will be on the need for supplemental support for planning and for the initiation of operational com- ponents. A number of applications for operational grants have been submitted or are in preparation. The Division has been deeply involved in the development and clarification of the review and approval processes which will be required for these applications. As a result of this study, it has become apparent that this process must estab- lish 3 new types of relationships: 1. There must be a continuing and spe- cifie relationship between the Division staff, the review committee (now ap- pointed on a permanent basis), the Na- tional Advisory Council, and the grantees. The frequent meetings of both the review committees and the National Advisory Council as well as the extensive staff negotiations with applicants represent beginnings in the development of these relationships. The creation of a branch for consultation and assistance under the direction of Dr. Margaret Sloan resulted from a recognition of this need. Further, applicants are being advised to make free use of supplemental applications so that their programs can more easily be developed by incremental steps. 2. It is necessary to develop flexible but specific involvement of other federal and nonfederal sources of support, including their review and approval processes. It is recognized that just as the program calls for an integrating and synthesizing activity on the regional level, the Divi- sion has a synthesizing and integrating responsibility to the grantees. In some instances it is clear that specific proce- dures must await the opportunity to work with concrete examples. 8. The review and approval process developed on the national level must be related to the review and approval mech- anisms which exist in the various re- gions. Basic to the goal of establishing the decision-making mechanisms on the local level is the assumption that differ- ent priorities exist in different parts of 26 Journal of Medical Education the country. However, neither the Na- tional Advisory Council nor the Public Health Service can delegate its funda- mental responsibility and accountability for the wise expenditure of federal funds. The mechanisms of the review process can be simply described. The regular process will be a familiar one: grants will be received and reviewed by the ini- tial review committee; additional infor- mation will be gained by site visits, which in many instances will be con- ducted by members of both the committee and the Council; and then there will be a recommendation by the Council and the final action involving administrative de- cisions by the Public Health Service. In addition to this regular process the staff will custom-tailor the review proc- ess to meet the particular needs of indi- vidual grants. In many instances this will mean obtaining additional informa- tion on scientific merit or other aspects from the existing expertise in other in- stitutes or bureaus of the Public Health Service or other agencies in the govern- ment to insure that acceptable standards are maintained; and it will also involve exploring the potentialities for support. The development of a decision-making process in each region is a prerogative of that region, and much time and effort have already been devoted to this area by the Division and by applicants through- out the nation. Some factors relevant to evolving effective processes seem to be either easily identifiable or particularly pertinent: (a@) The initiation of the first steps in the operational program along with continued planning should represent movements toward the fuller development of the regional program. (b) On the one hand there will be a need to determine the appropriate balance between depend- ence on retrospective data, opinions, and the experiences of others, and on the other hand there will be the need to ini- tiate activities which will themselves pro- vide the basis for future decisions. The VoL. 42, JANUARY, 1967 law anticipates the use of research and ex- periments, and the initiation of activities which, when evaluated, can be modified as indicated. (ec) Criteria for specific projects must be developed. The scope and flexibility of this legislation is such that there is no difficulty in listing great numbers of meritorious and needed proj- ects which could be supported. Suggested criteria for ‘setting priorities are as follows: 1. The degree to which the project would assist in the wise utilization of manpower. As one applicant noted, the regional group is not interested in tying up resources with fine projects for which the necessary manpower is not readily available. ; 2. The degree to which proposed proj- ects involve multiple institutions and types of institutions and, therefore, would lead to more effective development of cooperative arrangements, particularly in the initial steps. 3. The degree to which the proposed project relates science to service. 4. The degree to which the project will contribute to continuing education and training for physicians and other health personnel. 5. The degree to which latent talent or unique regional resources might be uti- lized more effectively. 6. The degree to which the proposed project represents a critical area which, if supported, will beneficially affect a larger program. A regional medical pro- gram offers the opportunity to bridge gaps and to support new and innovative approaches which of themselves may be only a small portion of much more ex- tensive activities. : Finally, of course, the fact that this is a broadly categorical program in the area of heart disease, cancer, and stroke must be taken into consideration. The Division has been convinced that as the programs proceed into the opera- tional phase, grantees will be well ad- A Nation Starts a Program/Marston and Yordy 27 vised to select those activities which they can see clearly, rather than depending on the development of some master plan in vague and unexplored areas. Therefore, it is anticipated that many will choose those initial steps which will contribute to further refinement of the basic deci- sion-making processes which they have established. As those who are involved in the pro- gram move along this not uncomplicated path, it is worth remembering the way a dean once described the problem of the vice president for health affairs in bring- ing together groups with nonidentical goals. After speaking to the value of such activities, he raised a word of cau- tion in the following way: ; What do they do? In short they try to hitch mules and cows to the same plow and then drive the rig. What do they try to do? They try to assemble the team, work to- gether, combine assets, etc. To continue to enlarge upon our metaphor of hitching two thousand-pound beasts together without rec- ognizing that the objective of one is to pull and the other to be milked could end with one going unmilked and the other sitting down. Both have highly and equally com- mendable objectives, but working together as a team neutralizes the effectiveness of each. The goal of the Regional Medical Pro- grams, like that of the vice president for health affairs, is to make the activities of its members more effective in their pursuit of their own goals. CONCLUSION The success of the Regional Medical Programs requires that medical schools as well as all other participants share authority as well as responsibility. Gard- ner (8) made the following statement in his monograph, Self-renewal: The Indi- vidual and the Innovative Society: Every great creative performance since the initial one has been in some measure a bringing of order out of chaos. It brings about a new relatedness, connects things that did not previously seem connected, sketches a more embracing framework, moves toward larger, more inclusive under- standing. . The beneficial changes which have been effected by the program twenty years from now will depend upon the extent to which it has stimulated creative per- formances which have contributed to con- stant improvement in the quality of medical service in the nation. REFERENCES 1. Bott, R. A Man for All Seasons. London: Heinemann, 1961. 2. COGGESHALL, L. T. Planning for Medi- Cal Progress Through Education. Evan- ston, I]inois: Association of American Medical Colleges, April, 1965. 3. Dryer, B. V. Lifetime Learning for Physicians: Principles, Practices and Proposals. J. Med. Edue., 37: June, Part 2, 1962. : 4, SHEps, C. G., WoLr, G. A., JR. and JACOBSEN, C.(Eds.).“Medical Education and Medical Care: Interactions and Prospects.” Report of the Eighth Teach- ing Institute of the Association of American Medical Colleges. J. Med. Educ., 36: December, Part 2, 1961. 5. Woir, G. W., Jr. and DARLEY, W. “Medical Education and Practice: Rela- tionships and Responsibilities in a Changing Society.” Report of the Tenth Teaching Institute of the Association of American Medical Colleges. J. Med. Educ., 40: January, Part 2, 1965. 6. President’s Commission on Heart Dis- ease, Cancer and Stroke. Report to the President. A National Program to Con- quer Heart Disease, Cancer and Stroke. (Volume I.) Washington, D.C.: U.S. Government Printing Office, 1964. 9. Guidelines—Regional Medical Programs. U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, Division of Regional Medical Programs, July, 1966. 8. GaRDNER, J. W. Self-Renewal: The Individual and the Innovative Society. New York: Harper & Row, 1965, P. 39.