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November 9, 1965

Mr. John Russell, President

John and Mary R. Markle Foundation
522 Fifth Avenue

New York 36, New York

Dear John:

I am writing you, as you requested in Baltimore on November
6, relative to the reasons behind my expressed feelings of
the importance to the Schools of Medicine of Public Health
Service Act Title IX ("Heart, Cancer and Stroke"). At the
outset let me simply indicate that my personal feeling is
that this Act, and its sequelae, will have an impact of
major importance on medicine and medical education. I
suspect the historians of the future will find its impact
equal to, or greater than, the development of the clinical
clerkship at Hopkins, the Flexner report, the evolution of
the full-time faculty or the growth of federal support in
medical research during the last two decades.

Why? Because this Act in one package immediately affects,

at a rather basic level, all three aspects of our profession--
patient care, education and research. It has been stated,
whether correctly or not (I will not debate), that it grew

out of a demand of our society for a better distribution of
the quality and quantity of health care, out of a need for
bringing the advances of the medical research scientist

more rapidly to the ultimate goal--the recipients of health
care. If it is to achieve this goal I am fairly confident

it will perforce have a direct effect on our national

medical research effort. 1 do not mean that it will
necessarily impede the basic research growth that has occurred
through the NIH, but I feel it will create a different
(hopefully additive) emphasis. There will be greater and
greater use of PHS funds for training grants, not for the
training of researchers but for the training of young men

in the clinical use of the information produced by the
researcher. The beliwhether of change in emphasis is

readily seen in the recent alteration of approach in the
Clinical Cancer Training Grants and in the very -recent
establishment of the Cerebrovascular Clinical Training
Grants. Here I would underline the term Clinical Training.
This change in emphasis is an obvious and necessary one in
order to produce one type of Manpower needed for the success
of Heart, Cancer and Stroke, It will in a relatively short
perfod of time significantly alter many of the post~praduate
educational programs going on in Medical Centers. In that
the pool out of which the participants in such programs will
be drawn will be essentially the same one as our current
research trainees, there may be even broader implications
for the future than an alteration in post-graduate programs
alone. ,

In addition I would anticipate a change in the kinds of
research (again I hope an additive change) that will be
supported. There will be more interface or applied
research. There will be far more social research in the
area of patient needs and patterns of distribution of
medical care. This will bring medicine and the social
sciences even closer together in common and related
research goals with great benefit to both.

However, I feel that even more startling changes will occur
as a result of the patient care implications of this legis-
lation. Over the years the University Medical Centers have
become moderately well isolated from the medical community
at large. I need not dwell on the reasons for this (growth
of full-time faculty, research emphasis, etce.), but the
"town and gown syndrome" is a real rather than imagined
disease, Much has been written about it and even national
Symposia have been held in an attempt to find a cure. I
would like to submit that Title IX will be the most
effective therapeutic modality yet conceived. Indeed as time
progresses, Title IX and its sequelae may prove to be as
specific for the "town and gown syndrome" as penicillin has
been for the Beta hemolytic streptococcus,

It will force’ the University Medical Center out of its ivy-
covered walls and out into the community at large. The Act
specifies regional medical care programs and stresses
throughout cooperation of all those involved in the provision
of medical care. It requires that patients be referred by
practicing physicians (a government-accepted AMA compromise
that was undoubtedly acceptable in that it was one of the
facets that insured cooperation). It goes further by
requiring that practicing physicians and local medical
societies be involved in the regional advisory committees.

A final check in cooperation occurs at the National Advisory
Council level as well. It will indeed be interesting to
observe the approach of those insular medical centers who
have shunned and occasionally scorned the local physician,
who have avoided the county medical society, and who have
decried the AMA from without, as they attempt to repair the
wounds created by their attitudes over the years. [It will
take considerable time and effort for in many communities
the "town and gown syndrome" is not only acute, but quite
chronic. For many of the State schools this aspect of the
problem will not be very significant in that’ their
relationships may already be fairly healthy. Having grown
up in the "land grant" tradition with extension services
having roots in the communities of the State, many have
already established some quite acceptable patterns of
relationship not only with the State medical community

but the community at large. However, even in these instances
there is not one situation that is not in need of improvement.
In other less fortunate institutions it will take a total
attitudinal about-face. I am convinced, however, that the
pressures are now, or will be in the future, sufficiently
great to bring about the 180 ° turn that will be required.
And I can only shout "hurrah", for in the long run everyone

will benefit.

The regional concept will bring the University Medical
Centers within various regions into far more intimate contact
with each other than has previously occurred. Many have

been isolated not only from the practicing community, but
from other medical schools ian their region as weli. Indeed,
in some instances there has been direct competition among
medical centers in a given region. It was interesting to

see the kind of. cooperation and new alignments that were
becoming evident at the recent AAMC meeting which were
stemming directly from the pressures of Title IX. Out of
this will come a more realistic, and hopefully more
efficient, approach to the provision of medical care in their

regions.

Not only will physician-to-physician communications improve,
but communications of physicians with the rest of the
“medical care team" will occur. As we attempt to improve
the quality and quantity of care, it will become even more
obvious than it is now that quality and quantity cannot go
hand in hand without more efficient expansion of the medical
and paramedical groups with close effective cooperation of

all concerned.

The effect of Title IX on medical education (and here I am
using the term in the "Coggeshall" sense) has the possibility
of being truly revolutionary. The basing of the programs

in "major medical centers" will intimately involve, either
directly or indirectly, most of the medical schools in the
country, and it will involve them throughout the entire
spectrum of medical education, I have already referred
earlier to some of the effects in the post-doctoral area

and will not comment further about this group.

A truly significant effect will be felt in the area of
continuing education. As you well know the AMA, the AAMC,
the AAGP, the various specialty groups and individual
medical schools have already had a try at seeking solutions
to problems in this area with varying degrees of success or,
I should say, lack of success. I am sure it is as obvious
to the powers that be in Washington as it is to me that the
key issue in the success of provision of increased quality and
quantity of health care is really education. This includes
not only the initial education (in medical school, residency
and the post-doctoral area) in what constitutes good medical
care and how it is best provided to all people in all
situations, but also (and probably more importantly) the
continuation of education in the whats and hows for the
lifetime of the physician. The changing patterns of care
and improved physician-to-physician relationships that wili
result from the medical care aspects of Title IX will provide
the vehicle by which continuing education can occur. I have
little doubt that those ciarged with the administration of
proposed programs will insist on a strong education under-
pinning for them. If they do not, then they have missed a
chance at providing strong therapy to one of the major
ilinesses in medical education today.

AS new patterns of care emerge under the stimulus of

Title IX, there will need to be changes in approach in
residency training programs. New patterns of care wiil have
to be backed by educational experiences which will permit
individuals to fit easily in them. Down the road I can

also envision greater governmental support for various
specialty programs that are currently under-manned. . This
wiil have direct effect on the size of these residency
programs. I can also see the possibility of the evoiution
5

of bona fide residency programs in "family practice" which
will bring about a degree of educational cooperation of
current specialties that has not yet been accomplished
within most medical centers.

I have already mentioned the greater involvement of

paramedical personnel that will result in the medical care area.
There will obviously have to be an increased educational effort
to help produce these individuals. In addition to these
quantitative considerations there will be (or at least should
be) qualitative alterations in academic programs. If there

is to be increased emphasis on the "medical care team", it
follows that this concept should be brought ‘into the education
of the future members of these teams. Thus students in
medicine, social work, clinical psychology, nursing, medical
technology, physical therapy, etc. should have opportunities
for interchange in their academic programs. This is going on
to a limited degree in some university medical centers and

not at all in others. Again here is an example of increased
interchange that might well result from Title IX.

If I have sounded overly optimistic about the over-all
implications of Title IX, it is because by nature I am an
optimist. I would not like you to think, however, that I

am sufficiently naive to believe these things are going to
happen overnight or that they are going to occur easily.

A great deal of turmoil and indigestion is going to result.
It would be my hope that this would move slowly enough to
permit the necessary adjustments without impeding the
progress that has been accomplished to date. The marked
changes between the original DeBakey proposals and the

final Act hopefully suggest there is at least cognizance of
what is being asked of all who are involved. One of the real
concerns of many people is the manpower problem. [In that all
of the areas involved are short on personnel to carry out
existing programs, great care will need to be exercised to
avoid a significant drop in quality as we expend our efforts.

I realize I have rambled and said little of which you are not
already aware. You asked for some of my thoughts about the
implications of Title IX, and in order to get them to you
quickly, I have given you a lengthy first-draft rather than
anything approximating a finished product.
If there are points which you feel are unclear.or need
further elaboration, I will of course be delighted to

try my best to be of help.

I enjoyed seeing you again at Philadelphia and Baltimore.
I am extremely pleased at the direction the 1966 meeting
seems to be taking. Ever since Williamsburg I have been
concerned about the imagery of the Dean's Office and the
lack of understanding of the faculty as to what is going
on in Washington and its implications for them. It looks
as though two birds may be killed with the same stone at

Whiteface.

With best personal regards,

William D. Mayer, M.D.
Associate Dean

WDM: cm: ddc