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Interview with Dr. Stanley W. Olson 
Date:  August 15, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  John Parascandola, Ph.D.
Transcriber:  Techni-type Transcriptions/DDR


Parascandola:  The interview you are about to see is one of a
series of interviews designed to record and document the history
of Regional Medical Programs.  With me in the studio today is Dr.
Stanley W. Olson.  Dr. Olson has had a long and distinguished
career in medicine, but of special interest to us today is the
fact that he was Director of the Division of Regional Medical
Programs from 1968 to 1970.  
     Dr. Olson, welcome to NLM.

Olson:  Thank you.

Parascandola:  Before we get to the period where you served as
Director of the Division of Regional Medical Programs, I would
like you to tell us a little bit of the background to the origins
of the program.  What can you tell us about how and why RMPs got
started?

Olson:  I guess the chief source of information that I had prior
to becoming involved myself was in my capacity as Dean of Baylor
University College of Medicine, of which Michael DeBakey was
professor of surgery.  As you probably know, Dr. DeBakey was the
chairman of the commission that developed the report on heart
disease, cancer, and stroke.  
     But even prior to that time, there is some background
information that might be useful.  The New Yorker magazine had an
interesting article called "The Noble Conspiracy."  It described
how Senator Lister Hill, who had oversight of both the
authorization and the appropriations committee for the Senate,
and Congressman John Fogerty had similar responsibility in the
House, how those two worked with Dr. Jim Shannon, who was
Director of NIH [National Institutes of Health], Mike DeBakey in
heart disease, Sidney Farber from the Boston Children's Hospital,
in cancer, Mike Gorman, who was with the Mental Health
Association, and, very notably, Mary Lasker, who was very much
interested in health generally.  They frequently got together to
talk about both legislation and appropriations, and it was often
said that the budget of NIH was set by that group rather than the
Congress.  But I think that it's important to know that during
the period when the appropriations for NIH were growing at a very
rapid rate, there began to be some major questions raised as to
what was happening to benefit the public as a result of the
expenditures.

Parascandola:  How the research related?

Olson:  Yes, how the research related to the improvement of
health, you see.  I think that it was out of that concern that
the commission was formed which developed the report, and then
the idea of Regional Medical Program to spread out from the
medical centers the information that was being developed, to make
it available more widely than it was up to that time.

Parascandola:  In that original report of Dr. DeBakey's
commission, it talked about regional complexes.

Olson:  Right.

Parascandola:  How did that relate to what actually came out as
RMPs?

Olson:  I think that they visualized the universities being
related to secondary centers, where people could go for
specialized care in heart disease, cancer, and stroke, but it was
pretty apparent that the practicing profession wasn't enamored of
that entrance of the federal government into the practice of
medicine.  I think it was the pressure from the practicing
profession that changed it so that the focus really became more
heavily placed on education and dissemination of information and
cooperation, and the bill that was adopted had a very specific
prohibition about not interfering with the private practice of
medicine, and that referrals, if any, in connection with
demonstration projects would have to be by referral by a
practicing physician.

Parascandola:  So during the legislative process, this concept of
regional medical complexes got changed.

Olson:  Right.

Parascandola:  You said the practicing physician, or medical
community, was that in the form of organized medicine,
organizations like AMA?

Olson:  I don't have any direct knowledge, but the understanding
that I have is that representatives of the American Medical
Association did, in fact, meet with President Johnson, and he
sensed that if this legislation was to be implemented, that they
needed to change the emphasis away from the complexes.  

Parascandola:  So then when the program got started, when the
bill got passed, RMPs got enacted.  What was your involvement,
even before you became director of the national program?  I know
you were involved with RMPs.  Maybe you could tell us a little
about how you became involved and what were the circumstances.

Olson:  I had spent most of my life in medical centers,
originally at the Mayo Clinic in Rochester, Minnesota, where I
took my training, and later as a member of the staff, then at the
University of Illinois, which had a large research and
educational hospital, and Baylor, which was the medical school
for the Texas Medical Center in Houston.  
     I had spent a year studying the relationship of medical
education to practice, because I was convinced that medical
centers, while they are extremely valuable, were failing in the
one major job of increasing the number of physicians who would go
into primary care, which is what most people need for their
health care.  So I took a sabbatical and studied that in New
Zealand and Australia and Sweden and England.  
     Then when I came back, I decided to leave Baylor and went to
Vanderbilt University, in Meharry [phonetic] Medical College in
Nashville as director of what was then called the Tennessee Mid-
South Regional Medical Program.

Parascandola:  So you were the director of one of those early
ones.

Olson:  Yes.

Parascandola:  Were you the first director of that program?

Olson:  Yes, I was the first director.

Parascandola:  What kind of experiences did you have with the
program?

Olson:  I think we were at first trying to understand what was
the intent of the legislation.  By the time I got there, the
preliminary planning had already defined the region.  The group
over at Memphis wanted to have a program oriented to the
University of Tennessee, so we took Middle Tennessee and Eastern
Tennessee and up to some of the southern sections of Kentucky. 
So that the region was developed, but this was sort of
preliminary.  Then I came in as the director to do the actual
development of the planning for operational activities within
that region.

Parascandola:  What were some of the kinds of programs you got
involved in with that Mid-Tennessee RMP?

Olson:  It was a series of things like trying to establish
coronary care intensive units in some of the hospitals that did
not have them, working with the people at Vanderbilt to try to
improve the radiation therapy for cancer.  We developed, with
Meharry, an out-patient unit that was focused primarily on
improving the diagnosis of illness, the so-called automated
screening programs.  Then there were a number of programs that
were primarily educational in focus, continuing education type of
activity, not only for physicians, but nurses and other technical
personnel as well.  

Parascandola:  You were only at that program about a year or so,
wasn't it, before you were invited to become director of the
national program?

Olson:  I guess it was about a year and a half, not quite.

Parascandola:  How did it come about that you were asked to be
the director of the Regional Medical Programs Division, I guess
it was at that time?

Olson:  I guess the primary contact that I'd had with Dr. [Robert
Q.] Marston, who was the first director of the division, was in
connection with a major conference that Regional Medical Programs
had sponsored here in Washington.  I worked with the staff to
help arrange for the conference.  Then we had developed an
operational grant proposal which I think the advisory committee
thought well of, and we were funded at a fairly high level.  I
guess it was a combination of those two that suggested that
together with the administrative background that I had had, that
I might be able to provide some leadership.

Parascandola:  So you were approached for the position when Dr.
Marston was planning on leaving?

Olson:  Right.  Yes.

Parascandola:  At the time, I think you told me in some earlier
conversations that when you were asked to accept the position,
that Regional Medical Program office was still at NIH, but by the
time you actually came aboard, had been transferred to HSMHA
[Health Services and Mental Health Administration].  Maybe you
could tell us a little bit about that transfer process, how and
why.

Olson:  I wasn't very familiar with what the reasons were, why
the government wanted to reorganize the Public Health Service,
but it's clear that they employed a consulting group that studied
the organizational pattern and had made the recommendation that
certain divisions be lumped together in what was known as the
Health Services and Mental Health Administration, HSMHA.  The
National Institute of Mental Health had been under the National
Institutes of Health, and Regional Medical Programs had, as well.
     The sense I had, I can't be sure of this, I never discussed
it directly with Dr. Shannon, but I think he saw that the program
that he had envisioned as a link between the research centers
that NIH was helping to support and the dissemination of
information was being pushed off to one side, and the emphasis
was more on education and service rather than a dissemination of
research results.  

Parascandola:  So he didn't perhaps see that as closely tied to
the NIH mission?

Olson:  He had been very active with it, you see, in establishing
the division, and I think he wanted very strongly to have it part
of NIH, but as it evolved and he saw what it was becoming, I
think he saw that it probably wouldn't fit as well as he had
hoped it would.  To use a phrase, I think he tossed a bone to the
people who were trying to put together a critical mass of other
agencies.

Parascandola:  To form this new agency.

Olson:  Right.  He probably had some of the same feelings about
the National Institute of Mental Health.  If he were pressured to
do something, he obviously wasn't going to recommend the transfer
of those agencies that were most focused on the things that they
were interested, namely basic research and clinical research.

Parascandola:  So in the meantime you thought you were coming to
NIH, and suddenly you discovered you were going to be in this new
agency.

Olson:  Right.  

Parascandola:  You obviously took the position, anyway.  Did you
have any particular concerns about that when you arrived?

Olson:  I had great concerns, you see, because if it had remained
a division of the National Institutes of Health, Marston, who had
been the director, would have had a great understanding of the
program and I could have gone to him for help and support and so
on.  As it was, the new division was created and it didn't even
have a director for over six months.

Parascandola:  HSMHA had no director.

Olson:  Mr. Irving Lewis, who had come from the Bureau of the
Budget, was acting director, and Irv Lewis is a very bright
individual, but as acting head he was sort of in charge to hold
things together.  Then Dr. English was appointed as the director
of HSMHA about six months after it was established.  

Parascandola:  How did you feel things went at HSMHA with
Regional Medical Programs?  Did you feel that there really was a
change in some way in direction of what you had observed?

Olson:  It didn't come about at first, you see, because it took
time for the new Secretary of Health, Mr. Robert Finch, and Dr.
English to try to identify what was the role of the Health
Services and Mental Health Administration.  I suspect that they
felt that the entry of the federal government into health
services through the Medicare and Medicaid program was something
that they needed to provide some underpinnings for, and clearly
that was necessary.  
     So the focus, I think, began to shift very subtly from what
had been the linkage between the universities and the surrounding
regions to putting emphasis on improving services.  This is not
something that the people who were involved with the Regional
Medical Programs had understood as its primary purpose when they
first came in.  

Parascandola:  So there was a change in direction that seemed to
come from the top.  I guess, in a sense, you were the person in
between, who needed to deal with the local regional programs and
the administration in the department.  What kind of problems did
that create?

Olson:  Let me make reference to one other division that had been
created for HSMHA, which was the Comprehensive Health Planning
Program.  In contrast to Regional Medical Programs, which had its
primary connections with medical schools, the chief connection
that the Comprehensive Health Planning had was with state health
departments.  Here I think there were two agencies, both within
the same division of government, and I suspect the people at the
top tried to evaluate where did they want to go in terms of
developing the federal government's role in health services. 
Suddenly, I think, Comprehensive Health Planning began to win out
and ultimately, of course, the decision was made that Regional
Medical Programs wasn't the agency that could carry out that kind
of activity.

Parascandola:  Both of these programs, of course, Comprehensive
Health Planning and Regional Medical Program, did deal with
regionalization, in a sense, of health services.  But do you
think they really did overlap in terms of what they were doing? 
Or was the overlap more apparent than real?

Olson:  I think the overlap was partial, because most of these
were state oriented, you see.  In other words, they were linked
into the state health departments, and obviously that's what
emerged out of that whole planning activity, whereas Regional
Medical Programs overlapped state, so that even though there was
a kind of state distribution, it wasn't identical.  There really
were fundamental philosophic differences, as well, the difference
of people who had been oriented, as I had been, to the university
and research and the other group primarily oriented to planning
and public health.  

Parascandola:  So there was some overlap, but on the other hand,
their missions were not really identical, the two programs.

Olson:  They weren't identical, but in a very real sense they
were competitive, you see.

Parascandola:  And Comprehensive Health Planning won out in the
end.

Olson:  In the end, they won out, and I think simply because the
Public Health Service for years had had a tradition of relating
to state health departments.

Parascandola:  You left in 1970.  By the time you left, did you
already sense that there were serious problems with RMPs?

Olson:  Yes, very serious.  

Parascandola:  Did you suspect at that point that RMPs might not
survive for much longer?

Olson:  Yes.  I had the feeling that NIH essentially had lost
interest in the program.  The universities had anticipated that
they would receive large sums of money to establish complexes,
and that didn't happen.  They tried to make do with the programs
that were authorized, but it really wasn't their main focus of
interest.  
     The medical profession, you see, which originally was very
leery about Regional Medical Programs, began to see that it had
some real merit in terms of the practicing physician, and I think
at the end they supported it strongly.  But I don't think that
they organized their support in an effective way, effectively
enough, at any rate, to save the program.

Parascandola:  Why do you think the program was terminated, or
what do you think were the main reasons that led to its
termination?

Olson:  As I recall, Paul Elwood, who was the child neurologist
from Minneapolis, University of Minnesota, and really the Kenny
[phonetic] Institute which was affiliated, was one of the first
people to come up with the phrase "health maintenance
organization." It was clear that there was a deep interest at the
secretary's level in getting hold of some of the problems of cost
in relation to the provision of services, particularly Medicare
and Medicaid.  
     I think it was that focus of interest that led them to
support a series of initiatives to establish HMOs and that,
together with the initiative for the Comprehensive Health
Planning, which had a statewide influence, I think both of those
captured the interest and the imagination of the administration,
and I think the Regional Medical Programs suffered because nobody
championed it importantly enough.

Parascandola:  It didn't have a really strong enough constituency
anywhere?

Olson:  I think so, yes.  

Parascandola:  I suppose the administration was looking for funds
for other programs, etc., and maybe looking for programs that
could be cut.

Olson:  You see, I think Irv Lewis pointed out something very
important.  He had been in the Bureau of the Budget, as it was
called at that time, and he pointed out that prior to the early
sixties, government revenues had been increasing, but then [John
F.] Kennedy began to push the space program and that was taking
$5 billion a year.  The Job Training Program was taking a huge
chunk.  Medicare and Medicaid both came on line in '65, you see,
and suddenly there were a whole series of programs, Housing and
Urban Development, President Johnson's War on Poverty.  Suddenly
money began to be tight.

Parascandola:  Not to mention the Vietnam War.

Olson:  Yes, of course.  So there was a whole series of
initiatives which suddenly began to require large appropriations
and inevitably people had to look to see where they could cut.  

Parascandola:  In its relatively short life span of ten years or
so, what do you think were the major accomplishments of Regional
Medical Programs?  And are there lasting effects that came out of
RMP efforts?

Olson:  I guess this almost has to be anecdotal, because as far
as I know, there really are no hard documented--

Parascandola:  Nobody's done a systematic analysis.

Olson:  Right.  As far as I know, no.  But the sense I had was
that this provided the medical schools and the medical centers
their first real opportunity to begin establishing linkages with
outlying communities.  Having been dean at Baylor for fourteen
years, working in the medical center, it was almost as though
here was an island of excellence and everything out there was
"other."  It was something that we had no direct contact with. 
Sure, physicians would refer patients and we would send the
patients back with information about what we had seen and done. 
But in terms of what was going on in the hospital, for example,
in Port Arthur, Texas, we really didn't have any linkage.  
     The Regional Medical Program brought a corps of people out
into the region, and I think that, in turn, was useful because
they began to see that many of the people whom they had trained
in their residency training programs were out in those small
hospitals and they were practicing pretty good medicine.  I can
remember going to a little hospital up in East Tennessee that had
about fifty beds and they had a total of five physicians on the
staff.  One of them had been the chief resident, a professor at
Vanderbilt.  

Parascandola:  So just opening up some ties between medicine and
the community and the medical schools was one thing that RMPs
helped to bring about, in your view.

Olson:  Then there are some other things.  For example, the Case
Western Reserve University, through its medical library,
established a linkage with all the hospital libraries in
Northeastern Ohio.  That linkage continued even after the
Regional Medical Program had ceased to exist.  So I suspect that
there were a number of programs of that kind that began to work
under the aegis of Regional Medical Programs.  Some of them
probably continued, others probably fell by the wayside.

Parascandola:  I know it's always hard to draw lessons from
things, but I do want to ask you, before we close, whether you
think there are some lessons we can learn from the RMP story that
may be of use to us as we plan for health services today and in
the future.

Olson:  I'm not sure that I can give a good answer to that.  

Parascandola:  It's a hard question.

Olson:  I would certainly say that you ought not to put a brand-
new program into a reorganized division and not provide it
leadership immediately.  That was what we had to deal with, you
see.  I guess the other question was whether the program, as it
developed, really took into account all of the other
corresponding developments that were taking place in the
development of the health care system for which the federal
government had responsibility.

Parascandola:  Developments like Comprehensive Health Planning?

Olson:  I guess Medicare and Medicaid were the more important
responsibilities that they had taken on.  You see, the government
had never really supported medical care services except through
agencies like the U.S. Public Health Service hospitals and the
military and the Veterans Administration, but now they were going
to provide services for civilians, you see, and a very large
group of civilians at that.  So if they were going to develop
some kind of a regional program, probably the emphasis on
categorical diseases may not have been the wisest thing to focus
on.

Parascandola:  Of course, that emphasis got shifted, didn't it,
as the program went on?

Olson:  Yes, but it was sort of a holding action and it really
didn't have the same thrust or the enthusiasm that the RMP
program had.  

Parascandola:  Is there anything we have left out?  I'm sure
there are many things we haven't touched on, but is there
anything you would like to add about RMPs or your experience
before we close?

Olson:  I guess the only thing that I could say is that I never
worked so hard for two years in my life and felt so little sense
of accomplishment.  Here was a huge bureaucracy that you had to
deal with, and you had all kinds of talented people in the
programs.  The kind of understanding and support that would have
been necessary to make the program effective just wasn't there,
so it was a sense of trying to keep faith with the people who had
joined the program and yet you didn't have the sense that at the
top level there was any conviction that they wanted it to
succeed.

Parascandola:  I thank you for being with us, Dr. Olson.  I
enjoyed visiting with you.

Olson:  Thank you.

[End of interview]