;I i@[ @t 'i i, DR. EDMUND D. PELLEGRINO see Contemporaries page 18 ri 117 ti 73 money tz 146 49 EdmundD. campuses in less than twenty @'ears. He has been bringing his Pellegrino, M.D. own brand of "i@elevance" to medicine. 0 Plato believed that to be a Dr. Pellegi@iiio Nvent from good physician one must experi- Oneonta to tlieii-little-known ence serious illness. In 1950, sev- Hunterdon Medical Center in en years out of New York Univer- Flemington, N.J.; to the Uni- sity College of Medicine and with versity of Kentuck@, College of a foot on the first rung of the Medicine (in 1959) when "it was research ladder, internist Ed- a cornfield in search of a cam- mund D. Pellegrino ",as stricken pus"; and about six years ago to with tuberculosis. A vear and a the State Univei@sity of New York half of bed rest, followed by a like at Stony Brook where he holds amount of time as supervising TB down three jobs simultaneously: physician at Homer Folks Tuber- director of the Health Sciences culosis Hospital in upstate On- Center, univei'sity vice-president eonta, N.Y., greatIN@ influenced for the Health Sciences, and dean his (areer. of the School of Medicine. Recuperation gave Dr. Pelle- In each post, he has left his grino time to "cogitate my way personal brand of innovation. back to health." And working in Unlike some who often pose rural Oneonta rekindled memories problems, then leave the solu- of two post-World War II years tions to others, he frequently as an Air Force medical officer in casts off the yoke of tradition and Montgomery, Ala. challenges the long-established "I was educated in the classi- educational assumptions to find cal tradition, headed for a classi- new ways of doing an old-fash- leave Stony Brook eventually, but cal role in research and teaching. ioned job: turning out good phy- I hope that if and when I leave But my experiences changed all sicians. Stony Brook, I shall have brought that. In Alabama, I came face to Dr. Pellegrino is impatient to the right people together and face with some of the medical finish one job so he can move have created an atmosphere so problems of rural America-the on to the next. "It's part of my the major ideas can go on suc- deficiencies in manpower, the lack philosophy," he explains. "One cessfully. This is my test of of adequate facilities. In Oneonta, shouldn't spend the bulk of his whether the things I've done have many of the same needs existed. life in a single endeavor. One genuine validity." I became convinced that one of ought not to spend his time too The trail that led to Stony the major areas of concern should long in one administrative post. Brook began at Hunterdon, be health care, and that educa- You don't grow that way. If you where Dr. Pellegrino began as @tion should be more closely relat- can't make a major impact in director of internal medicine and ed to meeting the needs of the seven to ten years, you @re not later moved up to medical direc- Zommunity." going to make it. For the good tor. Hunterdon was not well The New Jersey-born boy of yourself and everybody else, known then, but it was where he raised in Brooklyn knew that this you ought to move on to some- wanted to be. Hunterdon had a was what he wanted to do-work thing else." goal: to develop a comprehensive to help meet these needs. And When you move, leave a bit of health care plan for this rural- he has been doing it ever since yourself behind. "That's the real agricultural community of some during a medical career that has test of an idea," he says. "Does 42,000. taken him to three pioneering it remain after you're gone? I'll "It was the most exciting, most 1 q evtror acu a ac 0 Du vwi 7 o7s Each tablet contai probenecid and 0.5 mg colchicine Probenecid - helps reduce serum uric acid levels Precautions: Hypersensitivity may occur, especially with intermittent use, requiring cessation of therapy or dosage helps prevent or delay the formation of crippling reduction. Since probenecid raises plasma level of con- tophi jugated sulfa drugs, plasma concentrations should be Colchicine o although not an analgesic, produces checked occasionally during prolonged Maladministration dramatic relief of pain in acute attacks of gout * with sulfa drugs. A reducing substance, wnicn disappears helps lengthen intervals between acute attacks with discontinuance of therapy, may appear in the urine, giving a false-positive Benedict's test' NOTE: CoIBENEMID'-is indicated in the treatment Adverse Reactions: Probenecid: Occasionally, headache, of all stages of gout and gouty arthritis; however, gastrointestinal symptoms (e.cf., anorexia, nausea), in- it should not be started during an acute attack. creased urinary frequency, and hypersensitivity reaction.s including dermatitis have appeare@. Rarely, flushing, dizzi- While hypersensitivity to probenecid may occur ness, anemia, and anaphylactoid reactions. Hemolytic one- during continuous therapy, it is more likely to mia which in some instances may he related to a genetic occur with intermittent use. The appearance of deficiency of glucose-6-phosphate dehydrogenase in red reactions may requ.ire cessation of t@e'rapy or dos- cells. Extreme.ly rare instances of nephrotic syndrome, hepatic necrosis, and aplastic anemia. age reduct@'on. Colchicine: G.I. disturbances (e.g., nausea, vomiting, ab- Indications: Gout and gou,y arthritis except a presenting dominal pain, diarrhea), particularly troublesome in pres- acute attack. However, if an acute attack is precipitated ence of peptic ulcer or spastic colon. Toxic doses may cause during therapy the dru@ should be continued without severe diarrhea, generalized vascular damage, and renal changing the dosage, anct additional colchicine should be damage with hematuria and oliquria. Muscular weakness, given to control the acute attack. hich disappears with discontinuance of therapy, urticaria, Contraindications: Hypersensitivity. 14ot recommended in dermatitis, and purpura may occur and may require reduc- persons with blood dyscrasias or uric acid kidney stones. tion of dosage or discontinuation of drug; rolonged use p -e instance s, cause a aidlastic anemia, Warnings: In ra, henaturia, renal colic, and may qranulocytosis, ' peripheral costovert,--h,al pain have been reported. May precipitate neuritis. Loss of hair has been reported. In hepatic dysfunc- an acute attack of gout; theoretically, may favor urate stone tion, consider possibility of increased colchicine toxicity. formation, which may be prevented by alkalization of urine Supplied: Tablets, containing 0.5Gm probenecid and 0.5 mg and liberal fluid intake. When alkali is given, acid-base colchicine each, in bottles of 100. balance should be watched. Salicylates should not be For more detcriled information, consult your Merck Sharp given viith probenecid, since coadministration results in Dohrne representative or see the package circular. inhibition oL the uricosuric activity of the latter. Cell divi- sion in animals and plants can be arrested by colchicine. In certain species of animal under certain conditions col- 0 MERCK SHARP & OCHME Di@isio@ of me,ck & Co,lNc,west Point,Pa 194M chicine has produced teratogenic effects and has adversely affected spermatogenesis. Such effects have not been dern- WHERE TODAYS THEORY IS TOMORROW'S THERAPY onstrated in humans. COIB-ENEMID for gout and the pain of gout 17 LLIU rewarding part of my career," he head of Columbia University long espoused by the medical in- says. "It was there where I had School of Public Health and Ad- novator: that the many health my first insight into a key prob- ministrative Medicine. disciplines must work together lem in medicine's relationship to For Ed Pellegrino, Hunterdon for the betterment of the patient. society: the need for congruence presented me with a fresh piece Dr. Pellegrino believes, also, between what a physician does of canvas and a possibility of that the community should be an and what society expects of him." painting something personal, new integral part of a medical center, The grass-roots movement to and relevant." There, he had an that "those who participate in establish the center, initiated in opportunity to practice clinical patient care at a community level 1948, had just begun to take medicine, but much more. He should be brought together in ac- shape when he arrived. Launched was able to help fashion a com- tion and purpose." Hunterdon by a unique group of citizens- prehensive health care program provided office space and facili- poultry and dairy farmers, busi- in a slice of rural America. ties for such agencies as the, nessmen, industrialists, and corn- At Hunterdon, Dr. Pellegrino visiting nurse and homemaking munity leaders-it had the developed what was probably one services, the mental health asso- support of the county medical of the first comprehensive health ciation, and the community ser- society and had gained affiliation centers at a community hospital. vices committee. with NYU Bellevue Medical Its staff practiced community Unlike many hospitals where Center some 70 miles east. And medicine in a day before that general practitioners are denied it had been guided during its for- now-commonplace function even staff rights and must turn their mative stages by -none less than had a name. And deeply ingrained patients over at the door, at d E. Trussel, now with this service was a philosophy Hunterdon every GP in good Dr. Raymon ModernMedicine/October4,1971 19 @t4 tal, 'ii'tiat' standing with his medical society1 tliev @vere not as responsive to the University hospi 1 1 in(y I)eloii,s to the attending @taff. the health needs of societN, as one of tire country's first pliysi- This fits into the Pellegrino pat- they might I)c,,." cians"assistants proo-rams, imple- tei@n-. the GP, or family pli@@sician When he ari,l%!ect in l@entucky, mentitig @vays to inipron-e rela- to call h' ritical tioiislilps between doctors. social as he prefers im, should medicine was faced by c I A sys- educational issues: how to relate workers, @ind iiurses. And @@-liat lie be a coordinator of care. tem initiated by Dr. Pellegrino a health science center to the personally feels is slc,,nificaiit, his placed the GP in just that role. people it served: the need to in- departi-iient of medicine became Patients are admitted and cared trocluce behavioral and social one of the first in the country to for 1)3, the GP who has privileges sciences into the hc@altli sciences; appoint two general practitioners on the i-nedical, pediatric, and ob-i a way of acliie@,iii(,, a balance be- to its full-time faculty. Under the stetric staffs. Major surgery is t@@-een science and a more human- aegis of the department, the performed only by the full_time istic patient-orientecl outlook; school developed pro-rams for staff. But the GP remains the seeking answers to the question, the teaching of physical tliera- responsible agent. He admits and what more can be done in the pists, dietitians, and medical as- discharges, writes orders, and field of community medicine? sistants. Out of this embrvo ure@N, coordinates care. "'Here," he says, "I could the School of Health Professions Another Pellegrino innovation: grapple with these problems at which exists at Kentuckv today. at Hunterdon there are no 4 9 clinic their earliest stages. As professor At Kentucky, Dr. Pellegrino days" or "service patients." and chairman, I was part of a applied much of what he had Whether they pay or not, they're core planning roup under Dr. preached and practiced at Hun- all seen under the same condi- William R. Willard, dean of medi- terdon. It was there, too, where tions and their care is the same. ciiie. I was an unofficial 'idea he laid the groundwork for con- Each has an attending physician n@an'-a dean Nvithout portfolio." cepts he was later to apply at responsible for his care. as also while Working "from Ground Zero," Stony Brook. It w Hunterdon , Dr. Pellegrino be- he, along with the group Dr. Wil- at Kentucky that the Pellegrino lieves, demonstrates the basic lard had assembled, was able to philosophy began to appear in principles "worthy of considera- build a faculty that combined print in an endless flow of ideas. tion in part, if not in toto," by basic and fundamental clinical He considers himself almost as all communities planning health research with a concern for pa- much a philosopher as a plivsl- centers. And he took a bit of tient care and general internal cian. He is as deeply concerned Hunterdon with him to the Ken- medicine. with the needs of society as he is tucky cornfield that became a There were the ii-iyriad but with those of individuals he min- medical school. more routine chores in building a istered to as a clinician. These The 50-year-old physician ad- faculty and curriculum, of course. views, drawn from his writings mits, in retrospect, that he was But these were not enough to' and commentaries, give insiglit an unlikely choice for the post of satisfy a restless i-nan. Dr. Pelle- into the philosophy of the man: chairman of the department of grino was elected to the Execu- Medical ethics: "Societal and medicine. "I had deviated from tive Council of the University individual values are increasingly the established pattern," he says. Senate and then to its chairman- counterpoised in almost every "My research background, as a ship. And it was in that post medical act. Some ratiotial and result of my bout of TB, had suf- that he became involved in a re- just order must be established be- fered. But I fitted into Ken- vision of the academic plan for tween these values to ensure the tuckv's notion that significant the entire university. good of society while safeguard- changes in medical education At Kentucky, lie was instru- ing the traditional rights of the were urgently needed. We came mental in developing one of the person." into a sympathetic congruence- first comprehensive drug infoi,- Relevance: "Medicine is an in- that doctors were not meeting mation centers, expanding the strument of social purpose. it all the needs of the people,' that functions of the pharmacist at continued on page 29 doesn't exist as an intellectual In 1966, Di-. Pellecli-iiio brought earn "parenthetical degrees" and discipline, but only because soci-I this philosophy with him to on the diploma, as well as the li- ety has certain problems. Unless Stoii@- Brook. 4@'I'Iiis," he en- ceiise, the M.D. would be fol- lowed by the specialty. we address ourselves to the reso- tliuses, N@@a%,lna @iii arm to the n was A priniar3, goal will be to pro- lutiori of those problems, @@,e're campus outside his \\-iiidow, " 'ty to tal@e my ideas duce more physicians able to pro- not fulfillilig our responsibilities an opportune I new vide primary, preventive, and as physicians." and apply them to a tota care-N\,hat he be- Humanity: '@The most delicate comprehensive health sciences emergency . Liiiniet health of the phvsician's responsibili- centei,. lieves is the majol ties, protection of the patient's '@One of the major deterrents care need in the country today. airman of the AMA Coni- welfare, must be fulfilled in a new in the delivery of optimal health As ch i in- and Allied care," he believes, "is the failure mittees on Nurs , and complicated context. It is the he grapples with this physician's responsibility, to .;ee of communications ind lacl@ of Health, that group assessment and man- precise definition of functions problem daily. At the Lonal Is- agement are rational, safe and among health professions. Char- land campus, plans include personalized. He must guard acteristically, they carry out edu- courses leading to a master's de- against the dehumanization so cational functions in isolation. gree for nurses and at least bac- easily and inadvertently perpe- It's essential that they develop calaureates for others in allied health fields. trated by a group in the name of them in close cooperation from efficiency." the outset." While the "final profile" of the Competence: "Maintenance of This is what is happening at Stony Brook curriculum is still competence [is] a prime ethical Stony Brook. He has organized to be determined, basic features challenge. Only the highest stan- the center so that the deans of already are well developed. dard of initial and continuing pro- the colleges-Medicine, Nursing, Stony Brook will, if the options fessional proficiency is acceptable Dentistry, Social Welfare, Allied laid down by Dr. Pellegrino are in a technological world. 'I'his Health Professions, and Basic all put into practice, offer a mul- imperative is now so essential a Health Sciences-and the direc- titrack curriculum providing feature of the patient-physician tor of the University Hospital briefer initial exposure to basic transaction that the ancient man- participate as equals in policy- sciences and in-depth coverage date, 'Do no harm,' must be sup- making. of those sciences relevant to "spe- plemented by, 'Do all things es- He hopes to reexamine the "as- cial roles like medical research, sential to optimal solutions of the sumption that the basic sciences clinical specialty, community patient's problem.' " as now taught male for better medicine, family medicine, bio- Philosophy: "The major con- medical practice." medical engineering, and i-nedical cerii of contemporary philosophy "We must concentrate on the social sciences. Each track will is man's existence, and it is here introduction of the language of require a different concentration a dialogue fruitful to the physi- basic science," he says, "with a of basic sciences and clinical cian can begin. The functions of later concentration on those experiences. The undifferentiated the physician and the philosopher basic sciences i-nost relative to the physician of the past will be a are not to be confused. The doc- field or practice chosen by the rarity." tor proceeds by hypothesis student. In essence, the basic Stony Brook brings the health the philosopher clarifies and aug- science component will vary with professions together by provid- ments the concept, puts it in rela- the track the student chooses to ing common classrooms, clinical tion to the general history of follow." experiences, and models of pa- ideas, and raises the fundamental At Stony Brook, he hopes tient care simultaneously involv- questions of ends and values. The eventually to turn out physicians ing students from all of the relation of the two disciplines is exquisitely competent in a par- schools at the center. In addition, not one of subordination, but one ticular area but not in the whole a physicians' assistant program is of interpenetration." scope of medicine. They would Continued on page 34 Moderii Ntediciiie October 4, 1971 N4erck Sharp & Dohme viral immunology leader in announces: a sing e 'Inl'e ct'ion 0 0 .a ininistere at age 12 inont.. s .---or vaccination against t ree iseases \4-N4eas es 1\4un-1 u-:)e. sed for Stony already under way in the School programs propo ned to do just of Allied Health Professions. Brook are desi- Dr. Pellegrino believes a new that." health profession Nvill eventually He considers affiliation impor- 'ng all the ex- tant. And while he doesn't infer emerge, enconipassi one that patients in nonteaching hos- istino., health professions in new body dedicated to the im- pitals receive lower quality care, 'ty and lie feels they lose the advanta-e prevenient of coii-imuni individual care. It will engender of that "critical air of inquiry a "'spirit of medical ecumenism." prevalent in a university-affiliat- The Pellegrino blueprint calls ed institution." for earlier entry into medical "Affiliation is a univeysity's studies, a briefer stay there, and pastoral responsibility," he adds. flexibility in program selections. "It should be the concern of a The Stony Brool@ student will medical center to involve every have clinical experiences'practi- institution and professional in its cally from the day he steps on area." campus, but not all his studies Dr. Pellegrino realizes he "can't will be there.There will be time be everywhere at once," nor can on the wards and in doctors' of- he be all things to all people. But fices and provisions for "drop-out he tries. He is constantly on the periods for work, research or lib- go-lecturing, writing, working eral studies." behind the scenes rather than in Dr. Pellegrino is mapping plans the limelight, to further his medi- for widespread affiliation, stretch- cal philosophies. ing out to the more than forty Despite a heavy schedule, he hospitals on Long Island. Not refuses to let his laboratory and medi- scholarly activities take a back only will this bring better seat to the more demanding ad- cal care to the communities, but be believes it will provide the ministrative chores. His labora- kinds of experience needed by tory work concentrates on corn- physicians and other health pro- plex studie of the physical and s fessionals. organic chemistry of calcified tis- "A major deterrent to the ex- sues. He likes to work with small pansion in the number of health groups with an ultimate team goal professionals," he contends, "is of establishing a biochemical def- the limitation imposed by classic inition of metabolic bone disease. curriculum' structures and the in- Most recently, Dr. Pellegrino sistence on providing the major Iand his re earchers have been try- s Still serving... experiences for all students at the ing to determine where carbonate medical centers themselves. fits into the crystal structure and "By a judicious combination of they are taking a closer look at curriculum revision and the con- the calcium maturation of bone version of a number of communi- crystal in the alien embryo. Miltowff ty hospitals into major clinical "That," he says, "is a matter teaching units, it can become which has vexed chemists for a (m@@robamate) realistic to think in terms of sig- hundred years. We don't have the nificantly larger entering classes answer, but we think we've sup- WALLACE PHARMACEUTICALS J!yi in all the health professions. The Continued on page 38 Cranb@iry, N.J, 08512 34 Nlodern Nledicine / October 4, 1971 effectiveness of the combination vaccine M-M-R(MEASLES, MUMPS, AND RUBELLA VIRUS VACCINE, LIVE MSD) M-M-R has shown no significant reduction in ,(@i,oconversioii rates. The serocon- version rates remained at a sufficient level to demonstrate :i high de-ree of effectiveness. Year Vaccine Number Number Seroconversion Released Vaccinated Susceptiblie Rate 960/,6 Measles 1971 M-M-R 1,@)51 756 95% Mumps 940/i) Rubella seases The effectiveness of M-M-R (reflected in sei,ocoiiversion rates) could be reliably demonstrated in relatively small numbers of susceptible children, because of the laroe numbers of children tested with the conil)oiient vaccines. No untoward reactions peculiar to the combination reactions have occurred, such reactions m y a so occur vaccine (M-M-R) have been reported. ivithNt-,%I-R. A cause and effect relations p, however, has not been established. @Nloderate fever (101-102.9 F.) occurs occasionally. High fever (over 103 F.) occurs less commonl@,. On rare occa- Excretion of the live attenuated rubella virus from the sions, children who develop fever may exhibit febrile throat has occurred in the majority of susceptible in- convulsions. Rash (usually minimal and without gen- dividuals adrfiinistered the rubella vaccine. There is no eralized distribution) may occur infrequently. definitive evidence to indicate that such virus is con- tagious to susceptible persons who are in contact with Since clinical experience with measles, mumps, and the vaccinated individuals. ConseQuently, transnlission, rubella virus vaccines given individually indicates ivhile accepted as a theoretical possibility, has not been that very rarely encephalitis and other nervous system regarded as a significant risk. Adverse Reactions: Fever, rash; mild local reactions duration. The incidence in prepubertal children would such as erythema, induration, tenderness, regional appear to be less than 11/o for reactions that would lymphadenopathy; thrombocytopenia and purpura; interfere with normal activity or necessitate medical allergic reactions such as urticaria; arthritis, arthral- attention. gia, and polyneuritis. How Supplied: Single-dose vials of lyophilized vac- Occasionally, moderate fever (101-102.9 F.); less com- cine, containing when reconstituted not less than monly, high fever (above 103 F.); rarely, febrile con- 1,000 TCID,. (tissue culture infectious doses) of vulsions, measles virus vaccine, live, attenuated, 5,000 TCID@. of Encephalitis and other nervous system reactions that mumps virus vaccine, live, and 1,000 TCID5. of rubella have occurred very rarely with the individual vaccines virus vaccine, live, expressed in terms of the assigned may also occur with the combined vaccine. titer of the NIH Reference Measles, Mumps, and Ru- Transient arthritis, arthralgia. and polyneuritis are bella Viruses, and approximately 50 mcg neomycin, features of natural rubella and vary in frequency and with a disposable syringe containing diluent and fitted severity with age and sex, eing grea es in adult fe- with a 25-gauge, %' needle. Also in boxes of 10 single- males and least in prepubertal children, Such reac- dose vials nested in a pop-out tray tions have been reported with live attenuated rubella with a separate box of 10 diluent- virus vaccines. Symptoms relating to joints (pain, containing syringes. mso swelling, stiffness, etc.) and to peripheral nerves (pain, For more detailed information, con- numbness, tingling, etc.) occurring within approxi- sult your MSD representative or see AERCK mately two months after immunization should be con- the Direction Circular. Mercli Sha@p & 3HARP& sidered as possibly vaccine related, Symptoms have Dohme, Division of Merck & Co., Inc., IA7.,f P@i@f Pn lc)4RO )OHME plied a lot of new information His most absorbing and reward- which will give direction toward ing hours are spent in his study, developing a new theory as to adding to his collection of 4,000 just where the carbonate fits in." nonmedical books and dreaming Dr. Pellegrino expresses his like Cicero of a library in a garden views at many national commit- as the penultimate setting for a tees and task forces dealing with civilized life. the most significant issues in edu- At home there are eight Pelle- cation and the health professions. grinos besides himself. He and And while many are "progres- his wife, Clemintine, have seven sive," he prefers to confine them children, 9 to 26 years of age. to this arena, to worl-, within the "We're almost evenly divided" for existing framework of medicine. he says, "between those who are the "I eschew crusades and spectac- biologically oriented and those pain ular statements," he says. "What concerned with political scienFp." in lasting value would they have? Two of his sons are heade4 @0- ACUTE OTITIS MEDIA A few headlines, a day of glory ward medical careers. Thomas en- in the public eye, and ostracism ters the University of Kentucky by my colleagues." Medical School this fall. And Widely published, author of Michael, still in high school, ap- nearly 200 books and medical pears headed toward a medical papers, member of four editorial career. boards, a lover of words and an Two of his children are in- addict to using them well, Dr. terested in law, and the others are AURALGAN relieves pain Pellegrino believes writing, as we still too young to decide what fast ... reduces aural know it, may be on the way out. fields they wish to follow. In He's convinced that medical jour- keeping with his own childhood, Congestion. It is fully I compatible with systemic nals, as doctors kiiow them today, his home, he feels, is the major will fall prey to the growing so- "humanizing influence in my antimicrobial therapy, phisticatioii of the computer. life." 0 Even at Stony Brook, plans are Even as he dreams of new being made to train future physi- worlds to conquer, he seeks to cians in the use of the computer balance his multiple interests for medical care, diagnosis, and through deeper family involve- continuing medical education. meiit. And he looks forward to Otic Solution This poses a philosophic ques- 44 one more challenge while I still I tioii: will physicians be able to re- have the required mental and BRIEF SU@,4MARY taiii their individuality in an age physical agility new ventures AURALGAN Otic Solution Each cc. contains: of computerization? demand." This will come, per- Glycerin dehydrated ............ 1.0 cc. Dr. Pellegrino manages to do haps, in the "quiet years, an e4ly (Contains not more than 0.6% moisture.) just that by spending his time retirement fi@om posts of leader- Antipyrine . . . , @............. 54.0 mg. away from medicine indulging his shil) to more contemplative en- Benzocaine .............. ......... 14.0 mg. lifelong interests in medieval and deavors-adding to my library (Also contains 8-Hydroxyquinoline sulfate.) modern philosophy, in the trans- and, most important, writing a Supplied: r4o. 1000-AURALGAN lation of Latin poetry, by play- cultural history of medicine." Otic Solution, in package containing 15 cc. bottle with separate dropper. ing tennis or the piano, and by And in doing so, Dr. Pelleerino screw cap attachment. supervising his sons who keep the hopes to follow another Plato lawn of his Long Island home in prescription: the ultimate bleiid- AYERST LABORATORIES, trim suburban condition. ing of medicine and philosophy. D@ New York, N.Y. 10017 JOHN W. GERDES, Ph.D., Coorditicitoi @EGIONAI, BOX 5796, BOISE, IDAHO 83705 305 FEDERAL WAY, BOISE, IDAHO 83705 TELEPHONE: (208) 342-4666 September 20, 1972 Ms. Dorothy M. Bailey, Writer Office of Communications and Public Information Department of Health, Education and Welfare Public Health Service Health Services and Mental Health Administration Rockville, Maryland 20852 Dear Dorothy-. Thanks for sending me the copy of the Nurse Practitioner vignette which you prepared. It is an excellent condensation, with only three minor changes to be made: In paragraph 4, third line should read: ..."University Medical Center which was offering a (instead of its first) pilot program..." (Stanford no longer offers this specialized training - since the pilot program for five nurses was conducted.) The last sentence in paragraph 4 should read: ..."Since February, 1972 they have been employed as Family Nurse Practitioners under the sponsorship of an Idaho physician..." On the Back-up Sheet, the Core Staff Contact should be listed as Mrs. Laura Larson, R.N., in our Regional office, rather than Mrs. Merrell who is no longer with MSRMP. A sequel to the story, for your information, is that Dr. Edwards, the sponsoring physician, suffered a fatal heart attack July 2, 1972, and the Cambridge clinic manned by one of the Nurse Practitioners was closed. Just this month, the Clinic was reopened, when an Oregon physician offered to sponsor the Nurse Practitioner "until a permanent physician can be found... This is too good a program to let it die," he said. Sipcerel/y, (Mrs.@ Helen Thomson Coordinator of Information HT:kd l@: ( I ) @l @NI I @.@ 1 4 @ N t C, s C3, cl, c Press-D(,r,@r-crat D 49,222 -,-Upes for coast's Deit-,Ltal Cl'l'i-iic By Staff Correspondent of fields, accordit-ig to Keene. SACRAME.NTO - A rural! it was established by Dr. I dental cl@,ilc on the %Iendocino'Johii Frankel, a d@,iiti'st and v@,-l Coas, could keep its d@)ors ol,, z'O vea7-, k:ith ti2e U.S.i -; C,2, .1 I:c islati(.n iri!roduced ih@s 'I)e crilv ctinic for nii'ies ai@ounci' As_Qleml)!%7t-,ian B a r r y Kee!ie,'%vhich offers dental services. I D-Santa Rosa. "This project is ackiiowledgedi The Greenwood Proicct, u@ecilbv everyone as a iii(ist success-I :bv hundreds ri,@' nio@-tl,,7 fi.,l riic(,el," Keene jiisti children. 4n itii x.ear, is @!ear, it has t,)rovide(i threatened by a loss of to hundreds of patients funds. mostly children. The @@-as the su"t)jec.@t of a! "It enabled dcl,@taT St,,idci-its @l e nh y "ea@ure articlc last'and instructors a chance to d,)n-l iveekl,nd in t Bav Area ate their time and to serve people N%F@ia not otherwise Keetie's bli! i%ouid cljlliillueirece,,ve dental care," Keeie ad- the rural dt?n',@A ei; .nic D;",oi which is now ni The as.,enibl%rinan said his bill .S28.000 :!rant i.,,Id @,,pl)ropriaLc t 0 go%-er.,,,m--nt@@ Re,,TioiiLil the clj,,iic for atii)titer "so that care @Nill @,',,ie cli,@c, @n !o be available to of Eik, is scheduled lo be persons on the Nlendoci- ished in June because of a lack no Coast." 1,747) k@ s Ambulance The Emergency Ambulance Since none of the participating continuing program through serve to upgrade emergency Medical Technician Course hospitals are teaching in- Ukiah Adult Education. The care meets A,ith success. stitutions--- it necessitated students represent a three The following are the 'xi,3t of originated from Regional area and include the physicians serving as in- Medical Programs 99'@i e@ct making marty- sacrifices and county r u t o t e 6T[6-efs of Everett adjustments to accomod ate the imbulance, firemcii, forestry structors: Peterson, owner Of Willits students and it is gratefully and law enforcement and that these hospital personnel Robert Sm alley, ',%I. D. Ambulance service. acknowleged William Foster ;@I.D., and The course has been built to hospitals so willingly met the The course consists of lecture- Joseph Stetz @I.D. of %V@llits; State Department of Public demand in order to assure the Health spe@@tF6ns in ac- program of success. discussion-demonstration-, George Fisher '@I.D.; Richard cordance .vith"the'-new health observation and participation. Guthrie, -NI.D., Robert Werra, It was emphasized that it was 'Me classes were scheduled to NI.D., Jose Vill@ir;ca, '@l,.D., training bill AB 1730 which became effective for all am- no minor task to assimilate and meet at Howard Hospital but Robert Kraft, -%I .D.. Frank put on a course of this nature for because of their Si7e the Dziile@,, -@I.D., Eugene La-kass, bulance and rescue personnel in Wilson. ,March. 0 be facilities of Baechtal Grove M,D., Leland our area; but it has proven t exceptionally rewarding and School were graciously offered K.O. llidi.ilev, @I.D.. P, u, i) It will carry certification from the Ukiah Adult Education enthusiastically received. by Principal Paul tjbelhart. Curtis, and Richard School Principal Marshall There are presently 47 This is another example of the l,vrn2,n, . i'@I.D.. the Pro,,f,@@arr, lkve. students enrolled and many wonderful community effort Cc)orClinator all from !:kiah. Dr. R. Iyman is the physician times that figure anxious to and cooperation to see that a E)on Thomas, Fort coordinator and Martha enroll in the next class, a course of this nature which will Bragg. Pet son R.N., co-oaner of er Willits Ambulance is the clinical instructor and nurse coordinator. The instructors include 15 Mendocino County physicians, officer Stone of the Calif. High- way Patrol, Arnold Ormsby, Ormsby Ambulance, Joseph Calamusa, Administrator of Howard Hospital, Nlartha and Everett Peterson and Ken Donahue, Fire Cilief-Ukiah. The classes started in Jan. and will continue through June 12. Classes @vill be held in the evening with clinical ex- perience totalling IF hours. The clinical experience will be given at Howard Hospital, Ukiah General Lakeside @pital, and Red@)ud Hosi)ital. The students are requir@ to spend actual tii-ne working in the,hospital emergency rooms. A report of activities from the Cancer Advisory Committee: Special Listing Project of the Joint Commission on Accreditation of Hospitals BENJAMIN F. BYRD, JR., MD, FACS, Nashville Chairman, Commission on Cancer American College of Surgeons In the spring of 1972, a contract to identify members of the College and of liaison members resources available in hospitals in the United representing various national professional or- States with special capabilities in diagnosis, gaiiizations with a special interest in the field treatment, and education programs related to of cancer. (Ed. note: a current and complete heart disease, cancer, stroke, or advanced kid- i-ostei- of the Commission on Cancer can be found ney disease was entered into between the Joint in the ACS Bulletin, Vol. 58, No. 5, May 1973, Commission on Accreditation of Hospitals page 24). Because of the composition of the (JCAH) and the Regional Medical Programs commission, as well as its more than thirty Service (RMPS) of HEW. At about this same years' experience in surveying cancer activities, time JCAH entered into a subcontract with the decision was made for the commission to the American College of Surgeons, through its do the preparatory work as described herein. Commission on Cancer, to prepare that portion Cancer Advisory Committee for the JCAH related to cancer. The report by the commis- Special Listing Project was appointed, contain- sion is now nearing completion of its initial ing representatives from the American Academy phase, and it is the feeling of the commission of Pediatrics, the College of American Path- that Fellows of the College should be advised ologists, the American College of Radiology, of the fashion in which this report was put the American College of Physicians, and the together, and of the broad objectives that American College of Surgeons. Many of the guided the commission to its preliminary con- individuals from these organizations belong to clusions. other societies of regional and national scope The Commission on Cancer of ACS is named with special interest in cancer and related prob- by the Board of Regents and is made up of lems. A Steering Committee of the JCAH Special In brief . . . Listing Project studied at length the ways of ob- taining information that could lead to the This report presents a brief history of the categorization of facilities in the four fields of development @f a program ad inistered by the interest. It was agreed that a mail survey of Joint Co,(nmission on Accreditation of hospitals in the United States, other than psy- Hospitals to determine which hospitals, other chiatric institutions, should be conducted to than psychiatric, in the United States are assay the current availability of facilities and equipped and staffed to provide the diagnosis personnel in each institution. Responses to the and treatment Qf four major diseases (heart, questionnaire were received from hospitals cancer, stroke, or advanced kidney), and of the representing 94 percent of all acute care hospi- role of the Commission on Cancer in carrying tal beds in the United States. From the re- out its responsibilities, under subcontract with sponses to this survey of 7300 hospitals, an JCAH, for the cancer segment of the program. inventory has been prepared which identifies 18 American College of Surgeons MEETING OF YOUNG SURGEONS creased involvement in the areas of cost con- trol and quality care delivery in response to rising national interests. Discussions for achiev- ing these goals centered around the utilization of data obtained by continuing surveys, as in the Study on Surgical Service for the United States, or by analysis of computer data gen- erated by PSROS, HMOs, medical founda- tions, or the medical insurance industry. It was hoped that there would be increased dis- hernioplasty by family practice physicians is semination of this information through mech- declining and that recently trained family anisms such as the BULLETIN, or perhaps by physicians are not eager to carry out major trial sessions at Clinical Congresses along the surgical procedures. The need to define the lines of the open forum held by this commit- areas where family physicians, allied health tee last fall. personnel and surgeons might best use their The discussants were strongly interested in special talents and expertise in providing the the ACS developmental work involving norms best surgical care for the widest group of and guidelines for standards of surgical prac- patients was stressed. tice. It was felt that this activity at the Acs The problem of attracting well trained level could provide important support for surgeons to rural areas and smaller towns was surgeons involved with these activities at com- discussed. It was concluded that it would be munity or chapter levels. It was anticipated useful to encourage availability of information that these guidelines would improve the level concerning open surgical positions in all areas of effectiveness and competence as concerned of the country to surgical residents and sur- Fellows attempt to optimize both cost and geons considering changing location. Such quality of surgical care in their own hospitals. information would include surgeon to patient The workshop discussants wished to thank population ratios, type of other physicians in ACS for sponsoring these sessions for young the area, and other data. Further, information surgeons. Many gained additional insight into that would indicate that certain areas might the scope of activities and problems addressed be undesirable as a potential job site, such as by the ACS. All felt both stimulated and en- an already overcrowded surgical situation, couraged to become more involved in health would be included. care delivery issues. The increasing number of foreign medical graduates taking the board exams in surgery Workshop IV and assuming surgical positions in this coun- Surgical manpower distribution, try was discussed. It was concluded that the job placement, and recertification foreign medical graduates fulfill an essential CONSULTANT: role in this country at the present time, and Francis D. Moore, MD, FACS, Boston that there would be a health care crisis if CHAIRMAN: foreign medical graduates were not allowed William P. Longmire, Jr., MD, FACS, into the country. However, it was felt that Los Angeles many of the foreign trainees are exploited and RECORDF,R: do not receive training of high calibre. It was Stephen L. Wangensteen, MD, FACS, suggested that it might be useful to eliminate CharlotWville, VA surgical training programs that do not offer Considerable discussion focused on the role of high quality training. the family practitioner in performing surgical The problem of recertification was reviewed procedures. The College's position in this sensi- and it was believed that the College should tive and important area was pointed out (Ed. require attendance and participation in sur- note: see Bull., ACS, Vol. 58, No. 6, June 1973, gical programs of continuing education by 3, 29, 30 . its members. As an example, it was suggested How to deal on the local level with such pro- that a Fellow of the ACS should attend a cedures as endoseopy, placement of dialysis certain number of ACS meetings over a speci- catheters and closure of small lacerations was fied period of time. In addition, recognition, a matter for extended review. It was empha- in the form of a certificate, for attending these sized that a clear definition of what constitutes meetings might be considered. Physical capacity major surgery as contrasted to minor surgery was also mentioned as a possible factor in re- had never been delineated. certification. The overall consensus of the discussion was that the performance of operations such as Continued on page 29 July 1973 Bulletin 17 CANCER ADVISORY COMMITTEE the wide range of personnel and facilities that by the Cancer Advisory Committee and will be have special bearing on one of the four areas of submitted, upon approval of the Board of study. Commissioners of JCAH, to DHEW. The antic- At the same time this inventory was being ipated publication date of the criteria is July, accumulated, the Cancer Advisory Committee 1974. Both the criteria, when published, and was asked to prepare sets of criteria that would the inventory will be available to any person, permit categorization for the identification of lay or professional, requesting them. those institutions having special capabilities At the same time this work has been going for the care of the cancer patient. These criteria on, similar preparations have been completed were completed by the Cancer Advisory Com- and submitted in the fields of heart disease, mittee in January 1973, and then reviewed in stroke, and advanced kidney disease. Docu- conjunction with the inventory of facilities ments of the same scope and furnishing es- which became available about the same time. sentially similar points of reference will be The inventory has been submitted to the published in these areas at the same time as Department of Health, Education and Welfare the cancer documents. and will be published this summer by the Gov- Following are the Introduction of the Cancer nment Printing 0 Advisory Committee Report, and the opening er ffice. The criteria, following exposure to interested persons via publication paragraphs of the Guidelines for Categorization in professional journals, will be reviewed, to- of Hospitals for Cancer Patients. gether with comments and criticism, if any, The most important requirement would be a result from the criteria recommended by the special interest in the cancer patient on the committee. The governing thought has been to part of the staffs of such institutions. The en- improve the care of the cancer patient, and, to tire problem is made exceedingly difficult by this end, the following guidelines have been em- the great number of different disease complexes ployed in developing the criteria: included under the term "cancer". This neces- 1. Every cancer patient should be able to sitates consideration of the many capabilities find basic diagnostic services within his own required in evaluating the patient; in defining community; and carrying out treatment programs; in long 2. Every cancer patient should be able to term follow-up to provide rehabilitation, early find excellent diagnostic and treatment capabil- treatment of possible recurrent disease, and ities within his region; early detection of any new foci; and, most im- 3. The eventual goal will be to make all can- portant, in critical evaluation of the effective- cer services available as close to home as can ness of the treatment program in patient im- be justified; provement and Survival as well as cure. Only 4. Considerations of: (a) geography, (b) pop- as a by-product should the individual hospital ulation density, (c) limitations in numbers of concern itself with the problem of epidemiol- highly trained specialists, (d) economic limita- ogy. This is a different field and must be ap- tions on the availability of highly specialized proached in a different fashion from the re- and very costly equipment, and (e) the need quirements of Section 907 of PL 89-239 (as for a certain volume of cancer practice to main- amended by PL 91-515). tain expertise of a highly trained team for cer- The committee has held as a premise that the tain services, all point in the direction of re- cancer patient should be treated as close to his gionalization of services and the necessity of or her home as the availability of trained staff making available a stratified system of care; and specialized facilities will permit. The cri- 5. Hospitals vary in their size, number, and teria for various categories of facilities have degree of specialization of their staffs, and in been programmed to this end. the availability of specialized equipment and It is equally in the public interest that un- services; necessary reproduction of facilities should not Continued July 1973 Bulletin 19 CANCER ADVISORY COMMITTEE 6. Hospitals should also be differentiated ment of cancer patients should provide the as to their missions and each should try to following: identify that mission and range of services 1) Multidisciplinary approach: for all cancer most appropriate to its local situation; patients, with consideration of and access to all 7. Once a hospital has decided on its ap- modalities of therapy; propriate mission, it should endeavor to do 2) Education and training: must accept re- everything possible to fulfill its mission at as sponsibility for maintaining a structured pro- high a level of quality as possible; gram of continuing education in cancer for its 8. Wherever it is not practical or economi- own professional staff and community physi- cally feasible to have certain specialists on the cians, and for the development of a practical staff of a particular hospital where diagnosis level of cancer-oriented health education for and treatment for cancer patients are provided, allied health professionals and the lay com- arrangements for immediate consultation munity it serves; should be well established in advance so that 3) Assurance of quality care: must have no undue time is lost in obtaining expert ad- utilization review, medical audit, and discharge vice on any cancer problem. The patient can planning; then either be treated in that hospital with 4) Rehabilitation: full services available in benefit of expert consultation or referred for house or by referral; care to a hospital where the necessary exper- 5) Effective follow-up through a cancer regis- tise is available; and try and periodic re-evaluation; and 9. Where it is not practical or economically 6) Continuity of care: an established relation- feasible to have highly specialized and expen- ship with at least one extended care facility, sive equipment for the treatment -of cancer pa- nursing home, ambulant or limited care facility tients located in a given hospital, arrangements and a home care service. should be made for access to such treatment. On the basis of these considerations, the Can- It should be possible either to share such equip- cer Advisory Committee recommends identi- ment with another hospital or community re- fication of three general categories of hospitals source nearby, or to refer the patient to a more plus a special category including centers de- distant hospital or regional cancer center where voted entirely to the treatment of cancer, or to such equipment is available dustified by bav- the treatment of special types of cancer, or ing a large enough number of cancer patients limited to the treatment of special categories to maintain the expertise of the staff and to of patients (such as women or children). The keep the cost of the treatment per patient at a three general categories selected correspond reasonable level. essentially to those identified by the Commis- To be more specific, all hospitals accepting sion on Cancer of the American College of Sur- responsibility for definitive diagnosis and treat- geons. In summary, the Cancer Advisory Com- Cancer, ACS, 55 East Erie Street, Chicago, mittee for the Special Listing Project of JCAH Illinois 60611. The Cancer Advisory Commit- has reached agreement on sets of criteria based tee will welcome constructive criticism of the on the above guidelines which it proposes as a proposals in this to-be-published report and basis for categorization of hospitals. A detailed hopes the project will stimulate the health and report defining the categories and setting forth hospital professions to consider carefully the the appropriate criteria will be published in most appropriate development of hospital- selected professional journals in the near future. based resources for the care of cancer patients Fellows of the College interested in reviewing in any given hospital. this report may write to the Commission on 20 American College of Surgeons NEW ENGLAND JOURNAL OF MEDICINE - 8/19/71 - Vol. 285 No. 8 MEDICAL EDUCATION IN THE SOVIET UNION-STOREY 437 SPECIAL ARTICLE CONTINUING MEDICAL EDUCATION IN THE SOVIET UNION P. B. STOREY, M.D. Abstract Physicians in the USSR practice with- the Ministry has evolved an educational sys- in a system organized for flow of health- tem that binds all phases of medical educa- care services to the public, and for flow of tion and is noteworthy for its commitment of patients to appropriate back-up diagnostic and personnel, financial and organizational re- therapeutic facilities. The present medical-ed- sources to the lifelong improvement of a phy- ucation policy of the USSR Ministry of Health sician's knowledge and skills. The most im- is oriented toward increasing the qualifica- portant role is that of the 13 Institutes for tions of all physicians. This poses a complex Advanced Education of Physicians, under the problem for postgraduate medical education leadership of the Central Institute in Mos- in the Soviet Union. To meet the challenge cow. ONTINUING medical education in the Soviet other in the lifelong developments of the individual C Union ranks with undergraduate and graduate physician. medical education as a critical element in general quality control of the Soviet health-care system. As DIFFERENTIATION IN THE SOVIET EDUCATIONAL such, it is organized and funded on an All-Union SYSTEM scale in such a way as to assure it a top-priority role The process of differentiation begins with the in the medical educational establishment. @t is child in the 10-year general school, where his fu- closely integrated into the lifelong medical educa- ture is determined by the interplay of environmen- tional process, existing in dynamic balance with tal and personal determinants, Many of the 10-year other levels of medical education so that its own schools are specialized. For exai-nple, about 30 objectives and characteristics change and grow in schools in Moscow now specialize in providing relation to changes in the entire health-care system some of the curricular instruction in the English and its educational underpinnings Because of the uni- language, and two use the Spanish language. If versal organization of the Soviet health-care system, a child happens to live in the area served by such a which integrates its services, research and educa- school, and if his parents are agreeable, his primary tional components, continuing medical education foreign-laiiguage development is initiated. if during for given physicians or types and groups of medical his progress through the 10-year school, the child workers is closely oriented to the needs of their manifests a special affinity for a given discipline daily work. such as mathematics he may be transferred to a Soviet "continuing medical education" is carried school with stronger resources in that subject. In out under the auspices of the Institutes for the Ad- any case most students will receive a prolonged vanced Education of Physicians.* The Central Insti- exposure to mathematics, chemistry and physics, tute for such education is in Moscow. Its "centrali- which will prepare the eligible ones to take com- ty" is reflected in the fact that it is concerned not petitive examinations for entry into the medical in- only with its own pedagogic programs for pbysi- stitute. The present ratio of applications to available cians from the entire Soviet Union but also with places in the medical institutes is seven to one. the study of the methodologic problems involved in Granting successful outcome of the entry process, lifelong learning r p ysicians. a critical point of differentiation occurs in that the The function of the Institutes for Advanced Edu- prospective student now must enter on one of five cation is not really understandable outside the con- .1 le routes: the medical facult (lechebniy); the I)OSSID y text of the entire Soviet educational system and the I- . health-care system, both of which contain their own n@@iene faculty; the stomatologic faculty; the pedi- processes of differentiation that are related to each atric ficultv; or the medical-biologic faculty. Entrv into one of these routes represents a com- mitment that does not allow for crossover at subse- From the Department of Community Medicine, Hahnemann Medical quent points in time, except by re-entry. Thus, the College and Hospital, 235 N. 15th St., Philadelphia, Pa. 19102, where tin the Russian language the word "usovershenstvovaniye" carries reprint requests should be addressed to Dr. Storey. the implication that one's daily experience and reflection upon it The work done in development of this report was supported to a should contribute materially to the evolving maturity of the individual great extent by the US-USSR Health Exchange Program. personality. This is the lifelong process of usovershenstvovaniye o a "'Instituti dlya Usovershenstvovaniya Vrachey," which means lit- member of society, a process subject to both individual and social erally "Institutes for the Improvement of Physicians." control. 438 THE NEW ENGLAND JOURNAL OF MEDICINE Aug. 19, 1971 students who enter any but the medical faculty will characterizing quality that in turn determines his not in their careers be concerned with problems of ultimate eligibility for leadership in the profes- adult medicine or surgery. Similarly, the student sion. entering the medical faculty has elected not to be It is important to have an idea of this process of involved in the care of children. The medical- differentiation to understand the organization and biologic faculty is a new one. It was added four years administration of the continuing education process. ago to provide for students who wished to become The narrative used above to illustrate it is some- involved in the science of medicine and not in the what simplified but should suffice to afford insight care of patients. into the educational make-up of the Soviet physi- Until 1968 the curriculum lasted for six years, at cian. If further details are desired, the reports of the the end of which the student was assigned to his exchange missions in health' or the monographs by first clinical post@ Now a seventh year has been Field2,3 are helpful. added, the beginning of which represents a critical point of differentiation into the major medical and Standardization in the Soviet Educational System surgical specialties. The seventh year is approxi- Another general and very influential process in mately equivalent to the American "straight intern- the Soviet system must be considered - that of ship." The student from track one, for example, now standardization. The separate ministries concerned elects medicine or surgery or obstetrics and gyne- with education and with health care seek to make cology, and commits himself to that field of interest. uniform on a national @basis their respective proc- The addition of this year to the curriculum of the esses and their respective or conjoint products. medical institutes represents the decision of the They achieve this end either directly, by establishing Ministry of Health to move toward more specialized universally applicable educational objectives, curric- training of young physicians before they start their ula and norms of student response, or indirectly, by careers. operating through the corresponding ministries of At the end of the seventh year the student re- the various republics that make up the Union of ceivek."his diploma and seeks his first clinical as- Soviet Socialist Republics. Standardization is also signment, which will last for three years. This be- sought by a detailed characterization of the func- comes another critical point in the process of differ- tions of a given type of worker and by a close de- entiation because the strengths of the hospital or scription of the responsibilities and duties of a giv- polyclinic to which he is assigned will determine en positions his ability to pursue specialized study in a given Knowledge of these factors allows the faculty of field of medicine or surgery, and will,@condition his the Institutes for the Advanced Education of Physi- future selectability when he has completed his obli- cians to meet a most important educational constraint gatory first three years. For example, the depart- - that of knowing where a student is in his educa- ment of gastroenterology at his new hospital may be tional attainment and, critically, where he should be on the accredited list for training in gastroenterol- in terms of his job requirement. Application of this ogy. If it is not, he cannot move upward in the "cat- knowledge guides the faculty in the development of egories" of proficiency of this. particular area of curriculum and in the selection for a given course medicine.* of students with like'backgrounds and similar edu- At the completion of these first obligatory three cational needs. The further requirement for a more years the next critical point of differentiation occurs. detailed knowledge of the actual educational need This one is conditioned by many external factors as of the individual student in relation to his own per- well as by the make-up to this point of the young formance is attained by a process known as "precycle physician. As in any country, there are desirable and preparation." The prospective student receives a series undesirable posts, with a strong proclivity on the of assignments, of greatly varied nature,* which he part of physicians for the big city institutions. Such accomplishes in a given time, perhaps as long as six posts are available only on a competitive basis, so months, before his actual 11 presence" at the insti- that one's particular experience and qualifications tute. These assignments are turned in to a faculty are important determinants of eligibility for a given advisor, who reviews them and makes judgments on post. Position availability, whether as an advanced the educational status of the learner. The learner's trainee in the ordinatura (clinical specialty training) subsequent activity during his presence at the and aspirantura (academically and research oriented) course is shaped to some extent by this process of graduate programs or as a staff member, thus be- comes a determinant of the likelihood of and the tThe scientific organization of work is a highly developed methodology rate of progression of a physician through Cate- in the Soviet Union. It is abbreviated as NOT - from the initial letters of 'Nauchnaya, Organizatsiya Truda - the "Scientific Organization of gories III, 11 and I of a given medical specialty, a Work." fThis may range from submission by the student physician o the details of his own investigative study of a clinical problem, to his com- 'The degree of educational accomplishment and expected proficien- pletion of a work-study project in a narrow field now of special interest cy in a given medical specialty is indicated by "categories," Category to him - e.g., clinical electrocardiography as required for emergency I being the highest, and Category III the lowest. purposes. Vol. 285 No. 8 MEDICAL EDUCATION IN THE SOVIET UNION-STOREY 439 evaluation of his need, related to his observed per- based for the most part on the departments and ac- formance and the requirements of his position. tive clinical and research units of the many hospi- Any number of variations on this theme are pos- tal sand institutes of Moscow, under the administra- sible, ranging from rather I)road-scale coverage of a tive direction of the Central Institute. subject such as electrocardiograph,,, for a hospital AverN, important point to note about this is that ordinator ("ward physician"), or of the principles of the top-level personnel at these locations away froi-n social hygiene for a regional medical administrator, the Central Institute are not staff members of the to acquisition of a particular surgical skill by a peripheral institutions who "volunteer" to "run highly competent surgeon. courses" for the Institute for Advanced Training of The important point to be noted in seeking to Physicians, but the opposite: they are full-time fac- understand the Soviet continuing educational sys- ulty meml-)ers of the Central Institute who are located tem - its objectives, its organization and its pro- out where they can do their clinical and research grams to meet those objectives - is that norms do work, an aspect that is essential for their continued exist for both the individual student at a given competence as members of the faculty of tl-ie Insti- stage of differentiation and development, and for ttite. Ftirtheri-nore, all appointments to the Insti- the position that he occupies or seeks to occupy. tute's faculty are term appointments (seven-year , with a coi-nplex administrative and professional ar- Organization of the Continuing Medical Education rangement for reappointment or new appointments System to these prestigious positions. Such an organization- In the Soviet organizational system for health care al arraiigei-nent guarantees the priority of duties o there is the whole issue of upward mobility of phy- the incumbents. sician employees. This critical concept, in general, is missing from our own organizational notions con- Educational Programs of the Central Institute in Moscow cerning continuing medical education. Bec@itise of' its "central" role the Institute in M6s- In ten-ns of objectives the stated overall purpose cow accepts physicians from all over the country of the Soviet system is "the improvement of the and maintains a deliberate trend toward develop- professional skill and qualifications of the physi- ment of its l@rograms for the more highly skilled cian" - a goal that can be accepted as that of the phvsiciatis, leaving less highly developed resources American understanding of continuing medical edu- to be used -,It the more local facilities of the other cation. 12 institutes. Thus, the Central Institute attracts This improvement of the professional skills of the heads of local ptiblic-health and medical-care bodies physician is the concern of the USSR Ministry of (of republics, territories, regions, and large cities); Health. Soviet doctors can improve their skills at teachers from the higher i-nedical establishments city, at regional and at inter-regional (oblast) bospi- (the medical institutes and the postgraduate medical tals, at advanced training faculties attached to medi- educational institutes); top specialists (surgeons, cal institutes, and at the special institutes for the internists, pediatricians, obstetricians, psychiatrists, advanced education of physicians. There are 13 of etc.); head physicians of large hospitals or depart- the special institutes, located in Leningrad, Kazan, meiits of liosl)it@ils; and ]read physicians of sanitary Kiev, Kharkov, Minsk, Tbilisi and other cities, the epideiiiiologic stations and their laboratories. largest one being the Central Institute in Moscow, In 1965 the number of physicians who studied at which is related to all others. the facilities of the Central Institute exceeded The Central Institute in Moscow has 61 depart- 10,000. An increase in number of physician students in ments and 77 professors. In addition, it has 115 as- recent years has been attributed to improvement in sociate professors on its staff. The chairs of the educational methodology, and i-nost importantly to institute are grouped into five faculties: general medi- the introduction of the "pre-course exti-ai-nural and cine; surgery; pediatrics; medical liiology; and sani- course iiitraiiitiral" approach. tation and hygiene. The Institute is headed by a Before lie arrives at the Institute the physician rector and four pro-rectors, who are responsible for prepares for the intramural period at his own resi- training, research and administration. Its administra- dence without giving up his regular work. By read- tive facilities and some of its educational facilities ing the recommended literature and doing written are located at the large hospitals and the clinical assignments, including reviews of pertinent litera- research institutes of the city, with more than 9000 ttire and reporting on his own clinical or laboratory beds available to the Central Institute for its educa- investigations, be may go through a period of prepa- tional programs. ration of three to four months. All this work is guided Illustration of some of these features may be ob- I)v members of the departmental faculty of t e tained from reference to the Central Institute's Institute, ,N,Iio recommend to him the appropriate Annual Listing of Courses for 1970,4 which is a 47- literature and send him specially prepared and page description of the courses, their characteristics, printed lectures, methodical materials and training their duration and physician-student eligibility to aids. participate in them. The educational activity itself is The Institute believes that this period of prelimi- 440 THE NEW ENGLAND JOURNAI, OF MEDICINE Aug. 19, 1971 nar@, study lets him develop at his own pace a much recent physical addition to the resources of the more thorough knowledge of the subject being con- Central Institute is a high-rise "Dom Vracliey," or sidered and also gives the facultv the opportunity to house for doctors, which functions as hotel, res- evaluate him and to design his subsequent institu- tatirant and library for the participating pbysi- tional period of study more appropriately. This is a cians. Seminar rooms and electronic equipment convenience for the physician, his family and his are available for use at the building. place of work, and at the same time it allows the Fourthly, the course in electrocardiography re- Institute to increase its number of students. The (Iiiires a five-month period of home-study prepara- intramural or institutional component of the cycle tion, with a subsequent period of two months to will last for one to two months at a minimum. be spent at the Botkin Hospital. To facilitate the Some of these features are shown in Table 1, preliminary process, a practical manual in clinical which lists the particular educational offerings of electrocardiography5 was developed, and 3000 cop- one of the 61 departments of the Central Institute ies ptil@lished for the Central Institute. This for 1970. One may notice several special points serves as the reference source that the physician from this table and from the remainder of the cata- can use as he moves through his home study as- logue that illustrate some of the characteristics of signi-nents. the Soviet system for continuing medical education: Fifthly, the type of student is identified for To begin with, there are no short one-day, two- each course. Thus, the course in cardiovascular day or one-week "courses." Of the 406 courses and renal disease indicated in the third item in listed for 1970 by the Central Institute, very few Table I is designed for chiefs of service at back- are of only one month's duration. Thus, a colossal up level hospitals. commitment of educational resources by e Cen- Sixthly, of the five courses listed at the First tral Institute (and the other Institutes thi Department of Medicine at the Botkin Hospital, the USSR) is matched by a substantial r two are filled with physician students selected by investment of time and effort into each co the Ministry of Health itself. All courses are listed Secondly, preparatory home study and clini- in the nationally circulated twice-weekly newspa- cal experience are hallmarks of most of the listed per for medical personnel, the Meditsinskaya courses, with emphasis on melding of practical Gazeta. and didactic work. Seventhly, two of the courses (the second and Thirdly, the actual duration of the intramural third items in Table 1) are given away from Mos- part of the course in Moscow varies considerably. cow, in the smaller cities of Petropavlosk and During this time the participating physician main- Kaluga. tains his regular salary, and receives an additional Eighthly, the emphasis on cardiovascular subjects in this listing represents the function of the de- stipend to cover his expenses away from home. A partnieiit as beaded by Professor A. Z. Chernov. Table 1. Courses in Continuing Education offered by Depart- The listing of the courses of the Second Depart- ment of Internal Medicine I of the S. P. Botkin Hospital, ment of Medicine is oriented to chest disease and Moscow, in 1970. clinical pharmacology, which are the special com- petence of this department under Professor B. E. ITFM No. COURSF Votchal. I Functional methods of investigation of cardiovascular system: for general internists of hospital-polyclinic The actual content for two courses is shown in institutions of city of Moscow & Moscow region two addenda, which can be obtained on request.* Thematic study from Jan I to June 30 (course con- ducted by means of telecasting, on intermittent basis) The first of these, entitled "A Teaching Plan and Physician assignment by Central Health Office of Moscow Program for the Course of Specialization of Pediatri- 2 Current problems in cardiovascular pathology: for cians in Pediatric Hematology' I (Table 2), was de- general internists of Kamchatsky oblast Thematic study from Sept 10 to Oct 10 veloped by the Institute of Pediatrics of the Acade- Circuit course in city of Petropavlosk-on-the-Kamchatka lily of Medical Sciences of the USSR and reviewed 3 Diseases of cardiovascular system & kidneys: for general I)N, the director of the Department of Hospital Pedi- internists of Kaluzhky oblast Thematic study from Oct I to 28 atrics of the Leningrad Pediatric Medical Institute Circuit course to city of Kaluga on October 28, 1968; 250 copies of the teaching 4 Diseases of cardiovascular system & kidneys: for heads of medical divisions of republic, krai, oblast, & city plan were issued. hospitals Thematic study from Oct 26 to Dec 26 DisCUSSION Pbysician assignment by USSR Ministry of Health 5 Clinical electrocardiography: for directors of (electrocardio- The Soviet system of continuing medical educa- graphic) diagnostic stations, kray, oblast, & city hospitals tion differs in a number of major respects from the & polyclinics American concept of continuing medical education. Thematic study, precourse preparation from Aug I to Dec 31 There is no doubt that there is an enormous or- Studies at Institute will be in 1971 Physician assignment by USSR Ministry of Healtb 'From P. B. Stoi-ey, M.D., 235 N. 15th St., Philadelphia, Pa. 19102. Vol. 285 No. 8 MEDICAL EDUCATION IN THE SOVIET UNION-STOREY 441 Table 2. Course Outline for Pediatric Hematology.* specialized service in a given institution providing care for a particular population of children. ITEM No. SUBJECT MATTER No. OF TEACHiNci HR There is probably a historical determinant operat- LECTURE PRACTICAL TOTAL ing here, in that the principal function of the Insti- I Blood system in children 8 52 60 tutes for Advanced Education may previously have (morphology & physiology) 2 Current methods of 4 1 2 1 6 been to teach the essentials of a given specialty to investigation in pediatric cadres of physicians as the medical-care system hematology evolved following the Revolution and World 3 Clinical picture & dif- 82 408 490 ferential diagnosis of War 11. Now, with maturing of the general and diseases of blood system graduate medical educational systems, the role of 4 Immunobematology & 10 2 12 the Institutes has been reoriented to continuing blood transfusion in pediatrics education of physicians who are already specialists 5 Organization of care for 2 - 2 in their own fields. hematologic patients 6 Clinical cytology & - 18 18 The second question concerns the relation be- cytochemistry tween the Institutes and the graduate system for 7 Marxist-Leninist 24 - 24 production of medical specialists as such. The philosophy & medicine (in special program) connection is an intimate one - but again explica- Totals 130 492 622 ble only in the context of the Soviet system. The Institutes no longer produce the specialists as such Duration of course, 4 mo (622 teaching hr). - i.e., as a primary function. However, it will be recalled that the Central Institute in Moscow organ- ganizatiodal and financial investment in it. It is a izationally and financially supports an enormous principal form of medical education, comparable in facultv resource at the leading medical-care institu- investment of, resources to the undergraduate sys- tions of the city. These faculty members of the In- tem and to the graduate educational system that stitute for Advanced Education are full-time heads produces the medical specialists (i.e. the "ordina- Of service at their daily working institutions where tura" program'which produces the clinical special- the full-time training of specialists takes place. ists, and the "aspirantura" program, which produces These trainees thus represent one aspect of the the research scientists and professors). function of the Central Institute, as distinguished Perhaps the problem can be looked at through from the relatively short-term educational courses two questions, the first of which is whether this is provided for physicians already in practice, which the Soviet method for producing medical specialists. are listed in the Central Institute.s'annual schedule.4 The answer to this question has to be both yes and There is thus an organizational integration of con- no. There are the graduate programs, mentioned tinning education with graduate education that is above, that correspond to our residency and fellow- unique in its orientation. Continuing e ucation is ship training programs and ultimately lead to aca- the primary reason for the existence of the Institute demic and staff rank in the Soviet system. These are and determines its organizational arrangement. This the principal lines of development of the medical is in exactly the opposite direction from the Ameri- ,specialist and would account for the negative answer. can svstem, in which the graduate training is prima- But in terms of ordinary practicing physicians, who ry and continuing education is usually an accessory are not part of this academic and clinical elite, the burden. affirmative answer is appropriate. It is obviously Butrov and Alekseev, indeed, consider postgrad- intended in the course on pediatric hematology, for uate medical education to represent all medical example, that the trainees are going to be involved education that takes place beyond the undergradu- thereafter in pediatric hematology - but probably ate programs of the medical institutes. They divide not exclusively so. So that what one sees here is this conceptually into two consecutive stages: "spe- again an expression of the organization of the Soviet cialist training" and "further training," the former to health-care system that is hot directly translatable to provide the necessary theoretical knowledge and our own frame of reference. The working pediatri- practical skills in the specialty field concerned, and clan with a particular interest, for some reason, in the latter to improve qualifications continuously for pediatric hematology, or from a polyclinic or hospi- all physicians with clinical experience of not less tal that has a need for improved pediatric hemato- than five years.6 The latter stage represents the ma- logic service, can take out four months full time to jor investment by the physician in his lifetime of develop some special knowledge and skills to add self-improvement and by the society that supports to his capability as a pediatrician and to the man- him in this effort. agement resources of his institution. Depending The final question is how this system for ad- upon his professional background and the nature of vanced training of physicians mi e the institutional resources subsequently to be de- to- th -e American educa-i-i6n"'a'l-sysf6ffi.' veloped, the ultimate effect of the four months' it probably does n6i' 6---@6ry much practical educational program is, in fact, the appearance of a relevance at present for three reasons: the loose sys- 442 THE NEW ENGLAND JOURNAI, OF MEDICINE Aug. 19, 1971 teiiiatizatioii of American health care as compared care oi- in establishing the organization necessary to with the organized, highly structured Soviet system @ippro@ich that synthesis of interests. of health-care delivery in which appropriate ad- Finally, there is the (luestion of how these vaiicement and reward can be given to and limited three programs might get started, or how all three to those with better training and performance; the might function in rel@ition to each other, in the ab- decentralized, university-I)ased, independent nature seiice of an effective coordinating equivalent of a of our general medical educational establishment; iiiiiiistrn@ of health. This is the true imponderable and the predominantly local and episodic orienta- that plagiies the service and the educational compo- tion of continuing medical education in our country, nents of the American health-care system. How with no central or long-term direction available does any system operate without leadership and co- to it. ordination - a lack that is acknowledged through- There are, however, some potential frames of ref- out the system? It seems at least reasonable to sug- erence to which the Soviet experience might be gest that the idea of a national plan for continuing i:-el@'iiaht. One is the concept of a National Academy medical education, as proposed by the original for, Continuing Medical Education .7,11 The organiza- "Joint Committee" and developed by the Depart- tional and programmatic structure of the Central iiient of Postgraduate Programs @it the American Institute could serve as a useful model for the de- Medical Association,9 wedded to the basic concepts velopment of such a system, if the attempt were of the Regional Medical Program, as enunciated in ever made to develop continuing medical education the original report of the DeBakey Commission on in the United States on a nationally organized basis. Cancer, Heart Disease and Stroke,'O would have Also to be considered is the developing interest @'ielcled @t comparable nationwide effort if the two of the Department of Medicine and Surgery of the contemporary movements bad been pulled together United States Veterans Administration in establish- I)v t recognizable and recognized coordinating ing a nationwide system for the continuing educa- agency. In other words, there is a primary problem tion of its own medical personnel. Such an orga- in org@iiiization of our health-care system that would nized system for advanced medical education might have to be solved before a rational nationwide pro- find relevant models in the Russian system, both in gt--,Lii) of continuing medical education could be organizational terms and in pedagogic approach. developed. Like the Institutes, the Veterans Administration (;iveil a set of decisions that would lead to a na- Department of Medicine and Surgery now com- tioiial effi)it in continuing medical education, it mands or has access to large portions of the Ameri- would become most important to study closely the can health-care and bealth-education establishment. Soviet system for what information and guidance Its own organization of resources and manpower the experience with it i-night provide. could allow for mobilization and movement of per- sonnel for educational purposes. Educational objec- REFERENCES tives related to role needs could be determined 1. ['],,inning for Health in the Soviet Union: A Report of the May, with relative ease for 'v'eterans Administration phy- 1970 Exchange Group. Bethesda, Maryland, National Institutes of sicians at their different levels of activity. If such a He@tith, Fogarty International Centet- for Advanced Study in the systeifl were developed in the Veterans Administra- Health Sciences (in press) Field MG: Doctor and Patient in Soviet Russia. Cambridge, Har- tion it i-night serve as an extraordinary continuing vai-d University Press, 1957 educational resource for all practicing physicians. 3. l(ii,iii: Soviet Socialized Medicine: An introduction. New York, The Free Press, 1967 The handling of the educational needs of private 4. Kilend@irniy Plan Usovershenstvovania Vrachey for 1970 (1970 physicians in relation to the requirements of their Schedule for the Advanced Training of Physicians). Moscow, practices would be more difficult, but probably sus- (Central Institute for the Advanced Training of Physicians, 1969 5. Chernov AZ: Prakticheskoe Rukovodstvo po Klinischeskoy Elek- ceptil)le to whatever analytical systei-n would be trokiii-diographii (A Practic@il Manual in Clinical Electi-ocar- developed for Veterans Administration physi- diogi-,,iphy). Edited by AZ Chernov. Moscow, Central Institute for the Advanced Training of Physicians, 1966 cians. 6. Buti-ov VN, Alekseev VA: Postgraduate medical education in the The third, the Regional Medical Program, is not USSR. WHO Med Bull No 1-2, 1968, pp 1-2 yet sufficiently develo ed to allow speculation 7. D@trley W, Cain AS: A proposal foi- a national academy of con- p tinLling medical education. J Med Edtic 36:33-37, 1961 about its future organizational form, except to real- 8. Storey IIB, Williamson JW, Cistle CH: Continuing Medical Edu- ize tliit it is a nationwide program that does place cition: A new emphasis. Chicigo, American Medical Association, 1968 heavy emphasis on continuii-ig medical education to 9. Dryer BV: Lifetime learning for physicians: principles, practices, attain its goals of making the best in medical care proposals. .1 Med FdLic 37 (6): 1-134, 1962 ,available to all the American people. To date, how- 10, fliesident's Commission on He@ii-t Diseztse, Cancer and Stroke. Report to the President: A Nitionti Program to Conquer Heart ever, it has not been particularly successful in relat- Dise@ise, Cancer and Stroke. Vol 1. Washington, DC, Govern- ing continuing education to the problems of health ment Ili-inting Office, 1964 JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION I-',(Iucatiiity for (-Iiai)(,e July 1972 Allied health: @,i*.mensionsg dilemmas, and decisions J. WARRE-N PF,@'IRY, Ph.D. and Protes@or, Health Science 4dministration, a,-,d Dean, S@-@ril ol Ifeal,,h Related Professions, State trniz;ersity of iN'ew York at Bugato In 1968, o the American J.'Iivsical (I health professions are in a when I @poke t The allie f my tilk Nvas '.Cli TlierLkpy Association. the title o an,e State of ferment; change is the order 11 Is the Nanic of the Game: The Allied flealtli Pr(,fes- of the day. Here is a current update of ,ions." So rnu(-h has happened to the allied heart] recent det!elopments and problems. professions in the ii-iterim that only the inti@o U(3tio!l is still pertinent. I quote: Nfany great tliinkers'liave responded to a need to ex2j:t@.-i ti.,e concept of attitudes required for "cban,,e." NAPOLEON: One must clian,e otic's tactics every ten years if one wiilies to -naintain ozie 4tiperiorit3,. G.B. SIIAW; Progress is impossible " itliout chance; an@ tiloqc who cannot chance are tL;cless. WASITINGTON ItiVl'.\G: There is a rt,ii, f in even though it be from bad to worse; i, I have fcu-i(I in traveling in a ,tage coa(@ii, that i,, is ofter. a comfort to sliift orii@'s position and be I)niis(-d in a iif',IV AlittAtIANI LIN(@OLN: The do,,Iiia,, (if the quiet past ,ire iiiade- (juatf, to the stormy present; @-i our case is new, we. Ti,ii-st think and act anciv. Dimensions What has happened to the allied liciltb,. and occupations (Itiriii,, the past d(,,ca(Ic? of the expressed need and demand for qua,',fict', power to deliver comprehensive lic@ztitli care for ti-ti- country, oducatioti@'ll instittitio)tis at a'ti IeN-e!@ bearer to respond through ttie creation of new cOiticati(.vna, structures. Ne%v divisions, school,;, 'ITid colle-,@s for tlc Si allied health profes ctis have become one )f the rnost far-reaching innovations in '@ical@tli edi.ic-,tio@ii - q-v- crat decades Educational pro,,rams in the United States 'liive been identified for over 130 allied hei'i',Ii fields. Toda)-, over nine hundred colle-es and universities are in- volved in the education of allied health personnel at the baccalaureate de@ree or higher. At the same time, hundreds of corn unity junior colleges have already developed allied health pro-,rtrus. At least sevetitv co - leges and universities have foriied or are foriiiiiig ad- ministrative structures for allied lictltli programming. In addition, practically every hospital is "into" the training of allied lieiltli Nvoi-kers in one way or an- other. Front all of these sources. ,iiere is the t)oteiiiiiii for development of health iiiinpoiver at ail level,, scarcely dreamed of several vears a,o. Every health profession is anal),ziii,, the need for additional supportive personnel. Thus we see the bilities and responsibilities of each one is understood, emergence of an entirely new -roup of health per- appreciated, and utilized by the medical and dental sonnel. Health news is crowded with stories about coniiiiuiiit),, we Nvill never have a true system of the development of physicians' assistants, asQociates, health care. It must not be assumed that this level of and specialist assistants' Professions that have la- utilization will just happen; it must be tati,@lit as all bored long and hard to require @raduate trairtin-- for ititt.@,,ral part of medical and dental school curricula. e are now determinin- that assistants can enter I)ortaiice of this concept of utilization is spelled practic n The ini their fields with less formalized education. Unforttin. out in President Nixon's Health Message to Congress ately, much of ibis is bein- accomplished iiiL educa- in 1971. Nvitli the folloivin,t@) terse words: "We will also tion with all too brief attention to the careful analysis encourage. medical schools to train future doctors in of just how ,,his ne%%- cadre of workers will fit into the the proper use of other health personnel." health iniazipo%ver structure. Present clinical programs III 1969, in my presidential address to the Associa- will become the proving -,rounds on which the utiliza- tion of Schools of Allied Health Professions, I said: tion of three new health personnel will be confirmed Barriers Let%vcen and among the health professions must be broken down if we are to succeed ivitli a viable, effective or denied. Enrollment in curricula for the health professions health 1)roraiii. is it not now itbout tinif- to consider the re- lationiiip of each li(-attli profession to each other-with the is at all all-time lii-ii. Coti(-erned students, interested starting point of discussion riot based on the relationship of tn in identifyiti- arid enterin- careers in which they call the professions but rather the relationship of each to the C) n be of service to society, are discovering that jobs in systems of health care arid the function of each in relations the health field may come closest to meetili- their Per- ship to the pati(@nt" As we break down the I)oazidaries of in- difference, suspicion of intent, and concentrate on the Simi- sonal need for service. larities ivliieh exist in educational programs and in patient Thus we find more educational institutiotl-, geared care function, we will discover new ways to learn and work to offer more health pro-ranis for more students than together. t' ever before. The combination of these factors seems to point to an unparalleled opportunity to move ahead INADEQtTA'rE LEGISLATIVE AUTIIORITY AND FUNDING. in health manpower education that will ach7ieve the Another ditenima is that the health legislation of goals for both quantity and quality in health services the past has given little attention to the allied health for everyone. fields. The only important federal legislation was t' passed only six years ago with the Allied Health Pro- Dilemmas and decisions fe--,sions Traiiiin- Act of 1966. Tliou-Ii grossly and 0 ZD Wha@ then, is the "lian,,'up?" Why doesn't an eval- inadequately funded as yet, it has at least called atten- nation indicate that we are acliievin- pro@ram objec- ioii to all entire segment of the health community C) t) tives and fliat our health service system is functioning that has been liniping along with inadequate re- to its maximum capacity? Let us analyze the issues, sources. Because of the number of new prof@rams at for herein lie the reasons we still have a lona way to all educational levels developed in response 0to man- go. power needs, the net effect has been a lower level of fundin- of individual programs. Hundreds of new UTILIZATION OF -ALLIED HEALTH PERSONNEF-. Many programs have been established by universities and of us support the theory that health care in this coun. colleges to respond to the mandate of the expressed try 'will never be a workable system until all of the lic@iltli n(@(,cls. but federal ftinditi- has been woefullv fit: 0 altil professions are re@o,,iiized for what each call to assist them. The staff of the Division C, ;"@litrilitile. Priority ,ttici)ti4)!i must ;)(,- -i%,ert to educa- of Allit@(I health @Nlai)l)ower of the Bureau of Healt n ti@,lial arid clinical pro-rams at all If,-vels for the allied Pr@)feSSiOll:, E(]L](!@itioti and Mail ower TrainiiiF-, De- t@ p -1 11"@tltlt professions arid occupants, but until the capa- parinictit of Health, Fducation, and Welfare has waued an iiiten--c battle to t priority for fuiiditi-, sharp criticism le eled at these expanditi- tD ne v proarams. but educational pro@rams counting on firm support f,ack'. of adequately trained manpower to provide have been sorely disal)poii,,ted and discouraged. quality health care, rather than custodial supervision. Thiz- year we will carefully 2crutinize die effective- has been a major hindrance to advances in the care ne-,s of the new special improvement and special proj- of our older population and of the severely disa@led. ect grant approach to allied health fundin@. Addition- -@llatiy of the educational pro-ranis for the allied al funding has been authorized, and educational pro- lie@titli professions have an obligation to expand their grams xnust move witli alacrity to place the projects clinical programs to react and respond to these new of their institution in competition for these resources. facilities. Assistants, aides, and volunteers must be trained and siipervi-@d to participate in a comprelieii- 1,ACK OF QU@4L[Flfl) FA(:ULTY AND INSTRUCTIONAT@ sive manpower surge to asstire quality health pro- PFRSO-NNEL. One of the most serious irnpedimelit.-i to -rams in these new health facilities. the development of ativ profession or occupation is Neighborhood health care clinics and inner-city the unavailability of a k%,ell-qiialified cadre of iii-@truc- health 1)rojects. Current experience already dictates tional personnel. All of the allied health professions that aspirations for delivery of quality and quantity have been undergolti,- major technolo-ic advances; of licalt]L care in these new kinds of outreach facili- took mtt dietetics to verify this statement. ',Nlethods of ties will scletoni be a(,,Iiieved without delegating re- teaching innovations must be Cleared to the newer po- spoiisible roles to allied health ))crsoniiel for planning, tentials for self-iristrtiction. ams which pro-raninied instru(,tiori, de%-eloping, and implementing health pro-r and the latest teacliiii,, devices. 'Feaclier preparation ivill respond to the needs and objectives of the corn- for all educational levels has been placed lii(,Ii on the ititiiiity. Allied health educators must make every ef- priority lists of what we need to accomf)lisli our goals. fort to coordinate their clinical p ro@ranis with coop. crative pro@rams sponsored by Alodel Cities, Regional 0 NEW SETTINGS FOR IIEAITll 4:ARE DELIVERY sys,rEsis. Medical Programs, and Comprehensive Ilealtli Plan- One of the most si.-nificaiit challenges facin- the at- riin- in local communities. li.-d health professions today is to discover and imple- Rural health care. Statistics prove that the rural nient new geo-rapliic settiii,@s for clinical proarams. reas of the country are in as severe need of health 0 0 0 a I feel that dietetics, in the various ways in which the manpower as many urban sectors. Only recently has internship pro-rams have been established can serve the I)Iiglit of the rural community been given as a model. NVe must break the mold followed by too priority attention. Another challenge that will tax many of the health professions, i.e., the traditional allied health education will be to'orietit clinical 'edu- idea that the location for all clinical traiiiin,, of stu- cation for many of the allied health professions to the dents must be the hospital. Aittioti-ii reco-niziiiff the needs of primary care physicians in their efforts to special contribution of hospital setting for many pro- brain quality care to rural communities, including 0 ID grarm, we must create new clinical facilities for allied migrint workers' camps. health in all of the new settings for health care deliv- Health maintenance. I will not add to the con- ery systems that are receiving priority attention. troversy over the efficacy of health maintenance and These include: the establishment of Health Maintenance Organiza- Demonstration projects in nursing homes, extended tions (HMOs) as one of the new approac es to care facilities, and rehabilitation centers. The grow- health care insurance and making comprehensive ing geriatric population has prompted the building health care readily available. However, with emphasis of hundreds of new extended care facilities, b -ut only on prevention of illness and the maintenance of good now do we rec iiize the crucial manpower shorta-es health, more attention will be given to identifying 'Ofy rD - r for (itialifie(i I)erF-oiiiiel to staff them. From tli(, Pi-(@,-;i- early health problems iiid to the slitriti@ of health iii. delil of 11(@ tTflite(I lat@, on down. there has be(-ii formation concerniti- diet@tr)- and nutritional rob- p lem-,, drug information, alcoholism. birth control, en- Watts community in their efforts to establish a corn. ilied health educational pro vironmental control, abortion. and similar problems. I)relictisiN@e new a @ram. This will be shared and delivered where people Not only must we as a nation be in a better position learn in schools, tvork ii factories, and live iir to' provide a Iii,,Iier quality of health care in these homes. This shift in emphasis from a "sickness. s)-s- areas, but we must attract and hold minority repre- tem" of acute and intensive care to a prevention-cn- seiitation in the delivery of this care. vironmental and extended .care-reliabilitatiozi eni- Career mobility and equivalency testing. The phasis will require important cliaii@es in priorities in importance of these two concepts and the decisions educational programs. The allied health professions, needed to make horizontal and vertical mobility a alon- with medicine, dentistry and nursin- must reality and not just a dream cannot be un eresti. conscientiously reasons wavs in wlii(-Ii curricula can niated. The national attention being placed on aslltire implementation of the prioritv of prevention. equivalency tes@l@ is now be,,iiiriin- to reap Recruitment of disatlt,,uttt5rged @roups into the (livid(@iids as each profession i@esses the way-., in allied health professions. Is it not ji(3,.y time that Nve which academic credit can be (lerin,ed an(] awarded y recognize the important role xve must play in recruit- for other than pure classroom work. me minoritv -roiip@ to participate in allied health iD . C!) y '? laiiy members of the minoritv and other Conclusiott manpower. -@A i- ethnic -roups have made important contribution.,., to As professional educators, clinicians, and adniiiiistra. our professions, but -,vc mii t make a concerted ef- tors, are ,Vc ready to make decisions that Nvill re. fort to reinforce this position. T%Iucli of the delivery sl)ond to the changes in educational pro,,rardming -,h of health services in the n(nv --cttiii-s will be delivered and clinical ractice that each health field must C) p n- by representatives of itursitt--aiid the allied Iieaitli make? With financial resources. ti(,Iil(@r than ever, we n c professions. Openin,- up this number of new positions ]ain't. pull in our belt,-; and set for our,-elves a diflet-etit in the health field brings with it the obligation to rc- ..et of prioi-ities-tliose that reveal a deep coi@iiiiit- .al cruit many new professional personnel from tlios(@ iiieiit to cli,,@iii C. 9 n- groups disadvantaged in various ways from full par- "Yesterday is but today's memory and tomorrow ticipation in these advancements. I have the privil"c is today's dream," so the Prophet says. May sorie of of being one of two white persons serving on the iie%v the dreams expressed here prove to be, for the pro- [th national committee, Equal Representation in Allied fission of dietetics, the response to necessary changes lw@ Health, and some of my finest professional ex- that will bring you to an even greater role in health ,en periences have been in working with groups in the planning and health service in the future. .a iu- th New protein-rich dair product e y to A protein-rich dairy product that cotild double the milk supply for children of In ia uig has been developed by the Central Food Technolo-ical Research Institute of Mysore, India, with support from theinational Institute of Arthritis and Metabolic Diseases, ?,nd Bethesda, Maryland. The new product., called "Miltone," is a blend of pure peanut protein, hydrolyzed starch sirup, and ine or bitfi@lo milk. Previously, the residue after oil was extracted from peanutsi lizer and fced ' Now the peanut to protein I'Lsextracted by a new process ing research)@ and mixed with sive milk. After pasteurization and bottliji ed to markets and urban state iasis welfare centers for children of low-im ,ood As part of a long-term, nutrition Iresearch pro@ram, the goal of the Mysore project yin-. 2 c is to devel(--Pp I)rotein-ricii fo(Kl* and food sul)l)lejiit@tit@ from iiiexl)ejlsii,e indigenous, protein qotir(-es that will inilorovt@ the jiutritioiiil health of persons in countries Front liSil@iliA lit!altli jetports, 86: 91-9. 191-1. CORONARY CARE NURSE TRA'INING PROGRAM AN EVALUATION Ruth Scheuer A coronary care training project was established gram, 1970). In February 1970, the estern by the Western Penns7/lvaitia Reaional Medical P(,iiii@ylvania Itegional Program (WP/RMP) ini- Pro ram at t tiate(I a Coronary Care Training Project at the the knowled e, skills, and confidence of nurses ITniversity of Pittsburgh to meet community needs ca?ing f or coy c patients. To assess the effective- for ti@ained nurses to staff regional intensive CCU's ness of the four-week course a 120-item multiple- (NN-P/RMP, 1970). The four-week course included choice examination was developed, u,hich measured 117 hours of didactic instruction, laboratory and the nurse's knowledge as well as her confidence in clinical experience, independent studyi and evalu- that knowledge. Nurses were required to give the ation. correct answer to each item as well as to designate The following criteria were designated as essen- whether that answer was certain, a partial guess, tial to tile success of tile program: 1) participation or a guess. Posttest results.showed that nurses who in the four-week course would result in extending completed this specialized course perfornzed better the knowledge, skills, and confidence of nurses and with greater confidence than on the pretest. cai,in(r for patients with acute myocardial infare- Whereas only 27.4 per cent of the answers were tions; 2) graduates of the program would be able both correct and given with a high degree of cer- to titilize the knowledge and skills acquired; and tainty before the course, this figure rose to 66.3 per 31 patient care would be improved (Scheuer, 1970)., cenf following the course. A six-month follow-up The purpose of this paper is to describe the exanzination of participants showed that knowledge methods utilized and results obtained in the evalu- retention of coronary care principles remained high ation of these objectives. and that 77 per cent of the nurses tested were work- ing in intensive coronary care areas. The ultimate Method goal of the project was to improve the care of pa- tients in. intensive coronary care areas. An ongoing Upon entering the program, the student submit- method to assess morbidity and mortality in re- ted a questionnaire providing information on her gional coronary care units was established as a age, previous coronary care work experience, edu- result of this project. cational background, and expected area of em- ployinent at completion of the program. This information, in conjunction with pretest score re- DUCATORS responsible for specialized cor- sults, enabled the faculty to ascertain which stu- onary care courses need to demonstrate that dents niigl)t need extra help during the-course. E Inurses have the requisite knowledge, skills, Since the nurse in the CCU is required to take and confidence to perform effectively within the decisive action in critical circumstances, it4was coronary care unit (CCU) setting (Department of deeiii(@(i iii-iportant that she not only increase her Health, Education, and Welfare, 1968 and 1970; knowledge of acute coronary care during the four- Western Interstate Commission on Higher Educa- week program, but also that she exhibit confidence tion and Mountain States Regional Medical Pro- in this knowledge. 228 NURSING RESEARCH multiple choice 120-item examination was determine, in part, whether the nurse can apply her Aven befo're (pretest) and after (posttest) the knowledge and skills of acute coronary care, each This test included a Confidence of Knowl- nurse was requested to submit a copy of the CCU i' edge Scale' which measured changes in the student's policies and standing orders of the hospital in which knowledge a-s well as the degree of confidence in she was employed. Examination of these policies that knowledge. For each test item the student showed that, in some units, nurses were not per- indicated the correct answer as well as her confi- niitted to institute life-saving treatment such as dence in this choice based on the following criteria: defibrillation and administration of specific cardiac 1) CERTAIN-all three incorrect items could be iden- drugs. Consequently, the staff of the Regional tified; the correct item has been isolated. 2) PAR- Medical Program, in consultation with its Heart TIAL GuEs ne or more items could be identified Committee and the faculty of the Coronary Care as incorrect, but the correct item could not be iden- Project, developed and distributed comprehensive tified. 3) GUEss-no item could be identified as Coronary Care Unit Standing Order GuidelineS3 to incorrect. all hospitals in the region. A follow-up survey was The 120-item test was divided into eight planned to as-certain if, and how, these guidelines categories: concepts of coronary care, physiology, were adopted. myocardial infarction, norm'al electrophysiology, Although patient care statistics were collected in abnormal electrophysiology, pharmacology, compli- most hospitals with a designated coronary care cations, and pyschological aspects of coronary area, these data were neither systematically com- care. An analysis of the knowledge and confidence piled nor standardized. Therefore, a Coronary Care scores in relation to these specific content areas, Morbidity and Mortality Statistical Form3 was made for each course, enabled the faculty to exam- developed by the WP/RMP and introduced to hos- ine specific course content and determine areas of pitals whose nurses participated iD the program. weakness and strength within the program. The Statistics are compiled monthly by The nurse in the faculty could then set standards of performance unit and sent to the Regional Medical Program based on knowledge-confidence testing. office. Every six months reports are returned to A simulated coronary care area was built to serve each hospital summarizing -statistics from its ' own as a learning laboratory for students in the pro- unit with an analvsis of cumulative data from all gram, This unit contained teaching aids as well participating hospitals. as equipment available in most CCU'S. At the com- pletion of the program an Arrhythmia Anne,2 capa- ble of simulating specific cardiac emergencies, was Results utilized to test the student's arrhythmia recognition Comparative analysis of prie- and posttest scores and her ability to institute appropriate treatment of 200 students relating knowledge to degree of including: defibrillation, cardiopulmonary resusci- confidence is shown in Figure 1. Whereas only 27.4 tation, and definitive drug therapy. To complete per cent of all responses were both correct and given the course all -students were required to pass this with a high degree of certainty on the pretest, 66.3 examination. I)ei, cent of the responses on the posttest were A field coordinator attempted to visit each par- answered correctly and with a high degree of con- ticipant within six months following her training fidence. course in order to: 1) ascertain whether the student Pre-post knowledge-confidence scores by content was employed, either directly or indirectly, in the area are shown in Table 1. These data illustrate care of patients with acute cardiac disease; 2) ob- that the percentage of answers in each category tain a retrospective evaluation of the course by the which are both certain and correct is markedly student in light of her experience in the intervening higher on the posttest than on the pretest. How- six months; and 3) administer an additional post- ever, there is no difference between pre- and post- course examination which served as an indicator of test answers which were incorrect but given with a knowledge retention. This examination also was high degree of confidence. used to pinpoint specific areas of learning which The Kruskal-Wallis One-Way Analysis of Vari- needed to be reinforced. ance by Ranks (H Test) (Siegel, 1956, pp. 184-193) Because the ultimate goal of the coronary care was utilized to determine whether factors such as project is the reduction of i-norbidity and mortality age, prior work or educational experiences in coro- in patients with acute myocardial infarction, the nary care, and expected area of employment post- project criterion most difficult to evaluate, but per- course were correlated with student pre- and haps most important, has been the effect of the posttest performance (Table 2). The H Test indi- training program on patient care. The process by cated that pre- and posttest performance of stu- which this goal is achieved is multidisciplinary and dents 35 years and under differed significantly (at multifocal. the .01 level) from those 36 years and older (Table As policies and standing orders set by a hospital 2A). General educational background was not a significant factor in pre- or posttest performance 'The scale is adapted from the "Certainty scale" developed (Table 2B). Tables 2C and D illustrate that by the Office of Research in Medical Education, University of Washington, for the Washington-Alaska Medical Program. 2 3Tht@se are available upon request from the Western Penn- Arrhythmia Re@usei Anne t@ manufactured by the Laerdal sylvani:i Regional Medtcal Program, 3530 Forbes Avenue, Pitts- Medical Corp., Tuckahoe, New York. bijrgh, Pennsylvania 15213. MAY-JUNE, 1972 * VOL. 21, NO. 3 229 rrect and Incorrect Responses to 120- only pretest performance was affected by prior Figure I. CO Item Pre- and Postcourse Tests Relating Knowledge to education (formal or in-service) in coronary care. Degree of Confidence' When students were grouped into categories de- .instruction (Table 2E), lineating prior arrhythmia 65 63. 3 experience monitoring patients (Table 2F), area in which employed (CCU or areas other than CCU) 60 to entering the course (Table 2G), and ex- 55 0 Ppreictred area of employment I)ostcourse (Table 2H), Pretest N @2 00 significant differences in pre_ and posttest perform- z 50 Posttest N =198 ance among the groups were note4cl. wu 45 Since initiation of the Coronary Care Training Project, the field coordinator has made approxi- 0. 40 mately 184 visits to individual students within six z- 35 months following their completion of the course; - 142 students (77 per cent) were found to be viorking w 30 27. 4 in an intensive coronary care environment. This oz 25 25.1 0 figure correlates with the number of students who 20 A19 . 0 expected to return to an intensive coronary care 6. 7 environment after completing the course. Six per 15 13. cent of the students were no longer working, and 1 o8. 2 17 per cent were working in areas other than inten- sive coronary care. 7. 2 Data on follow-up testing of 120 students were collected. Eighty-five students were given identical precourse, postcourse, and follow-up examinations. Sixty-five per cent of their total responses were correct on the pretest, 88 per cent on the posteourse CORRECT INCORRECT test, and 85 par cent on the follow-up examination, indicating that knowledge retention of coronary -Pretest raw mean 72.9 (61 per cent correct) care practices at the six-month follow-up remained Ilo,,,ttest raw mean 98.1 (82 per cent correct) high . In September 1970, the follow-up test was Table 1. Knowledge-Confidence Scores by Content Area Expressed in Percent' PRE- POSTTEST PRE- POSTTEST ANSWERS IN RELATION TO C( CORRECT ANSWMRS IN RELATION TO CONFIDENCE (2) PARTIAL IN GuEss (3) GuEss PRE 81, T PRE 0 T PRE POST PRE POST o/. o/o c/o a/ Concepts 1 16.0 :.o 1.5 1 5.0 - 4.0 - Physiology 33 27.0 19.0 9.0 8.0 18.0 8.0 12.0 1.0 Myocardial tnfa-retion 21 2 28.0 17.5 5.0 1.5 9.0 9.0 21.0 11.5 9.0 1.5 Normal electro- physiology 21 35.0 76.0 21.0 10.0 9.0 1.0 6.0 6.0 15.0 6.0 14.0 1.0 Abnormal elee- trophysiology 22 21.0 61.0 22.0 17.0 11.0 2.0 8.0 10.0 20.0 18.0 18,0 2.0 Pharmacology 14 23.0 55.0 23.0 18.0 10.0 2.0 7.0 10.0 23.0 13.0 14.0 2.0 Complications 6 23.0 64.0 30@O 21.0 7.5 1.0 4.0 6.0 21.5 7.0 14.0 1.0 Psychological aspects 2 40.0 65.0 26.0 11.0 2.0 1.0 14.0 13.0 16.0 10.0 2.0 Total points 120 27.4 63.3 8.2 2.0 -Pretest N=200 students Pre est mean=72,9 t' Percent correct = ol Posttest N = 198 students Posttest mean = 98.1 Percent correct = 82 230 NURSING RESEARCH Table 2. Pre- and Posttest Performance Related to Student Background' (N = 198) A. AGE PRETEST PERFORMANCE** POSTTEST PERFORMANCX** AGE NUMBER % % GROUP (0/0 ) MEAN CORRECT MEDIANI MEAN CORRECT MEDIAN Up to 35 161 (81) 74.7 62.2% 75 99.9 83.2% 100.5 36 and over 37 (19) 65.0 54.0,7o 62.5 90.1 75.1% 89.1 B. GENERAL EDUCATIONAL BACKGROUND PRETEST PERFORMANCEI POSTTEST PERFORMANCEI EDUCATION NUMBER GROUP ( 0/0 ) MEAN CORRECT MEDIAN MEAN CORRECT MEDIAN Dlploma only 176 (88.9) 72.6 6 0. 5 Olo 72.5 97.8 81.5,7. 99 Collegiate 22 (11.1) 75.9 83.OVo 78 99.9 83,00/o 100 NC@ PREVIOUS COURSE CORONARY CAR]@ NURSING PRETEST PERFORMANCE** POSTTRST PERFORMANCE' FORMAL COURSE NUMBER 0/0 % GROUP (%) MEAN CORRECT MEDIAN MEAN CORRECT MEDIAN None 172 (87) 71.7 59.7% 73 97.7 81.4 clo 99 Up to I week 10 (5) 76.2 63.5% 75 96.9 80.7@o 97 2 weeks and over 16 (8) 83.7 69.7% 84 101.9 84.9% 103 it D. PRIOR IN-SERVICE EDI'CATION CORONARY CARE NURSING PRETEST PERFORMANCE** POSTTEST PERFORMANCE' IN-SERVICE CC NUMBER % 0/0 GROUP (%) MEAN CORRECT MEDIAN MEAN CORRECT MEDIAN 0 to 5 hours 130 (66) 70 5 8.3 O/, 69.5 97.2 81.0% 99 6 to 20 hours 58 (29) 79 65.SV@ 78 99.9 83.2% 101 Over 21 hours 10 (5) 1 7&5 63.7 olo 79 98.8 82.3-/o 99 E. PREVIOUS ARRHYTIIMIA INSTRUCTION PRETEST PERFORMANCE** POSTTEST PERFORMANCE** INSTRUCTION NUMBER 0/0 0/0 GROUP (0/0 ) MEAN CORRECT MEDIAN MEAN CORRECT MEDIAN None 50 (25) 63.3 5 2.7 -lo 61 93.5 77.9% 94 Up to 10 hours 84 (42.4) 73.7 61.4 clo 65.5 98.5 8 2.0 clo 101 11 hours and over 64 (32) 79.3 6 6.1 0/0 78.5 100.9 84.0 Olo 102 P. PREVIOUS EXPERIENCE MONITORING PATIENTS PRETEST PERFORMANCE** POSTTEST PERFORMANCE* EXPERIENCE NUMBER % % GROUP MEAN CORRECT MEDIAN MEAN CORRECT MEDIAN None 45 (23) 63.1 52.6% 60.5 94.5 78.7% 95.5 Up to I year CCU-ICU 86 (43) 73.6 61.3 clo 74 98.7 8 2.2 clo 100 Over 1 year CCU-ICU 67 (34) 78.7 6 5.6 lo 77.5 99.5 82.9% 100 G. AREA WORKING IN PRIOR TO COURSE PRETEST PERFORMANCE** POSTTEST PERFORMANCE** AREA NUMBER % % GROUP MEAN CORRECT MEDIAN MEAN CORRECT MEDIAN CCU-ICU 127 (64) 77.1 64.2 &lo 77 99.8 83.20/c 101 Other 71 (36) 65.4 54.50/o 64 94.9 79.1 'lo 96 H. EXPECTED AREA OF EMPLOYMENT POSTCOURSE PRETEST PERFORMANCE** POSTTEST PERFORMANCE* AREA NUMBER 0/0 GROUP MEAN CORRECT MEDIAN MEAN CORRECT MEDIAN CCU-ICU 159 (80) 75 62.5% 75 99.1 82.6'Yo 100 Other 39 (20) 64.3 53.6% 61.5 93.7 7 8.1 clo 96 Based on Kruskal-Wallis One-Way Analysis of Variance (H-Te@t) (fr(ini Siegel, 1956, pp. 184-193) Not significant .05 level of significance .01 level of significance MAY-JUNE, 1972 9 VOL. 21, NO. 3 231 Table 3. Six-Month Follow-up Test Scores Related to RUTH SCIIEUER (Mount Sinai Hospital School of Area of Employment Nursing, New York, New York; B.S., University of Pittsburgh, Pittsburgh, Pennsylvania) is research MEAN FOLWW-UP associate and assistant to the director of evaluation, AREA OF NUMBER SCORES CORRECT Western Pennsylvania Regional Medical Program, EMPLOYMENT TESTED Pittsburgh. Nurses working In ICU-CCU 30 85.5 Nurses working in ;area.,; (,ttier Ttian ICU 5 68.4 have not been fully determined, a system for evalu- ating morbidity and mortality of patients cared for Total 35 83 in the CCU has been introduced in the Western Pennsylvania region. Whereas no hospital was re- porting its monthly CCU Statistics prior to 1970, 47 of the 67 hospitals with intensive coronary care shortened because of time restrictions. Test results areas in Western Pennsylvania were participating of 35 students given the shorter follow-up examina- in the study at the end of 1971 (Reed and Scheuer, tion are shown in Table 3. Xs might be expected, 1972). This type of record keeping and feedback nurses working in intensive coronary care areas hastens the recognition and correction of specific scored higher than nur-ses not working in these problems and leads to improved health care deliv- areas. ery to patients with acute myocardial infarction. The nurse's responsibility in this evaluation hell).-, Discussion to reinforce her role as a key member of the staff of her unit. Comparison of pre- and posteourse examinations In conclusion, evaluation of the %TP/RMP Coro- measuring knowledge and confidence showed that nary Care Training Program is an ongoing multi- participa6on in the coronary care course increased purpose, multidisciplinary effort. Not only does it the knowledge as well as the confidence of the par- encompass knowledge of how many nurses are be- ticipants. The Confidence Scale is a valuable in- ing trained to care for patients with acute myo- strument for measuring changes in the student's cardial infaretion, but it also provides valuable ability to predict the correctness of her response. information regarding the learning process and how The scale has been used in student counseling when this process is translated into improved patient care discrepancies between the student's predicted for the region. knowledge and actual knowledge are displayed. Students who demonstrated more knowledge than confidence or the reverse could be assisted by the References faculty to explore ways in which to correct knowl- edge or confidence deficits. REED, DAVID, AND SCHEUER, RUTH. Reporting statistics Follow_up student interviews indicated that the in coronary care units. Penn Med 75:53-55, Jan. 1972. majority of the students returned to care for pa- SCIIEUEP, RUTH. An Evaluation Guideline. Pittsburgh, tients with acute coronary disease, and, therefore, Coronary Care Nurse Training Program, Western utilized knowledge and skills learned during the Pennsylvania Regional Medical Program, 1970. (Un- four-week program. Test scores at six-month fol- published) low-up suggested that although knowledge reten- SIEGEL, SIDNEY. Non Parametric Statistics for the Be- tion of coronary care principles remained high, havioral Sciences. New York, McGraw-Hill Book Co., those nurses who did not return to an intensive coronary care area required frequent follow-up in- 1956. struction to maintain the level of performance U. S. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRA- achieved at the end of the course. TION. An Evaluation Study of Coronary Care Nurse Analy,sis of student baseline data related to pre- Training. (U. S. Public Health Service publication no. and posttest scores helped the faculty determine 2145) Washington, D. C., U. S. Government Printing which students might need extra help during the Office, January 1970. program. Nurses over 35 as well as those partici- Outlook for Coronary Nursing. Proceed- pants without prior experience in acute coronary ings of a conference at Wheaton, Md., May 23-24, 1968. care might require additional assistance during the (U. S. Public Health Service publication no. 1926) four-week program in order to perform at the level Washington, D. C., U. S. Government Printing Office, of tho.se who are younger or have had some experi- 1968. ence in coronary care. The data suggested that WESTERN INTERSTATE CO specific courses designed for students based on their UNCII@ ON HIGHER EDUCATION prior experience in acute coronary care might prove AND MOUNTAIN STATES REGIONAI, MEDICAL PROGRAM. more efficient than a single course in which all stu- Evaluation of Coronary Care Nurse Training; a Col- dents, regardless of their background, are included. loquium for Teachers of Coronary Care Nursing held Although the effects of this course on patient care at Missoula, Mont., June 18-20, 1970. WESTERN PENNSYLVANIA REGIONAL MEDICAL PROGRAM. The author acknowledges the assistance of Enid Goldberg, Annual Report. Pittsburgh, The Program, May 1970. Ph. D., R. N.; Constance gettlemeyer, R. N.; David E. Reed, M. D., and Douglas Vaughan (Unpublished) 232 NURSING RESEARCH c 0 v i@- iC A T I 0,@@ S @l t,@, n I o II i(, f @s @)i' Ai-izo3ii ()@l I -\,\"X. Ai- i(lkll --loll t C; ?eQuest fo,- I;Ie@-ature @@o,-,, G @ii(, i@tcl Iiat ii,, 5tOt'ion is checked of a resource, oi oil. l@i4,("4_ - brcify y a,-i Ar:zoria Medi,:a@ 4o cl;ii Nctwo.-k technician. i), W. Ilie Ioitr)ial of -ilie SOUTH CAROLINA Medical Association JULY, 1972 -VOL. 68, NO. 7 SOUTH CAROLINA REGIONAL MEDICAL PROGRAM -VINCE ',%IOSELEY, NI.D., Coordinator THE SOUTH CAROLINA REGIONAL MED L LC -A.4,, Rk-M-,. PLAN FOR MANPOIN'ER EXTENSION, AND FOR TI-IE REGIONALIZATION OF SERN'ICES AND RESOURCES TO liN'IPROVE IIEALTH CARE The Ilegioilal Nledical Pro(Trani in Soutli Carolina is I)eincr greatly expanded in efforts invol,.-iii(T lic@iltli manpower de\-elopinciit, primary li@ilth care de'N-elopmeiit pat- terns and re"ionalizzition of licaltli facilities, DiaiipoN\,cr and other resources. This article 0 outlines bow SCII-'\IP Proposes to Handle its I)i-oa(ler function. After consideration of the bealth needs and vide for early case finding, earlv diagnosis, ambu- manpower deficiencies at professional teeli- ],,ttorv care, and preventive medicine in its broadest ip a e. Efforts to improve nutrition and emergency -els in Soutil C ro- iiieclicii services are additionally reco@ ized as ob- nical and occi ational le\ sells n lina, the Re,,ional Advisorv Group at its . I Annual' Nicetiii,r on December 9, 19-10 A New \Iissioi) Statenient for Regional \fedical adopted the follo@\,iii(y statement: Prot4riiiis wis adopted I)y the Nationil Advisory Council in jtine 1971. According to this, R.\IP is a "The South Carolina Regionil \Iedical 1'rograiii is to "flilictioziing and actioii-oriented consortium of pro- continue pro,,raDIS for physicians dentists, ntirses, %,iders respoi)si\,e to health needs and problems. It technical, allied health professional tiici occupational is a fi-,iiiic%\-ork within which all providers can coiiie grotips, directed towards improving patient care 1)), together to ii)eet health needs that cannot he iiiet continuing education and demonstration programs for 1)@- individual practitioners, health professionals, lios- the iiiipron-eiiietit of health i)iinl)o%%,er, the (teiiioiistra- I)itals arid otl)er institutions acting alone. It also is tion and ciicouriigeiiient of new techniques for (liag- (lesi,,iie(i to take into account local resources. patterns nosis tnd treatment, p ,raiiis for the iiiiproveiiieiit of practice and referrals all(] needs. As such, it is a ro., of facilities, particiilti-I), coiiiiiittitity hospitals, ind potentially, important force for I)riiiging ai)out and research and triiiiiiil- in iii(-tliods to improve the assisting N%,itli cliaiitTs in the provision of personal delivery of health services ind care. In addition to health services and care@" devoting ttti,iitioti to disease areas of I)riiiiarv Coll- NfcetiiiiZ in \I)-i-tle Bt!@icli @pril 29-30, 1972, the cei-ii - heart disease, cancer, and stroke, ki(Itic), dis- SCII.Nll"s Itegiotial A(l@,isor), Group authorized the case iii(i otlit@r rcl,,itc(-l diseases - these programs are orgiii)izittion to I)roa(leii its goals in the following in to utilize the specified]]% id ntifie(I resources in(i order to@ support planning iiicl organization of lirik,,i,-Cs ill Nvt),s target will (.Ica] effccti%-ely .%,itli such coilliiitillit), I)ased health e(Iticiltioil prt)gt-iiiiis; I)I.Orllotc prol)leiiis is cost control, increased accessil)ilit%" a c ii I I)I@iii for pli\-sici@iii assistant training projects; iiiil)ro%-(,(l ct)iiiiiitii-,ic.itioiis, iiid inil)ro%-c(l standards. support ,tti cxl)ayi(lecl role of the iiiirse; coordinate 'I'liroti,,Ii the Nlc(liciil District Coiniiiittecs of the reerkiitiiieiit iiid placement for tic%v pi-of(@.ssi Olial cate- ltegioll@ll and their coiiiiiiittee gorics; evaluate impact arid performance of new relittiotisl)il)s in liaison ,%-itli agencies concerned \%,itli types of personnel; encourage iiiijil)oN\@er surveys plai)iiitig or a(iiiiiiiistr4itioii of Health care programs, arid recruitment programs; develop lic@iltli 1)rofessioiid data tre to he developed %vill lead to issist- carcei- opportunities for minority groups; develop atice in proper planning and pi,iorit), setting in and iii)plejiieiit iii-scr%,ice education progi@aiiis to respect to specific poptiLitioti arid geographic needs career l@i(Iders tjid to tipgrt(le the perforin- It) order to assist in cost coiitt-ol, emphasis is to he @iti(,c of existing health personnel. specifically directed to@vai-d I)rograiiis \%-Iiicii N%-iU pro- Also, that a mechanism be established for con- JULY, 1972 293 Nf(,(Iical Program has been directed to assist all project and pro,,ram directors of current operational SCRINIP programs in extendinr ist applicants for -ne their service, and to ass w projects to focus their activities along the broader lines of enhancing the availability and quality of health care. The principal objectives of the @SCRI\IP staff, in accordance ,N,ith National Advisory Council iNlission statements and the Regional Advisory Group, are to: 1. Promote demonstrations among providers at the SCRillil officials confer with 1) r. Harold loctl level of both new techniques and innovative ll,trl,,ulies, Director of Itegional Iledical 1'ro- delivery patterns for improving the accessibility, grams Service, IN'ashiiigtoii, 1). ('., during recent Advisory Group meeting in Alvrtle Ileach that efficiency, aiici effectiveness of health care. resulted in an expanded health .care de%-elol)ment 2. Stimulate and support those activities that will role for SCIt.,Nlll. Shown are (left to right): Dr. both help existing health manpower to provide Charles 1'. Summerall, 111, tssociate coordinator; more and better ctre, and will result in flie more Dr. Vince ilit)sele),, coordinatoi-; Dr. 31argulies and Dr. James W. 'Colbert, Jr., chairman of effective utilization and distribution of new kinds SCIZ31P's Advisory Group. (or conil)iiiations) of health manpower. Further, to (lo this in a way that will ensure that profes- tiniiing cooperative regional studies and modification sioiial and technical ,ictivities of all kinds (e.g. of the obstacles that discourage physicians from enter- ii)foi-iiiational, training) lead to professional growth ing and remaining active in primary community, prac- -iii(I development. and are appropriately placed tice of medicine. obstacles and opportunities that @N,itliiii the context of medical practice and the influence primary care roles for nurses and other coiiiiiiiinitn" by assisting with the development of paramedical personnel and obstacles to ambulatory Coiiiiiiiinitv Based Education Progrims, and with care imposed 1)), third part), pa),ment: encourage prot,,raiiis for the implementation of the ',\atioDal use of a recently developed Problem Oriented '.\fedi- Eiiiergei)cy Health Personnel Act. cal Record; design systems of public information 3. Encourage providers to accept and enable them regarding available health services and personal pre- venti%,e health iiieasilres, support emergency medical to iiiitiate regionalization of health facilities, man- power, -,ind other resources so that more appro- services through education programs and deiiionstra- priate and better care will be accessible and tion projects; reduce infant inortilit), in minority populations, especially tl-Lrotigli development of pre- available at the local and regional levels. In fields where there are marked scarcities of re- natal care services and nurse ii-iidwifery programs. . I Additionally.. that shared bioengineering services sources, such as 1-idiiey diseases particular stress programs be developed to provide improved safety, will be placed on regionalization so that the costs of such care may be moderated. reliability and efficiency in hospitals, clinics and practitioners' offices; conduct studies on the de- 4. Identify, develop, and facilitate the iii-iplementa- -,,elopj)ient of facilities or programs for economical tion of new and specific iiiechanisii-is that provide dojiiiciliary care for the incapacitated, particularly quality control and improved standards of care. Such (ItialitN guidelines and perfomiaiice review the elderl),; determine specialized services that are appropriate. needed and available and through link- mechanisms will.be required. especially in relation ing of facilities achieve the maximum amount of to new and i-nore effective comprehensive systems cooperation among hospitals and institutions. of health services, and by recent legislation and And that SCRI\IP be prepared to work in coopera- draft guidelines will be necessary if R.\IP is to tion with tppropriate professional societies who I)Iav its role in health manpower training, emer- express an interest in ex loring alternative care de- geiicy medical services, areanvide health education, p ,iii(I the nIODitoring of (Itiality ' f liverv systems and that SCRMP assist appropriate o care in lli\lo's prof.essional associations in developing programs and experimental health delivery systems. assuring (Itiality health care. In considering the health manpower and Broadening of SCR,\IP's efforts in beilth care other service deficits in South Carolina, it is delivery represents an expansion of the initial con- very apparent that in addition to numerical cept of RMP as a vehicle to speed the flow of deficiencies, distribution problems are of con- scientific knowledge to health providers in connection with heart disease, cancer, stroke, and related dis- siderable magnitude. eases. Despite the fact that the Medical Univer- The staff of the South Carolina Regional sity of South Caro na is rapidly expan ing 294 THE JOURNAL OF THE SOUTH CAROLINA MEDICAL AssocIATION its classes in the several Colleges, -not only through on-cainpus programs but by consortia extending its undergraduate academic training into several comniunity hospitals throughout the State, it is evident that this will be accom- panied by a considerable time lag, and that other ways to deal with the professional man- power shorta(,es and other immediate prob- lems must be developed. Among these are an extension of existing manpower resources at all levels by: 1. Utilization of assistants and new types of personnel; 2. Better coordination of transportation and c.ommunications for consultation, instnic- The SCRMP supported state%-,-ide Ciiildren's tion and referral; Heart Screening Ilrograni is carried out by Dr. 3. Application and more widespread utiliza- Arno Hohn (right), Medical Uni%@ersity of S. C. tion of new technology; Hospital, assisted by Miss Julia Breeden. 4. Improved resources sharing throughout the ordination and implementation of these sev- Region through program planning. eral and related activities in the Region, in- It was pointed out by the RAG in Decem- eluding combinin- funds from other agencies her, 1970, however, that in order to procure or foundations, both public and private, NN,itli better planning and a more systematic utiliza- those of RNIP for study or operational grant tion and application of a .,ariety of data, iii- purposes. eluding socioeconomic data, to assure priority CONCEPT: of effort, evaluation of efforts, and perspec- It is evident that for an effective regional tives as to alternatives,, would require the or statewide program to be developed, and in expansion and development of appropriate 0 consideration of other iiexN, program activities and qualified staff. As a result of this, the now being developed or supported by Fed- Regional Advisory Group approved the use of Developmental Component Funds for an ad- eral appropriations, that an..overall cooi-diiiat- ill(, body for the entire State should be de- vanced planning studv. Out of this study has -,eloped to which the Ile(rioiial '\Iedical Pro- developed the following concept for the co- grain can effectively rel@ita at the Recioilal 0 In addition to its established sub- level. 'ty relationships with re- region or conimuni gioiial councils, CHP-(b) a(lencies, Appala- cbia, '-\Ioclel Cities, Coastal Plains, and other health planning bodies or councils, the SCRNIP noxN, has effective sub-re-ional opera- -er, and par- tioiis. At the State le%-ell bonve% ticiilarly in view of the compactness of the entire State.in geography, transportation and comnluiiicatiODs, a regional systems and pro- gram planning resource is urgently needed. This is needed for full community of effort in order to provide for true regionalization of Nurses receive updated coronary care training through ctitirse,, supported by the S. C. Itegional resources and regional plaiiniii-. Cu)-rcntly, Medical 1'rogriiii. Slto%%-ti are (left to right): there is no overall coordination or single re- Sandra Harrington, IZ.N., Kingstree; Linda lieaty, It.N., Myrtle Ileicii; Lillian White, lt.N., Jantes source for service to assist community or sub- Island; iNI.'try Weaver, It.N., Walterboro; Dr. regional area planning activities or to assist 1'eter ('. (,,xzes and Jan Ileroil, of the Medical University of S. C. Division of Cardiology. or develop regionalization linkages for im- JULY,1972 295 by the Regional Medical Programs Service and the NIH for Areawide or Comi-nunity Health Education Centers. 'I'o approve, establish local guidelines, mon- L itor and evaluate such activities a Regional Planning Committee of the RAG is to be organized in order to involve in its delibera- tions a number of health-related agencies, professional association representatives, gov- erniiieiital representatives, educational institu- tioii representatives members of the public, representatives of CHP bodies, and the mem- bers of the Medical Districts Committee, of whom the majority are now representative Introducing new technology is an important RAG members. part of the expanded SCIZ'.,%IP mission. An ex- This resource will also provide guidance ample is linking community hospitals by te for Program staff to be recruited by SCRMP phone to major medical centers for coronai care consultations. Above, Nlary Harrelson, R.P in order to be capable of providing the con- sends heart patient's -electrocardiogram (EKG) sultative staff s port needed by community from Dorchester County Hospital, Sumnierville, UP to the 'tledical University of S. C. Hospital's CCU health study groups. by telephone. 'I'he expanded activities of SCRMP pro- grain staff, will be directed towards coordina- provement of health care by systems ap- tioii of manpower training, coordination of proaches, or to regionalize commi-inication continuing education, program planning and and consultative activities for health services. development, systems analysis, provision of The staff of the South Carolina Regional appropriate consultation in a variety of socio- Medical Program is currently providing to C, economic areas needed in health planning, some degree such coordination of effort, as and for the development of demonstration or was demonstrated in the package presentation of the several grant. applications submitted as experimental programs and the evaluation of these, and especially to serve as an agency a program for the improvement of health for assistance in program planning with in- manpower through Physician Assistants Train- (lividual community efforts to provide for an i-ng Programs and consolidated as a combined grant application to the National Center for overall regional strategy. Health Services Research and Development . One may ask if the present SCRMP staff and tci the Health Manpower Bureiu of the is not in some sense providing for these sorts NIH and more recently for a similar co- of activities now. The answer is Yes, but only ordination in respect to developing a com- ii-i a limited degree. munity based health education center linkage The projects of the South Carolina Re- for several related projects involving several gional NIedical Pro-ram, though initially in community hospitals. 1968 and until 1970 almost entirely cate- It is also evident that such statewide co- gorically oriented, have broadened. This ordination of effort is immediately needed in occurred rapidly for most as soon as project view of the statements and recommendations directors knew that their efforts could be made in the Public Laws for the adiiiinistra- expanded beyond the strictly categorical and tion of the Emergency Employment Assist- narrower areas of care. The Program Staff has ance Act of 1971 (PL 92-54), the Compre- also sought to guide applicants for new proj- hensine Health Manpower Training Act of ects especially to design and expand the ser- 1971 (PL 92-54), and the Nurse Training Act vices of currently exsiting personnel through of 1971 (PL 92-577), the National Center for ncxv technology, have promoted the re@train- Health Services Research and Development ing of personnel, and have consulted with application guidelines and those developed others interested in new arrangements for the 290 THE JOUR,-,'Al, OF THE SOUTII CAYTOLINA MEDICAL ASSOCIATION delivery of services. Ambulant care and ser- materi@ils can be skillfully focused to promote ,.-ices to isolated or deprived areas liaN-e been chaii(res or new ways for communities iii an encouraged,,aiictfiiiaiicially aided to improve overall sense, or to prevent duplication comniunications. Educational supports for through the promotion of sharina of resources In professional and technical ,rotips have been and ci ities. extensively and assi(luousl-\- organized and Past attempts to provide certain of these supported, particularly atteinptincr via our coiistilt@ition services by or through out Re- Educatioii Service ET\'-Teleplioiie System (,ioiial Office Pro(,ram Staff, lia\-e been and other communications s%-steins to support limited by force of various c@ctinistaiices, the '@\IUSC to provide education to improve such as funding and the time available be- services and care at the comiiiuiii@, level, and @-oiid that required by ongoing operations provide this iii ways xcqtiirii),, as iittle loss of itiid development. time as possible for those receiving this in- Other tgencies, with certain of these structioii to be away from their evei-NldaN- cal),.tl)ilities, are likewise limited to iiistitli- professional practice. tioiial needs, and thus at many community We are iioNN@ attempting to assist others to levels, decisions Lre too ofteii taken x@@itliout utilize funds other than R'\IP funds fliat are the benefit of exact data or the sort of gi-iid- now beconiin(, available tlirou-ii the Eiiier- ance needed for sound planning and for gency Emplovii-lent Assistance Act of 191-1 alteriiati%7e approaches, and often with dul)li- (PL 94-54), and the Health Niaiipo@N,er Triiii- catix,c efforts. incr Act of 19'il, both the Comprehensive We believe, therefore, that South Carolina Act (92-5'iS) and the -Nurses Trainiii,, Act can profit from a strona committee of the (92-571-',, to further these sorts of activities, RAG made til) of individual members NN-lio and esl)eeiall\r to focus these iii selected bos- liaN-e of themselves each appropriate stature, pitals -,N-bere expanded regional sei-\-ices',tiid reitsoiial)lc authority, sufficient autonomy, and stipportin-, services for ,icljac-ciit smaller bos- political impact, tnd who can establish bv pitals can be established tbroti(rh the Coi)i- presti(,e and leadersliij) recognition plans for mi,inity-Based Healtl-i Education Center type better coordination and use of funds and concept and expanded hospital service (,rants' to ,x,ork at the State level with corn- a(les m-Liiiitv interests iii developing pro-raiiis and As we look at NNbat is needed, let us coii- systematic approaches to deal Nvitli local prob- sider what the Col-iimuiitiv-Based Health Ed- leiiis, but yet present tli@se from beina too tication facility for expanded manpoN@,ei- can isolated; but rather to be ible to eiicotira,e do Nvitli funds xn,hicli are I)eiii- i-nade available Iiiika(,es and resource sharing xn@itli some I)v the Coii,,ressioiial Acts previously men- @itithoritati%,e backup. This will not only tioned. better utilize SCII'I\IP funds available for We are leariiiii,, from our Nieclical District iinprON-iiia community health care, but I Committees what the community xx,isbes and assist program development ,N,ith fi-ilids from health needs are. TI-icre is, lio%%,e,.,er, no truly other sources. coordiliatiiic, I)odNy statewide iioNN@ to assist Such a comi-nittee will need supporting and able to serve iii expanding or coordi- staff capil)lc of providiii(, studies and re- nating efforts except as our Regional Ad- search to improve community health, and, ill x,isory Groul) and its comniittees do iionv; addition, by an appropriate staff section act these can and should assist i-nore Nx-idclv. to guide educational activities needed in ctir- Likewise, sources for sn-stenis laniiiiig, ca,alti- ricultuii iiid program pl,,tiiiiinc,, for comiiiu- p ation, pro(fl-aiii plaiii)iii(,, analysis of N@ai-ious iiity-I)ased health education activities to pro- data, essential for aii@, plaii \vith long-range iiiote expansion of nonprofessional man- prospects, do not exist in a coordinated way power, more i-iiiiformity of curriculum and through pi-ioi,it), settiiig4l'-@evaluatioiis, ti-,iiiiiii(y, and transferability of traiiiiiicf ex- and the de-%@elopiiient of alternatives and fli(, pericii(@cs,l)y recognition of or certification of promotion of educational and infori-nation@il itcadei-nic equivalency for technical and oc- JuLY,1972 297 ants to expand the efforts of the iio@v limited number of lieiltli professionals, which latter groups, despite all efforts by professional schools Nvill continue in short supply for many years. N@7e have advised the GoN,,ei-iior's Office and the Commission on Iliglier Education of our current plans to develop this concept of regioiializ@itioii of effort by expanding the of the Nle(lical Districts Corn- iiiittee. Through this Same mechanism, better coordination of all State a,,eiicies relating to tli(@ health field \@,e believe can be achieved, as NN,ell as better utilization of all our educa- tioii@il resources in the various coheres in our State, coiniiiiiiiit), and pi-i\-ate institutions, incluciiii(, those of the infedical UiiiN,ersity, and our technical as N\-ell as general educa- tioii.,il facilities. TI)is iicN\,Iy e nded committee -,N,ill exert xpa its efforts to. ii-nprove health iiianpoNN-er needs I)v activities ,x,bicb: I-.jicotirage the establishment or maintenance of pi-oLraiiis to ille@,iate shortages of health personnel in areas. designated, tlirotilah training or retraining 'Niedi A Poison-Drug Information Center at the @ - siicli personnel in facilities located in such ireis, or Cal University is supported by SCIt.111'. @kl)ove, to otliei-N@-ise improve the distribution of health per- Sidney Smith, a pharmacist in the NIUS(' flos- pital's Department of Ilbirmaccutical Sci-N-ices, soriiiel I)v area or I)y specialty group; checks information received from a computer in "B. l'o pi-on@icle trammel programs leading to i-nore responding to t telephone query concerning poison efficient titilizttion of health personnel; or drug information. "C. 'I'o iiiitiate new types and patterns or improve cup@itional level personnel NN,itbin the Rc(yion, existing patterns of trainiii,@. retraining, continuing and thus simultaneously expand trainiii to education, and ,i(l@,,ince(I training of lie@iltli personnel, 9 increase the availability of services and health including teachers, administrators. specialists, and para-profession@ils (p@irticiil,,ti-IN@ , p]insiciaiis assistants, care, along NNitb improved employment and (rental tl)er,,ipists, and pediatric nurse practitioners)-, advancement opportunities. "D. 'fo encourage iie%v or more effective approaches It is only by such coordination of effort to the organization ID(] clelivern, of lie@iltli services that deadheading in the health service pro- through training iiidiN7idtials in the use of the team at)i)roacli to cleli%,ei-y of health services other- fessional or occupational fields can be pre- wise; vented, that career opportunities can be "E. To assist Sttte, locil, or other regional arrange- opened, and that able people can be ii-iaiii- iiieiits among schools and related org,,ij)izations and tailied in employment as a result of improved institutions; and "F. 'ro promote i-egiojialization of services through career opportunity in the health service fields. iiiipro%@c(l coii)iiiiiiiicatioiis iiin,olviiig the SCRMP It ",III be only tlirouh such efforts that the 0 \IUSC 11-Ilospital Networl-, in cooperation with the turnover rate of some skilled and semiskilled Stite ETN7 in(I telephone system and other NIUSC employees in healt.h facilities can be al)at(@d, coiiiiiitii)icatioii resources." and that job barriers cai be penetrated so We hope members of an expanded Nledical that occupational and educational ladders can District Committee to iiiiproN7c Community be achieved. -Only in this N,.,ay can the staff 11@tltli Services will achieve coordination of Nvorkers of smaller bospital.@ be assured oppor- effort in trial of iienv systei-ns, tiid in extend- tunities for staff advadceiiieiits and receive iiig miiipoxx,er, ictivities which IINIP is vitally the sorts of continuing education needed to iiit(-i-csted in and charged ,N,itli, but NN?Iiieli it become and remain effective aides or assist- cqiii only acliicv(,@ noNN, piecemeal because it 298 THE JOURNAL OF TITF SOUTH CA11OLINA ,%Irr)iCAL AsSOC1.4,TION exists as only one of the several sep@ii-ate by demonstration and training techniques, health-related or(ranizatioiis. aettiiliv assistiii(, existing manpower expiiii- It is by this route that we believe or-anized sioii, and is health care more accessible, .\Icdiciiie and medical edtication@il institutions effective, and efficiently delivered@' If not, can likc\\,ise best exert tlieii- strcii(Ttlis and should the objectives of the program be kno,.\rled,,c in t,,uidiiiiee iii)d c\@aluatioil. cliaii,,ed or projects discontidued? There are In order to better cai-r\- out its mission in decisions vital to the SCIINIP and other Re- South Carolina staff functions and coni- gioiial i\lcdical Pro-rzims. Simply expanclina ZD C) mittees of the Ile(lioiial Advisor Group will programs and expeiidiii,, funds -will not be n y 11 0 be reorganized aiid be functionally oriented helpful to health care, nor merely expanding rather thin cate(yoriciillv oriented. Committee iiiaiiponver. menil)ersl)il) \\-ill also reflect this to (ireater It will require leadership, effort, and co- degree thin previously. The SCRNIP will be operation by the physicians and community able to respond more qLiickIN, to iien@, oppoj-- leiclei-s to accomplish the ii-npro\@ements tuniti(,s for the physicians of South Carolina, needed and sought. and other members of the health profcssioils, SCBNIP can and sliould provide the fraiiie- to assist in seekiii,, and secul-iiic, the support for the actions needed. needed that The proposed membership of the newly A. Promote iiiion(,, providers at the local cxl)iiiic](@d committee will consist of the follo,,N,- level new techniques and iiino\,ati\-e deli\-ei-v iii(y i-epreseiitatiN,es, most of wlioi-ii are now patterns to iiiiproN,6 accessil)ilit),, efficiency members of the RAG: and effectiveness of health care. The State Board of Health B. Support activities that would help to T)ie S. C. -\Iedical Association Council and improve utilization of existiii(r maiipo\@,ei- and Foundation new kinds of niatipo\-,,er, especially in nuclei-- Ilealth Insurance Providers served areas. TI)c S. C. Department of Vocational Re- C. Encotira-e re-ionalizatioii of ' health habilitation facilities. The S. C. Departi-neiit of Education 1). Assist in developing specific mechanisms The S. C. Department of Public NVelfare for quality control and approved standards of 'Technical education schools care. The Commission oii I-li(,her Education E. Like\x,ise, the promotion and develop- Office of Coli-ipreliciisive Health Planning, iiiciit of systei-ns for ( 1) nionitoriiia the qiial- State Board of Health ity of health care; (2) improi-einent in einer- -Nleinl)crs from the public gency me ica services. The S. C. Hospital Associ,ition F. By such supports to health services de- Tli(, Goveriior's Plaiinilicr & Grants Office In livery sN @stenis, I)ette-.- utilization and improved foi- Community Affairs distribution of health manpower for services The S. C. Department of Meiital Health and patient care should result. Tlic! S. C. @Niciital Retardation Commission G. Lastly, but of priinar), importance, is The S. C. Nurses'Association the function of yearly evaluation tiid re- Ilepi-eseiitati%,es of allied health science evaluation of the SCIliNIP pro-raiii and its schools component projects. Are the programs really, The Nledical University of South Carolina JuLY,1972 299 Vol, 286 No. 4 RAI)I.;k'I'ION I"[,()O%l E'I' SPECIAL ARTICLE RADIATION THERAPY IN NEW @HAMPSHIRE, NIASSACHUSETTS AND RHODE ISLAND Output and Cost BERNAIZI) S. 111,00%1, OSLEI@ I,. I'E'I'I'-I@SON, Ni.1)., ANI) S.kNIUI:I, 1). Abstract There are large variations in input, out- far higher proportion of patients with cancer, an put and cost of radiation therapy among different the therapy provided is more expensive. The categories of hospitals. Hospitals with simi 'lar pa- greater cost is due mainly to the larger and tient loads exhibit similar investment, staffing pat- more diversified staff administering radiation terns and disease mix. The use of facilities, equip- therapy. ment and staff in low-patient-lbad hospitals is less Five major centers could provide the necessary intensive and includes a high proportion of benign radiation therapy in the area studied. The cost conditions. The high-patient-load centers make would probably be higher, but the results could more intensive use of their resources and treat a well be superior. ISING medical-care costs throughout the world 1)), iiii@, t@-pe of irradiation diiriii(, 196f). Since dzit@t I Rhave induced a search f'or greater efficiency of collection I)etran in June, l@)70, the fiiiaiici@il resource allocation and more effective delin,erv of iiiatioii Nvas gathered for the previous hospital fiscal health and medical care. \ILicli of the rise is due to @,eai, of October 1, 1968, through September ')O, the increase in utilization of medical services and to 1.9C)(). 'Flie patient tre@ttmeiit (lat@i %vei-c g@ttliered for the changing nature of the practice of medicine, the year ending December 31, 1969. which involves the greater use of expensive and The cl@it,,t recorded for e@iell patient iiiclll(l(@(i tile complex techtiolo,.,), ai-id procedures, Tile product, c@itegoi-v of disease, number of treatments, iiii)@iti(@tit as Feld,,iteiii has ei-npliasized, has changed.' i\lost or otitl-)i,itient, first or recurrent ('()LIl@s(. of, c(!oiloniie research is coiceiiti-iited on the large are- ai)d tN@I)e of treati)ieiit (stipcr\,olt@i@,c-, ortlio\@oltiIL4e, as - on hospital and insurance costs, and on prinia- superficial], radioactive iiiipl-,iiit oi- applications. ry physician changes - and not with the smaller These dita ,N,ere oi)taii)ed from eitliei- tli(,, components that make tip each of the areas. This iiielital lo(., book or the individual patient ii-c@itiiieiit study concentrates on one such component, radia- records. tioi-i therapy. The information on hospital income i,liid exl)eiidi- ttires N@!,ts available oill@7 in aggregate 0 f' i-ii) and Nvits- OBJECTIN@E o]3t@iiiied from tl)e hosl)itzil's fiscal records. Of tli(- The purpose of this investigation is to deteriiii- sampled hospitals, one provided no tbei-@il)@- during nii-te the various t@,pes of diseases currently being 1969; -,mother that treated oi)ly -'-)5 patients declined treated I)v irr-,Idiatioii, total patients treated, the to ftiriiisli information on the disease categories of number o'f treatments given to each patient, the to- patients treated. The definitions of the fiii@tilciiii tal number of treatments given iii each radiation- terms used conform to standard iccotiiitiiig or eco- therapy unit ai-id the hospital costs of therapy. iioiiiic usage.* STUDY DESIGN RESULTS A sample of all hosl)it@ils iii New llitrnpsbire, All tile information gathered was separated into Massachusetts ;iiid Rhode Isl@ind from the uiiin,erse three categories - input, output and cost. The data providing rAdiittioTi tlierap@@ was selected rLtiidoiiil-,7 on input are concerned with the f@icilities, c(Itiii)- after stratification I)v reaching function (universal iiici)t iiid personnel. The data on Output deal Nk-itli y affiliated, ot@ier teacl)iiig and iioiiteacliiiig) .iiid I)v the patients, their disease and treatment. Fiii@iiiciiii number of treittiyieiits given during 1968 (less than diiti i-elite to the income and expenditure under- 1500 treatments, or low patient load, 1500 treat- tikeii 1)@, the hospital. 7'/ie hospital Lost i.@ oitlil ments or more, or high patient load). One fourth of the cet-tt(,tl with the (Iii.(!e@t 1))-ovivit)ii of i-(tdicitio@t itcli cell %k,ere studied, Nvith it minimum of I)il. It does not include inpatietit costs. It does iii- hospitals in e one hospit@il sttidied per cell. cIti(le costs of continuing or student education iii- The patient population included everyone ti-e@ited ctirr(@ci by the department. Ti-iivel expenses or -,viiires I forgone by patients are @ilso excluded. From the Dcp,,trtniefit of PreN,enti%,e and Social Niedicine, Harvard Input -,True the Derirlrer,@i -f C'ornmi-nitv NI(-(Iicine- I Jniver- sity of Pennsylvania School of Nledicine (address reprint rcqucsts to Mr. Bloom at the Department of Preventive \Iedicine, Harvard Nledi- \@12gs- 02115). NE\V 01: \IE1)1(:INE Table 1. Facilities and Equipnient, by Hospital Group, 1969. I rE"l liosi@il;\l (iKOk.1' t@ll%'IRSITY KI.I.AIEJI offiER IEACIfIN(i A B -4 No. of lio@pit@ils 4 2 2 3 2 3 Ficilities (ft") 12.865 475 2,200 1,060 5.113 l@870 I'(Itiipnient: SLIVei-voltage: 1-inear accelerator 2 - - - I I - - Betatron Cob@kit 3 - - I I Orthovc)ltage 4 2 2 3 1 Superficial 4 2 2 .- 2 1 Total capital investment S 1,504,346 $72.3 35 $223.500 $99,350 S4;42@603 S)73.,;6.@ 'A indicates high, & 11 low p@itient load. able for the provision of radiation therapy and tlieii- number of patients treated, total Treatments (zil.'ell 1969 cost. Table 2 shows the personnel and the and average i-itiml)er of treatments for each Patient cost for fiscal 1968-69. The larger treatment centers are presented. The range is from a 101%11" Of 4.3 tre,-,',- have more extensive facilities and equipment, a ments per patient in a iioiiteaching, low-patieiit-loid greater number and di-,,ersitv of skilled manpower, @i hospital to a high of 19.() treatments in a iiiiiversit,. larger capitil investment and higher personnel affiliated, high-patient-loid major medical cei-,tey costs. In the hospitals with high patient loads, per- These differences -,ire due i-nainl\, to the iiiix of dic- soniiel costs are a far higher proportion of total costs eases treated. The in,@ior medical centers tre-@ I more patients, iiielil(lill,- maiiN7 rnalixiiaiit le,;io!Il- than in those \k,itl low patient loads. The lCw-treat-' I ment-load hospitals provided their few treatments more difficult to treat, and give more treatments t(, by borrowing personnel from the radiology depart- each patient. The low-pitient-load hospitals, in con- meiit. There are few, if -tny, nonpli\ personnel trast, treat more benign --rowtlis -,Ii-id fewer pi-ol-,Ie-@i-@ (physicists, dosinietrists tnd radiation technologists) cancers. The ver\l large range in patients and treat- to provide the complete range of services for patient ment@ is striking. treatment. In all low-patient-load hospitals, the bulk Table 4 slio\@,s the patients' Treatment status - of the personnel cost is for the part-time physician whether treated on an outpatient or inpatient his;-. and technician. The higb-patieilt-load hospitals, and \,,7hetlier a first or recurrent course of treatment with their greater diversity of staff, show a wider The iioiiteacliiiig hospitals, usuall\- located outzi@t- distribution of cost among the various personnel the metropolitan areas, provide more priiiiar\. tre@il- categories. ineiit, \vbereas the te@icliiiig hospitals include Output greater proportion of treatments for recurrence- The low-pittiont-load hospitals treat a larger propo3,- In Table 3, the aggregate statistics on the total tioii of their patients as outpatients, owing in Itrzr Table 2. Number, Type and Cost of Personnel, by Hospital Group, October 1, 1968, to September 30, 1969. ITEM HOSPITAL CIP.OTJP' UNIVI:RSIIY REI-AFEF) OTKER TEACHI!'G NONL EkC 141" A B A 8 A No. of hospitals 4 2 2 2 No. of F7Et radiotherapists 7.5 0.15 0.75 0.1 1.8 No. of F'FE physics personnel 5.6 0 0.8 0 0 No. of F-FE teclinol 11.0 0.25 2.0 0.@ 4.06 0 ogists No. of f7fF all other personnel 11.5 0.45 0.55 U.;" Annual personnel cost $563,903 $7,660 $88,499 $6.9@@) % of total cost 67.7 35.8 56.7 20.9 66.4 72 \-(,I. 28C) No- -1 RADI.,%']'ION E'l- Table 3. Total Patient and Treatment Loads, by Hospital Cost Group, 1969 Of tli(,, expenses iiictii-i-ed b@, the hospitals ft)r t'@ -O\,Islo 14(APITAL PATIENT No. oi@ TOTAL I-OTAI, AN l@l@A(;I. it of rit(li@itioii therapy, the cost of GRokip LOAI) HOSI@ITALS PAT]f.NTs TIEAT.@IENTS II([-Af\[[.,,TS/ I)eii-s most he@i,,,il\, oil the liigii-I)iitieiit-load PA I I UiiiN,crsity High 4 2,232 34,798 15.6 t@ils. 'file exteiit of stziffiiig and costs in tile related (13.2-19.0)- 1),,ttieiit-lo@id liosl)it@tis is, by contrast. lo\%-. Expense Lo%\, 2 151 1,450 9.6 supplies is relatively minor- in all lio,;I)itlt'IS, t,- other High 2 545 5,766 10.6 though in all Iiigli-pati(,iit-load I)osl)it@ils tile\- teaching ( 9.4-15.4) ttite it higher percentage of tile total. O\-eylie@t(I @ill Low 3 56 810 14.5 del)i-e(@iatioii expenses are iiiversel\- I)i-o,,lortii)titl (I 1. 7-1 S. 1) patient load. The largest portion of' e.\I)(-ii@es in Noiiteachiiig High 2 640 10,875 17.0 low-I)atieiit-load hospitals, which is fixu(, is (13.8-18.7) Low 3 254 1,843 7.3 overhead tiid depreciation. 4.3-11.1) N@,'Iieii total costs are viewed in rel@itioti to ntin)l)ei- of patients treated and Treatments -,i\ *Figures in parentheses are ranges. average costs are greatest in t e iig -I)iltiei-it- measure to the treatment of nearly more I)eiiigii hospitals (Table 7). The onl@, exception is the ()tli..- conditions. teacliil'ig-bospital group providing less thrift l@5i@ Table 5 shows that patients -%\,itil malignant I)roc- treatments. This is due, in part, to the iiicltisiti-,i it esses account for the btilk of all patients (83 per the sui-vey of one hospital tli@it did not provide t- cent) and for an even larger proportion of all ti-eat- treatments during the year tender sued-\-, thus d ments (96 per cent). The range, by hospital group, iiig the average costs. The reason for the y however, is great - from 30 per cent to 98 pci- eclat I)er-patieiit loid fotind in the Iiigli-treatiiient-l(i,,.,'. for patients and fi-oiii 68 per ceiit to 99 per cent for hospitals is the larger and more cost]\. staff.. treatments. Patients \vith cancer were cliaracteristi- slio\vn iii Table 2. it radiation over two week,, or Ili eN,erN, hospital studied the cost of ,)ro,.-4c call), givei-i r-,xtc-iisi\?e more, whereas those with benign conditions tisti-,IIIN' radiation therapy far exceeded the income deep". received one to four treatments. with only three exceptions. One made oiilx. a 0 n Table 4. Percentage of Primary Treatment, Treatment of Recurrence, Inpatient and Outpatient, by Hospital Group. 19-@. HOSPITAL PATIENT No. OF TOTAI- % PRIMKRY %'I'REATNIENT % CROUP LOAD HOSPITAI S PATIU@N IS TREAT NIENT OF RECURRENCE OUTPATIENT I%PkT-.Fl I University related High 4 2,232 73.2 26.8 66.8 Low 2 151 70.9 29.1 69.6 Other teaching High 2 545 80.2 19.8 67.7 -,2. e Low 3 56 73.2 26.8 98.2 1,8 Nonteaching H igh 2 640 89.1 10.9 77.7 Low 2 229 93.9 6.1 97.4 :!.6 a All hospitals 15 3@853 77.9 21.1 71.1 29.9 In all the hospitals studied, with the exception of mal profit, and two covered expenses. In the noiiteicliiiig, low-patient-lo@id ones, there is t hospitals income covered less than 50 per ceit c%.' great deal of siiiiiiarit@- in the distribution of the costs. Five aclditionil hospitals generated en,-,)i!,,--, malignant diseases treated (Table 6). In most liospi- income to cover only between V2 and '/3 of their cc@-' tals about 50 per cent of all patients were treated One other hospital met 80 per cent of its costs fr.,)I,@ for three types of cancer - those of the lungs and incoi-ne. breast and the l@,i-nphoma group. In 1969 there were 67 hospitals in '\ew liailil- Table 5. Total Patients and Treatments, Percentage of Malignant and Benign Conditions, by Hospital Group, 19C--O HOSPITAL CIROUP PAIIE@%T LOAD T(ITAI- % N%'IIH CANCER % wiT ti BL NICN PAIII@NIS IREA1.11L."[S PATIENTS TREAT SI LNTS PATIE@NIS i- University related High 2,232 34,798 94.8 98.6 5.2 1,4 55.6 Fl".Il Other teaching H igh 545 5,766 65@3 87.7 34.7 12.3 @O Low 56 810 98.2 99.5 1.8 0.5 l@ QIK RA A 96.0 15.6 4.0 192 'FIIE NE"' Ol,' NIEI)I(@INF@ Iitn. 27, l@)72 Table 6, Diagnosis, According to Site, and Percentage of Total Patients, by Hospital Group, 1969. SilL 1-01 Al P@%l [i-N I F, U.Ni%,i Rsii), Rr..I.AIED I'@) 01 li@,it I'LACilIN(i NoN I F.ACIIIN(; lii6ii 1,0,A tfl(;Ii low 141(@ll Ntalignant: Oral 3.1 3.9 0 0.2 1.8 4.7 0 Pharynx 1.4 1.4 0 1.1 1.8 2.5 0 Gastrointestinal 6.7 8. I 2.6 5.5 10.7 5.1 1.7 Nose, car. larynx 2@6 3.2 0 0.6 1.8 3.4 1.7 Lung 15.3 18.6 4.6 13.4 12.5 12.5 311 Breast 16.5 17.3 13.2 i 5.6 28.6 16.6 9.6 Female reproductive 8.5 9.9 2.0 6.8 5.3 9.4 1.7 Male genital 2.5 3@2 1.3 2.2 0 1.6 0 Kidney, ureter, 3.9 4.1 0 4.0 7.1 4.5 1.7 bladder Skin 4.3 3.4 2.0 3.5 3.6 7.2 7.9 Lymphatic s%@stem 9.8 12.4 3.3 7.3 3.6 8.3 0.9 (1@@tiiphonia) Other 8.9 9.2 26.5 5.1 21.4 8.6 1.3 Nonnialignant: All 16.4 5.2 44.4 34.7 1.8 15.6 70.3 All hospitals 100.0 (3.853)* 100.0 (2,232) 100.0 (151) 100.0 (545) 100.0 (56) 100.0 (640) 100.0 (254) 'Figures in p;irenthees indicate tot@@l patielit5. sliire, Niassachtisetts and Rhode island that had fit- st@iffilig levels, larger and more complex f@ici ities cilities for radiation tlieral)v. \lore than 65 per cent Fire(] e(Iiiipnieiit an(] deal with i-nore I)rol)lem dis- gave less t)iati 150() treatments per Nlear.,2 NIost of eases. the e(iiiil)zne)it was for either stipei-fi cial (40 units) The cost of building and e(Iiiil)piiig the facilities, or ortlio-,,oltage (65 units) tre@itnients, There were 13 altliott,,,Il large, is overshadowed I)y the total ex- col)alt units, two of \N,hicli were in lo,,N,-p-,ttieiit-load peiidittii.es that will I)e incurred over the operatiii(r hospitals. For %@erv hi,@b-eriei-gy irradiation there \vas life of the unit. On the average, @iiintiil operating available one Betatron, three van de Graaf genera- costs \vere e(Itial to 64 per cent of total investment. tors and four linear accelerators, all at higli-I)atieiit- with a range of 14 per cent to 151 per cent. The load centers. low-p,,Itieiit-load hospitals incur average operating The total investment and cost of operations of all costs eqtial to 17 per cent of gross investment, radiation facilities in the tliree-state area has I)een \vliere@is in the Iiigli-patieiit-load centers, average - estimated from the study sample data (Til)le 8). operating expenses equal 75 per cent of The bigii-pi,ttieiit-load hospitals, 20 of the 67 hos- gross investment.. pitals with radiotlieral)), f@icilities, ac(-otiiit for 60 per DISCUSSION cent of the total iii\-estiileilt outlays provide 93 per cent of all treatments and inctir 90 per cent of the This investigation has dei-noiistrated large varia- annual Costs in the three states. It is evident that tioiis ill input, otitpilt and cost of radiation ther@ip\-. average annual operating costs and investment are Ilosl)itals \\,itli sii-niiiir patient loads and teaching similar for all hospitals with low patient loads. This functions showed little variation in investment in is dtie to similar facilities, e(Iiiil)i-iieiit and staffing facilities and e(Iiiipilleiit and in personnel, ])tit high- patterns. The higl)-I)atietit-lo@id centers show higher 1)iitieiit-load centers had capital investments three to ol)er,,ttii-ig costs and iiivesti-neiit. They have higher five times greater tl)@iii those of tile lo\v-l)atieiit-load Table 7, Total Expenditures and Average Costs, by Hospital Group October 1, 1968, to September 30, 1969. fiOSPITAI (;ROt,P PAII@'T No. or TolAl COS] AN'L.R (;E A\ F-RA(,E I,OAD Hosi,IIALS COST/PA I ]EN r (s) COSIft RF.ATkiFNT (S) University related High 4 832,706 374.93 23@94 (321.91-406.3 I)* (16.9i-30.20) Low 21,404 141.75 14,76 (13'-).97.156.63) (11.97-22.1-1) Other teaching High 2 155,966 28 1.53 26.98 (260.08-396.79) (25.79-1-7.531 I-OW 3 33,380 596.07 4 i.21 (449.82-5 13.73) (29.72-43.81) Nonteaching High 2 1784628 288.58 16.41 (182.8'-)-330.95) (13.21-17.70) ')n4 65 28.20 %,()I, 286 No. @l RAT)IA'I'ION 'I I-"[' Al,. I Table 8. Estimated Gross Investment and Annual Operating Costs of All Radiation-Therapy Units in New Hampshire, N?iassa- chusetts and Rhode Island, by Hospit@il Group, 1969. liost-ii Al- (jRot@p ['A I If-Nl No. OF IIIAI [A) A\ I IZA(;@. F-Sl III @l I 11 IANNLIAI, AVFT(A(IE .'kN't It LoAr) I l(JSPI rA] S ]'OIAI (;R,)Ss 01-i i@ %I INC; COST S0111@RAII.I(i(l)lt I I S fiosi@il,@l, S University, related 11 igh 8 2,557.000 3 19.625 1.974.142 246.768 l@o\k, 1 2 806.000 67.1 67 116.560 9@7 13 Other teaching H igli I 0 1,137.000 1 13.700 1.72'-,475 172.248 Low 1 4 597,000 42,643 136,158* 9.7 26 Nonteaching liigh 2 49 1.000 24 5.500 178.628 89@314 Low 2 1 1,205@Ooo 57.38 1 19 1.140 9.102 All htispitals 67 $6,793@000 S i(it.388 S4.3 19,103t $64.464 Includes total cost of hospital unit that perfL,inied no therapy. tintcrest iricotiie foregone not includei in ittiN@ estiniziled cot@. hospitals. N\'Iieii the investment per case is coiii- is stril@iiig. The radiotherapists, wl)o \,,,ere -,I,,,,-are of pared, the differences disappear. These two f@ictors, this fact, repeatedly st@tted tli@it the appropriate low investi-nedt and fe\,,, personnel, allow IoN\7ei- titi- I)ital i-oles ,A,ere reversed: the niijoi, treatment ceii- lization without any Increase in cost per patient. ters \\,ere often treating patients palli,,iti\,elN- \N-lieii This, however, limits tl)e versatility, and range of tli(*, should have I)eeii providing the priiiiar\, treat- treatment capabilities as compared to the high- iiieiit, and tl-ie smaller hospitals were giviii@l, the patient-lo,id centers and ma\, limit the raii(,,e of I)a- course of treatment when they should Iiiix-e tieiits who can OI)tain optimum care in the lo\x,-Io,,id I)eeii hospitals. The final criteria for ziiiv treatment (!enter is prod- In addition to the problems of financing kind cost ticti\,it\,, which not oiil%- iiivol\,es \-olliiiie I)tit has a is the shortage of the personnel needed to direct dimension of qtialitv. riie final case outcome is the and give radiation tliertp@,. There are simpIN, not I)est iii(@@istire of qtizilit\-. ]:)o the more expeii@in-e c-,i-iougli pli)@sicians, pl,-,@sicists, d(,siiiietrists all(] tc!cli- hi@,l)-I)@itieiit-lo@ici (centers produce iiiore ciires. iiologists ill this stil)sl) ecialtv to treat the number of loiigei- stirn,ival or fewer coml)licatioiis'@@ This stiicl\. patients who coiild be expected to benefit from this his no data oil this (Itiestion. Ilowe\@(-,r, Grahaiii and therapy.'-' PLlotic,eL- presented e-,@i(leiice that the survival rate In the lo\?.,-patient-load hospitals, tl)e diagnostic \N,@is better in Iiigli-patieiit-load centers for patients radiologists and oti-ier staff provide the radiation ti-(!@.ited 1)), irradiation for cancer of the cervix.-3 The therapy on a part-time basis. The diagiios - superior result was ttril)tite tic radiolo a d to the special physical gist must perform the functions of the pli),si(@ist and f@icilities and equipment, a concentration of clinical dosimetrist and even of the technician. This repre- material and the gre@iter experience and skill of the sents borrowing of people -,,%,Iio have other priiil-.trv staff. Thus, the crux of the question rests on the functi(iiis and is a poor utilization of a r@idiologist's (iiiilit@7 of the product and higlili(l,lits the need for data oil the results of treatment reflecting surx-6-,-al time - not only because lie is performing too iiiaiiv functions but also I)ecitise it detracts froi-n his pi-i- tiii-ie and the qtialit)- of life during survival. N@'itli mary function of diagnostic radiology. This lowers rise of' the criteria established bNl the Committee for his productivity in both functions and also runs Radiation Therapy Studies' and the findings of Gra- counter to ,he increasing trend to separate diagiios- liai-o iiid Paloticek,3 it appears that the future coi,.r,;e tic and therapeutic radiology in training__and in should be to strengthen the m@ior centers and practice. don the units with lo,.N- patient loads. The diseases and conditions treated in the bosl)i- The r@iiige of operating costs experienced bx- the tals with high "Ind low patient loads were quite individual hospitals was great. It costs three times different. The high-I)atieiit-load units treated larger as much to treat a 1)@itient in the most expeii-;i\-e numbers and percentages of cancer. The low- liigii-I),Ittient-load center as in the least costl@- ION\-- patient-load iiiilts treated niann, I)enigii conditions, 1)@itieiit-load hospital. The high costs are due, @t., our such as bursitis, pl@iiitir \vart, keloid, ten(loi)itis and data have slio-,N,ii, to the larger and more diversified el)icondyliti.s. E(juitlly striking, ,Nas the small amount st@iff gi\,illg i-@idiatioii therapy. The tre@itnieiit of more of radiation therapy given foi- I)eiiign conditions in 1))-ol)lciii cases and the use of a great varietN, of the liigli-I)aticilt-loid centers. One call only as@- equipment coiiti@ii)ittes to big ier cost. whether this w@is due to ,I lack of time oil tlleil- \Nitliiii the homogeneous liigli-I).iticiit-load, seliedtiles for ll)illor dise@,ises or wlietl-ier tliev ill)- i-otil) there was also it 9 posed different criteri@t for the use of radiation costs ol' therapy. There was a per-I)atieiit ct)@t therapy. diff'ei-(-iice of 3() per c7ciit t)et\\eeil kill it At file Iiigli-I)atieiit-lo,,id centers, especially iiiost expensive hospitals. \N'itliiii other liosp, i, .1 . ... ... -,I -)O i)pr celit to NE\%' 1'.N(;I,ANI).)Ot'RN,.@l, Ol-' Nil.@Dl(',INE 2-,. l@172 194 be dii(.@ to diff(@riiig (@iiiiical tecliiiies, st@iffilig I)at- per c(@lit of the patients ti,e- l,ted foi, engineer. teriis, i-nix of diseases tre@ited oi- t(-ttiitl management A iiiiiioi- expansion of' the lo@id of the iii@@joi- treat- of the r-lidiittioti-tliei,@11)@7 units. If these cost iii(,@iit cei)tei-s could -,tl.)sort) this small load. Such iit \N,otild cori-(,(-t tli(@ inefficient use of differences are due to the management of the units, sa\@iiigs to the pretreat and the hospital can be personnel in the lo\N,-p@itieiit-lo@id liospit@ils. chie\,ed I)N, al)l)lic@itioii of modern iii@iiiageiiieiit fit jti(Igi)i,, the location of iii-lkior treatment centers, a I teciiiiics and business practices to the operation of one must consider not on]\, the cost of construction the units. and operation but also the travel cost, triL\-el time It itl)pears ti-iat service industries in general, and -,Iiid loss of income I)v the patient. This ;ii-gues the medical indtistrn, in 1)@ti-ticiilztr, -,Ire (Characterized against total centralization of radiation tlieriij)-,-, but by low prodticti\,itv and few economics of scale. As ol)N@iotislv does not support the current practice of hospitals increase the scope and magnitude of their hospitals operating at -a low capacitn- \%-itli an patient @ind tre@,itineiit load, new and varied st@iff are inefficient vise of personnel. added, the use of technology is intensified, and \lore than @)5 per cent of the population in the costs rise faster than output. Massachusetts, New Hampshire and Rhode Island The use of radiation in the trez-ttiiieiit of cancer arei live %vitliiii 80 km (50 miles) of a mi@ior f@icilit\ has been expanding steadilN, for the past 75 years. Five centers, lockited at existin(i institutions. \\,otild i%lajor advances during the past two decades have be a more appropriate number than the 67 currently given rise to a greater demand for i-adi@itioti therapy, in operation, with still more planned to coii)e on- further specialization of radiotherapists and more line in the immediate fi-ittire. Four Iiigl)-piitieiit-loid iiiteiisi%-e use of f@icilities and equipment. centers loc@ited at Hanover Cited \@ialicliestei-, New An iiiil)ort@int question is the number and type of Hampshire, Springfield, \la.@s-,Icbusetts, and Pro\@i- centers needed to treat the expected patient load. deiiee, Rhode Island, along with the centers in Bos- Six hundred and tliii-tv-ei(rlit patients Nvere tre@tted tf.)ii, could eiisil), handle the entire patient load and in the i-rost proclii(-tiN,e (.-enter in the saiiil)le. flow- i-neet the test of patient convenience. ever, in oliserving the utilization of facilities and equipnici-it the opinion was reached that a sul)stan- We are indebted to the 1'ri-St@tte Regional Niedicii Pro- tial increase in productivity could be accomp'l.islie(I grain foi- financial aid, advice and rich). with little addition to personnel and cost,;. Although capital otitla-,.s ire a si-iiall part of the totl] expeiidi- REFEIIENCES ttire incurred over the operittiiig life of the units, 1. Feldstein NIS: The Rising Cost of Hospital Care. Cambridge, they can scarcely be justified for the treatment of Ni@isszichLisetts, Harvard Institute ot'Econo ic Research. 19 i 'I. Peterson Ot.. Duffy BJ: A Report on Ra iotheritpv Faziiities and few patients when other well equipped and staffed Personnel in the Tri-State Region. Boston, Medic,-il.Care and Edii- units lia\re iijiused capacity. cation I-oiindatioii. lncoi-poi-@ited. September, 1970 Ctirreiitl),, there are 13 m@ijor treatment centers in Graham JB, Paloucek F: Where should cancer of 3 the cervix be Massachusetts, New Hampshire and Rhode Island. treated'? a preliminary report. Am J Obstet Gynec@ll 9-:405-409. 1963 Nine are in the Nletrol)olitan Boston area. Two Of 4. Comniittee for Radiation Therap@, Studies. A PrcKiect for Radia- these ire undergoing exp@,Liision programs that will tion 'I liet-itpy in the UniteLl States: A final report prepared by the Subcommittee on Regional Nledical Programs of the Ctmniittee for .,ic their ctl)acitv. The eight low-patieiit- Rittliation Therapy Studies. Bethesda, National Institutes of greatly iiiereit load hospit@ils in the sample accounted for onlv Health, October 24, 1968 MEDICAL PROGRESS THE BIOSYNTHESIS OF COLLAGEN (First of Three Parts) Nii(:IIAEI- 1. (;IZAN-l', ANI) I)AR@%']N .1. I'Ro(:i@op, I-Iii.D. TNTEIII,--ST in the I)io(-Iietiiisti-@, of coll@i,,@en de- titice in diseases of connective tissues Collagen is JL i-i%ics ill pitrt from its iil)tii-idittice, in 1)@tri fi@t)ii-i its pi-ol),Il)]-,7 the i-@iost rroteii-i in the I)tijti@iii unusual properties tiid in 1)@ti-t from its likely iiiil)or- body, ,tiid it is the iiitkior constituent of most collitecli@;e 'kissitc, -). f')!Il- I-roni the departments of Medicine and Biochemistry. University of 1)oiieiits of these tisstic@,s are el;tstiii, t related fibrous @,@ii the Ilhilkicielplii@i (iencral Hospital (@@ddress reprint ,,irl tlle lIss of siti,,zir polymers known @is JOURNAL OF ri It) or,, @., I It @ (11 Pilrw YO[@K, N. Y. h'iO%']-HLY 230,000 DEC 1971 4@ UR@IP,L OF AMERICAN JO INURSING N. to R.N. in One Year tiEW YORK, ti.Y. L.P. MONTHLY 230,000 in New Alabama Program 197 i Philcarnpbell, Ala.-Licensed practi-. DEC cal nurses are now able to obtain an iate in applied science degree assoc one and become registered nurses in Louisiana Nurses Have Grant year instead of two at the new Ex- for Continuing Education New Orleans, La.-The Louisiana ntal Mobility P rth- perime rogram at No -State Nurses Association here has west Alabama State Junior College. received a grant from the Louisiana Average age of the 30 students Regional. Medical Program to set up enrolled this year is about 40@ a statewide system of continuing according to Norma Ferguson, direc- education programs for nurses. tor of nursing. They are taking a Amount of the grant is $100,000. heavy course load-18 hours a quar The program is administered by ter, she said, and were required to LSNA under the direction of Mal- colm Martin, a specialist in commu- nity development, and seven region- I challenge the first level by examina al coordinators, who must have tion. They take their clinical experi- degrees in nursing. The coordinators, ence at one of five local hospitals. located in Baton Rouge, Shreveport, The first year is funded by the Lafayette, Lake Charles, Alexandria, State Board of Education, with Monroe, and here, will assess local matching grants of $25,000 from the needs for continuing education and Alabama Regional Medical Program then will plan seminars and short- and the Manpower Training Act. An term courses to be conducted by additional $10,000 came from the nd schools of nursing. North Alabama Hospital Council. universities a Regional coordinators will work with statewide and regional advisory councils The grant expires in February, when the nurses association hopes to be re-funded or to obtain funding from the state legislature to connect the program with the state university svstem. IMAGF= COMMUNICATION BY TELEPHONE Milo M. Webber and Howard F. Corbus Saint Agnes Hospital, Fresno, California and the Univervity of California Hospital, Los Angeles, California A simple, inexpensive, reliable systei n for trans- STUDY PROTOCOL mitting organ imaging examinations to remote loca- Ninety scintillation scan examinations were trans- tions would have manyuseful applications in nuclear medicine. In this pa I mitted. The type of examination and the display per we will review our experi- material used are shown in Table 1. Before each ence with a method of transmitting radionuclide transmission, a brief clinical history was given. The images to a distant location using slow scan tele- image was interpreted by the receiving physician vision and ordinary telephone lines. I with the interpretation being recorded. At a later EQUIPMENT time, the films were viewed directly with the same clinical information and another interpretation was Ordinary (real-time) television is suited to motion recorded. The results of the telephone and direct picture-type visualization of the happenings at a interpretations were then compared and tabulated as distant location. Nuclear images, including radioiso- positive for pathology, negative, or equivocal. Organ tope scans and gamma scintigram pictures, generally imaging examinations were recorded as "positive" are static; therefore it is not necessary that the capa- when an abnormal cold or hot area could be identi- bility of real-time television be present. It is possible fied on at least two views with anatomic correlation to send images one frame at a time by a facsimile. and the official interpretation recorded an abnormal However, facsimile does not lend itself easily to the finding. Renograms were interpreted as abnormal format of the radioisotope scan. Generally facsimile when one or both analog curves depicted a delayed -is used with opaque material and is limited to a fixed peak (over 5 min)'Or a delayed excretory phase size. Certain television techniques, however, are (over half the peak value at 15 min) and when serial adaptable to transparencies such as are used in nu- scintiphotographs confirmed the sequence of events clear medicine and can also be used with various shown in the curves. "Equivocal" interpretations in- sizes and shapes of original material, whether trans- cluded organ imaging examinations in which varia- parent or opaque. tions in size and shape might be attributed to The method used in this study involved a slow- anatomical variation (usually liver and perfusion scan video system adapted for transmission over existing telephone lines. At the transmitting terminal, the equipment consisted of a television camera, tele- Received Oct. 2), 1971; revision accepted Jan. 25, 1972. vision monitor, video converter (Colorado Video. For reprints contact: Howard F. Corbus, Dept. of Nu- ' clear Medicine, Saint Agnes Hospital, 530 W. Floradora Inc.), standard x-ray view box,-and telephone data Ave., Fresno, Calif. 93728. set (Bell 602C Data Set). The receiving terminal was,equipped with a video converter and magnetic rotating disc storage device (Colorado Video, Inc.), television monitor, an(.' -,n identical data set. The receiving video converter contained a video disc .memory feature which allowed the transmitted image to be retained on the television monitor until the next transmission. The equipment was compact and could be housed in a small cabinet or desk top -,.j ,(Fig. 1). No special wiring except for the telephone was required. Simple telephone pickups and ampli- fiers were helpful for conference use. A zoom lens accessory for the television camera was used and was felt to aid in rapid adjustment for the various FIG. 1. Receiying terminal for nuclear medicine image commu- film sizes, reducing times of setup for transmission. nicotion system. Reprinted from the JOURNAL OF NUCLEAR MEDICINE, June, 1972, Volume 13, Number 6, pages 379 - 381. WEBBER AND CORTIUS no instances in which a positive direct interpretation TABLE 1. TYPE OF EXAMINATION AND had been preceded by a negative telephonic inter- DISPLAY MATERIAL TRANSMITTED pretation. In four cases a telephonic interpretation Type of No, of Type of of "equivocal" was followed by a positive reading. examination loses material transmitted No. Since, however, an interpretation of "equivocal" groin icon 57 X-ray film, 10 X 141 251 would be an indication for either direct viewing of Liver scan 15 X-ray film, 14 X 17 70 the films or further examination, it was concluded Lung scan 8 Polaroid format 9 that no significant abnormalities were missed during Renogrom 6 Renogrom graphs 5 Thyroid scan 2 Radiographs 2 the interpretation of the transmitted images. gone scan 2 Data sheet I Seven examinations might be considered as "fa e Totals 90 338 positive" transmissions. One was read as abnormal by telephone and normal directly. Four were read as positive by phone and equivocal by direct inter- lung scans) and probable artifacts or abnormalities pretation. Seven were interpreted as equivocal by seen in only one view. The official interpretation phone and negative when viewed directly. recorded the type of abnormality and usually sug- gested additional or repeat studies. "Negative" inter- EVALUATION pretations consisted of those examinations in which Comparison of the two methods of interpreting no abnormality was noted and the official interpre- organ image examinations reinforced the authors' iation was recorded as normal. The two interpreta- overall impression of the transmission technique, tions of each scan were then compared. Observations namely, that examinations transmitted in this manner were also made regarding the reliability of the sys- can be interpreted promptly and with a degree of tem, resolution, photographic factors in the gamma accuracy sufficient for clinical use. The resolution images which made for best transmission, and cost. of the imaging instruments displayed on the actual The general routine was as follows: The initial films did not appear to be degraded in transmission telephone contact was made. A single view was trans- since the abnormalities on all positive examinations mitted (equipment takes I 00 see), after which verbal were identical and no significant "false-negative" discussion took place using the talk mode of the transmitted interpretations were rendered. Further data set while the image was retained on the receiv- experience in transmission technique and improved ing monitor. In practice, four or five patient exami- equipment should decrease the incidence of "false- nations were transmitted and discussed in a period positive" interpretations. The system was sufficiently of approximately 1 hr. Much of the discussion in- flexible to permit transmission of material of varied volved the technique of scan performance and the composition and size. diagnostic -question posed by the particular exami- Except for films of low contrast, all organ image nation. examinations recorded on radiographic.film were The transmitted material included primarily radio- graphic films upon which scan images bad been made (Table 1). It also included Polaroid displays, reno- TABLE 2. COMPARISON OF TELEPHONIC gram graphs, some radiographs, and printed ma- AND DIRECT INTERPRETATIONS terial. The use of a zoom lens permitted quick Interpretation Phone Direct changes of film size between transmission. The tele- identical 68 Positive 32 32 vision camera was used with a standard view box. Phone positive, Negative 36 48 No special masking was required. direct negative I Equivocal 19 10 Phone negative, Technically In the course of this study, four 10 X 14 or two direct positive 0 inadequate 3 0 14 X 17 transparency scans were generally grouped Phone positive, - - and transmitted at one time, which made it possible direct equivocal 4 Total 90 90 -Phone negative, to transmit four views of a brain scan at once. direct equivocal 0 Phone equivocal, direct positive 5 RESULTS Phone equivocal, The comparison between the telephone interpre- direct negative 9 Phone technically tation and direct interpretation is shown in Table 2. inadequate: In 68 of the 90 examinations, the two interpretations Direct positive I were the same. When both interpretations were posi- Direct negative 2 tive, the abnormal features were identical; i.e., the Total 90 positive interpretations were consistent.- re were 380 JOURNAL OF NUCLEAR MEDICINE IMAGE COMMUNICATION BY TELEPHONE transmitted without difficulty. With proper mag- displaced downward from the main image. The ap- nification, 35-mm negatives could be transmitted. pearance was not unlike "ghost" images which are Scintiphotographs displayed on Polaroid film were occasionally@seen in real-time television where more successfully transmitted as were analog curves re- than one path for the radiofrequcncy picture signal corded during renograms. Gross features of selected exists. The artifacts could be eliminated on many radiographs could be transmitted, such as cardiac occasions by breaking the circuit and reestablishing size on chest x-ray and isolated findings in contrast the connection. studies. The system was simple to operate at both the sending and receiving terminal. Nuclear medicine FUTURE APPLICATIONS technologists were able to operate the transmitting The participants in this study have been encour- terminal after approximately I hr of instruction. I . aged by the technical capability of the system and Setup time was minimal and the combination Of intrigued by the teaching potential of asimilar sys- zoom lens and television monitor eliminated the need tem. It is our hope that future studies of this sort for special masking. No transmission was cancelled will facilitate further the application of t e univer because of equipment failure except for a period sity teaching center's special knowledge and experi- when telephone service At the receiving station was ence in a community hospital setting. Additional interrupted due to an earthquake. No maintenance formally structured teaching projects will be under- was required during 4 months of regular use. Al- taken to explore this potential more fully. Improve- though cost figures were kept during the study, the ments in equipment can be expected to result in special design of the experiment and recent changes im roved resolution, faster transmission, and re- p in equipment rendered this information meaningless. duced costs. Improvement in the quality of the Replacement of the data set with a standard voice images should make it possible to transmit radio- coupler will reduce the fixed cost substantially, and graphs, photographs, and written or printed material. toll call time undoubtedly would be shortened in a Improved storage devices may make it possible to working situation. Even with the system as it was store a series of examinations at the receiving end used, it was concluded that the cost was reasonable of the terminal to be interpreted at a later time. and within the budget of a moderately active de- Smaller hospitals, especially those in remote loca- partment.' tions, might wish to perform routine organ imaging examinations and arrange for immediate interpreta- LIMITATIONS tion at a distant center. Several hospitals might be Slow-scan television is suitable for static images linked to a single center with the necessary trained Ionly. However, serial images from d namic studies physicians to provide expert interpretation, thus pro- y can be transmitted in groups of six or eight frames. viding an important category of diagnostic service Cerebral flow studies and serial scintiphotographs to a population of patients who otherwise might not taken during renograms were transmitted in this receive this service, or who might have to be trans- manner. The system was unable to detect and trans- ferred to a point where the service is physically mit small changes in image density at the white end available. of the gray scale, in spite of the contrast enhancement effect of minification. As a result some underexposed SUMMARY films or films of low contrast could be interpreted The investigators evaluated a slow-scan video directly but could not be transmitted successfully, system capable of transmitting static nuclear medi- even though the minified image on the receiving cine scan images over the telephone line. The system monitor could be adjusted to a degree for contrast was found to have potential for future applications and brightness. Resolution was grossly inadequate in bringing nuclear medicine services to small, remote for routine radiograph transmission. Accurate inter- hospitals. The results of this study indicate that no pretation of printed material was limited to block positive examinations were misread. However, there lettering of I in. or larger. Further refinement in the was a tendency for television interpretation to be equipment will probably enhance the capability to equi-vo(-al or positive when direct interpretation was transmit printed material since the manufacturer P--gative. It was felt that the difficulties which w ere proposes its use mainly for this purpose. encountered in this initial use of the system could Distortion of the image and noise artifarts wf're be overcome occasionally bothersome but rarely pre,,,-,P.Ied inter- pretation of !he image. The type of arti@fact that was ACKNOWLEDGMENT most distressing was an imaot, if lesser intensity or T,his study was made possible by a feasibility grant from of reversed etav scale w@l'o@h,was occasionally seen t Calif@rnia Regional Medical Programs, Area IV, UCLA. Volume 13, N,- .,,jer 6 lw 6, -@II)INDAY, OCTO"r'(? 15,1972 .77' @77 41 4 -11 NcTi)v VII W(, @-.1 N I O'U-. .9 to ille roi3,, wf)n,@ail ks W, fit it in bj?r ri i?, ri wo!", iNiveft I-%). Sle c w i @@oti never z!, e t t@) 9 af a (@oixir)iltiiid fn@el, ire of 'lie le-i't L si ;,you, just (,o t@,e bEst yt),v as V- -ler sto -ilacii w T@a@- cle-;sion px-obably s"@-;ed ti-@e it Nv@as a 41 o del@i@vei! t -aii(i 1.)r. ed aitd (',,ove A riccO,'e broiiglii up fr@,;Ii ali.Ve. Ile lirit C IC Sli.1w. blf@ocl. ]'tit i@@ coiritic, l@;, "r-ie ba k h(ti-,- from.? Th s(i * * * e aorta'? O,,- some organ,." @he v-,.,olllttj live 'Lh,@,cjz,yh Ili@, ,ty a' LL-ip tO s a;, (It yi A @few tb@ caiiii of as ilie vvo)-ian 'aive begtri a toward ri@cove,-y. @IAI)ISO.N. Di- A. "lu- M a,@c, s I II,-,w b,-eed of doil-- ri,aki- a d f y c a I he Co. re A Or @i el ik@ "ly IT t 3,, r d '3v a i;e ',lilt hi,@,,, ill til(, @icink he wit' to sht-,o me 1 0 to a...d' n 'i@ rj a r@ "yo-O Dr. 4-Frcciu,,,ntj,yl even ti-@ e At @i Yi,. il I Dr. Moyl -ra 5 before deciding his next move. can exami,,its X y C I'@ -i f CA@es-- c-@dar'iy ccn- bf@ b-oL it tiki@-s a c, tre of trauma p4,- i ., , i rflic pri@iiz)%v aiid th(,- -dar,,,, ficisritils usiially don't or@ P..tqe 'live ttie manpo%ver or@ deck 24 lio,,trs a day, no,- can the@v a@ f) @@i i' I -ri ij t@. c 'Lo I.,Iicil for,4 thc., sop@,,'sti,,,ated equip. Tile l@atii),,ial S a y (o tr"es. O.C i.itiulrc. Ca,,, a riioth-- h they Ct!l (@T@'), if t'iclre 1.5 @l Zll;l"clreti at Says i.,i or so Fie to "Yoi Say hospital bill of the .1@vay, is to stal)ili.@ted the pa. Of'k-ei-i it Lot be NVCI"Iillil ivLtt) lived was ibout tieiit the ri,,,ht *.he a, r- y@ vilyiell@@, if 1)atij?,ii- ivlys, and star,' , ili,@c iiil- lve, fluids - for the tril) to tic It larger to th(, cty fatliers 4,1 I-IAD A LO-]' of trc)u,')Ie@ evil 4;r -,iid It,'@d thein 'We gotta do @@i Etircipe, t@e. trend is ari- rel,,ioial trauma liospi- Air, Ciri-,ey, r@l' A-@)- biiiir,'C. It got ary wits all' ,'I " says ollief I)eco,.qiiog @-tp. , '@l. raise 11 in 'Ct)is p@ Here leisili,ll, to t@ i).Titil -@-e can get sonic a% I A 1) IO.N' I SCIOS@, lie, y of tile" Los Angeles fiLis a Avis oi, witl, Nll'-,RSE," s.-3?s i\ir,. So does Dr. Gcd, bad I NNi@6 to it if risky y T II @v 4(10 CIE 'k, IV' ra,@ed for i@,c: S',), XI care.) Army personnel and' thei,- says ;@Irs. Carney, to talk she is, and especially ii-lien she families arc iloNim by DC-9 eaclr Avitli the man next door. Ilis sees the teciia,,cd diii,,Iiter of year from all over the United, w@ifc was one of the womerf the men next door. She looks iti' States. killed." the niirror, and the ravi-es of She lools at her three the accident arc barely visil)lo. "THE HARDEST thing," children, and.think-s how lucky ."It's a fantastic hospital," she says. "Tremendous care, and so personalized, when r wrote my thank-you letters, I' almost wrote to the small city doctor. I think I still i)IPS. C@kr.NEY isn't alone. Dr.',Nloylaii -cts the tough ones. There was a girl from Por- tal-c, ivitli 28 stab wounds- inflicted by an unknown as- sailant. There was t farm I)ov,. pitched from a tractor and run over by a plow. The'anal irea ivas enucleated, literally scooped out to the abdominal cavity. There was an'cldcrly, man, victim of a guti %vouird, and two little Eait Side girls, badly burned when a pan of grease caught fire and the fire spread to their clotliin,-. And, with a proaram to bet- ter utilize the services - of regional trauma centers under way, more ind more of the most grievously injured per- sons is-ill come to lkladison ind other centers, and more and more lives will be saved. Maybe ygqrs. 1) Ive to W,:ijt Llt) I i' @-(iii oi' cliaiif.,P. to Ali .1 It yiiii a b b@_i say ,ii@, And it will 'la] si)ecia"ltj traiieil lo clit I Mad,'@on f;renic,-t',Iohn Kommer,'Yight, iti<,>,"s an their training., Bernie Schmeizer, the instructor, Lend of Corol Krebs, R.N.,.watch his -.-og,-ess. ir(lyen,bu@ 'tube t'IVII @'-n Charles Dirienzo as port PI .,State Photn Ity Ed-tvin Stein Nvil' have a half dozen tged do@v-n on 'a- '[le inay tie ,tirway, Df!r Solis ethic for -@vill'it car al,@lie i C Is alon'.@ @vitti h it-II, iiit tvbjcb, tinder., Vi.,e a,-roti@it (if if yf,,tir Ie,-trt is ttit! doctor's orders, lie'll be able to-'. r pill or just JL ucf ANC-1@' r@ietticaltiort 'that h@- ca@i Yiv(!@ N@f 'I, it'@( net,,. 'Flic- fejeral I)el)t. I)f AS ",,;IkiE Al@t.,c@UTA@ @-i,-t i,,i the tit' si@loi,s. Wt.!If.-,re is i-tivitig emergei,,cy@ y a f.,Y NV 3 As rt)f,-@,ro. operation, wit,i a view ot cut- ti"oli De Leie"llc@'I.1,y zi". )',,is i)i'lc44!,@ the tilig dtf@vii on ileal,b-.,. 41 i @Lg iiiat he can see you,- el ec f(itteral sLil)V)Orti foi- cifiertz"ey w so -:Lr c) c a- i - d- r a m. care service. Five Nvere granted. One le dt,@ei S llve,3,a,l Cy( II TI, -s" W;,l 'I'ile cloctfj,, can t,?Il I 'liit 1- el eel lip azid thin fileriiaii 11 (I %V ly ovfl is ,,,c kilt.! (.'re! le ki by Lie %art. s :ire -Neil "IT A -N JOUN'TS y 44.@) start Wi?i c, Car (it-' ti at wpy.. yv-.ii -,,art lqicy.,rc Daillx, ZL r,,-emon Ga.-Y irserts cirwa-Y i@-ito dum, my while jchnt Ts-inkle and Bob Gessie,- look ori. Dr. %'-Iaude, Toylor is a.l@ right. I&,, sp@nt a lot of ournoi Pholos b, E-:dwi,@i stain 'f le f i r@.rrc,@n a re a 'A CT.-cr til,e .,lot friin booLs, but by t-a@,i 'c@@ u says based O,(jdor. d-ia:L-,-@ c, s is d i @' iL:@ p do 4cli, . - I ial. iev're ir@ t., Or he @,,iy sk@r, ove- C r,. i III let wil.@ by some ri,,orA.,ih@-y@re let- rcp Soii-@el t:iie her%)- -add, of the a D @osriital to take @i h,-di -f fee@i,iqiici @n,,qd Zlies before ii,-, g,@ to the r, b,.,riieil. person to a B or all Al burbles be riei;vc.-(,,d. p'-Ita-,, died I)eeatise ',Iie,v %.were Vi'@hen tire first *@,roup of Big liospittil @.-ho.@c tic., care@ re Carl,,, li, g",vc at the rate of once iiren,,exi has been trained, a is no', ]left, I @irti @.ow to i-i @,-t all ,.xv'jee a In @) start, IV-ith )O ':' -- o@ ' by 'Ctic of the v-ear, t., s t; L h I. -g.lio1v to sul,p t 'C Ve A an @l,, i a roLs del;!tv,4;, d And @tiremer, are @,And tile iri.,Ii)rtiat-oti @vill be grai.ifyi@if, 'Lhili@; .he@ ('file our @,wliole p,,oiet." says Dr.' a person iook;s r-@t!* low to cope t;vith iiis., c @vhj-,@! urico@i:sl_lioas T@lie of a @icart attack will be -V@lor, 141.s tile SPrif of,, I rorLI;e4 -1 nf! @v;"It,s ricit, ;s not restricted 4LO ile [1@ie f-i@Ist year. CG;)t,)Cratt,)n on all 'Loveis li CIYc C dedi ,tted, say the Avile is str,Cl-.en ill his -'lo-no, tbare the -@r@ IV.',h i@t vollnzc,;- amid now ilif! - "A good many one-!La., ae- '@O cmerge,,7.cl, the rext tacWlt-,?, t@,L, nu@,ics, ,h& ;,-n(i says? cidliits -are C,-iuse-ul either b@ o!id ')O ;" l@l",e tb;rd il-ic 'cs, te -;-2@V about ill I Heart attaclil;, wih T4,,-,L,"i sli-iare L, C@o7cn or -o -s,@ a't p a g e,, i,@, a 'or. video '@rL3irAl,,,g falls. - Lo dt). -l, '@d or I)y ys !)r T yL @he @ls %'no to @,iii all HI@ ifibs r)f t@:e AND, IF E car- O'%E Oli' T b be to f lie 4CI, V r.,3 (.,f is a'@ Is o h,- @,i nor h ai @_. Pi corlrle. 'kil:lr r-rii;zhv. b@,-,.i !7,c;-,rL af@tixk, use @,f troy!' 11 tile thc, ;tal@, far '%he or all is P,!Cjplc of he etcr@n- a-,! bi,,@@ ei--- ca-@i ;-ef 4 4i,(! er,@e, -en,-y ri%,,.)rri, on a portable c, F-. h, @t 'r@ !,-i i,@ i@- i.Ili(! a,-ifl on @tlo tills -is into start ni, says Dr. v heart 1 5 i,, i i i A)itals ,@ts ARKANSAS REGIONAIL, MEDICAIL PROGRAM 500 UNII'EI?SITY TONVEI@ IILDG. 12TH tT ITNIVERSITY Ll'rrl,E PO('K 722 6 4 5 (AREA COI)F, 501) It'. SILN'ERBLArr,.NI.D.,.COOltl)l',ATOIC September 5, 1973 M E M 0 R A N D U M TO: Mike Posta, Acting Chief Mid-Continent operations Branch Regional Medical Program Service @enneth Endicott, M.D., Director Health Resources Administration Department of Health Education & Welfare FROM: Arkansas Regional Medical Program Even though the present administration is desirous of stigma- tizing RMPS we in Arkansas are reminded daily of how our citizens have been helped. Enclosed is a recent article regarding Medical Technology training. JW:lw Enclosure a lab h@ - Lz3 By ODARE MURPHREE, MT(ASCP) Little Rock, Ark. Techs in Arkansas, small labs are not only unable to participate in continuing education, but frequently are undertrained to begin with. A Little Rock hospital lab is beginning to do something about that, though, with the help of a three-year Federal grant. WHILE MAKING their consulta- with an up-to-date lab employing to equip our classroom, pay instruc- tion rounds among nine Arkansas 60 registered techs and performing tors and clerical personnel, and pick rural hospitals, three of our pathol- 500,000 procedures a year. So in up the travel expenses for instruc- ogists reached a common conclu- 1969, we applied for a Federal tors who hold seminars in small hos- sion: Laboratory techs in those hos- grant through the Arkansas Re- pitals. And we now provide contin- pitals simply needed more training. gional Medical Program, and at the uing education in hematology, They saw, for example, one lab 'in same time spent $20,000 to prepare blood banking, general and, special which Coombs serum was added at a classroom in which to uporade the chemistry, urinalysis, serology, bac- the start of a crossmatch before the training of rural techs. Our grant teriology, and microbiology. protein was removed, thus making application received letters of sup- We've recruited our trainees it impossible to obtain an incom- port from the state health depart- through various professional pub- patible crossmatch. Another tech ment's Bureau of Laboratories, the lications and plain word-of-mouth. boiled Diazo reagent because he Arkansas Society of Clinical Pathol- Most of the m, despite the variety thought it should be yellow before ogists, and the Arkansas Society of of courses we offer, have wanted being used in manual bilirubin pro- Medical Technology. Three years to learn more about bacteriology; cedures. Another lab staffer did and three revisions of the. applica- four of our present class of 10 are prothrombin times by the sweep tion later, the grant was approved; it involved in this training,. and 10 of hand on the wall clock. Not all lab covered three years, effective July the 12 on our waiting list have ex- work in rural Arkansas is of this 1, 1972. We requested a total of pressed interest in it. It's not sur- nature, but the fact remains that $79,538, which the Federal Gov- prising, because bacteriology-a de- some labs have techs with little or ernment approved initially. How- manding discipline with which most no training. ever, with recent cutbacks in Fed- rural techs have only occasional In 1968, Baptist Medical'Center eral spending, our grant period has contact-tends to be Arkansas made slight progress toward a solu- been reduced to two years, and the techs' weakest area. tion by training three of these techs total amount we'll get is closer to In bringing rural techs to our lab for one week each at hospital ex- $39,000. This has forced us to re- for training, we've worked out a pense. We felt, though,- that we were duce the numbe'r of techs we rather unusual trade-off. Usually equipped to do much more than planned to train each year from 40 we're able to send a replacement to that. Ours is a 440-bed hospital to 20. the trainee's lab to work there as Nevertheless, the Federal money long as the trainee is with us (one The author is chief technologist at Baptist Medical Center. we've received so far has enabled us to eight weeks). Our replacements 36 MEDICAL LABORATORY OBSERVER Du ng a two-week stint in bacteriology, trainee Don Dixon gets _eriencestudyinggrainstains,coachedbytechBarbaraMonroe. MLO )!ULY-AUGUST 1973 37 How a big cit,,, lab helps rural techs A Spending time in several lab departments traitlee,51ieila Htirt performs a crossinatch (top) Under the scrutiny of fecii Julie Etidsley, then tries her hand at a niicrogasometer. 40 MEDICAL LABORATORY OBSERVER are recentl graduated techs, who y generally have difficulty finding work in technologist-rich Little Rock. The small hospitals do their ON part by paying the replacement's salary and providing him with lodg- ings, as well as continuing to pay the trainee's salary. It's well worth mentioning, inci- dentally, that the replacements have typically been enthusiastic about their experience in rural labs (though none as yet have elected to remain wo rking in one). They find that, in contrast to their large-lab orientation with its emphasis on specialization, small labs want them to be generalists; they also find they have more direct contact with phy- sicians and patients and are able to correlate lab results and patient care more closely. Our trainees are housed in rooms at the nurses' residence and take meals at the student-personnel caf- eteria (the costs are borne directly by the hospital). They work at our @i lab in an apprenticeship situation lo,@ from 8 A.M. to 4:30 P.m. daily, under the close supervision of a sec- tion chief or an experienced tech he appoints. Lectures and slide presen- tations are offered when needed, and the trainee has a reference li- Trainee Dixon watches as Mrs. Monroe reads culture plates. brary (financed by the grant) at his disposal. Bacteriology is the inost-sough t-af ter training. Specifically, the trainees are taught to perform up-to-date pro- cedures and operate modern equip- ment. For example, in bacteriology, trainees are given unknowns of stock cultures we keep on hand and are taught to identify bacteria and perform sensitivity tests. In hema- tology, the trainee studies a number of unusual slides under the dual mi- croscope, with the assistance of a veteran tech, and is expected to identify the atypical cells on a blood MLO JULY-AUGUST 1973 41 'B' it lab helps rural techs 19C y f) i fill t, As section head Laura Pierk6wski Hur' brushes up on urinalysis. Soon. she 11 return to h4 b %.J smear. Blood bank trainees are 0g) taught to perfomi blood. in- cell eluding back typi ng) ana cross- on atches: serums contain dies are given the tr ee o is a ected to identil m fari the 'incompatible c prov typing, back Our trainees cc e man bckgrounds. Oi 5 the tr years' experience in a but eral call A no formal training, sp eek hospital adi learning to identify a cians c blood cefls. A forme ment in thei teacher, who became our coi fo at training, spent more c our bacteriology 1, our tr@ aar's formal tr results, ol, spent a wi qnd facu ba And a CLA the traini ician's office le annual re ology-e 0 m it's f btahe at cultw e ter analysis of uri cultures @om in some cases. small@ sh aren't able to send a tec ita to them. Thanks t an 90 e're@ able to send fac aft tors Present seminars a' Based o pitws upon request. The, the needs so far-on red cel think it' @@@ fi . mEbir-,AL, Bo 6RY ossERvER I i@ : I 5 @ I A System of Continuing Medical Education Based on Medical Audit WILLIAM R. FIFER, M.D. THERE ARE 5,000 physicians in Minnesota methods such as medical television, tape cassettes who are in clinical practice. As individuals they and videotapes are available. are solely responsible for maintenance of their Although there is no organization of this series Clinical competence. As student, intern or resi- of random experiences, there is certainly more dent, the physician devoted all of his attention to continuing medical education offered than any of learning. Now his principal activity is patient us can use. care. To do this job well, he must constantly up- Learning Theory date his medical knowledge. Due to rapid infu- Educators tell us that retention of knowledge sion of new information from biomedical research, depends on its utility and its relevance. a physician's knowledge store has a half life of Educators also tell us that there is a "teach- less than ten years. A physician who fell asleep able moment" at which time we are maximally like Rip Van Winkle ten years ago would not receptive to new knowledge. In clinical medicine know about Rhogam, about ethambutol, about we reach the teachable moment when we are staging procedures for Hodgkin's Disease, about confronted with a clinical problem. We then coronary bypass surgery, about amniocentesis, etc. call a consultant, go to the library, or in other @onal Medical Programs were created to close ways acquire a needed piece of information to the, gap b&twee I tower and the practic- solve the problem of John Smith. We will remem- ing physician. Northland Regional Medical Pro- ber the problem and our solution long after we gram, like all Regional Medical Projzrams, has em- have forgotten the source of our information. phasized continuing medical education (CME) as Identification of Continuing Medical the principal means to upgrade the quality of medical care. The basic question in CME is "Who Education Needs needs to know what?" and we have begun to im- Given an almost unlimited number of oppor- plement a statewide system of continuing medical tunities to learn, how does a physician decide what education based on the determination of knowl- to chooses When we divide medical practice into edge needs by review of actual patient care, medi- what we know (knowledge) and what we do cal audit. (medical care), the question becomes: What is Modes of Continuing Medical Education it we need to know in the context of what we do? How do physicians continue their medical edu- There are three currently popular means of deter- mining needs: self-assessment tests, individual cation? First, patient care experiences are a vital practice profiles, and medical audit. learning resource. Second, consultations and daily Self-assessment examinations are now offered contact with other physicians contribute greatly. Third, hospital staff meetings, medical and special- by specialty societies in many fields. The internal ty society meetings provide new information. medicine examination is called MKSAP-11, and is Fourth, continuation courses are provided in abun- sponsored by the American College of Physicians. dance. Fifth, reading medical books and journals It is divided into nine subject areas and may be continues to educate. Finally, innovative leamino taken either as a closed or open book test. The examinee, after taking this test, learns two things: (1) what he knows of internal medicine divided Feasibility Study by the University of Nfirmesota Component of the Program Staff of NRMP, Inc., supported by HEW grant #5 into nine categories, and (2) how he compares G03 RM@l. The opinions presented do not constitute en- with his peers. dorsement by HEW or NRMP, Inc. Dr. Fifer is a Professor, Department of Medicine, University Individual practice profiles measure not what a of Minnesota Medical School, and Associate Director, Northlands Regional Medical Program. physician knows but what he does. Developed by DECEM13ER, 1972 17 MINNESOTA MEDICINE the University of Wisconsin Medical School, this patient care. Thus, we hoped to "set tops spin- technique is as follows: A physician carries a tape ning" at a rate of five per year, and hoped they recorder with him for several days, recording would keep on spinning after our seed money sup- information for each hospital visit, office visit, and port was withdrawn. At present, four of the five telephone call. The tape is then analyzed and a will continue the program on their own, and we report describing his practice profile is sent to the have begun working with four new hospitals. [Al- physician. Along with the profile, the physician bert Lea, Fairview (downtown), Methodist (St. receives an educational prescription which says Louis Park) and St. Cloud] in the second year of "inasmuch as you do these things, you need to the program which began April 1, 1972. know these things." The University then lists those courses, meetings, lectures, etc., most perti- Methods nent to the knowledge requirements defined by To implement our program, we have worked his practice analysis. directly with the affiliated hospitals to assist their Medical Audit is defined as a system of contin- DCME's and medical staffs to establish a system uing medical education based on the evaluation of medical audit. In addition, we have conducted of the quality of patient care as reflected in medi- monthly medical audit workshops, an annual state- cal records. We feel that medical audit is superior wide hospital staff conference, and an annual to either self-assessment exams or practice profiles continuation course on medical audit at the Uni- in that it demonstrates the application of medical versity of Minnesota. To establish an audit pro- knowledge to patient care situations. gram in a hospital, we found it necessary to teach The Minnesota Medical Audit Program is fund- the process to the medical staff. ed by Northlands Regional Medical Program, and The process of medical audit involves six steps: promoted by the University of Minnesota program 1. Criteria must be defi@4 for optimum care staff. Described as a "Feasibility Study of Medical of the disease or condition to be studied. If we Audit," the program began April 1, 1971 in five study patients discharged with a primary diagnosis Minnesota community hospitals (Austin, Fergus of diabetes mellitus, we set the recording of fun- Falls, Hibbing, Virginia and Worthington). These duscopic examination for 95 percent of the pa- hospitals were selected because of their diverse tients examined as a criterion. geographic distribution and because they were 2. Actual care must be reviewed to display relatively "closed systems' in which the medical existing practice patterns. We may study 100 staff-hospital relationship was well established. consecutive admissions for diabetes mellitus and Their sizes range from 64 to 185 beds, and their find that 36 percent of the charts have fundu- medical staffs contain from 17 to 40 physicians. scopic examinations recorded. Altogether, they comprise 142 physicians and 663 3. Ideal vs. actual must be compared to deter- acute beds. mine if a gap exists. In our example, the gap is To qualify for participation in the study, we between 36 percent actual performance and 95 asked each hospital to meet four conditions: (1) percent optimal performance. approval of the program by the governing board, 4' Gaps must be translated into educational administration and medical staff, (2) medical objectives to form the basis for a continuing edu- records information retrieval capability (four of cation program. In our example we state the our first five hospitals have PAS/MA.P), (3) will- objective in this way: "Following an education ingness to create an education budget to respond program on diabetic retinopathy, 95 percent of to identified educational needs, and (4) apoint- the charts of patients discharged with a primary ment by the medical staff of one of its leaders to diagnosis of diabetes mellitus will contain a re- work 20 percent time as director of continuing corded funduseopic examination. medical education (DCME). Northlands Regional 5. The education program must be implement- Medical Program provided the funds for the ed. We may decide on a series of three presenta- DCME position. It was understood by the hospitals tions, one on classification of diabetic retinopathy; that NRMP financial support would be withdrawn one a presentation of fundus photographs and/or at the end of the one-year study period. We felt clinical experience sessions; and one on photoco- that one year was adequate to determine the value agulation techniques with laser beam. of the medical audit program in terms of improved 6. Finally, we must evaluate the program at an 18 MINNESOTA MEDIC .I,NE SYSTEM OF CONTINUING MEDICAL EDUCATION appropriate interval. In our example, we study actual care. The medical staff then performs the the next 100 consecutive records of patients evaluative step by comparing the optimal with the discharged with a primary diagnosis of diabetes actual level of care to detect gaps which may be and determine the number of recorded funduscopic closed by continuing educations examinations. If actual performance remains at In addition to working with individual hospitals 36 percent, our program failed; while if fundu- to assist them to institute audit, we have con- scopic exams jumped to 82 percent, we caused a ducted monthly medical audit workshops using a change in leamer behavior. 44 show and tell" format in which various hospitals What are the requisites for a hospital staff to present audits. Nurses were included initially, perform medical audit? First, they must be but now have split off into a separate group to efficiently organized. The common practice we develop nursing audits. We accept this split as a encounter is horizontal review of care rather than temporary expedient, and plan to bring the health vertical (holistic or patient-centered). We have team together by focusing on patient-centered often recommended a reorganization of medical (vs. professional-centered) and outcome-oriented committees with the anchor committee (called the (vs. process-oriented) audits. audit or professional activities comniittee) sys- In addition to the workshops we sponsored two tematically reviewing profiles of patient care. more formal conferences: The first of these was Second a medical staff must have a medical the First Annual Minnesota Hospital Staff Con- records department capable of information re- ference in September, 1971. This two-day in- trieval on demand. If an audit committee of six vitational conference was attended by manage- men decides to study the management of diabetes ment teams made up of trustees, administrators mellitus by reviewing all the charts for one year, and key medical staff leaders from each of 27 hos- they might first decide what basic information pitals. The theme of the conference was the should be recorded on all diabetes charts. This quality of medical care in community hospitals. information can be quickly provided by the Its objective was to convince trustees that the medical record librarian from the computer print- responsibility for quality was legally theirs, and outs (PAS/M"). Then they might select for that they discharged this responsibility through deeper study a certain group of diabetics which the organized medical staff. We followed this UP are disi)laved in groups on the computer print- with a two-day continuation course at the Univer- outs. Having decided to look at diabetes either sity of Minnesota on the "how to" of medical broadly or at a specific problem in diabetes, the audit in October, 1971, attended by 63 physicians committee first sets pattern criteria for optimal from hospitals all over the state. We feel these performance, then goes to the records to see how companion efforts have helped to create a broad actual care measures up to optimal standards. climate of acceptance of medical audit in @e- The information they need to review care may be sota, and have developed a cadre of physicians divided into: (1) that which the medical record capable of leadership. librarian can get from the PAS/MAP computer Results printouts (example: percent of funduscopic It is premature to evaluate the success of the exams), (2) that which the medical record li- first year's effort. We intentionally structured the brarian can find by studying the chart (example: program loosely to permit great diversity of activ- percent of diabetics taught foot care), and (3) ity among the participating hospitals. We felt the that which requires medical judgment and hence program would be more likely to succeed if it review of the record by a physician (example: was their very own rather than a University pro- app riateness of the surgical therapy of diabetic gram in their community. Because each hospital rop peripheral vascular insufficiency). In this way, is so different politically and organizationally, the the comniittee can systematically review the care program took different.forms at different sites. of diabetics in their hospital to determine what Despite operational obstacles, and thanks to continuing education in diabetes is most appro- dedicated work by the DCMEs and small staff priate for their medical staff. committees, the first year's hospitals developed Iin organt.zing medical audit, only the medical skills in medical audit, learned to develop their staff can establish optimal standards. The med- own pattern criteria, and learned to formulate ical records department prepares the displays of education programs for the medical staff in re- Drict,,m[IE-R, 1972 19 MINNESOTA MEDICINE sponse to specific gaps identified by audit. They as a group, for every single patient cared for in accomplished dozens of audits despite heavy pa- the institution. tient care demands. Education programs were 2. Medical staff organization is a problem. produced and when an outside speaker was em- The medical care appraisal function is spread ployed, he was informed of the educational ob- about in many committees and each hospital jective before he spoke to the staff. Time has must solve this problem in its own way. Some not yet permitted completion of the audit cycle redesigned their committee structure, others left to see if the education resulted in change of the committee structure essentially intact, and re- physician behavior by re-audit of the disease or assigned functions. Common to all, owever, was condition. We await these re-audits with great the perception of a need to be organized to accom- interest. plish the job of medical care appraisal. Subjects dealt with by the first year's hospitals 3. The state of medical records is a problem. included the use of antibiotics, anemia, diabetes Since medical audit requires "the evaluation of mellitus, myocardial infarction, appendectomy, medical care as reflected in medical records," hypertension, duodenal ulcer, cholangiography, the record becomes the key document. If the cholecystectomy, the use of tranquillizers, and record is complete, legible and contains a concise urinary tract infection. In some instances data discharge summary, the record librarian is able to were pooled and shared by the hospitals. abstract it for PAS/MAP. The latter step permits Two hospitals, in auditing myocardial infarc- another chance for error, however, and we ame tion, concluded that pacemaker capability was that the record abstract was often the weakest link necessary for optimal care. As a result, members in the information retrieval chain. of each medical staff returned to the medical 4. Definition of optimum criteria by the medi- centers for training in the use of transvenous pace- cal staff is a problem. They are much more inc ined makers. Another hospital, after auditing myocar- to simply "take a look at a subject and see how dial infarction, decided they needed to know more we're doing," without having first defined stand- about serum lipids, and instituted a series of medi- ards. The criteria committees often asked for cal staff education sessions designed to improve "cookbook" standards developed by "the experts," their diagnosis and therapy of hyperlipidemia. and had to learn that the educational value of Audits of diabetes mellitus led one hospital to standard setting probably equals that of care institute a series of educational programs on re- evaluation. cent advances in the therapy of diabetic retin- In addition to continuation and expansion of opathy. They selected this topic after discovering hospital-based medical audit, we plan to extend that only 34 percent of the patients discharged our program activities this year. Beginning April with a primary diagnosis of diabetes mellitus had 1, 1972, Northlands Regional Medical Program their fundi examined. Another hospital concluded, has funded demonstration projects to extend audit after studying their diabetic care, that they needed to increase the use of other health professionals to: (1) the outpatient setting, and (2) the prob- lem-oriented record. These new directions rec- (nurse and dietitian) in the education of the dia- betic patient. ognize and attempt to correct two limitations of Almost every audit disclosed room for improve- hospital-based medical audit. The first is that ment and indicated a specific behavioral change hospital-based audit does not apply to the medical that was desired. The medical staff felt that an care, which takes place in ambulatory settings. educational program would produce the desired Three group clinics (East Range Clinic, Virginia; result in some cases; in others, they chose a Nicollet Clinic, Minneapolis; and the St. Louis procedural or operational solution. Park Medical Center, St. Louis Park) have been funded to carry out computer-based audits of out- Discussion patient care this year, and we look forward to We can generalize about a few things we their results with great interest. learned in the first year: Audit of the problem-oriented record attempts 1. Before action occurs, an attitude change to correct a second deficiency of the conventional must occur. We have seen a general acceptance hospital medical audit-namely that it accepts the of the peer review process, and of the concept diagnosis as given, and is unable to critically study that the organized medical staff is responsible, diagnostic process or outcome. By auditing prob- 20 MINNESOTA MEDICINE SYSTEM OF CONTINUING MEDICAL EDUCATION lems rather than diagnoses, we can set criteria for Swmary and evaluate the care of 100 consecutive admis- Northlands Regional Medical Program has be- sions for chest pain or headache, or jaundice, etc. gun to develop a system of continuing medical This strategy moves us closer to the real world of education based on needs demonstrated by the patient care and offers exciting opportunities for process of medical audit. This system offers the doctors to apply the educational process to their potential to: (1) increase the relevance of contin- own logic sequence in patient management. Two uing medical education by relating it to patient hospitals (Bethesda Lutheran and Miller in St. care, (2) provide on-site leaming experiences in Paul) began these demonstration projects on April community hospitals, (3) merge continuing medi- 1, 1972, and we will be greatly interested in cal education and patient care by making the com- their results. munity hospital a teaching hospital, and (4) Ei)ove all, improve patient care through continuing med- ical education. I)FCEMBER, 1972 21 A Dialogue with Sir William Osler on PostgTaduate Education Critique of a Northlands Regional Medical Program RUSSELL V. LUCAS, JR., M.D. T WAS A TYPICAL August night in Minnesota, ical performance. We hear, for example, that sultry, wind gusting, sheets of rain assaulting my 1/3 of recent medical school graduates fail to con- window and distorting the lights occasionally ap- tinue postgraduate training once they start prac- pearing in the inky black. I had labored some tice.' Estimates suggest that 20-70% of all time, in vain, to prepare an evaluation of "A pilot M@D.'s fail to participate significantly in post- project in postgraduate education in pediatric graduate educational endeavors.112 cardiology and neonatology." My friend Win Sir William: Miller was acting like an editor. All creativity had "Things haven't changed much then! Let me escaped. I gazed vacantly out the window. recall what I thought about that at the turn of A rich warm voice projected from the shadows. the century. Bear with me if I falter occasionally; "I had an interest in postgraduate education, per- you're aware that we don't remember w at we haps I can help." I turned to see a tafl slender write.* man of impressive bearing. His black hair was If the License to practice meant the completion beginning to recede, a full moustache adomed his of his education how sad it would be for the upper lip, and his black piercing eyes were set off practitioner, how distressing to his patient.3 by full brows and an acquiline nose. Despite his I was moved to sadness by a physician of my acquaintance who appearance, he seemed a warm and understanding crawled up on the bank and the stream left him man. there, but he did not know it.3 Sir William Osler. On the other hand, the country doctor who During the discussion that ensued, I had the maintained his skills and utilized his opportunities wits to take some notes which I used later in for postgraduate education filled me with joy." recording our conversation. Author: Introduction "You're implying that the physician, now as Sir William: then, lacks appropriate motivation for continued "Before we get down to your problem, what learning." is the state of medicine these days?" Sir William: Author: "Some perhaps, but that's not the whole story- "Not too well if we take at face value what is What about the professor, the medical school, who described by the press, the 'lay medical journals', are bypassed by the stream of medical knowledge. and politicians of all,callings. They lament the I used to call that condition 'old fogeyism'. widening gap between medical capability and med- Would you know the signs by which, in man or institution, you may recognize old fogeyism? This report is based on a demonstration project entitled "Pilot There are three; First a state of blissful happiness Study in Postgraduate Education in Pediatric Cardiology," spon- sored by the University of Minnesota. it was a romponent of and contentment with things as they are; secondly Northiands Regional Medical Program, Inc. supported by HEW a supreme conviction that the condition of other ran,*' G ' Rm-M2l. The opinions presented do not Institute .g.d..,.e.toby NRMP, Inc., or by the Department of Health, people and other institutions is one of pitiable Education and Welfare. inferiority; and thirdly, a fear of change, which Dr. Lucas is Professor of Pediatrics, Dwan Professor of Pedi- atric Cardiology, University of Minnesota School of Medicine. not alone perplexes, but appals.3 *Direct quotes from Sir William's writings are in references. Other conunents are poetic license, but reflect the author's understanding of Osier's philosophy. Are these signs of old fogeyism in today's pro- 22 MINNESOTA MEDICINE SIR WILLIAM OSLER fessors and medical schools?" liked the idea, modestly funded us, and helped us Author: define the following goals: "Yes, in some the condition is quite advanced." 1 . Provide immediate postgraduate education in Sir William: pediatric cardiology throughout Minnesota, "Then perhaps faulty postgraduate educational 2. Established more effective methods of post- methods play an important role in the failure of graduate education; and physicians to participate in postgraduate educa- 3. Encourage local physicians to assume a tional opportunitiesi" larger role in their postgraduate education." Author: Sir William: "We thought so! In our design of a pilot study "You call $30,000 a year modest! I recall when in postgraduate education in pediatric cardiology, little more than twice that, $70,000, was the total we started with the assumption that faulty educa- budget for all 1 1 Canadian medical schoolS.4 My tional methods were a major factor. We believed apologies! Let's hear how you attacked those that our own past efforts and others failed because worthy goals." they: Methods and Results a. did not identify the needs of the learner-physi- A . Utilization of the Crippled Children's Service cian; b. allowed little active participating by the learn- Cardiac Clinic as a focus for Postgraduate Edu- er-physician; cation c. too often provided a mass of unintegrated Author: facts; "Through the encouragement and cooperation d. did little to develop analytical abilities or of Dr. Mildred Norval, arrangements were made judgment; to utilize the crip led children's cardiac clinics as e. did not allow the acquisition of new skills; and p f. were seldom conducted in the physician's nat- foci for postgraduate seminars. In our three year uraI environment."* experience, thirty crippled children's cardiac clinics Sir William: in nine Minnesota communities were utilized. In "Well, Well. What's necessary for good post- each of these clinics, 15-75 children with cardiac graduate education then?" disease are seen. The clinics are staffed by pe- Author: diatric cardiologists from the Mayo Clinic, St. "We thought the following: Louis Park Medical Clinic and the University of l@ The specific needs of the practicing physician Minnesota. A number of different educational must be identified and the curriculum de- programs were utilized in conjunction with the crippled children 's cardiac clinics over the period signed to meet them. of the pilot study as follows: 2. The practicing physician must actively par- 1 . Informal lectures. ticipate in the learning process. An eight session curriculum designed to meet 3. The postgraduate program must be person - the needs of the racticing physician in the ized so that differing needs of individual p physicians may be met. area of pediatric cardiology was formulated 4. A significant portion of the program must and utilized. This gave the visiting pedia- occur in the physician's local environment. tric cardiologist guidance for his discourse 5. The program should be patient oriented. and eliminated the possibility he would 6. The program must be conceived as contin- talk about his favorite defect or his cur- rent research efforts. The lectures were utng over the professional lifetime of the given during noon lunch breaks at hospital physician." staff meetings, in the early afternoon at the Sir William- cardiac clinics, in the late afternoon at the "I see. You're trying to switch from a teacher oriented curriculum to one that's oriented toward cardiac clinics, and at night after dinner and the physician learner, How did you go about it?" in conjunction with county medical society @thor: meetings. The noon and early afternoon ses- sions were least well attended." "The Northlands Regional Medical Program, a Sir William: federally funded, regionally directed organization "Perhaps practicing physicians are still busy in *Editor's Note: These several points apply to all phases of medical equation their clinics and miss lunch." DEcEmBER, 1972 23 MINNESOTA MEDICINE Author-. Sir William: "That's right. On the other hand, the late after- "Perhaps, but do all your teachers teach? I noon and evening sessions, though better attended, doubt it. Some won't. Others, who will, aren't had a rather high percentage of inattentive physi- asked. This looks like a problem money is not cians." required to solve, but rather harmony and good Sir William: will in our profession. "Hypoglycemic and sobriety factors, respec- Medical men, particularly in smaller places@ live tively." too much apart and do not see enough of each other. In large cities we rub each others angles Author: down and carom off each other without feeling the "Our next method was: shock very much ... as a preventative of such a 2. Patient oriented case discussions after cardiac malady, attendance upon our annual meetings is clinics. These sessions allowed the physician absolute, as a cure it is specific."4 to participate in the examination of a child Author: with congenital cardiac disease and discuss "Perhaps then, even if some of our pedagogical the details of management. In one variation, methods were suboptimal, the fact they encour- patients with 'interesting and common prob- aged physician dialogue was most important." lems were held over and presented to the Sir William: "Quite so. physicians for their examination and discus- Author: sion. This was a most valuable exercise if "Sir William, your words about the isolation there were a small number of physicians. of physicians brings to mind a totally unexpected However, if more than 3 or 4 physicians at- result of our educational efforts in the crippled tended, a great deal of time was wasted children's clinics. It has to do with: while each patient was examined and the 4. Education of allied health personnel in the sessions lost clarity and direction. For a small Cardiac Clinics. Early in our program, the number, this type session was a most effective public health nurses and social workers in educational device. A second variation, use- the cardiac clinics asked for educational ses- ful for a larger number of physicians was to sions tailored to their needs. They were aware present the history and physical findings, re- of the many problems faced by t commu- view Xrays and electrocardiograms of a num- nity in providing the optimal environment for ber of patients. Each case was the basis of children with heart disease. Therefore, com- discussion, often spirited, of the problems munity school, hospital and @public health posed to the -practitioner." nurses, social workers, and school administra- Sir William: tors, teachers, and athletic directors were in- "That sounds better. The focus is now on the vited to special sessions at the close of the patient." cardiac clinics. Brief explanations of con- genital heart disease and rheumatic fever Author: "Our next approach was: were given followed by a lengthy question 3. Physician attendance at the crippled children's and answer period. The discussions centered clinic. The practicing physician often visited the car- on the child with heart disease; his habilitation diac clinic to review the findings and manage- and rehabilitation, special school and activity ment of a patient he had referred. This programs required, his medical, dental and nursing needs, as well as the psychologi provided an opportunity to review thoroughly stress imposed on the children and their the physical findings and the natural history families." of the cardiac disease and its management." Sir William: Sir William: "NovV you ire getting somewhere! You've re- "Those are the things we doctors used to take discovered the perfect medical learning situation, care of.19 the triangle of student-patient-teacher." Author: Author: "That's true, but most physicians today wel- "This was unquestionably the best learning ex- come this help. The major problem, as it is in all perience, but it takes one teacher for every student. human affairs, is meaningful communication. We T'hat's an expensive method." saw evidence that avenues of communication be- 24 MINNESOTA MEDICINE SIR WILLIAM OSLER tween the allied health personnel, parents, com- I . impart the knowledge and skills necessary to munity physicians and medical center physicians the recognition of the sick infant. were unclogged by these shared educational ex- 2. Provide the knowledge and skills necessary periences." for appropriate therapy in the areas of oxy- Sir William: genation, heat control, feeding, acid base and "So you had 30 of these educational programs electrolyte balance, treatment of infections, in nine Minnesota communities. How many stu- and treatment of congestive cardiac failure. dents?" 3. Provide the means to determine when a sick Author. infant requires transfer to a specialized diag- " 1 80 physicians, and 290 nurses and other allied nostic and treatment center and the methods health people." of optimal transfer of the infant. Sir William: An in-service training program, lasting one-half "May I ask two critical questions. First regard- to one day was given in 21 hospitals. Each pro- ing the scope of the program. I recall that I once gram was conducted by a physician and an infant said pediatrics was the best specialty, because intensive care nurse from the University of Min- children's ailments were too diversified to allow nesota Hospitals. Preliminary discussion between t I Much specializations But pediatric cardiology; he visting team and the community hospital per- isn't that splitting the hair pretty fine?" sonnel established the specific local situation and A problems with@in the context of the above goals. uthor: "That we learned. The NRMP people thought In the 21 hospitals, 380 nurses, LPN'S, and tech- so, too." nologists and 45 physicians were served." Sir Wifflam: Sir Winiam- t'i suppose it is still true that many of the new "Secondly, while the cardiac clinics were in the and specific medical facts and skills are soon ob- physician's community, they weren't really in his solete." practice environment. About the hospital centers all that is best and Author: highest in the profession of medicine. In it, not in "True enough@ Important as these new facts the medical school proper, not in the laboratories, and skills were, a more important consequence of not in the museums, we doctors I ive and move and the in-service programs was the establishment of have our being."6 improved communication among nurses, techni- Author. cians and physicians. We also observed that the "We recognized the validity of both of your University nurse-doctor team improved their un- critiques. Therefore, in 1970 we embarked upon derstandine, of infant care." a program to provide postgraduate education in the care of the sick infant in community hospitals." Sir William: B. In-service Training for Nurses and Physicians "The teacher usually accrues the greater benefit in Neonatal Intensive Care in his encounter with a student." Author: Author: "Several factors favored utilization of infant I "Evidence that improved patient care resulted care as a focus for an in-service educational pro- trom these programs can be found in several areas. gram for physicians and hospital personnel. These Changes in nursing and hospital procedures were often instituted during and immediately after the included the recent improvement in definitive care in-service session. Several institutions sent one or for infants born with serious cardiac defects and more nurses to infant intensive care units for other congenital problems, the almost revolution- long-term trainino,. Finally, there was a significant ary improvements in supportive care for infants, C, the need for the acquisition of new technical increase in the number of sick infants referred to skills, and new treatment philosophies in the care neonatal centers in Minnesota and an equally of infants. Further, since the infant has a limited dramatic improvement in their initial recognition, response to illness, the techniques of medical care local care, and transport. necessary for the infant with serious cardiac dis- Sir William: ease applied equally well to all who are sick. The "These programs represent considerable effort. goals of our in-service program were to,. I'd be interested in knowing the participants.,' DECEMBER, 197Z 25 MINNESOTA MEDICINE Author: wish to shoulder the responsibility for their own "The NRMP through funding and by helping us continuing education. Many it seems, hand over to continuously refine our goals, and evaluate our this most important responsibility to others, their progress. The Division of Crippled Cbildren's societies, their journals, their medical schools." Services, director, and clinic personnel, made the Sir William: cardiac clinics possible. The Minnesota Chapter "A little harsh, don't you think, on both stu- of the AMA, the Minnesota Chapter of the Acad- dent and teacher? As I once predicted, medicine emy of General Practice and the State Board of in the U.S. provides the world's keenest inspira- Health provided approval and support. tion.113 The County Medical Societies and the hospital Author: staffs, provided their meeting times and facilities "Sir William, your life and writings reflect a re- for our programs. The St. Louis Park Clinic, the markable sensitivity to the medical needs of your Mayo Clinic, and the University of Minnesota, time. This sensitivity to your own era, accounts provided the teachers pediatric cardiologists and no doubt for your unusually accurate prescience of nurses for all the programs." our present time. Would you care to predict what Discussion and Conclusions lies in store for medicine in the U.S. today?" Sir William: Sir William: "Recall that I've said few men over 40 retain "It would appear you and your colleagues have their creativity. It's been ;i while since I passed achieved modest success in reaching your first that milestone. Moreover, the mark of an old, two goals. You have carried postgraduate educa- perhaps wise, man is to know when to quit. How- tion into Minnesota. You also seem to have ever, an old fool seldom can resist the chance for instituted some improved methods of postgrad- a final word. uate study. First, postgraduate medical education is too But what have you done to encourage the physi- important to be left to the professors, or to the cian to assume greater responsibility for his edu- societies, or to the journals or to the government. cation? A physician should return to formal study It must be nurtured, like life itself, by each physi- for several months every few years. During all cian. He must accept all the help he can get, my tenure at John Hopkins, I held courses for searching always for the defects in his knowledge, practicing physicians. the faults in his reasoning. To meet these good earnest students from all I would encourage him in a keenly skeptical parts of the country, some of whom have been in attitude ... ever remembering Benjamin FrankIin's practice fifteen or twenty years, stimulates ones shrewd remark that 'he is the best doctor who optimism as to the outlook of the profession."3 knows the worthlessness of the most medicines.'7 Author: Second, all augers well for American medicine "We must admit to failure in this regard, Sir as long as it retains the excitement of discontent, William. In three years, only one physician the tumultuousness of conflict, the ecstasy of dis- availed himself of this opportunity to return to covery, and the humility of commitment. the University for one or two months, even with Finally, each physician marches to his own a modest stipend provided for study. Perhaps our drum. Learn the beats of your colleagues, so as offering was too specialized. Perhaps we did not to understand them better, and to more fully ap- "sell" hard enough. It may be physicians don't preciate your own beat." References 1. Vollan DD@ Postgraduate Medical Education of the United 3. Osler William: The importance of post-graduate study. Lancet, States' Report of the Survey of postgraduate medical education 2:73, 1900, carried out by the Council on Medical Education in Hospitals 4. Osler William: The growth of a profession. Canada Med Surg of the American Medical Association, 1952-1955, Chicago, i 14:129, 1885, American Medical Association, 1955. 5. Osler William: Remarks on specialism. Boston Med Surg J 2. The Physician's Continuing Education. Report of the status and 126:457, 1892. objwdves of postgraduate education by the Comniittee cn 6. Osier William: On the influence of a hospital upon the medical Profe@ional Education of the American Heart Association, profession of a community. Albany Med Ann, 22:1, 1901. New York, 1961. 7. Osler William: The treatment of disease. Canada Lancet, 42: 899, 1909. 26 MINNESOTA m REPRINTED FROM THE journal OF THE TENNESSEE MEDICAL ASSOCIATION OWNED AND PUBLISHED BY THE ASSOCIATION FEBRUARY, 1972 VOLUME 65, NO. 2 Self-l?eview Conferences., A Contribution to Problems of Continuing Education and Peer -Review E. WILLIAM ROSENBERG, M.D.* Amid the increasing demands upon physicians 1. The local group of physicians choose some both for more continuing education and for aspect of practice to consider. more control of quality of practice, there ap- 2. The same group agree upon criteria of per- pears to be at least one bright spot. That is formance and outcome that would represent a the increasing evidence that there are some rel- desired level of practice. atively simple and painless maneuvers that may 3. The group review their recent work to see provide the profession with a solution that will if these criteria are being met. satisfy both demands simultaneously. 4. If they are, that subject is passed and a Slee,l Eisele,2 Brown,3 and Uhl4 among others new one considered. have pointed out the feasibility of a process of 5. If they are not, discrepancies between ideal self-correction based upon an improved per- and actual practices are aired. A suitable pro- ception of actual practice shortcomings. While gram of self-improvement is begun and con- described in varying terms, the essential process tinued until actual practice is found to coincide is as follows: with desired standards. It can be seen that, in addition to a com- mitment to quality, such systems require as their CREDIT AVAILABLE two key elements: 1) a staff large enough and 1. The American Academy of General Practice sufficiently informed to draw up adequate cn- awards physicians who participate in these teria of performance for each of the many areas informal conferences two hours of prescribed of practice, and 2) a method sensitive enough continuing education credit, provided they are to detect actual levels of practice performance. scheduled 30 days in advance. If not, each physician who participates receives two s Information about a stairs own patterns of of elective credit. practice is now available through the Profes- 2. The American Medical Association has ac- sional Activity Study/Medical Audit Program cepted these conferences as eligible on an (PAS/MAP) provided to client hospitals by hour-per-hour basis for credit under category the Commission on Professional and Hospital four of the Physician's Recognition Award. Activities (CPHA) in Ann Arbor, Michigan. 3. The Joint Commission on Accreditation of The PAS/MAP service, although widely used Hospitals has acknowledged that these con- ferences fulfill their revised requirement in in some parts of the country, is used by only continuing education, i.e. that the medical a few hospitals in Tennessee and by even fewer staff of a hospital "provide a continuing in the 75 county region encompassed by the program of professional education, or giv! Memphis Regional Medical Program. The PAS/ evidence of participation in such a program.-- MAP reports can be obtained by even the I smallest hospitals and we expect that Tennessee *From Memphis Regional Medical Program, 969 Physicians will find this sort of information in- Madison Avenue, Memphis, Tennessee 38104 and The creasingly available as more and more hospitals University of Tennessee College of Medicine, Memphis. install the system. 102 SELF-REVIEW CONFERENCES-Rosenberg February, 1972 Without difficulty to all but the large, 4) The consultants, usually two, drive to the specialist-staffed hospital is the capability of conference site and review with the local doctors deriving suitable internal standards for which to how the patients were and might have been aim. The local definition of desired standards is managed. not only a major part of the educational aspect The conferences were begun (under the name of the program, it also seems to be vital in gen- "Advanced Clinical Conferences") as what we erating acceptance of the plan by most doctors. hoped would be a realistic way of dealing wi After working with such systems for almost two of the most common objections to conven- twenty years, Slee has stated that doctors will tional continuing education programs ("I can't rarely alter their previous patterns of practice get away," and "The programs aren't about to conform to any standards that they did not what my patients need"). have a voice in setting. Discussing the management of actual cases A recent report5 of the AMA Council on instead of delivering prepared talks appears to Health Manpower identified this problem and meet both of these objections at once. The indicated a special concern for the physician conferences are patient-related and thus clear- who either has little or no hospital contact or ly relevant. Also, by removing the need to pre- who practices in a small or unaccredited hos- pare and deliver a lecture we have been able pital. to broaden our potential faculty to include most of the practicing specialists in our region. Since SELF-REVIEW CONFERENCES these practicing specialists constitute about 50@o Very small hospitals are a feature of the 75 of our physician population, it is possible to county Memphis Regional Medical Program utilize this very large but underused group' to region and also of Tennessee. Just over a provide a widely-dispersed faculty with a con- year ago a program of what we are now calling sultant/participant ratio averaging one to four. "Self-Review Conferences" was begun as a co- Table one shows the topics of conferences operative effort of the Memphis Regional Medi- during the first twelve months of the program. cal Program, the Division of Continuing Edu- cation of the University of Tennessee Medical TABLE ONE: Topics of Conferences Units, and the Tennessee Chapter of the Ameri- Acute Chronic Hepatitis Hypertension can College of Physicians. In the first twelve Acute Myocardial Infarc- Kidney Disease months of the program we have sponsored 61 tions and Arrhythmias Leukemia or Lymphomas of these conferences, and as we have gained Anemia Liver Disorders Arrhythmias Management of Cardiac more experience with them, have come to look Athletic Injuries Arrhythmias on them as perhaps providing a measure Of Breast Disease Neurosurgical Injuries both standard-setting and internal review for Cardiology Obstructive Pulmonary the very small hospital staff. Cholesterol Disease Briefly, the mechanism of these conferences Dermatology Organic Phosphate Diabetes Poisoning is: Emphysema Oncology 1) A small group of physicians (who need Cigarette Smoking Pancreatic Disorders not constitute a hospital staff) select some area Endometriosis Pediatric Neurology of patient care to review. ENT Pediatric Problems in 2) They prepare three or four case abstracts, Exercise and Rehabilita- Dermatology tion for the Cardiac Renal Failure including details of how they managed their Patient Ruptured Uterus cases. Hopefully, no physician works up more Gastroenteritis Sexual Problems than one case. Gastroenterology Sickle Cell Disease . 1. Bleeding Sore Feet 3) The Memphis Regional Medical Program 1. Disorders Summer Complaint- is contacted. We find two qualified consultants Heart Diarrhea and Colitis who agree to study the case abstracts and Heart and Circulatory Toxemia critically review management in light of current System Urology medical thinking. The visiting faculty has been composed of both practicing specialists and full- Among the features of the program that time University of Tennessee faculty (in a ratio pleased us were its low out-of-pocket cost of three to one) who have been glad to do this (consultants travel and talk without compen- without compensation. sation, except for their travel expenses), and February, 1972 SELF-REVIEW CONFERENCES-Rosenberg 103 the increased personal contacts between rural dividually by participating physicians. These practitioners and metropolitan consultants, and conferences thus do not raise any of the emo- between practicing specialists and full-time fac- tionally-induced hackles conjured up by the ulty members. By and large, the conferences term "peer review." have been very weh-received. Also, while the Yet if the participants will start to think bulk of our program has consisted of inter- of the conferences as a place where they can changes between practicing generalists and spe- effectively "seff review" their practice habits cialist consultants, we have had meetings where rather than a place to "keep up," we shall a group of internists discussed appropriate cases have achieved a major advance. Williamson7 with visiting consultants. has clearly shown that keeping up and knowl- edge alone do not insure proper performance. FLTTURE PLANS By shifting the emphasis of the program toward We hope that our decision to change the an increased perception of patterns of patient name of the conferences from "Advanced Clin- care, we believe we can move from peripheral ical Conference" to "Self-Review Conference" concerns about "how well-informed are the was not just an exercise comparable to the doctors?" to the crucial concerns about "how widespread attempts to alter various corporate well are we taking care of our patients?" images by similar techniques. We believe we have enough experience with the program to References have confidence in the mechanics of an in- 1. Slee, Vergil N.: Measuring Hospital Effective- formal, across-the-table conference between a ness: Patterns of Medical Practice, The University of local group and visiting consultants where it Michigan Medical Center Journal, 35:112, 1969. is the participants' own chart abstracts that 2. Eisele, C. W.: The Medical Audit In Postgraduate are being discussed in front of the local col- Education, Eisele, C. W. (ed.) The Medical Staff in league and visiting consultant alike. the Modern Hospital (New York: McGraw-Hill Book There have been instances in which one or Co., Inc., 1967), p 213. 3. Brown, C. R., Jr., Uhl, H.S.M.: Mandatory the other participant group were disappointed, Continuing Education: Sense or Nonsense? JAMA, usually either because a local group expected 213:1660, 1970. a lecture and was not prepared to really par- 4. Uhl, H.S.M.: Continuing Medical Education, New ticipate or when a consultant came and gave Eng J Med, 284:50, 1971. a lecture that a prepared group did not want. 5. AMA Council on Health Manpower: Continuing For the most part, however, the conferences Competence of Physicians, JAMA, 217:1537, 1971. have been conducted in an atmosphere that re- 6. Freymann, John G.: Leadership in American stores one's faith in old-fashioned words like @edicine: A Matter of Personal Responsibility, New professional" and "colleague." r-ng J Med, 270:710, 1964. 7. Williamson, John W.: Evaluating Quality of It must be emphasized that the initiative for patient Care, JAMA, 218:564, 1971. the conferences comes from the local group, (EDITOleS NOTE: Reference No. I is reprinted in its the choice of a topic is theirs, and the se- entirety as a special item in this issue of the JOURNAL lection of what cases to present is made in- p. 140.) ning on a regional and community Special Communication hasIis of an order never heretofore adopted in this country. With the nee- . al or community plan- @essary region nodap ning, the medical facilities ill be The Co t of w .recognized as possessing at least. three major levels of capability for serious illness, emergency i e-sup- Stratified Medical Care port units, special-care uni (coro- nary, pulmonary, intensive), with Irving S. Wright, MD continuation@care facilities, and re- gional reference centers. The plan- ning will require (a) careful differ- here appears to be emerging terial and manpower resources in- entiation of function based on the a remarkable unanimity from volved when several hospitals located categorical needs and the capacity of Thoth professional and public in close proximity develop highly the facility and (b) a close inter- sources that medical service must be complicated services such as open- relationship between the participat- reorganized in the immediate future. heart surgery, coronary-care units, in personnel and facilities at all 9 The simple approach which first oc- advanced radiation and angiographic levels. curs to some is to provide more funds sections when the case load indicates Type I Facilities.-Using as an ex- in the hopes of quickly. producing that a single unit could handle all ample the middle-aged man who medical facilities and personnel and cases more efficiently. The approach develops an acute myocardial in- greatly improved medical service. has been to review all pertinent medi- farction, stratified medical care Those who are experienced in this cal literature and to draw on the life should operate as follows: No longer problem recognize that funding is in- experiences of the approximately 150 does he lie@ at home awaiting the turn deed essential but that instant results members of the commission to pro- of fate. His introduction into the sys- are not to be expected. It takes years vide a set of authoritative guidelines tem, which may be terme type and not months to traifi physicians, regarding the resources and mecha- facilities, may come through his pri- nurses, and technical personnel. It nisms which will be essential as we mary physician who, once the diag- also takes many months, often sev- face the future. These reports have nosis seems probable, directs him to eral years, to plan, fund, and develop appeared serially in Circulation the emergency room of the nearest new or renovated facilities and to as- (May-July, 'Dee 1970; Jan-Aug 1971) well-equipped hospital. If a modern semble and pretest the rather com- and periodically in some other jour- ambulance with life-support equip- plex equipment and units now consid- nals and, judged from the great@ num- ment or a more elaborate mobile coro- ered essential for modern medical ber of requests for reprints and fur- nary-care unit is available, so much care. In order to provide. quality care ther information, they have proven