I would like to center my comments to the maldistribution of doctors. This is directly related to the decreasing number of graduating doctors going into general practice and an increasing number of general practitioners either retiring or going back to enter into a residency program.

First, many students go to medical school with the idea of becoming a general practitioner and to serve the needs of the many. The general attitude of medical school quickly alters this thinking. The general practitioner is regarded as a less than adequate doctor and is essentially classified as a second-class citizen among his peers. It is a wellknown cliche that the upper one-third of the class become researchers, the middle third the specialists, and the lower one-third the general practitioners. After investing the time, money, and effort necessary in getting a medical degree, why not invest a few more years and be able to practice the type of medicine you will be the happiest practicing 10, 15, or 20 years after you have finished training. In medical school you are taught by specialists, advised by specialists, and influenced by specialists.

The small community, in many instances, does not offer the type of living to which an urban oriented family is accustomed. In most cases the educational system is not up to the standards of the schools in the larger communities, and why should one subject his family to this.

The workload is tremendous, and the physical demands on the individual are also great. In many cases if the doctor goes to the small community he will realize that he is it, there will be no help, and in most cases the challenge is too great. Most young doctors are inadequately prepared to meet this challenge.

Part of the problem could be met with the establishment of family practice specialities in more medical schools. The AMA has established a specialty board of family practice. The Farm Bureau in some States has selected a number of places in a medical class and have subsidized their medical education, and in return the graduating doctor must practice a certain number of years in a community below a certain size population.

More doctors will feel adequate enough to meet the challenge if they are better prepared. Along with this, some prestige must be given to family practice.

The American public is spoiled with the best of everything. They are specialist minded and their health care is no exception.

I would like to make one quick comment concerning the attracting of doctors into the ghetto. First, I think it is necessary that the ghettos be made safe for the doctors. I personally have had my car stolen once, a brick thrown through the window another time. I was shot at a third time, and all the contents were stolen from my car on two different occasions. This has happened during my 4 years at medical school here in St. Louis. I honestly am afraid to go to the ghettos.

I would like to make a quick comment also concerning the use of paramedical personnel. This relates to Senator Abraham Ribicoff's article in the Saturday Review on August 22, I believe. He makes a statement, "Is it enough to leave paramedical training in the hands of universities and junior colleges in the academic isolation of the college campus or, on the other hand, should such training include a combination of both academic education and medical school training alongside medical students and doctors?"

If paramedical people are to be trained side by side with doctors, ut, zing the same facilities, why don't we just train more doctors side y side with more doctors and turn out more doctors and leave the trong of the paramedical to the areas limited to their training.

I would I ke to just throw out a couple of questions which I don't know the answers to. I would like to know to what extent and to what ingrve these personnel are to be trained. Who is to assume the legal restonsuality of their performance! I would also like to know would ay of you or your families be satisfied with the treatment given by an aced trained paramedic.

Senator EAGLETON. I will answer those for you when you finish. Dr Fiordelist. In summary, I think the doctor is not adequately pared to deliver the small community type of medicine, not men

prpared for the dissuasive attitude of the medical school, and, ne, the small communities do not offer enough incentive to the docfor vid especially to his family.

nator EAGLETON. Thank you, Doctor.

Wat's your specialty!

Dr FIORDELISI. None as yet. I am a straight surgical intern intendto specialize in general surgery.

❤ator EAGLETON. What is your home?

I'T FIGRDELISI. My home is here in St. Louis now.

Net stor EAGLETON. If you get your board certification in surgery, ́re do you think you will practice!

Dr FIORDELISI. I have no idea.

Senator EAGLIPTON. But not North St. Louis for sure.

Dr FIORDELISI. I wouldn't rule it out. I don't know.

Serator EAGLETON. I took your previous testimony to be that you ,an't rule it in because you were afraid to go to the ghetto. Ir FIORDESI. I don't know what the conditions will be 5 years

fr n. now.

Serator EAGLETON. Assuming they are no better.
Dr FIORDFISI. Probably not.

Sestor EAGLETON. Referring to your statement where you ask questions and also where you say it would be better to turn at more doctors and leave the paramedical personnel to the areas for their training suits them, you don't envision then when you are practice, the utilization of paramedical personnel to assist you in the rendering of your services?

Dr. FIORDELIST. No, I didn't say that. I am referring to the article where Senator Ribicoff says

Set stor EAGLETON (interrupting). That is in the record, and he sugthat the paramedical personnel cannot be properly trained in e splendid isolation of an academic environment such as a junior or a 4-year college, but a significant portion, albeit not all, part of their training has to be as in a medical teaching hospital. Do

Voi dispute that?

IT FIORDFLISI. No, I believe it is done now. Nnator EAGLETON. Here is your statement. "Paramedical people are to be trained side by side with doctors utilizing the same faciliwhy don't we just train more doctors side by side with more ators and turn out more doctors and leave the training of paraal to the areas limited to their training." I took that to mean to get them out of the hospitals.

Dr. FIORDELISI. I am referring to the way he made the statement that you train paramedical personnel in the basic sciences and in the practical application of medicine side by side with the doctors. If you are using the same facilities and the same people doing the teaching and everything, why don't you

Senator EAGLETON. Well, it is a different degree of exposure. Are you familiar with pediatric assistants?

Dr. FIORDELISI. Yes.

Senator EAGLETON. Are you familiar with the allegation, at least, that a good pediatric assistant can save the pediatrician himself up to 60 percent of his man-hour time.

Dr. FIORDELISI. I am not familiar with statistics as far as timesaving and so on and so forth.

Senator EAGLETON. If that be the case, and it is cited in some of the medical literature, including the "American Medical Journal," wouldn't it just be commonsense for a doctor to avail himself of such specialized paramedic talent so as to better utilize his time in the bringing of medicine to more people who are obviously in need of it?

Dr. FIORDELISI. Right. That is why I said I would like to know to what extent and to what degree these personnel will be trained. That was another question.

Senator EAGLETON. Well, the extent to which they are being trained, the best example now is the pediatric assistant, and the theory is that in the whole gamut of the delivery of medical services, under control of the teaching hospital, just as at this hospital they train somebody to move bedpans around or they train somebody to open the door in the morning and to lock it at night, they will also train a civilian person to render assistance in the delivery of health services up to his intellectual limit, in association with the professional.

Dr. FIORDELISI. Fine.

Senator EAGLETON. You also asked would any of you or your families be satisfied with the treatment given by an advanced trained medic.

Don't many nurses in offices now, when you either take yourself or your children to a doctor's office, doesn't a nurse sometimes stick the thermometer in your mouth, doesn't she take your blood pressure? They can even administer an electrocardiograph. X-ray technicians take the X-ray plates, so is it unseemly that somebody who doesn't have an M.D. shingle can do something in connection with the medical profession?

Dr. FIORDELISI. Right. Again I say I would like to know to what

extent.

Senator EAGLETON. Do you think that is the sole limit of the utilization of nonprofessional manpower?

Dr. FIORDELISI. I don't know.

Senator EAGLETON. Well, you have been in medical school 4 years. You are now an intern. You have had some exposure to the medical training process. Based on your judgment here for these 4 years, do you think there is an expanded role for civilian personnel to play in the medical field?

Dr. FIORDELISI. I don't know. As a student and as an intern I am doing practically everything anyway. I move the bedpans.

Senator EAGLETON, Doctor, what we are seeking to do is to relieve you of that onerous and odoriferous burden and having others trained to do it so that you could use your your talents to optimum advantage. Dr. Fiordlist. I would appreciate that.

Senator EAGLETON. Thank you very much

Senator EAGLETON. As our next witness we have Dr. James M. W too, M.D., past president, National Medical Association. Is Mr Mosley going to accompany you?

Dr. WHITTICO, Mr. Mosley, would you come here, please.

I appreciate your giving representatives of the National Medical Assocation an opportunity to testify.

Senator EAGLETON. Would all of you identify yourselves for the record, please.

Dr WHITTICO. I am Dr. James M. Whittico.

Mr. MOSLEY, Julian Mosley.

Senator EAGLETON. Before we get that, I will list off for the record, to follow up Dr. Fiordelisi's testimony, the list of nonprofessional personnel as currently being employed by the military in Vietnam, where some degree of medical services are occasionally needed, I take it. Scope and range of paramedic specialist, and I will read them. There are 16 of them. Cast specialist; brace specialist; dental laboratory

alist; optical specialist; medical corpsman: medical specialist; elopical specialist; OR specialist; neuropsychiatric specialist; orthopede specialist; physical therapy specialist; electroencephalographic stes salist eve, ear, nose, and throat specialist: preventative medicine speralist; EGC BMR specialist: X-ray specialist. So under the extes of war at least these specialists have been identified in Viet

Dr Whittico, would you now please have those accompanying you

ify themselves.

MSCRUGGS. Karen Scruggs.

Mr. BOND. William Bond.

Dr. Nichots. Dr. Henry Nichols.

STATEMENT OF JAMES M. WHITTICO, M.D., PAST PRESIDENT, NATIONAL MEDICAL ASSOCIATION

Dr. WHITTICo. Honorable Senator and members of the Senate submittee, I will do my very best to keep within the time limit.

I appreciate this invitation to appear before you to testify in gard to the plight and problems of education for the health professors Your mere presence here and in other hearings such as this & ross the Nation gives encouragement to those of us in the health 4ssions who have cried out over the past number of years about eet picture of health in these 50 United States and locally here Mouri; and to those of us who have been spiritually and mentally red by our inability to obtain sufficient legislative and financial 'p to implement plans for correction of these inadequacies, inequities, 1 the insufficiencies of the educational process for the health proots and their delivery of medical care to the people of our country, a" of the people.

I would like to take this opportunity, at the risk of losing a few ➡nds, to thank and to commend Senator Eagleton for his personal

sensitivity, interest, and empathy for the problems in the Nation and locally that have existed in the educational system of the health professions, particularly as far as input and helping to acquire appropriations locally here at the St. Louis University School of Medicine.

I feel that without such interests of people such as these that this Nation would succumb to the enemy within, that being physical, mental and moral sickness, decay, and death.

As you gentlemen are well informed, even though we boast of being the richest Nation in the world, and even though we boast of being the mecca of medical education for our professional society of nations, here in the United States our infant mortality rate is worse, our maternal mortality rate is worse, our children's physical performance rate is worse, the incidence of morbidity and mortality of many diseases is worse than in some other nations of the world.

The United States cannot hope to raise its average level of health without acute attention to the least of these, its minority groups, its poor, its disadvantaged black or white. Nor can this Nation hope to raise its average level of health and medical proficiency while keeping its minority groups and disadvantaged down in abject poverty, segregated and substandard housing, discriminatory and substandard educational facilities and opportunities, discriminatory and insufficient employment opportunities.

We have talked long and loud over the past number of years about the need for changing the health care delivery system in this country and meeting this critical situation, but I submit, gentlemen, that as indicated by the objectives of this hearing of your subcommittee. whatever system is employed, excellent health care delivery cannot be obtained without the education of more and better health professionals. When I use the term "health professionals" I refer to the entire spectrum of medical and allied medical careers.

The health of this Nation will be raised only by expert activities of these health professionals at a grassroot level in our cities and our rural areas, the suburbs and the ghettos, but, as you are well aware, there is a grave shortage at all levels of the health professionals. I also humbly submit to you gentlemen that the ideal health standards. of this Nation will never be accomplished until there is a firm commitment and involvement at all levels of our society, from the President and his Cabinet to the Congress and the Senate of the United States, to the Governors and legislators of our States, the mayors and official constituency of our cities, the medical professionals in our counties, down to the individual consumer on the streets of our communities.

Senator, I need not remind you or the members of the subcommittee that the health situation in these United States is critical. Nor need I, of all people, attempt to inform you that to gain populace support and sense of involvement requires intensive publicity and educational programs to awaken their awareness and sense of involvement and sense of personal responsibility if any serious objectives on a national scale are to be obtained. People as a whole are slow to become involved, but I have the greatest confidence that the people of this Nation can rise to the occasion of a critical moment.

Involvement of people at levels of our society must be obtained. People must cease to think of our health professionals in the third