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Interview with Dr. William D. Mayer
Date:  October 3, 1991
Interviewer:  Dr. Donald Lindberg
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Lindberg:  I'm Donald Lindberg.  I'm Director of the National
Library of Medicine.  It is my privilege today to interview Dr.
William D. Mayer.  This is part of NLM's study of the history of
Regional Medical Programs in the United States.  
     Bill, thanks so much for being with us.  You have held many
distinguished positions in medicine, but the one that draws our
attention today is taking us back to 1966-67, I believe, when you
were Associate Director of the Division of Regional Medical
Programs here at NIH.  Have I got that right?

Mayer:  You have it right.  

Lindberg:  Does it seem at home to you still?

Mayer:  Yes.  I've gotten back frequently, not only in terms of
the days of RMP, but then in the days of my involvement with the
National Library itself.  

Lindberg:  Among the other good things, you were Chairman of the
Board of the National Library of Medicine.  We were very pleased
to have you do that.  
     Let me ask about RMP.  We're interested in a lot of aspects
of it, but just for the moment, what do you think was its best
contribution?  We'll look at some of the failings.  What was
best?  What did it do well?  

Mayer:  I think what it did, when it succeeded, it succeeded in
truly building the regional cooperative arrangements that were
called for in the initial legislation.  I really think that was
the core.
     The second thing, and this comes from my own bias, I guess,
is that I think it really did provide a major movement in
continuing education in the health professions in this country. 
Before RMP, clearly the medical educational continuum of
undergraduate, graduate, and continuing education, continuing
education was the stepchild.  It is still, to some degree, today,
but I think RMP moved continuing education for health
professionals into a larger prominent role.

Lindberg:  Do you think regionalization, per se, is a valid
concept?

Mayer:  I'm still a strong believer in the concept of
regionalization.  Indeed, if that concept hadn't begun to slip in
the implementation of RMPs for multiple regions, I think things
would be very different today in this country, because I really
do think that regionalism is the way to go in improving health
care delivery, as well as in the transference of medical
information and knowledge in this country.  

Lindberg:  There are a number of questions that have arisen in
this investigation on the history of the programs, but I think
that the convener function of RMP has always been pointed to by
quite a few persons we've talked with as a high point.  One of
the questions is, did it lose its way, did it lose its focus when
it forgot about heart, cancer, stroke and talked about disease in
general.  What's your opinion on that?

Mayer:  I think it lost its way when it forgot about the
underlying process, and the underlying process, as far as I was
concerned, was the regional cooperative arrangement.  I guess I
personally saw heart disease, cancer, and stroke and unrelated
diseases as a means of demonstrating how the regional cooperative
arrangements could work, because I think if the process had been
put in place, and in some places in this country it was being put
in place, that it could have applied to multiple diseases.  To me
it was the process at the core which was the key of RMP.  

Lindberg:  What did the Congress think it was supposed to be
doing?  

Mayer:  That opinion changed.  The initial legislation and what
was passed in Public Law 89.239 was very clear.  The primary
purpose was to establish--how was it worded?  It was to encourage
and assist in establishment of regional cooperative arrangements
among medical schools, research institutions, and hospitals, and
then it went on to further elaborate on it.  But the primary
purpose was the establishment of regional cooperative
arrangements, and it was clearly stated up front as number one in
the law.  So I think that piece of it, by the Congress initially,
was locked into place in terms of their intent, and I'd have to
say it was locked into place of those of us who started it, who
started it from the Washington scene, as the Division of Regional
Medical Programs.  We saw those grants that came in, those
applications that came in, as not only what were they trying to
accomplish in the content kind of way, but was that content
helping the establishment of the regional cooperative
arrangements.  That emphasis was there initially from the
beginning, both in the legislation as submitted by Congress, as
well as in the initial implementation of the program.

Lindberg:  Bill, that language makes it seem as if regional
cooperative arrangements come naturally.  Did that work that way?

Mayer:  No.  No, no.  I think the language was extremely well
developed, because it said "provide grants to, encourage and
assist in the development of."  As you and I both know, the issue
of territoriality is a very real issue, and whether that's among
medical institutions, whether that's among other kinds of
activities.  Establishing regional cooperative arrangement takes
a tremendous amount of energy, ego strength of an institutional
nature, as well as an individual nature, to overcome that
territoriality.  

Lindberg:  Are there some good examples to point to, or
accomplishments of RMP?

Mayer:  Of RMP?  Yes.  Here I now reflect not from the national
level, but go back to Missouri.  As you know, I left to go back
in June or July 1 of 1967, after having been with RMP as its
associate director for fifteen months as the dean and director of
the medical center at the University of Missouri, and in that
capacity, ended up being chairman of their review committee and
had a chance to see what was happening in Missouri.  Indeed, the
implementation there had a similar kind of flavor, that it
developed cooperative arrangements not only within the medical
institutions, but cooperative arrangements between and among very
diverse fields within the university structure and then, in turn,
with various hospitals and even individual physicians out in the
communities.  Superb kind of implementation.  I can tell you from
the standpoint of an individual who was then out on the firing
line of implementing RMP, as its demise came closer, I said to
myself, "They're really throwing away the mechanism that is in
place in the federal government to address many of the problems
we're facing," and they're still facing today in the health care
arena.  

Lindberg:  In the Congress, were there champions?  Were there
people who were really enthusiastic about the program?

Mayer:  I think there were.  I think part of the program came, I
think in terms of the reorganization, when the program left the
NIH administratively to go to Health Services and Mental Health
Administration (HSMHA).  It took it out into another kind of
base.  The NIH, at least at that time, was fairly politically
immune, and once it got out, people saw this, and various
congressmen saw this, as a mechanism of accomplishing some of the
things that they thought ought to be accomplished and changes
began to get inserted into it.  My own feeling is if it had
remained in the NIH, much of that outside political pressure
would not have occurred, at least to the same degree, and the
original intent could have been sustained until it had gotten
clearly in place across this country.  

Lindberg:  Did you have any insight into why it got moved?

Mayer:  No, I really don't.  It got moved after I left.  It was,
I think, at the time that Bob Marston then subsequently left to
become the administrator of the Health Services and Mental Health
Association and unfortunately was there only six months, and then
fortunately became the Director of the National Institutes of
Health.  It would have been nice if it had gotten moved back, but
by then it was already in place and the chances of moving it, I
suspect, were not very high.  

Lindberg:  It wasn't the personal fiefdom.  What do you think
about the lessons that one might take from this RMP experience? 
We still have some of the same problems in health care delivery
and distribution of health care services in the U.S. we had when
all that started.  There's some talk about plans once again to
solve those difficulties.  What can we learn from the RMP
experience?  

Mayer:  I think several things.  The original intent was to try
to do something about the bench to the bedside, the linkage of
science to service that came out of the DeBakey Commission
report.  Those needs are still out there.  The key to RMP was
to say that those issues ought to be addressed at the regional
level, number one, and they ought to be addressed by health
professionals.  The key to RMP was, in my judgment, it brought
together the health providers, whether those were physicians,
nurses, or whether those were voluntary health agencies or
medical societies, but it brought them together.  They were the
providers who could do something.  To me, that was a key piece,
as opposed, for example, to the Comprehensive Health Planning,
which had a public base and a governmental base.  I think the
concept of RMP was valid.  One, it was regional, and, two, it was
placed with the people who could do something and actually take
some action.  And that's why the demonstration grants were such a
key part of RMP, because those health professionals could, in
fact, demonstrate the good that could come out of this
demonstration of that cooperative arrangement.  The joy of that
was once they got together to do that, they said, "Hey, we can
also do some other things using this same mechanism," that didn't
cost the federal government a cent.  And they began to develop
again, to go back to the original comment, a process was put in
place by which they could come together to get some things done.

Lindberg:  How did you get interested in RMP to start out with?

Mayer:  It's like many of the serendipitous things that happen in
medicine.  In 1966, I happened to have been on the four-person
planning group for the 1966 M_____ Scholars meeting, and we had a
meeting in Baltimore in 1965 of ourselves plus John Russell, who
was then the president of the M_____ Foundation, to plan the 1966
meeting.  The meeting was in November.  It was literally one
month after RMP had been signed into law in October by LBJ.  John
Russell, it turned out, had been asked if he might think about
writing an article about this new thing that was being developed,
and in the course of the discussions with him, I'd had some
interest in it, had followed the DeBakey Commission, he said,
"Why don't you put some of those thoughts down in writing?" 
     Well, again fortuitously, my plane was five hours delayed. 
I began to scribble all kinds of things, and when I got back to
Missouri, I dictated a five-and-a-half page single-spaced letter
to John Russell about what RMP could do.  
     Unbeknownst to me, Bob Marston, also a M______ Scholar, was
being courted by, I think then, the NIH, to assume responsibility
for being the first director of this new animal.  I think my
letter found its way to Marston through John Russell.  The next
thing I knew, I was meeting with Marston and then Vernon Wilson,
by then dean and director at Missouri, in Miami at a meeting in
December saying, "How long can you be away, Mayer, from Missouri? 
How long can you come to Washington?"
     To make a long story short, out of that breakfast meeting in
April of 1966, I arrived here in Bethesda with Bob Marston, to
function with him as his first associate director.  It was one of
those odd things that just came out of a casual conversation and
changed my thinking about a lot of things in life.  It was a
superb experience.

Lindberg:  Brought you into the land of serendip.  

Mayer:  Yes, brought me into the land of serendip.  Martha
Phillips, who was the original grants management director for
RMP, and I, again almost serendipitously, ended up, a decade
later, together in the Academic Affairs Division of the Veterans
Administration Central Office, and we used to chat about the
early days of RMP.  We called it Camelot, because it truly was
Camelot in terms of trying to take a very simple piece of
legislation with a very broad philosophic concept and bring it to
some kind of reality.  That first year and a half was very
exciting.

Lindberg:  Do you think that there was anybody out in the world
that expected RMP to reduce the incidence and/or prevalence of
heart disease, cancer, and stroke in theory?

Mayer:  Oh, yes.  I thought it could.

Lindberg:  In a hurry?

Mayer:  Yes.  And many others, I believe, thought it could have a
major impact, both in terms of preventive issues, but major
impact in terms of making sure that what is developed by the NIH
and by others, either under the NIH's rubric or elsewhere, at the
scientific level to be transferred fairly rapidly into the
practice arena in terms of patient care.  Some of that happens in
university medical centers if you just happen to be in the right
medical center with the right disease at the right time.  That
transition happens quickly.  If you aren't, it happens very
slowly, even today.  

Lindberg:  Actually, there are some numbers that suggest that
heart disease changed quite easily measurably within five years
of RMP, but the other two moved more slowly.  I'm just raising
the question of what were the expectations.  Do they explain the
demise of the program, or do you have another explanation for the
demise of the program?

Mayer:  I guess my own thinking was that it was a political
demise that came about for multiple kinds of reasons which all
came together to a final outcome which I think was a major
mistake, because I think RMP was just coming into its own in
terms of being able to put into place the processes to accomplish
the very thing that people wanted to ultimately have
accomplished.  Yes, there was the confusion with Comprehensive
Health Planning and how were they similar, how were they
different.  Indeed, Bill Stewart's, the surgeon general, first
report to the Congress in 1967 devoted four and a half pages to
try to explain the difference between CHP and RMP.  And that
confusion finally, with the Health Planning Act of '74, I guess,
when they were melded together, then became impossible.  
     Secondly, I think there was the issue that we talked about
in terms of territoriality, not easy to overcome.  
     Thirdly, I think the issue around the changing thoughts,
once it started to get a little bit politicized, about what this
mechanism should or shouldn't do, and the differences of opinion
around that politicized it and had different people picking away
at it for different kinds of reasons, and then slowly a crescendo
began.  There was all of the Cap [Caspar] Weinberger material
around--and I don't pick him out individually, but as a
representative of some thinking that the structure that had been
developed had a high overhead just to support the structure that
wasn't producing an outcome.  What they had forgotten was that it
was that structure that was providing the glue for the regional
cooperative arrangements that weren't costing, in some of the
outcomes, a cent to the federal government.
     So I think all of those things.  Then, finally, the ultimate
coup, I think, was the loss of the demonstration grants.  

Lindberg:  I don't know about that.

Mayer:  Not only in terms of--

Lindberg:  Did they lose authority for demonstration grants?

Mayer:  It was the loss of the funding.  They were able to
maintain the authority for the demonstration grants because they
were key to the glue to demonstrate what good things can happen,
but then finally they stopped funding the demonstration piece of
it, and once they did that, you know, then the glue started to
come unhinged, even out in the periphery.  So I think all of that
came together.  Again I go back to the original, what I think was
a mistake, to move it out of the NIH, both in terms of kind of
scholarly feeling state that was represented by residing within
the NIH, plus the kind of political protective blanket that the
NIH really represented.

Lindberg:  Do you think it had anything to do with politics at
the level of Democrat versus Republican, old president versus new
president?

Mayer:  I don't know.  If it did--

Lindberg:  You didn't see any of that?

Mayer:  I didn't see it, but by then I was on the periphery of
it.  Once you're outside the beltway, some of the inner dynamics
of what goes on inside the beltway gets a little blurry.  Perhaps
Dr. [Harold] Margulies or Dr. [Herbert] Pahl, the final two
directors, would have a better opinion of that issue in terms of
the inside politics of what was going on.  

Lindberg:  Switching back to the earlier parts, did you have any
contact with AMA [American Medical Association] as the program
was spinning up?

Mayer:  Oh, yes.  

Lindberg:  We're told that AMA didn't like the DeBakey report,
but did play a role in drafting the legislation and blessing the
legislation.  Were they helpful as the program got started?

Mayer:  Yes, and helpful, and we linked to them.  When I say
"we," particularly the continuing education development, because
clearly AMA was a major player, and still is, in the continuing
medical education arena, and they had launched several
experiments of their own in continuing medical education, which
ultimately they unfortunately backed out of, and we built bridges
with them all along in it.  Once the AMA got Purpose C in the
legislation--Purpose C, as you may recall, had the caveats in it
that this would not interfere with practice patterns, it would
not interfere with the administration of hospitals, which
satisfied the AHA, and with that caveat provision, clearly
spelled out the purposes, I think some of those initial fears of
a governmental-run sequence of complexes or centers out there
dissipated.  I think the AMA saw the continuing education issue
as an issue that they themselves could continue to be involved in
and saw our efforts and supportive efforts as positive.  

Lindberg:  So they helped you?

Mayer:  Yes, the staff of the AMA helped a great deal.  Pat
Story, for example, was a tremendous help.  They also helped
support some of the efforts of the growing directors' group in
continuing education.

Lindberg:  Bill, are there things in the RMP years, the
achievements and program, that you're personally proud of?

Mayer:  I'm personally proud of the thrust in continuing
education that occurred.  Would they have developed to the level
they have without RMP?  I don't think so.  I think it came at the
right time as a stimulus to a group of people who understood that
continuing education of health professions for the thirty years
after they finished their boards is moderately important.  But I
think it gave them some credibility, which they've subsequently
used, and which I think medical schools are now understanding
more and more is an important responsibility that they have.  So
that, from my own personal bias, educational standpoint, was an
important contribution of RMP.  
     What it did for me personally was to simply reinforce the
concept of regional cooperative arrangements.  It's not by
happenstance when I left the Veterans Administration in
Washington now twelve years ago, I went to Norfolk, Virginia,
where the Eastern Virginia Medical Authority, now Medical College
at Hampton Roads, had established the Eastern Virginia Medical
School, because here was a medical school that was established
(A) without a university base and (B) without any university
hospital.  Totally dependent upon the cooperation of all those
hospitals of the universities in the area and the practicing
physicians and other health professionals in the area in order to
carry out their academic mission.  To me it was a classic example
of regionalism in action.  And I still believe in it.  The
regions of this country are so different that I don't think the
feds can lay on a mandate that will work.  I think the regions
have to develop them themselves conceptually, and anything that
can be done to stimulate that, I think, is in the right
direction.  That's why I was so optimistic in 1965 when I wrote
John Russell originally about RMP, because I saw it as a
mechanism to really make a difference.

Lindberg:  I think you did make a difference.  Thanks for being
with us.

Mayer:  Don, my pleasure, as always.

[End of interview]