“oe division of regional medical programs A communication device designed to speed July 26, 1968 the exchange of news, HOSPITALS MAGAZINE - Journal of the American Hospital information and data on Association - Features Regional Medical Programs Regional Medical Programs The Juiv i, $968 issue of HOSPITALS, the Journal of the American Hospital Association, featured several aspects of Regional Medical Program activities, particularly as thev are relating to hospitals. Attached is a reprint of ail of this material as it apreared in that issue, including the index. It should be noted that the full proceedings of the American Hospital Association Invitational Conference on Hospitals and Regional Medical Programs, held on June 13-14. 1968 and reporte: in this material, are now being edited and wil’ he made available when they are ready in the near future. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE. Bethesda, Maryland 20014 1968 ANNUAL MEETING - ATLANTIC CITY - SEPTEMBER 16-19 . ; JOURNAL OF THE AMERICAN HOSPITAL ASSOCIATION JULY 1, 1968 Reprinted from HOSPITALS Journal of the American Hospital Associatio Volume 42 July 1, 1968 Printed in U.S ee wn ES. REGIONAL MEDICAL PROGRAMS=A PROGRESS REPORT JOURNAL OF THE Volume 42 AMERICAN HOSPITAL Number 13 ASSOCIATION July 1, 1968 21 48 56 60 63 70 75 78 Published semimonthly by the American Hospital Association Edwin L. Crosby, M.D., executive vice president and director SPECIAL REPORT Conference on Hospital Involvement in Regional Medical Programs e Highlights of Two-Day Proceedings e Keynote Address by Jack Masur, M.D., All Hospitals are Not Equal Regional Medical Programs: Case Studies 1. Intermountain Program Focuses on Community Hospitals C. Hilmon Castle, M.D. Urban centers lead in research, but regional programs focus on community hospitals, where most health care is delivered, 2. Albany Program Emphasizes Community Strengths, Relationships Frank M. Woolsey Jr., M.D. Initial activities in the regional medical programs serve as guides for total program planning and provide feedback on results. 3. Academic and Public Agencies Work Together in Missouri Program Vernon E. Wilson, M.D. Missouri program projects enlist the aid of academic and public agencies to improve the quality and availability of health care, 4. Local Action Groups Involve Communities in Kansas Program Charles E. Lewis, M.D. A network of projects carried out by local action groups is the basis of the Kansas Regional Medical Program’s operation. Regional Medical Programs: The View from the Hospital Two leaders in the hospital field were interviewed for their views on the proper role of the hospital in Regional Medical Programs. Trends in Blood Banking (Part Two): Component Therapy, Frozen Storage Promise Fullest Use of Blood Resources Dorothy W. Green The use of packed red cells, frozen cells, and other types of component therapy is a boon to patients and to blood banking. MATERIALS MANAGEMENT Evaluating and Standardizing New Products Albert Carroll The committee evaluating new hospital products should think about use, costs, waste—for these also improve standards. PHARMACY DIGEST Pharmacists Realign Goals with New Laws, Health Programs LAUNDRY DIGEST Differences Noted Between Soaps and Detergents ENVIRONMENTAL SANITATION DIGEST Salmonellae Found in Enzymatic Drain Cleaners rights reserved. Printed in the U.S.A. Memo from the editor We met Dr. Leona Baumgart- ner, the distinguished public health worker, for the first time at a meeting at headquarters the other day. We have always associated her with the campaign to substitute the unambiguous “flammable” for “inflammable” on gasoline trucks and the like. “Flammable,” clearly prefer- able, is now widely accepted. But that isn’t the case with “flam- matory” and, strangely enough, neither the second nor the third edition of the unabridged Mer- riam-Webster lists it, sticking with “inflammatory” despite the “not”? meaning of the prefix “in.” That led us to look for some other opposites, such as “ept” for “inept.” “Ept’’ isn’t a word in either of the big books. We have never heard the adjectival “ruth” as the opposite of “ruth- less” and, although “ruth” does make the Second Edition, the Third recognizes, quite rightly, its disuse and drops it. On the other hand, “couth,” as in “uncouth,” has grown from the Second to the Third. In the Second, “couth” is limited to the unfamiliar “familiarity” mean- ing of the word but in the Third it comes into full bloom as the opposite of “uncouth” in all of that word’s definitions. o HOSPITALS is published the first and sixteenth of each month by the American Hospital Association, 840 North Lake Shore Drive, Chicago, Ill. 60611. Tel. 645-9400, Area Code 312, Cable Address AMHOSP. Second class postage paid at Chicago, Ilinois.s SUBSCRIPTION RATES: $7 for 1 year; $12 for 2 years; except the two-part August 1, Guide Issue $3.50. (Subseribers outside the United States and Canada add $1 per year for postage.) CHANGE OF ADDRESS: Notice should include the old as well as the new address, including ZIP code number. Four weeks’ notice is required. The local postmaster should be notified. ©1968, by the American Hospital Association, all $16 for 3 years. Single copies 50 cents: SPECIAL REPORT Regional Medical Programs were authorized under P.L. 89-239, signed by President Lyndon B. Johnson in October 1965 with the specific intent of improving the nation’s health resources for the diagnosis and treatment of heart disease, cancer, stroke, and related diseases. The legislation called for an effective partnership between the federal government and hospitals, physicians, medical schools, research institutions, and voluntary and public health agencies to improve patient care for these categorical diseases. In November 1967, the American Hospital Association ex- pressed full support of the Regional Medical Programs and voted to undertake the development of activities and ma- terials that would be mutually helpful to hospitals and Re- gional Medical Programs. In this issue of HOSPITALS, J.A.H.A., is an editorial (Page 47) pressed full support of the Regional Medical Programs and gional Medical Programs. Also, four articles appear describing Regional Medical Programs that are now operational. On June 13-14, the AHA sponsored an Invitational Confer- ence on Hospital Involvement in Regional Medical Programs. The purpose: to clarify issues, air differences of opinions, identify common goals, and, on the basis of these discussions, recommend regional and national methods for accomplishing these goals. The following eight pages of the Journal contain a special report on the Invitational Conference, concluding with its keynote address by Jack Masur, M.D. More Hospital Involvement Needed: Group Views Regional Medical Programs Her involvement in Regional Medical Pro- grams so far has been disproportionate to the potential contribution hospitals can and should play in the diagnosis and treatment of heart disease, cancer, stroke, and related diseases, in the opinion of most speakers and panel members at the Ameri- can Hospital Association’s Invitational Conference on Hospital Involvement in Regional Medical Programs held at AHA Headquarters, Chicago, June 13 and 14. Nearly 100 persons affiliated with hospitals, Re- gional Medical Programs, and the AHA attended the conference to review the developing relationships be- tween hospitals and Regional Medical Programs, Ed- win L. Crosby, M.D., director, American Hospital As- sociation, was general chairman of the conference. Dr. Crosby expressed the AHA’s continued interest in and support of Regional Medical Programs. He told the participants that the conference could help clarify the role hospitals should play in the administration of the programs. Other speakers discussed the concept of Regional Medical Programs, the role of hospitals in the plan- ning process, cooperative arrangements, and specific RMP’s that are already operational in various parts of the nation. HOSPITAL INVOLVEMENT D. Eugene Sibery, executive director, Greater De- troit Area Hospital Council, Detroit, emphasized that the hospital must be a major participant in the pro- cess of planning Regional Medical Programs. Mr. Sibery declared that hospitals provide an unparalleled organizational structure that “marshals the largest reservoir of community health resources, involves on its governing board a cross-section of community leadership to provide broad community involvement, continuously identifies changing community needs and develops means to be responsive to those needs, responds to the needs of physicians and other health care professionals, and permits physicians to organize into a meaningful group for the provision of insti- tutionally related health care.” Mr. Sibery also pointed out that hospitals are the focal point at which medical theory can be converted into practice, continuing education of medical and PARTICIPANTS AT the conference listened intently, taking many notes, as speakers and panel members discussed hospital involvement in Regional Medical Programs. paramedical personnel can promote high quality pa- tient care, and the organization of services under the categorical framework of Public Law 89-239 can best develop. Unfortunately, Mr. Sibery said, “hospitals have not been involved extensively in the planning process” of Regional Medical Programs. “Perhaps,” he con- tinued, ‘‘this is the result of lack of interest or under- standing on the part of hospitals. Perhaps it is a result of the orientation of the RMP agency. Regardless of the reason, the result is the same—an essential par- ticipant in the planning process seems conspicuously absent.” Mr. Sibery’s viewpoint de-emphasized the fact that many cooperative arrangements between hospitals and other institutions involved in Regional Medical Programs have been developing since the enactment of P.L. 89-239 in 1965. To date there are 54 Regional Medical Programs, 13 of which are operational; 11 more will become operational within a few months. The degree and intensity of hospital involvement in DONAL R. SPARKMAN, M.D., coordinator, Washington-Alaska Re- gional Medical Program, Seattle, reviewed the role of hospitals in the program he directs. Seated at right is George W. Graham, M.D., President-elect, American Hospital Association, and director, Ellis Hospital, Schenectady, N.Y. Regional Medical Programs at both planning and op- erational levels, however, has varied from region to region. ‘DEFINITE COMPLICATIONS’ L. Brent Goates, administrator, Latter-day Saints Hospital, Salt Lake City, Utah (involved in the Inter- mountain Regional Medical Program), agreed with Mr. Sibery that there have been definite complica- tions in hospital involvement in Regional Medical Programs, Mr. Goates said, “It is unquestionably true that the process has produced many concerns and uncom- fortable moments for many persons. Years of radi- tion and custom leading to isolationism, provincialism, pride, and near-sighted concentration on self-interest must be broken down. The dialogue, now forced by ‘cooperative arrangements,’ however painful, is pro- ducing results, and is a wonderful tonic to help us tool up for the unprecedented challenge that lies ahead in reshaping the mechanisms of a much more efficient delivery system for health care in the United States, “While participation at the conference table is vol- untary, of course, there are just enough incentives to keep the participants on the job. The medical schools might be quick to abandon the uncomfortable trans- formation to become truly ‘community-oriented’— except that if they did, much revenue would be lost to their coffers. And the hospitals, finding progress so agonizingly slow, might also want to give up—but they know that a new health care system will emerge from the struggle, and their role might be diminished somewhat unless they participate freely. Thus, though many are more highly motivated, the stakes are high for everyone. With much patient, long-suffering, and diligent work, the ‘answers will be coming into focus soon.” POSITIVE EVIDENCE Although the nature of hospital involvement in Regional Medical Programs was viewed as question- able by most participants in the conference, empiri- cal evidence was presented that demonstrated, at least numerically, that hospital representatives have been engaged in Regional Medical Programs to a con- siderable extent. Roland L. Peterson, chief, Planning Branch, Divi- sion of Regional Medical Programs, National Insti- tutes of Health, Bethesda, Md., reiterated the intent of P.L. 89-239: “Linkage with and among hospitals and other major health resources is a categorical imperative of the law that established Regional Med- ical Programs.” Mr. Peterson pointed out that failure to comply with this policy has resulted in the rejection by the National Advisory Council for Regional Medical Pro- grams of several initial planning grant applications involving very prestigious institutions and person- alities. Mr. Peterson, before presenting data that showed how many hospital representatives are currently active in Regional Medical Programs, gave an oper- ational definition of hospital involvement: “There are two different aspects of Regional Medi- cal Programs. The first distinction relates to the plan- ning and development of a decision-making process as a part of that planning activity. Hospital involve- ment in this aspect of Regional Medical Programs is defined as a hospital administrator or other hospital representative such as a trustee, chief of staff, or full-time director of medical education being a mem- ber of the Regional Advisory Group. Under the law (P.L. 89-239) that group has the final regional re- sponsibility for decision-making in terms of the na- ture and scope of the program. Involvement, by our measure, can also include membership on the several planning and review groups which are now generally found in all Regional Medical Programs. These latter planning and review groups—variously referred to as ‘planning task forces, ‘planning subcommittees,’ ‘local advisory committees,’ and ‘local action groups’ —have two broad areas of responsibility: (1) the planning of operational programs and activities, in- cluding the establishment of priorities and needs, and (2) the review and recommendation to the Regional Advisory Group of individual operational projects meriting local approval.” Community and teaching hospitals, both large and small, are represented by some 1000 hospital persons on all 54 regional advisory groups, according to Mr. Peterson. These hospital representatives also are active on planning task forces and subcommittees and local action or advisory groups. Nearly 600 hospitals, almost every state hospital association, and a number of hospital planning agencies are included in this group of hospital representatives. (See Tables 1, 2, and 3.) TABLE 1—REPRESENTATION OF HOSPITAL PEOPLE ON RMP DECISION- MAKING AND PLANNING GROUPS Total No. No. Hospital Involved People Percentage TOTAL 4589 1007 22 Regional Advisory Groups 1956 300 15 RMP Planning and Review Groups* 2633 707 27 “Includes both RMP Planning Task Forces and Subcommittees, and Local Advisory or Action Groups. TABLE 2—BREAKDOWN OF HOSPITAL REPRESENTATION ON RMP DECI- SION MAKING AND PLANNING GROUPS Planning Regional and Advisory Review Groups Groups Total Percentage TOTAL 800 107 1007 100 Hospital Staff: Hospital Administrators 133 297 430 43 Chiefs of Medical Staff 14 58 72 7 Chiefs of Service 34 42 76 8 Boards of Trustees 9 57 66 7 DME’s and Other Hospital MD’s 35 138 173 17 Nurses and Other Allied Health 15 86 101 10 State and Local Hospital Associations 36 19 55 5 Hospital Planning Agencies 24 10 34 8 TABLE 3—-BREAKDOWN OF HOSPITALS, BY KIND AND SIZE, INVOLVED OR PARTICIPATING IN REGIONAL MEDICAL PROGRAMS KIND SIZE (Number of Beds) Total Number 100- 200- 300 and of Hospitals Community Teaching 0-99 199 299 over Planning and Decision-making 551 81% 19% 33% 26% 15% 26% (54 Regions) Operational Activities 531 91% 9% 60% 16% 9% 15% (13 Regions) AFTER DISCUSSING hospital involvement in. their respective Re- gional Medical Programs, speakers answered questions from the floor. Seated from left to right: J. Gordon Barrow, M.D., coordinator, Georgia Regional Medical Program, Atlanta; Paul D. Ward, coordina- tor, California Regional Medical Program San Francisco; and Stanley W. Olson, M.D., coordinator, Tennessee-Mid-South Regional Medical Program, Nashville. Mr. Peterson further noted that “these hospital people constitute some 22 per cent of the total num- ber of individuals serving on these planning and de- cision-making groups. In comparison with other par- ticipating groups, this is a favorable percentage. For example, private practitioners, including medical so- ciety representatives, constitute about 24 per cent of the total; medical school officials about 18 per cent; voluntary and official health agency representatives about 16 per cent; and public representatives about 11 per cent.” OBJECTIONS TO RMP’S Although Mr. Peterson’s figures proved that hos- pital people are involved in Regional Medical Pro- grams to a considerable degree, most of the con- ference’s participants were not impressed by the numerical basis of his argument. Hospital involve- ment, it was generally agreed, means far more than merely belonging to regional advisory groups and subcommittees. At the concluding session, Frederick N. Elliott, M._D., assistant to the director of the American Hos- pital Association, reviewed the issues discussed at the conference. Dr. Elliott stated that most participants in the conference felt hospital involvement in Re- gional Medical Programs was far less than was de- sirable. “The monetary basis of Regional Medical Pro- grams,” Dr. Elliott declared, “dovetails with agencies and institutions already receiving substantial federal funds of one sort or another—namely, university hospitals and medical centers. Because such institu- tions and agencies already have close ties with the federal government, they have become grantees for Regional Medical Programs for reasons other than the main one that should dictate allocation of these funds: need, This procedure,” Dr. Elliott continued, “discriminates against hospitals not affiliated with universities and medical centers. In other words, Re- gional Medical Programs are not utilizing the po- tential of community hospitals to the fullest in pur- suing the intent of P.L. 89-239.” Dr. Elliott emphasized that community hospitals are the focal point of health care; as areawide plan- ning and comprehensive health care programs evolve, community hospitals will offer even greater potential for Regional Medical Programs. And, finally. Dr. Elliott pointed out, as the AHA restructures itself on a regional basis, it will be in an even better position to relate hospitals to Regional Medical Programs. CONCLUSIONS AND RECOMMENDATIONS The issues discussed during the conference were summarized by Mr. Sibery. He spoke against tradi- tionalism, parochialism, and provincialism in the hos- pital and health care field, simultaneously praising the potential of P.L. 89-239 and P.L. 89-749 (Com- prehensive Health Planning and Public Health Ser- vices Amendments of 1966). “There is a new concept of the hospital that is evolving,” he said, “one which recognizes that hos- pitals are corporate, entities for the provision of com- prehensive health care to the community, entities composed of medical and paramedical personnel, the administrator, and the board of trustees, who are community leaders. While the private sector has taken the initiative in many areas of health care, the federal government has tried to fill the remaining gaps and will continue to do so. In the past, hospitals have placed too much emphasis on inpatient care, too little on other areas of health care. The new, evolving concept of the hospital makes it an integral compo- nent of a comprehensive health care system. Re- gional Medical Programs must recognize this concept and support it.” Mr. Sibery recommended that the American Hos- pital Association both lead and define the role of hos- pitals in the implementation of both P.L. 89-239 and P.L. 89-749. In particular, he urged that this issue be studied thoroughly and acted upon during the 1968 annual meeting of the AHA at Atlantic City, Sept. 16-19. The federal government, Mr. Sibery suggested, needs to coordinate the administration of Regional Medical Programs and comprehensive health planning legislation at the national, regional, and state levels. The mutual objective of both legislative acts is to provide health care for all Americans, he said, and intelligent, complementary planning and administra- tion, with the full recognition of hospitals’ potential, is necessary if that objective is to be reached. s All Hospitals Are Not Equal by JACK MASUR, M.D. AS WEEKS ago, some of us old fellows were sit- ting around, stroking our clean-shaven chins, and ruminating on the spate of health legislation we have had in the last few years. How can we imple- ment the new programs? How can we recruit and retain enough competent staff for Medicare, Medi- caid, Health Professions Education Assistance, Re- gional Medical Programs, and Comprehensive Health Planning? What is a true partnership for health? How do we mobilize the resources of men and wom- en, money and facilities, and time and understanding to achieve these worthy goals for Americans? Over the second cup of tea, one of the more literate members of our cadre quoted the oft-forgotten pas- sage from the Gospel according to St. Luke: “For which of you, desiring to build a tower, does not first sit down and count the cost, whether he has enough to complete it? “Otherwise, when he has laid a foundation, and is not able to finish, all who see it begin to mock him, saying, “*This man began to build, and was not able to finish.’ ” We all agreed that “cost” should not be read like a fundamentalist. We thought it would be more pru- dent to count the “cost” of our tower in appropria- tions and doctors, hospitals and group practices, Jack Masur, M.D., is assistant surgeon general and director, Clinical Center, National Institutes of Health, United States Public Health Service, Bethesda, Md. paramedical health workers and administrators. And on that note of perplexity, the old men went home to rest for the next day at the office. Several days ago, I prepared to come to this con- ference to count the “cost” of our Regional Medical Program as we leave the talking stage and enter the doing stage. There entered my mind a story—the story of the seriously sick man: Minister: “Have you made your peace with the Lord and renounced the devil?” Patient: “Considering the fix I’m in, I'm not going to make an enemy of anybody.” IMPORTANT THINGS HAPPEN A hospital is a place where important things hap- pen every day. It is a place where people who are sick and in trouble are sent to get help. It is a place where doctors and nurses and other trained workers strive to diagnose, to cure, and to console them. It is a house where all of us endeavor to better the people who are brought to us... so that the sick may re- cover their health by the care and diligence of doc- tors and nurses and others. In thousands of hospitals we concern ourselves only with today’s patients. We use what we were taught long ago; we use what we have gained from our own experiences; and perhaps we may also use what we have gleaned from the writings of others who are more learned than we. In some hospitals—not many hospitals, and cer- tainly not enough hospitals—we concern ourselves with today’s patients and with tomorrow’s patients. In these centers, teachers prepare young men and women for the health professions. In these centers, many kinds of doctors and scientists engage in re- search for the acquisition of new knowledge. In these few hundred hospitals, where there are per- sons with lifelong commitments to teaching and to clinical research, we are more likely to witness the restless pursuit of excellence in the care of the sick and the reaching out for more effective ways to pre- vent suffering in the future. The reason we are gathered here is that we now have the chance, through RMP, to bring to many, many other hospitals that are concerned only with today’s patients ‘the know-how that is continuously being improved in the larger centers of learning and teaching. All hospitals are not equal. About 20 years ago, under the Hospital Survey and Construction Act, we embarked on a program to increase the number of hospitals and to improve the geographic distribution of hospitals, with special emphasis on economic need of the states and on the attraction of physicians to rural areas. Government funds have supported the construction of many small hospitals in all parts of this country. There have been many beneficent results from the government subsidy in the creation of so many new hospitals in the past two decades. But we must face up to the fact that in 1968, two-thirds of our gen- eral hospitals are under 100 beds. In fact, three out of four general (nonfederal) hospitals are under 200 beds. In terms of the number of hospitals—not the proportion of beds—we are a country of mostly small hospitals. Small hospitals are useful for delivering babies and setting broken bones, but I hardly need remind you of the limitations of lack of house staff, diffi- culties of recruitment of professional and technical staff, and absence of other resources to deal with the modern diagnosis, treatment, and rehabilitation of patients with heart diseases, cancers, strokes, and related diseases. FAILURE IN REGIONAL PLANNING To acquire proper perspective, we ought to re- member that a basic premise in the formulation of the original Hospital Survey and Construction Act in 1946 was the introduction of regional planning as the essential mechanism for articulating small, me- dium, and large hospitals. For a variety of reasons— professional chauvinism, medical economics, institu- tional autonomy, civic pride—we have failed since 1947 to achieve effective systems of regional planning. Like many other good ideas, this type of collective voluntary planning, through representative regional organizations, takes more than 20 years to consum- mate. The Regional Medical Programs now afford us the opportunity to improve the odds in favor of that random patient going to the random doctor who sends him to the random hospital. Or, to put it in bureaucratic terminology, the Regional Medical Pro- grams can be the orderly process required for the organization and coordination of health services in a geographic area—utilizing local enterprise and responsibility—to improve the quality, efficiency, and availability of health care. This is a time of trouble. Violence around us, war in Vietnam, riots in the cities, student: revolts, marches and demonstrations, readjustments in gov- ernment financing—these all contribute to what is called the ordeal of change in our society. It will be hard to make constructive changes in the rigid pat- terns of health care. There are plenty of long-term problems which burden the polyprofessional com- plex in which hospital administrators, trustees, physi- cians, coordinators, and public officials serve through- out this nation. I select just three of these problems for special mention at the opening of this conference on hospital involvement in regional medical pro- grams. They are crucial, I believe, in the future determination of whether there will be a place for the voluntary system in the health scheme of our country. Let us spend a few moments on (1) costs and quality, (2) doctors and management, and (3) planning and government. Our people want and deserve the best hospitals we can design, equip, staff, and operate. It makes good sense for all of us in government at the local, state, and federal levels to nourish and sustain vol- untary hospitals and health agencies so that we can use all that is good in the voluntary system to carry out the public responsibility. COSTS AND QUALITY Ever since the end of World War II, people in our society have wanted and needed and expected more health care. The massive growth in prepayment and insurance protection for the families of working men and women did not suffice. A prosperous nation was urged to provide more government assistance to the aged, the handicapped, and the poor. During the past few years, Congress has responded with legislation authorizing enormous new medical programs. Our hospitals have not been overwhelmed. They have accepted the greater load. They have adjusted to the demands for higher wages by health workers, who have been in short supply. Costs have escalated rapidly: more than two and a half times as fast in 1966 as in previous years. And they are now rising even more sharply. For some time now the atmosphere has been pol- luted with a lot of pejorative rhetoric about hospitals, doctors, and dollars, and the high cost of being sick, of getting well, and of dying. Speech writers para- phrase the professional analyses of trends in an af- fluent period when the demands exceed the supply, and we are told from many platforms that there are serious deficiencies in the organization, financing, and-delivery of health services in the United States. There is even some perseveration about the uncon- trolled runaway escalation of medical costs. We are admonished to bring the costs down but to keep the quality up. Unfortunately, some of the ‘badmouth” talk about rising wages without commensurate increases in pro- ductivity leads to allegations of inefficient manage- ment. However much we hospital people may feel put upon by those who would penalize the so-called inefficiencies, the hard cold fact is that few people understand why hospital costs have gone up so steadily and so rapidly. We have not succeeded in explaining the inextricable relationship between quality and costs. Although the people want the best that modern medicine can provide, most of them do not yet accept the fact that the higher quality of hospital care justifies the higher costs. DOCTORS AND MANAGEMENT Most of you are familiar with the fable which was recounted earlier this year in the report of the Sec- retary’s Advisory Committee on Hospital Effective- ness: “The intelligent visitor from Mars was interrogat- ing a hospital administrator on the purposes, func- tions, and administration of a hospital. The Martian was told that the doctors in the hospital order the procedures for patients and thus determine how the resources are used and what work members of the staff do—that the physicians decide which patients to admit and when to dismiss them. “