IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL.
BmE-22,
NO.
2, MARCH 1975
The Biomedical Engineer and J. H. U. BROWN,
the Health
95
Care
System
SENIOR MEMBER, IEEE
Abstract-The future of biomedical engineering is not in the classroom or the laboratory. The funds available are simply not designed to support the further development of a basic science base, and they are miniscule compared with the nearly $100 billion per year spent on health care. The biomedical engineer must turn his attention to problems of the system as a whole. Each year the cost of medical care rises sharply and unfortunately a part is due to the often unnecessary sophistication or over-development of instrumentation. Research and development are badly needed in the areas of automation. Need for computer controls, communications and transportation, system design, optimum utilization of resources, and redesign of the system to provide health care where the people are rather than where the doctor is located are all indications that the biomedical engineer can find a fruitful career in these areas rather than in the rapidly saturating areas of teaching and basic research.
WHAT ARE WE TRAINING FOR
IT IS AXIOMATIC that changes in technology in either concrete or theoretical form will also affect the system into which it is placed. So far, however, with the exception of innovative instrumentation, technology has made little impact on the total health care system. The development of the artificial kidney, pacemakers, automated clinical laboratories, and intensive-care patient monitoring have made very real advances in individual patient care. They have not markedly affected policy although practice has improved as a direct result. Those R & D efforts which will markedly affect the policies of health care are just now beginning to surface. The studies on cost of medical care, bed utilization, quality of care, use of physicians' assistants, the informed user, etc., are all designed to affect the whole system and the policies of the government, the community, and the practitioner. We must enmphasize that it is the physician who will direct the health care system. The use of technology will provide other hands, enlist paramedical support, and save time and money. The engineer must be in close collaboration to achieve these ends. The health care system today is under many strains. The complexity of modern medicine places a premium on the exchange of information and the handling of data. The physician is faced with increasing pressures toward group practice, the advent of a variety of paramedical personnel who may pose as great a threat as a help to him, and the many problems of a system that is not designed to handle the nuinber of cases it receives. Each of these problems demands an immediate solution,
and most of the solutions are in the area of technology. Most of the needed medical technology is state-of-the-art in electronics-we do not need new breakthroughs or theoretical studies. We need to apply the knowledge now present in engineering to the often mundane problems of everyday medicine. Many of these problems are not glamorous, but they are worthy of solution. And before the health care delivery system can progress they must be solved. Many of the present diagnostic approaches are fully instrumented but the procedures have not been combined in a system of health care. A few examples of such systems follow. THE RECORDS SYSTEM The present health care system is based on patient records. In the large majority of cases these are piles of documents related only in a time sequence and with no detectable relationship between the problems of the patient and the records of progress. The patient who transfers from one part of the system to another is at a great disadvantage. His records are difficult to transfer, the numbering systems do not coincide, and the new unit to which he transfers may use a different record format. The theoretical solution is simple. We desperately need a standardized admissions form and discharge abstract, and we need some form of problem-oriented patient record. These records must be computer-based and should be tied to the billing and bookkeeping systems in the hospital. This is an engineering problem pure and simple. But like so many facets of health care, it has a strong sociological base. The work of C. B. Jackson in COMPAS, Weed in Vermont, the HIS system of the Indian Health Service, and Octo Barnett at MGH, indicates that such solutions are possible. The system must be used by doctors and nurses, so it must be acceptable to them.
THE MANAGEMENT SYSTEM Many problems are related to the hospital as a system. We have not taken advantage of the savings in time and money resulting from proper use of technology. For example, through efficient use of computers, diets can be planned, nurses' schedules can be arranged, purchases can be coordinated, and procedures can be scheduled. The operating costs of the hospital can be reduced. There are many problems relating more directly to the patient and his needs. The present laboratory in the average hospital may perform hundreds of thousands of tests Manuscript received March 14, 1974; revised July 1, 1974. The per year. These tests are often archaic-performed in the opinions in this paper are those of the author and do not necessarily same manner as the same test of 50 years ago. They have reflect those of the federal government. The author was with the Health Science Center, University of been mechanized, not automated. Tests are inaccurate and Texas, San Antonio, Tex. 78229. He is now with the Southwest Re- often must be repeated many times. There is no real prosearch Consortium, San Antonio, Tex. 78284.
96
control and no real operations research on the procedures and the arrangements in the laboratory. We need true automation of the hospital laboratory, new tests that are more specific, and new approaches to the design of health delivery systems. One example will suffice. We are now seeing more and more the development of multiphasic health testing based on the premise that repeated tests on an individual can record changes in health status. Several difficulties arise. In the first place, such tests may not be reliable unless they are repeated at regular intervals of once a year or more often. Secondly, the tests are useless unless the results are tied closely to a follow-up and treatment regime. Finally, the tests may not be valid for the purpose for which they are intended because many of the tests used are designed to measure overt illness, not incipient disease. Technology must produce new tests, determine the frequency, provide the automation and provide data handling methodology to reveal results and permit follow-up. cess
CLINICAL CARE Other problems occur in handling the critically ill. We use invasive techniques that actually may be measuring the wrong parameters-and this on a critically ill patient who needs as little interference with his life processes as possible. Again, technology may help solve the problem. The newer magnetic flowmeters, for example, can be used to measure blood flow without arterial puncture. In another vein, trauma and emergency illness is the nation's third largest disease. Each year hundreds of thousands of people die and millions are hospitalized from injury, heart attacks, and other major sudden illnesses. It has been estimated that 25 percent of all these deaths could be prevented with an adequate emergency care system. The problem is enormous when it is considered that no city in this country has a totally adequate emergency system at the present time, and only a few hospitals of the 6,000 in this country can meet the standards for a Class 1 emergency facility. More than one-third of all the ambulance pickups in the country are made by hearses with untrained drivers, and the patient, in the vast majority of cases, is delivered to an emergency room inadequately equipped and without a trained emergency physician in attendance. Each of the problems, transportation, communication, etc., is an engineering effort which has not yet been attacked on a systems base. AMBULATORY CARE We have been discussing the hospital and its problems, but the hospital is only a small part of the system. For every 1,000,000 people in the hospital beds of the nation, there are 20 times as many in outpatient clinics and in doctors' offices or receiving no care at all. We must turn our attention from the sick care of the hospital to preventive medicine and health care of the citizens as a whole. Here again, technology plays a critical part. To supply care to all people and to provide them with access to the system means that we must turn to another kind of care. The physicians in the rural areas must be provided with advice, assistance, and backup. It is now
IEEE
TRANSACTIONS
ON BIOMEDICAL
ENGINEERING, MARCH 1975
possible to connect the rural practitioner with a medical center through terminals that can help him bill his patients, read his ECG's, process laboratory data, and keep patient records. We can place paramedical personnel in remote areas and connect each with a physician through a satellite or microwave link.
Another way to promote access to the system is to develop units that can provide comprehensive medical care to an enrolled population. These large health maintenance organizations (HMO's) will depend upon testing, education, and immediate treatment to reduce hospital stay and, therefore, costs in the system. Each unit, which will serve tens of thousands of subscribers, will require a healthy technical back-up in computers, laboratories, transportation, etc. One of the major problems in applying technology to health care is that we are not dealing with a clearly definable subject. It is true that the health care industry at more than $80 billion per year is one of our largest industries. It employs millions of people in thousands of locations. It should be ripe for technology and the advantages of mass production that come with technology. However, any development in the medical market is expensive. A product to be used on humans requires thorough testing and high development costs, and it may not command a large market. The feedback is all negative. Without a firm patent policy, a manufacturer hesitates to incur heavy development costs with risk of recovering funds. We must break this chain, and the government eventually will have to undertake some of the development costs with return based on profits. As large-scale organizations develop with greater demands for uniform equipment, the standardization of products will occur more readily, and the market will be stabilized. HEALTH CARE RESEARCH AND DEVELOPMENT In defense and space exploration, which are systems or networks, the characteristics of the component parts are largely determined by a single organizational entity, the user. System specification, research, development, production, service, product performance, and marketing are all controlled by a single user dealing with a complete technological package. Successful R & D without a plan is an insufficient incentive to encourage the business community to invest scarce financial and manpower resources to exploit the results of that R & D. A fully developed business plan, on the other hand, provides a measure of risk against which management can compare available options for investment and subsequent profit potential. National R & D programs in health-related fields have not been closely coupled to the resources of technology. In 1969, Charles D. Flagle noted that there is no formal counterpart in health to the mechanisms "in which defense planners and representatives of advanced technology industries engage in a speculative systems development." The newly formed and developing national network of Rehabilitation Engineering Centers (REC), supported by the Social Rehabilitation Service (SRS), appears to have some of the characteristics essential to the effective
BROWN: HEALTH CARE SYSTEM
application of technological developments for the improvement of health service. A network of five Rehabilitation Engineering Centers has been established with principal funding provided by the Social Rehabilitation Service. Each center has strong teaching affiliations with medical and engineering schools, and a substantial patient load. Each of the Centers has been assigned specific areas of study as central objectives. Eleven different institutions are involved in the five centers. Each center will collaborate with laboratories and industry to carry new devices and techniques through all phases of r-esearch, development, and clinical evaluation to active production and patient use.
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the dynamic of the medical community. The users of the technology are not well acquainted with its potential value, the private entrepreneur (the physician) rarely purchases in quantity, and standards of manufacture have not been set. For these reasons, the medical market is unstable, risky, and expensive to enter. Most large companies get a greater return on engineering talent through mass-produced items. A means must be found to develop an interface between the inventor, the developer, the manufacturer, anid the user. The inventor is usually supported by grants or contracts and as such has little opportunity to develop an idea to the prototype or testing phase. The biomedical engineer is again at a disadvantage. Industry is unwilling to invest capital and talent in expensive development and preproduction testing. The logical middleman in the chain is the Federal Government. Past experience indicates that when a prototype has been developed and tested through government sponsorship, industry becomes interested in production. A strong technological base in the health sciences can be developed only through widespread dissemination of information and persuasion of the medical community together with enlistment of resources. The newly developing HMO's offer an ideal opportunity to bring technology into full use. The HMO's are an outpatient oriented prepaid health care delivery system which will enroll large groups (Kaiser has more than 1,000,000 members) and therefore offer a large enough economic base for develop-
STATE OF TECHNOLOGY IN HEALTH CARE DELIVERY Many advances have been made in the use of technology for the delivery of health services, and the promise seems great. However, the situation is not as fruitful as it might be. MVIuch technology is not yet available for widespread distribution although a great deal is in the process of feasibility testing. It is significant that more basic science applications (mass spectrometry, clinical analysis) and other single test ideas are much nearer widespread clinical application than are the ideas which will lead to system development. In other words, we are able to develop an instrument to measure a single parameter, but we have not yet been able to develop the system to examine the entire body or to manage the health care system or a series of ment. As a corollary to development, standardization must be sub-systems. This illustrates more than any other the The creation of a health care system where heavbe more in must considered. health care reason why engineering into the be records can transferred from one point to another with ily oriented towards the system approach than dividual instrumentation approach. Instrilmentation has complete understanding requires the standardization of tests, records, and many parts of the system as a whole. been developed and applied and will continue to be. Any savings of scale can be accomplished only with mass THE TRANSLATION OF R AND D INTO production, and this requires definition of a standard BETTER MEDICAL CARE product. Each of the above approaches does not depend on the The U. S. government spends about $150 million per sophisticated research engineer's developing comhighly year on medically related R and D projects. The largest instrumentation. In most cases, it is the direct plicated single effort is NIH ($60,000,000) although there is some of knowNn ideas at many places in a non-system. application question about the definition of the field in NIH, with NASA ($25,000,000), HSA ($15,000,000), DoD ($8,000, TRAINING FOR DEVELOPING TECHNOLOGY 000), AEC ($5,000,000), and various other agencies makIN HEALTH CARE ing up the balance. Within the Health Resources AdminIt is critical that everyone understand that technology istration the largest single funding point is the BHSR be exploited only insofar as personnel trained to do can ($10,000,000) with CDC, RMP, and CHS contributing other things can use it. NASA/HEW has launched the small programs. The overall result has been the production ATS-6 Satellite which will provide video/audio comof many devices and much assessment of methodology and will link the remote villages in Alaska munications but little development of a system to relate health care in Arizona on Indian reservations to a the and villages with technology.' and the IHS computer system in Tucsystem consulting Furthermore difficulties in exchange of information link will permit a much greater emphasis The video son. between agencies usually means that technology developed and education training of paramedical personnel. on in one arm of the government is usually unknown to ana contract with Lockheed Missiles NASA has signed other program. The NASA Technology Utilization Proand to provide a technology-oriented Division Space graim was developed to make technology generally availausing pararmedical personnel system care delivery health ble but has not been highly successful. remote rural populations in to care health and providing One of the main problems of technology utilization is simulation of the delivery of health care to astronauts in long term space flight. An important element will be vans I1 Technology is defined in its broadest sense to include all of which can provide service and training in remote locations. applied science in medical care.
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Each of these systems makes significant use of paramedical personnel rather than physicians to deliver the majority of health care. As a result, each system must contain training, elements which enable the non-physician provider to query the computer or a physician and obtain information, updating of facts and reference material as needed. That this is feasible has already been demonstrated by the Army AMOS program. The AMOS system provides an interactive interface from a paramedical operator to a computer in which the steps in physical examination and diagnosis are clearly defined on the computer by a series of questions and a branching tree which allows decisionmaking and decides whether the decision is up to the physician or his assistant. Such training can be extended in various degrees to the professional. Several medical schools now have computer-assisted instruction where the student can converse with the computer exactly as he does with a live patient with responses from the computer based on questions similar to those asked a live patient. This provides rapid learning of diagnostic procedures and points up errors sharply. At the University of Vermont, Dr. Lawrence Weed has developed a much more sophisticated system for the use of the specialist. This program is capable of permitting the physician to make choices of treatment, to program medication, order diets, etc., all tied to a problem-oriented patient record. As the system is based on the logic of a physician's thought processes, this is an educational tool for the specialist. Of less total sophistication but of equal interest is the CAPO (Computer Aid to Physician's Offices) program developed by Bolt, Baranek, and Newman in Boston. This program allows the physician to call up specific treatment regimes such as electrolyte balance, radiation dosage, ECG diagnosis, management of chronic disease, and many others. The physician can supply data from his patient, and the program suggests treatment, reminds of forgotten elements, and performs as a live consultant would on the same case. The process is one of both training and education. At the level of the hospital and total patient management, as opposed to the usual doctor-patient interrelationship, the El Camino Hospital in California has developed the Meditech system. This program admits the patient, calls for specific lab tests, diets, etc., and in general programs the patient's progress in the system. It is a training device as well since all possibilities are listed, and the physicians are asked to make choices of what they would like to have done. The results of previous tests can be recalled so that further tests can be ordered or different procedures instituted. Here again, the engineer must be able to interact with the physician to provide the data needed in a desirable format. Twenty-one hospitals in NTew Jersey are linked to a computer in New York which prepares and returns a treatment plan for patients receiving radiation therapy. In California an O/B unit is linked to a nearby computer which monitors the fetal heartbeat for abnormality during delivery. Several hospitals are now linked to a central com-
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH
1975
puter which can evaluate the performance of pacemakers implanted in the chest and indicate any deterioration of
performance. In this country we are faced with a real problem of handling a relatively large rural population where the physicians are scarce. We have mentioned the use of paramedics, but it is obviously of importance to be able to update the knowledge of present physicians and extend their capabilities to handle more patients better. This is particularly important now that New Mexico as one state requires that the physician have 120 hours of instruction each three years in order to maintain his license. As this practice spreads it poses a real problem in continuing education. As one solution, a physician has been linked by phone line to a computer center 120 miles away. He is able to keep his patient records, get ECG's read by the computer, enter data and receive library references and material to update his knowledge on specific topics, and provide consultation on difficult problems. Although this system was devised to enable a rural physician to handle more patients better, the system is linked to a university medical center so that it can also be used for continuing education. The commuinications and systems engineer is a vital part of the operation. We have hundreds of thousands of persons who need kidney dialysis. This procedure costs perhaps $10,000 per year in the hospital, but if a means of training were avaailable to train the individual in the home to do dialysis on a relative or himself the cost might be reduced to $3,000. Some 2 million Americans have high blood pressure. We mav eventually come to a means of monitoring the more critically ill of these and providing treatment in the home. The same situation occurs with other chronically ill and with the diabetic who can be trained to regulate his blood sugar and diet. The need exists for a major mass production effort to produce a standardized instrument and monitoring facility for each disease entity. The BBN CAPO operation currently furnishes patient education programs in diabetes, family planning, obesity, lunig disease, dieting, and hypertension as a start in the direction of helping the patient help himself. The several programs now available to allow the patient to take his owin history in a computer format offer a similar opportunity.
AN OVERVIEW OF TRAINING The training of biomedical engineers so that they fit into the complex system described above is a difficult task. The engineer is highly trained in a particular and often highly specialized task and is motivated to work in the industry. It is difficult to retrain him in broader, often more responsible areas, in fields with which he has no previous knowledge. The newly developing health and welfare areas demand a committed individual, cross-trained in both biological and engineering disciplines and with an innovative mind. The program proposed by the Department of Labor for retraining is inadequate. It may be possible to retrain the technicians by on-the-job training, but the engineer cannot be retrained without formal education in-
BROWN: HEALTH CARE SYSTEM
cluding course work in biological or medical subjects. At At present only 140 schools in the United States offer reasonable retraining facilities, and only 50 of these are first rank. The total that can be retrained, at the most, is 10 per year per school, or 1,500 persons. Secondly, under the present constraints of funding, most hospitals, medical organizations, and state and city agencies cannot afford to hire such talent even when available and trained. The priorities are such that patient care, student education, or simple policing of the environment must, of necessity, absorb available funds, and the systems engineer or the highly trained research scientist must take second place. It is possible to envision the retraining of technical personnel to take care of electrical equipment, serve as maintainers of expensive equipment, or to serve as physicians' assistants in operating rooms or in anesthesiology or X-ray departments. Here less formal schooling is necessary, and this can be coupled with on-the-job training. The estimated need may be large in the future but is relatively small at the present time, and the only way to place many of these individuals after training would be for the government to subsidize hospitals and laboratories or salaries. Many technical jobs in the medical care system are humdrurm routine, and turnover is high. The cost effectiveness of a training program may not prove satisfactory. On the other hand, the aerospace industry as a whole is organized with talent available to it from a wide spectrum of professions. It has physical plants and facilities for manufacturing which could be modified for other purposes. N\lany of the aerospace companies (Lockheed, Aerojet, etc.) are already engaged in health services on the periphery. The unity of men, plant, and machines should be considered in attempting to solve the overall problem. Several approaches could be adopted. An overt but very rapid response system would be for the government to approach the industry with the promise of relatively large-scale contracts for medical, transportation, and ecologicalenvironmental research and development, on the condition that the companies furnish a five-year plan of action, agree to devote a certain percent of their efforts on social problems, and agree to establish a link with the community actually placing men, and, if necessary, machines in community locations. The health portion would be conducted in conjunction with formal ties to a health organization such as a hospital, HMO, etc., to which the company would detail personnel for actual on-the-job training and work. This would serve several purposes: It would engage the company directly in the health care system, it would engage the health component directly in technical improvement, and it would provide training, experience, and work for engineers not only at the company but in the health unit. Similar arrangements could be made for elements of the social system, including education where systems analysis is badly needed along with improvement in technology. The end result would be a more rapid movement of the technical sphere into social systems to mutual advantage. In addition, a development leading to the production of devices, as it inevitably must, the company
99
could be licensed under government patents to produce and sell instrumentation providing a means of reducing the federal commitment and increasing the financial base of the industry. It must be apparent that there are at least three different kinds of individuals, all of whom are biomedical engineers. The problem of training in biomedical engineering is complicated by the fact that three different types of training now exist. The training of the past few years consisted of taking a competent engineer (usually) or a competent life scientist (much more rarely) and giving him a smattering of the other area with little attempt to acquaint him in depth with the problems. This resulted in a man who was expected to learn by "on the job training" and who ended up relatively unsophisticated in the field in which he was not primarily trained. One of the reasons this occurred was the dynamic of education. The engineer or the biologist was required by the undergraduate curriculum to take courses only in his specialty or in closely related areas, and it was considered a waste of time for him to be trained in a remote area. The situation is changing. Some schools have relaxed curriculum requirements so that undergraduates can cross disciplinary lines. Training in biomedical engineering is now no longer a special course (meaning especially watered down) in the cross discipline. Engineering students are taking medical school courses in competition with medical students, and the reverse is also true. This may not be all that could be desired since in many cases the medical school or even graduate school courses are not designed for the needs of the engineer. But at least the attempt represents an upgrading of standards. We must look to the production of a third type of training-that of the truly integrated curriculum especially designed for the biomedical engineer and tailored to his needs in departments or institutes of biomedical engineering. Precisely what this training should be cannot be completely defined as yet, but the initiation of special courses and programs at many of the better universities now providing training in biomedical engineering indicates the trend. The basic question has still not been asked nor answered. Who should be trained and how many? The National Institutes of Health in the support of its training programs has taken a position that in a period of shortage of qualified people and in a rapidly developing field it is more important to train the basic researchers who will go into an academic environment and reproduce their own kind. It was hoped that as the universities and present training programs become saturated, more trained scientists would be pushed into development and delivery of health services. We now come to the basic question. If a young man is trained as a biomedical engineer, how assured can he be of a career in his field? A few years ago the question would not have been so easy to answer, but now the possibilities are increasing daily. The present training programs report that they have little difficulty in placing graduates. Unfortunately, almost all of them are going into an academic setting, mostly into departments of physiology, biophy-
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL.
100
BME-22,
NO. 2, MARCH
1975
not in the research laboratory and the medical school. The funds available in this arena for support of either the technical base or the salaries do not begin to compare with the total health-care expenditures. Each year the cost of medical care in toto, and as individual services, rises sharply. A part of this is due to the new technical advances, and there is a limit to the percentage of the GNP which can be used for such purposes. Each year also, the efforts of the federal government and of private foundations are aimed in large part at better health services for the population as a whole as opposed to better technical support for the individual illness. This means simply that the directions of biomedical engineering must change. Our attention to instrumentation and sophisticated research problems must be in part relegated to other services, system design, technology designed for mass use, and a new attitude towards cost-effectiveness of the system as a whole. WHERE ARE WE NOW It is here that the biomedical engineer can play a major The diatribe above is designed for one purpose-to part in the new generation of health service delivery and point out that the future of biomedical engineering is find a major social function in help for his fellow man.
sics, etc. With the federal shift in emphasis from basic to more applied research, the departments may soon be saturated. We can indicate the magnitude of the problem. In 1965 the sale of biomedical instrumentation reached about $500 million. All industrial forecasts indicate that it has topped $1 billion in 1974. The increase in the number of hospitals, the demands in medicare and for other health services, and the needs of the physician for better instrumentation all indicate an increasing demand for products and for the biomedical engineer who is interested in development. This equipment is constantly updated and expanded. In addition, we have relied in the past upon fortuitous developments for new instrumentation. Now the spinoffs from the basic research programs, and the search for new parameters of measurements may result in vastly increased demands which cannot even be estimated.
The Biomedical Engineering Quandary JOHN E. JACOBS
Abstract-As of this date, biomedical engineering has become a recognized profession. The full impact of its efforts in the health related fields is just becoming visible to the leaders of the health delivery systems. As a profession it differs markedly from traditional engineering disciplines; however, that is the reason it has come into being. The demand for individuals well trained in the biomedical engineering sciences appears to be insatiable. This is due to the belated recognition by many members of the health delivery system hierarchy of the true role and contribution of the well-trained biomedical engineer. This article discusses the sociological and technological factors that have been influencial in the establishment of the science of biomedical engineering.
INTRODUCTION THIS ARTICLE is written with an awareness that it is Ia portion of the special issue devoted to thorough analysis and, understandably, individual opinions regarding the whole gamut of problems and proposed solutions for the biomedical engineer dilemma. With this in mind, the entire issue is cited as the appropriate reference for the following material. Manuscript received June 27, 1974; revised September 26, 1974. The author is with the Biomedical Engineering Center, Technological Institute, Northwestern University, Evanston, Ill. 60201.
To appreciate fully the ramifications, problems, and future for biomedical engineering training and its product, the biomedical engineer, it is essential that one be aware of a) the requirements to assure that a profession becomes successful, b) the historv of the introduction of the engineering sciences in the biomedical disciplines, c) federal policies regarding the encouragement of this introduction, d) the organizational structure of the university as it relates to national purpose, and finally e) the government's current and future role in health delivery and consumer protection. Each of the factors mentioned above has important bearing on the present and future status of biomedical engineering. For a scientific discipline, particularly engineering, to prosper it must have 1) a basic science foundation, 2) a recognized national need, 3) challenging research which is unique to the particular science, 4) training programs at all levels to the Ph.D., 5) professional society activities, 6) technical forums and publications, 7) rewarding career opportunities for all levels of graduates, and 8) a sense of purpose and achievement provided to the individuals involved. It is in the context of the above considerations that this article is written. Understandably, the miiaterial that fol-
BmE-22,
NO.
2, MARCH 1975
The Biomedical Engineer and J. H. U. BROWN,
the Health
95
Care
System
SENIOR MEMBER, IEEE
Abstract-The future of biomedical engineering is not in the classroom or the laboratory. The funds available are simply not designed to support the further development of a basic science base, and they are miniscule compared with the nearly $100 billion per year spent on health care. The biomedical engineer must turn his attention to problems of the system as a whole. Each year the cost of medical care rises sharply and unfortunately a part is due to the often unnecessary sophistication or over-development of instrumentation. Research and development are badly needed in the areas of automation. Need for computer controls, communications and transportation, system design, optimum utilization of resources, and redesign of the system to provide health care where the people are rather than where the doctor is located are all indications that the biomedical engineer can find a fruitful career in these areas rather than in the rapidly saturating areas of teaching and basic research.
WHAT ARE WE TRAINING FOR
IT IS AXIOMATIC that changes in technology in either concrete or theoretical form will also affect the system into which it is placed. So far, however, with the exception of innovative instrumentation, technology has made little impact on the total health care system. The development of the artificial kidney, pacemakers, automated clinical laboratories, and intensive-care patient monitoring have made very real advances in individual patient care. They have not markedly affected policy although practice has improved as a direct result. Those R & D efforts which will markedly affect the policies of health care are just now beginning to surface. The studies on cost of medical care, bed utilization, quality of care, use of physicians' assistants, the informed user, etc., are all designed to affect the whole system and the policies of the government, the community, and the practitioner. We must enmphasize that it is the physician who will direct the health care system. The use of technology will provide other hands, enlist paramedical support, and save time and money. The engineer must be in close collaboration to achieve these ends. The health care system today is under many strains. The complexity of modern medicine places a premium on the exchange of information and the handling of data. The physician is faced with increasing pressures toward group practice, the advent of a variety of paramedical personnel who may pose as great a threat as a help to him, and the many problems of a system that is not designed to handle the nuinber of cases it receives. Each of these problems demands an immediate solution,
and most of the solutions are in the area of technology. Most of the needed medical technology is state-of-the-art in electronics-we do not need new breakthroughs or theoretical studies. We need to apply the knowledge now present in engineering to the often mundane problems of everyday medicine. Many of these problems are not glamorous, but they are worthy of solution. And before the health care delivery system can progress they must be solved. Many of the present diagnostic approaches are fully instrumented but the procedures have not been combined in a system of health care. A few examples of such systems follow. THE RECORDS SYSTEM The present health care system is based on patient records. In the large majority of cases these are piles of documents related only in a time sequence and with no detectable relationship between the problems of the patient and the records of progress. The patient who transfers from one part of the system to another is at a great disadvantage. His records are difficult to transfer, the numbering systems do not coincide, and the new unit to which he transfers may use a different record format. The theoretical solution is simple. We desperately need a standardized admissions form and discharge abstract, and we need some form of problem-oriented patient record. These records must be computer-based and should be tied to the billing and bookkeeping systems in the hospital. This is an engineering problem pure and simple. But like so many facets of health care, it has a strong sociological base. The work of C. B. Jackson in COMPAS, Weed in Vermont, the HIS system of the Indian Health Service, and Octo Barnett at MGH, indicates that such solutions are possible. The system must be used by doctors and nurses, so it must be acceptable to them.
THE MANAGEMENT SYSTEM Many problems are related to the hospital as a system. We have not taken advantage of the savings in time and money resulting from proper use of technology. For example, through efficient use of computers, diets can be planned, nurses' schedules can be arranged, purchases can be coordinated, and procedures can be scheduled. The operating costs of the hospital can be reduced. There are many problems relating more directly to the patient and his needs. The present laboratory in the average hospital may perform hundreds of thousands of tests Manuscript received March 14, 1974; revised July 1, 1974. The per year. These tests are often archaic-performed in the opinions in this paper are those of the author and do not necessarily same manner as the same test of 50 years ago. They have reflect those of the federal government. The author was with the Health Science Center, University of been mechanized, not automated. Tests are inaccurate and Texas, San Antonio, Tex. 78229. He is now with the Southwest Re- often must be repeated many times. There is no real prosearch Consortium, San Antonio, Tex. 78284.
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control and no real operations research on the procedures and the arrangements in the laboratory. We need true automation of the hospital laboratory, new tests that are more specific, and new approaches to the design of health delivery systems. One example will suffice. We are now seeing more and more the development of multiphasic health testing based on the premise that repeated tests on an individual can record changes in health status. Several difficulties arise. In the first place, such tests may not be reliable unless they are repeated at regular intervals of once a year or more often. Secondly, the tests are useless unless the results are tied closely to a follow-up and treatment regime. Finally, the tests may not be valid for the purpose for which they are intended because many of the tests used are designed to measure overt illness, not incipient disease. Technology must produce new tests, determine the frequency, provide the automation and provide data handling methodology to reveal results and permit follow-up. cess
CLINICAL CARE Other problems occur in handling the critically ill. We use invasive techniques that actually may be measuring the wrong parameters-and this on a critically ill patient who needs as little interference with his life processes as possible. Again, technology may help solve the problem. The newer magnetic flowmeters, for example, can be used to measure blood flow without arterial puncture. In another vein, trauma and emergency illness is the nation's third largest disease. Each year hundreds of thousands of people die and millions are hospitalized from injury, heart attacks, and other major sudden illnesses. It has been estimated that 25 percent of all these deaths could be prevented with an adequate emergency care system. The problem is enormous when it is considered that no city in this country has a totally adequate emergency system at the present time, and only a few hospitals of the 6,000 in this country can meet the standards for a Class 1 emergency facility. More than one-third of all the ambulance pickups in the country are made by hearses with untrained drivers, and the patient, in the vast majority of cases, is delivered to an emergency room inadequately equipped and without a trained emergency physician in attendance. Each of the problems, transportation, communication, etc., is an engineering effort which has not yet been attacked on a systems base. AMBULATORY CARE We have been discussing the hospital and its problems, but the hospital is only a small part of the system. For every 1,000,000 people in the hospital beds of the nation, there are 20 times as many in outpatient clinics and in doctors' offices or receiving no care at all. We must turn our attention from the sick care of the hospital to preventive medicine and health care of the citizens as a whole. Here again, technology plays a critical part. To supply care to all people and to provide them with access to the system means that we must turn to another kind of care. The physicians in the rural areas must be provided with advice, assistance, and backup. It is now
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possible to connect the rural practitioner with a medical center through terminals that can help him bill his patients, read his ECG's, process laboratory data, and keep patient records. We can place paramedical personnel in remote areas and connect each with a physician through a satellite or microwave link.
Another way to promote access to the system is to develop units that can provide comprehensive medical care to an enrolled population. These large health maintenance organizations (HMO's) will depend upon testing, education, and immediate treatment to reduce hospital stay and, therefore, costs in the system. Each unit, which will serve tens of thousands of subscribers, will require a healthy technical back-up in computers, laboratories, transportation, etc. One of the major problems in applying technology to health care is that we are not dealing with a clearly definable subject. It is true that the health care industry at more than $80 billion per year is one of our largest industries. It employs millions of people in thousands of locations. It should be ripe for technology and the advantages of mass production that come with technology. However, any development in the medical market is expensive. A product to be used on humans requires thorough testing and high development costs, and it may not command a large market. The feedback is all negative. Without a firm patent policy, a manufacturer hesitates to incur heavy development costs with risk of recovering funds. We must break this chain, and the government eventually will have to undertake some of the development costs with return based on profits. As large-scale organizations develop with greater demands for uniform equipment, the standardization of products will occur more readily, and the market will be stabilized. HEALTH CARE RESEARCH AND DEVELOPMENT In defense and space exploration, which are systems or networks, the characteristics of the component parts are largely determined by a single organizational entity, the user. System specification, research, development, production, service, product performance, and marketing are all controlled by a single user dealing with a complete technological package. Successful R & D without a plan is an insufficient incentive to encourage the business community to invest scarce financial and manpower resources to exploit the results of that R & D. A fully developed business plan, on the other hand, provides a measure of risk against which management can compare available options for investment and subsequent profit potential. National R & D programs in health-related fields have not been closely coupled to the resources of technology. In 1969, Charles D. Flagle noted that there is no formal counterpart in health to the mechanisms "in which defense planners and representatives of advanced technology industries engage in a speculative systems development." The newly formed and developing national network of Rehabilitation Engineering Centers (REC), supported by the Social Rehabilitation Service (SRS), appears to have some of the characteristics essential to the effective
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application of technological developments for the improvement of health service. A network of five Rehabilitation Engineering Centers has been established with principal funding provided by the Social Rehabilitation Service. Each center has strong teaching affiliations with medical and engineering schools, and a substantial patient load. Each of the Centers has been assigned specific areas of study as central objectives. Eleven different institutions are involved in the five centers. Each center will collaborate with laboratories and industry to carry new devices and techniques through all phases of r-esearch, development, and clinical evaluation to active production and patient use.
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the dynamic of the medical community. The users of the technology are not well acquainted with its potential value, the private entrepreneur (the physician) rarely purchases in quantity, and standards of manufacture have not been set. For these reasons, the medical market is unstable, risky, and expensive to enter. Most large companies get a greater return on engineering talent through mass-produced items. A means must be found to develop an interface between the inventor, the developer, the manufacturer, anid the user. The inventor is usually supported by grants or contracts and as such has little opportunity to develop an idea to the prototype or testing phase. The biomedical engineer is again at a disadvantage. Industry is unwilling to invest capital and talent in expensive development and preproduction testing. The logical middleman in the chain is the Federal Government. Past experience indicates that when a prototype has been developed and tested through government sponsorship, industry becomes interested in production. A strong technological base in the health sciences can be developed only through widespread dissemination of information and persuasion of the medical community together with enlistment of resources. The newly developing HMO's offer an ideal opportunity to bring technology into full use. The HMO's are an outpatient oriented prepaid health care delivery system which will enroll large groups (Kaiser has more than 1,000,000 members) and therefore offer a large enough economic base for develop-
STATE OF TECHNOLOGY IN HEALTH CARE DELIVERY Many advances have been made in the use of technology for the delivery of health services, and the promise seems great. However, the situation is not as fruitful as it might be. MVIuch technology is not yet available for widespread distribution although a great deal is in the process of feasibility testing. It is significant that more basic science applications (mass spectrometry, clinical analysis) and other single test ideas are much nearer widespread clinical application than are the ideas which will lead to system development. In other words, we are able to develop an instrument to measure a single parameter, but we have not yet been able to develop the system to examine the entire body or to manage the health care system or a series of ment. As a corollary to development, standardization must be sub-systems. This illustrates more than any other the The creation of a health care system where heavbe more in must considered. health care reason why engineering into the be records can transferred from one point to another with ily oriented towards the system approach than dividual instrumentation approach. Instrilmentation has complete understanding requires the standardization of tests, records, and many parts of the system as a whole. been developed and applied and will continue to be. Any savings of scale can be accomplished only with mass THE TRANSLATION OF R AND D INTO production, and this requires definition of a standard BETTER MEDICAL CARE product. Each of the above approaches does not depend on the The U. S. government spends about $150 million per sophisticated research engineer's developing comhighly year on medically related R and D projects. The largest instrumentation. In most cases, it is the direct plicated single effort is NIH ($60,000,000) although there is some of knowNn ideas at many places in a non-system. application question about the definition of the field in NIH, with NASA ($25,000,000), HSA ($15,000,000), DoD ($8,000, TRAINING FOR DEVELOPING TECHNOLOGY 000), AEC ($5,000,000), and various other agencies makIN HEALTH CARE ing up the balance. Within the Health Resources AdminIt is critical that everyone understand that technology istration the largest single funding point is the BHSR be exploited only insofar as personnel trained to do can ($10,000,000) with CDC, RMP, and CHS contributing other things can use it. NASA/HEW has launched the small programs. The overall result has been the production ATS-6 Satellite which will provide video/audio comof many devices and much assessment of methodology and will link the remote villages in Alaska munications but little development of a system to relate health care in Arizona on Indian reservations to a the and villages with technology.' and the IHS computer system in Tucsystem consulting Furthermore difficulties in exchange of information link will permit a much greater emphasis The video son. between agencies usually means that technology developed and education training of paramedical personnel. on in one arm of the government is usually unknown to ana contract with Lockheed Missiles NASA has signed other program. The NASA Technology Utilization Proand to provide a technology-oriented Division Space graim was developed to make technology generally availausing pararmedical personnel system care delivery health ble but has not been highly successful. remote rural populations in to care health and providing One of the main problems of technology utilization is simulation of the delivery of health care to astronauts in long term space flight. An important element will be vans I1 Technology is defined in its broadest sense to include all of which can provide service and training in remote locations. applied science in medical care.
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Each of these systems makes significant use of paramedical personnel rather than physicians to deliver the majority of health care. As a result, each system must contain training, elements which enable the non-physician provider to query the computer or a physician and obtain information, updating of facts and reference material as needed. That this is feasible has already been demonstrated by the Army AMOS program. The AMOS system provides an interactive interface from a paramedical operator to a computer in which the steps in physical examination and diagnosis are clearly defined on the computer by a series of questions and a branching tree which allows decisionmaking and decides whether the decision is up to the physician or his assistant. Such training can be extended in various degrees to the professional. Several medical schools now have computer-assisted instruction where the student can converse with the computer exactly as he does with a live patient with responses from the computer based on questions similar to those asked a live patient. This provides rapid learning of diagnostic procedures and points up errors sharply. At the University of Vermont, Dr. Lawrence Weed has developed a much more sophisticated system for the use of the specialist. This program is capable of permitting the physician to make choices of treatment, to program medication, order diets, etc., all tied to a problem-oriented patient record. As the system is based on the logic of a physician's thought processes, this is an educational tool for the specialist. Of less total sophistication but of equal interest is the CAPO (Computer Aid to Physician's Offices) program developed by Bolt, Baranek, and Newman in Boston. This program allows the physician to call up specific treatment regimes such as electrolyte balance, radiation dosage, ECG diagnosis, management of chronic disease, and many others. The physician can supply data from his patient, and the program suggests treatment, reminds of forgotten elements, and performs as a live consultant would on the same case. The process is one of both training and education. At the level of the hospital and total patient management, as opposed to the usual doctor-patient interrelationship, the El Camino Hospital in California has developed the Meditech system. This program admits the patient, calls for specific lab tests, diets, etc., and in general programs the patient's progress in the system. It is a training device as well since all possibilities are listed, and the physicians are asked to make choices of what they would like to have done. The results of previous tests can be recalled so that further tests can be ordered or different procedures instituted. Here again, the engineer must be able to interact with the physician to provide the data needed in a desirable format. Twenty-one hospitals in NTew Jersey are linked to a computer in New York which prepares and returns a treatment plan for patients receiving radiation therapy. In California an O/B unit is linked to a nearby computer which monitors the fetal heartbeat for abnormality during delivery. Several hospitals are now linked to a central com-
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH
1975
puter which can evaluate the performance of pacemakers implanted in the chest and indicate any deterioration of
performance. In this country we are faced with a real problem of handling a relatively large rural population where the physicians are scarce. We have mentioned the use of paramedics, but it is obviously of importance to be able to update the knowledge of present physicians and extend their capabilities to handle more patients better. This is particularly important now that New Mexico as one state requires that the physician have 120 hours of instruction each three years in order to maintain his license. As this practice spreads it poses a real problem in continuing education. As one solution, a physician has been linked by phone line to a computer center 120 miles away. He is able to keep his patient records, get ECG's read by the computer, enter data and receive library references and material to update his knowledge on specific topics, and provide consultation on difficult problems. Although this system was devised to enable a rural physician to handle more patients better, the system is linked to a university medical center so that it can also be used for continuing education. The commuinications and systems engineer is a vital part of the operation. We have hundreds of thousands of persons who need kidney dialysis. This procedure costs perhaps $10,000 per year in the hospital, but if a means of training were avaailable to train the individual in the home to do dialysis on a relative or himself the cost might be reduced to $3,000. Some 2 million Americans have high blood pressure. We mav eventually come to a means of monitoring the more critically ill of these and providing treatment in the home. The same situation occurs with other chronically ill and with the diabetic who can be trained to regulate his blood sugar and diet. The need exists for a major mass production effort to produce a standardized instrument and monitoring facility for each disease entity. The BBN CAPO operation currently furnishes patient education programs in diabetes, family planning, obesity, lunig disease, dieting, and hypertension as a start in the direction of helping the patient help himself. The several programs now available to allow the patient to take his owin history in a computer format offer a similar opportunity.
AN OVERVIEW OF TRAINING The training of biomedical engineers so that they fit into the complex system described above is a difficult task. The engineer is highly trained in a particular and often highly specialized task and is motivated to work in the industry. It is difficult to retrain him in broader, often more responsible areas, in fields with which he has no previous knowledge. The newly developing health and welfare areas demand a committed individual, cross-trained in both biological and engineering disciplines and with an innovative mind. The program proposed by the Department of Labor for retraining is inadequate. It may be possible to retrain the technicians by on-the-job training, but the engineer cannot be retrained without formal education in-
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cluding course work in biological or medical subjects. At At present only 140 schools in the United States offer reasonable retraining facilities, and only 50 of these are first rank. The total that can be retrained, at the most, is 10 per year per school, or 1,500 persons. Secondly, under the present constraints of funding, most hospitals, medical organizations, and state and city agencies cannot afford to hire such talent even when available and trained. The priorities are such that patient care, student education, or simple policing of the environment must, of necessity, absorb available funds, and the systems engineer or the highly trained research scientist must take second place. It is possible to envision the retraining of technical personnel to take care of electrical equipment, serve as maintainers of expensive equipment, or to serve as physicians' assistants in operating rooms or in anesthesiology or X-ray departments. Here less formal schooling is necessary, and this can be coupled with on-the-job training. The estimated need may be large in the future but is relatively small at the present time, and the only way to place many of these individuals after training would be for the government to subsidize hospitals and laboratories or salaries. Many technical jobs in the medical care system are humdrurm routine, and turnover is high. The cost effectiveness of a training program may not prove satisfactory. On the other hand, the aerospace industry as a whole is organized with talent available to it from a wide spectrum of professions. It has physical plants and facilities for manufacturing which could be modified for other purposes. N\lany of the aerospace companies (Lockheed, Aerojet, etc.) are already engaged in health services on the periphery. The unity of men, plant, and machines should be considered in attempting to solve the overall problem. Several approaches could be adopted. An overt but very rapid response system would be for the government to approach the industry with the promise of relatively large-scale contracts for medical, transportation, and ecologicalenvironmental research and development, on the condition that the companies furnish a five-year plan of action, agree to devote a certain percent of their efforts on social problems, and agree to establish a link with the community actually placing men, and, if necessary, machines in community locations. The health portion would be conducted in conjunction with formal ties to a health organization such as a hospital, HMO, etc., to which the company would detail personnel for actual on-the-job training and work. This would serve several purposes: It would engage the company directly in the health care system, it would engage the health component directly in technical improvement, and it would provide training, experience, and work for engineers not only at the company but in the health unit. Similar arrangements could be made for elements of the social system, including education where systems analysis is badly needed along with improvement in technology. The end result would be a more rapid movement of the technical sphere into social systems to mutual advantage. In addition, a development leading to the production of devices, as it inevitably must, the company
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could be licensed under government patents to produce and sell instrumentation providing a means of reducing the federal commitment and increasing the financial base of the industry. It must be apparent that there are at least three different kinds of individuals, all of whom are biomedical engineers. The problem of training in biomedical engineering is complicated by the fact that three different types of training now exist. The training of the past few years consisted of taking a competent engineer (usually) or a competent life scientist (much more rarely) and giving him a smattering of the other area with little attempt to acquaint him in depth with the problems. This resulted in a man who was expected to learn by "on the job training" and who ended up relatively unsophisticated in the field in which he was not primarily trained. One of the reasons this occurred was the dynamic of education. The engineer or the biologist was required by the undergraduate curriculum to take courses only in his specialty or in closely related areas, and it was considered a waste of time for him to be trained in a remote area. The situation is changing. Some schools have relaxed curriculum requirements so that undergraduates can cross disciplinary lines. Training in biomedical engineering is now no longer a special course (meaning especially watered down) in the cross discipline. Engineering students are taking medical school courses in competition with medical students, and the reverse is also true. This may not be all that could be desired since in many cases the medical school or even graduate school courses are not designed for the needs of the engineer. But at least the attempt represents an upgrading of standards. We must look to the production of a third type of training-that of the truly integrated curriculum especially designed for the biomedical engineer and tailored to his needs in departments or institutes of biomedical engineering. Precisely what this training should be cannot be completely defined as yet, but the initiation of special courses and programs at many of the better universities now providing training in biomedical engineering indicates the trend. The basic question has still not been asked nor answered. Who should be trained and how many? The National Institutes of Health in the support of its training programs has taken a position that in a period of shortage of qualified people and in a rapidly developing field it is more important to train the basic researchers who will go into an academic environment and reproduce their own kind. It was hoped that as the universities and present training programs become saturated, more trained scientists would be pushed into development and delivery of health services. We now come to the basic question. If a young man is trained as a biomedical engineer, how assured can he be of a career in his field? A few years ago the question would not have been so easy to answer, but now the possibilities are increasing daily. The present training programs report that they have little difficulty in placing graduates. Unfortunately, almost all of them are going into an academic setting, mostly into departments of physiology, biophy-
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not in the research laboratory and the medical school. The funds available in this arena for support of either the technical base or the salaries do not begin to compare with the total health-care expenditures. Each year the cost of medical care in toto, and as individual services, rises sharply. A part of this is due to the new technical advances, and there is a limit to the percentage of the GNP which can be used for such purposes. Each year also, the efforts of the federal government and of private foundations are aimed in large part at better health services for the population as a whole as opposed to better technical support for the individual illness. This means simply that the directions of biomedical engineering must change. Our attention to instrumentation and sophisticated research problems must be in part relegated to other services, system design, technology designed for mass use, and a new attitude towards cost-effectiveness of the system as a whole. WHERE ARE WE NOW It is here that the biomedical engineer can play a major The diatribe above is designed for one purpose-to part in the new generation of health service delivery and point out that the future of biomedical engineering is find a major social function in help for his fellow man.
sics, etc. With the federal shift in emphasis from basic to more applied research, the departments may soon be saturated. We can indicate the magnitude of the problem. In 1965 the sale of biomedical instrumentation reached about $500 million. All industrial forecasts indicate that it has topped $1 billion in 1974. The increase in the number of hospitals, the demands in medicare and for other health services, and the needs of the physician for better instrumentation all indicate an increasing demand for products and for the biomedical engineer who is interested in development. This equipment is constantly updated and expanded. In addition, we have relied in the past upon fortuitous developments for new instrumentation. Now the spinoffs from the basic research programs, and the search for new parameters of measurements may result in vastly increased demands which cannot even be estimated.
The Biomedical Engineering Quandary JOHN E. JACOBS
Abstract-As of this date, biomedical engineering has become a recognized profession. The full impact of its efforts in the health related fields is just becoming visible to the leaders of the health delivery systems. As a profession it differs markedly from traditional engineering disciplines; however, that is the reason it has come into being. The demand for individuals well trained in the biomedical engineering sciences appears to be insatiable. This is due to the belated recognition by many members of the health delivery system hierarchy of the true role and contribution of the well-trained biomedical engineer. This article discusses the sociological and technological factors that have been influencial in the establishment of the science of biomedical engineering.
INTRODUCTION THIS ARTICLE is written with an awareness that it is Ia portion of the special issue devoted to thorough analysis and, understandably, individual opinions regarding the whole gamut of problems and proposed solutions for the biomedical engineer dilemma. With this in mind, the entire issue is cited as the appropriate reference for the following material. Manuscript received June 27, 1974; revised September 26, 1974. The author is with the Biomedical Engineering Center, Technological Institute, Northwestern University, Evanston, Ill. 60201.
To appreciate fully the ramifications, problems, and future for biomedical engineering training and its product, the biomedical engineer, it is essential that one be aware of a) the requirements to assure that a profession becomes successful, b) the historv of the introduction of the engineering sciences in the biomedical disciplines, c) federal policies regarding the encouragement of this introduction, d) the organizational structure of the university as it relates to national purpose, and finally e) the government's current and future role in health delivery and consumer protection. Each of the factors mentioned above has important bearing on the present and future status of biomedical engineering. For a scientific discipline, particularly engineering, to prosper it must have 1) a basic science foundation, 2) a recognized national need, 3) challenging research which is unique to the particular science, 4) training programs at all levels to the Ph.D., 5) professional society activities, 6) technical forums and publications, 7) rewarding career opportunities for all levels of graduates, and 8) a sense of purpose and achievement provided to the individuals involved. It is in the context of the above considerations that this article is written. Understandably, the miiaterial that fol-
