We will now have a group of area physicians: Gerald L. Miller, M.D., president-elect, Missouri State Medical Association; Wallace P. McKee, M.C., president, Jackson County Medical Society; Maxwell G. Berry, M.D., chairman of the board of governors, American College of Physicians, past president, American Society of Internal Medicine; Francis M. Maple, M.D., president, Missouri Society of Internal Medicine, chief of staff, St. John's Hospital, Springfield, Mo. STATEMENTS OF GERALD L. MILLER, M.D., PRESIDENT-ELECT, MISSOURI STATE MEDICAL ASSOCIATION; WALLACE P. MCKEE, M.D., PRESIDENT, JACKSON COUNTY MEDICAL SOCIETY; MAXWELL G. BERRY, CHAIRMAN OF THE BOARD OF GOVERNORS, AMERICAN COLLEGE OF PHYSICIANS, AND PAST PRESIDENT, AMERICAN SOCIETY OF INTERNAL MEDICINE; AND FRANCIS M. MAPLE, M.D., PRESIDENT, MISSOURI SOCIETY OF INTERNAL MEDICINE, AND CHIEF OF STAFF, ST. JOHN'S HOSPITAL, SPRINGFIELD, MO.

Dr. MILLER. Senator Eagleton, I guess I have been elected to launch these statements.

With your permission, I will confine my remarks to attitudes, activities, and policies, perhaps, of the Missouri State Medical Association as it reflects upon the several issues that seem to be germane, which you alluded to in your communication of August 27.

I think in the interest of hopefully avoiding repetition and redundancy I will stick to this and my colleagues can hit other issues.

First and foremost, I think the State organization has demonstrated its alinement of support along the general attitude of the AMA concerning the need of Federal funds in medical education. This, I think, the AMA has done in recent years and certainly this has been an official position taken. This, of course, in the face of increasing manpower needs and major shortages. The Medical Association established its support or its concern about the manpower problem, the support of the medical school in Kansas City first officially by resolution at its assembly meeting in 1968, reaffirmed its position of this being a priority item in the great need our State had so far as manpower is concerned, and in its most recent assembly in Kansas City in 1970 not only re-established this as a priority item but further extended this to, at least, encourage the additional participation of Federal funds and State funds in the existing medical schools so that they might extend their productivity in graduating medical schools. I think this became a real concern to the medical community of the State following the Olson report, which was an organ of the Commission on Higher Education of the Governors. This report, among many other findings, as it related to the general health manpower situation state, reflected something in the neighborhood of three point seven young people entering medical schools per hundred thousand in our State. A State to the near north, Nebraska, has over seven per hundred thousand. Kansas, Iowa, Illinois, all other States were significantly above the input.

I think this perhaps received more attention and this created more concern that we were, in fact, not getting sufficient young people into the field of medicine in Missouri than in perhaps any other thing,

and following this MSMA has been vocal and lent great support to this.

I should like to speak briefly to another area that has received considerable thought and development, namely, the doctors' assistant program, which has been alluded to earlier, and all of us accept the existing programs which really give no thought to medical technology, radiology, lab technology. We have included the 17 States throughout the States, which you mentioned. Washington, there are about 13 ongoing programs, we have reviewed all of these and have conducted a survey of our doctors of the State to determine need, that is, a willingness to use this in Dr. Jones' practice, and, at the same time, recognizing the great problems that we have in liability insurance, certification, et cetera. We are moving along with this and I really feel quite optimistically the State organization will sponsor and will have programs moving in the next 12 to 18 months. This is slow and laborious, but it is that kind of a problem.

Senator EAGLETON. Licensure is no small problem.

Dr. MILLER. That is right.

I would then point to one other area of concern and activity of the physicians of the State, which hopefully will be dear to your heart, and that is peer review, the entire matter of congressional recommendations and the AMA recommendations. This is not new and perhaps the hour is 11:55. But the State organization has been very much involved in the development in collaboration with the osteopathic organization of the State of a State peer review mechanism to concern itself with quality care, the cost and the utilization, and to use this as an educational mechanism as well, people and physicians. I hope I am not overly optimistic when I say we are far enough along with our total format that this should be functioning in the next 60 days. This will be a statewide program. Its panel mechanism will function rurally as well as in urban areas. Ultimately we feel optimistic about the development of physician profiles, patient profiles, disease profiles for which there is some vestive in California.

Senator, I really think these are the primary areas that the State has been active in or is doing some thoughtful progressive work in the many areas that you alluded to, and I will be most pleased to answer any queries that I can, but I think with that I would perhaps stop and let my colleagues move on.

Thank you for my permission to appear here.

(The prepared statement of Dr. Miller follows:)

PREPARED STATEMENT OF GERALD L. MILLER, M.D., PRESIDENT-ELECT, MISSOURI STATE MEDICAL ASSOCIATION

Gentlemen, at this hearing I will serve as a representative of the Missouri State Medical Association, and in the interest of hopefully minimizing redundant comments and duplication of reporting, I shall confine my remarks to the attitudes, activities, and policies of the Missouri State Medical Association as they reflect upon several of the specific areas for discussion which Senator Eagleton has alluded to in his communication to this panel on August 27, 1970.

Concerning the question on manpower problems relative to delivery of health services, the Missouri State Medical Association has supported the position of the AMA relative to the use of federal support for medical education. A copy of the memorandum dated July 10, 1970 from Ernest B. Howard relative to AMA policy is made a part of my statement. Specifically, so far as the problem of a medical center, educational center, and medical school in Kansas City, the Missouri State Medical Association has been quite firm in its position in recent

years. Its assembly in 1968 resolved to support the development of a four-year medical school in Kansas City, Missouri. It reaffirmed its position at its Assembly Meeting in 1969 concerning this support, and at its Assembly Meeting in Kansas City in 1970, restated the dire need as a top priority item in health manpower problems, the development of the Kansas City Medical School. It further supported the additional use of federal monies and other monies available to expand the productivity of existing medical schools within the state.

It is, I am sure, common knowledge that with the Olson Report, a study launched by the Commission on Higher Education some two or three years ago, that the input of Missouri citizens into medical education for the training of physicians per se was low in the central states. The figure that I recall rather clearly was that there were 3.7 young people going into medical education per 100,000 in the state of Missouri; this was compared to over 7 per 100,000 in Nebraska and figures in between, which were significantly above Missouri, in Kansas, Iowa, Illinois, etc. These findings, together with other significant statements in the Olson Report reflecting our serious manpower shortage in the state, accelerated the activities and the support of the Missouri State Medical Association to correct as quickly as possible this significant and serious deficit.

Relative to the development of paramedical skills and involvement in the training of paramedical people, it goes without saying, I think, that the development of a major medical center will accommodate significantly the shortages in various other paramedical personnel by parallel educational efforts in nursing, medical technology, etc.

Further, the Missouri State Medical Association has been active over the period of the last two years in developing programs for doctors' assistants. As is known to all, many such categories exist at the present time, perhaps in lesser levels of doctor support than is envisioned in this effort, namely, in laboratory technology, radiology technology, assistants in ophthalmology. There has been a recent surge of interest in midwifery again to supplement the care of uncomplicated cases in obstetrics. The effort of the Missouri State Medical Association has been to review those 17 or 18 existing programs throughout the states that have been established on various levels, some on the university medical center campus, some in the form of preceptorships, covering almost the full spectrum of medicine. We have worked hard at trying to identify need so that appropriate programs might be set up. Such an effort does involve many items to be cleared, such as liability, certification, the matter of interstate transfer of such personnel, and it is hoped that a working program will be launched in several areas reflecting upon doctors' assistants to lighten the load of physicians in the very near future.

Leaving some of the other specific areas to which Senator Eagleton has alluded to my contemporaries who shortly will be reporting to you, I would go to one other area of activity in the state organization which will reflect upon quality care, cost control, education and, certainly, utilization. I refer to the development of a state-wide Peer Review mechanism, the evolution of which we have been very much involved with, over a period of at least a year. The format has been established, this will be a state-wide program with, hopefully, uniformity of review throughout the state, covering rural and urban areas. The effort is being done in conjunction with the Association of Osteopathy of the State of Missouri, with superb cooperative spirit on the part of both associations to accomplish this task. The present timetable would hopefully see this effort functioning in the next 30 to 60 days.

Senator Eagleton, I think these represent primary areas of activity and reflect attitudes of the state medical association regarding a number of points that you have made. Because I believe that the other areas will be discussed by subsequent witnesses, I will conclude my report, and, of course, will be most happy to respond to any queries or questions that you might have relative to our activities or attitudes regarding any problems of concern to your committee. Respectfully.

Memorandum.

JULY 10, 1970.

To: C. H. William Ruhe, M.D., Director, Division of Medical Education.
From: Ernest B. Howard, M.D.

Re: Federal support for medical education.

At its recent meeting the Board of Trustees considered the statement on federal support for medical education adopted by the Advisory Committee on Un

dergraduate Medical Education and approved by the Council on Medical Education in March. As you recall the statement urged that the highest priority be placed on achieving the necessary minimum federal support for medical education.

The Board indicated its full agreement with the principle of the statement and stated that it is, in fact, existing AMA policy that there is urgent need for the production of more physicians and that broad support of medical education from all sources is necessary to meet that need. AMA has testified before both House and Senate Appropriations Committees to the necessity for increased federal support of medical education and before various legislative committees in favor of legislation to provide such support, and such efforts will continue in the future. In addition, AMA staff has been providing assistance to staff of the Department of Health, Education, and Welfare and various legislative staff personnel in the development of new or extended legislation which may be needed for the support of increased medical school enrollments.

The Board of Trustees has been and will continue to be dedicated to the production of a supply of physicians adequate for the health needs of the United States and to the provision of educational opportunities in medicine for all Americans interested in and qualified for the profession.

STATEMENT OF WALLACE P. MCKEE, M.D., PRESIDENT, JACKSON COUNTY MEDICAL SOCIETY

Senator EAGLETON. Dr. McKee.

Dr. McKEE. I guess I find myself in the position of representing private practice in Kansas City to a certain extent, and to review it a little bit:

The medical community here is organized and waiting the development of this new medical school. The county medical society was requested by Vernon Wilson about 2 years ago to say that they would support it, in order to start his activities to really help bring this here, and the county medical society did enthusiastically endorse it, as it has endorsed the concept for many years.

Senator EAGLETON. Do you view it, doctor, as a real golden opportunity to develop some new innovative, creative, new departures in medical education?

Dr. MCKEE. It seems very exciting, because I think most practicing physicians like the opportunity of being in an educational atmosphere. As you probably know, certain medical students of the type just out of high school will be actually going into private hospitals this fall. The private hospital I happen to work in, I believe there are 12 who will be going to this hospital this fall to start becoming acquainted with medicine. We will be involved in the teaching, and we think that in this medical community we have an excellent resource for training students without actually hiring full-time teachers, certainly economically desirable from both sides.

At any rate, the county medical society is firmly behind the medical school. It has actually tried in the 1950's, before the University of Missouri expanded its medical school in Columbia, to get a medical school here.

Senator EAGLETON. Let's not rewage the old Columbia-Kansas City battle.

Dr. McKEE. I wasn't bringing this thing up for any heated feelings, but just to mention that we have been interested in this.

I think we have medical resources in this area that are particularly good and we should have a fine medical community. It certainly lends itself to all kinds of good medical care. There are a couple of small

points, perhaps, that I would like to mention. The development of practicing physicians has become very important to most aspects of medicine, M.D.'s have tended to develop more specialists, as has been mentioned. The osteopathic physicians we just heard indicated there have been more family care physicians. We want to have more family care physicians, too, whether they are called internists or general practitioners or whatever.

Another question that you asked, which interests me, is how do you get care to the rural areas and the ghetto areas, places that may be, for certain reasons, undesirable. I would personally like to go out and live in an area where I didn't have to worry about pollution, where I could see the stars in the evening, and so forth, but there have to be certain inducements, not just financial. Financial inducements probably has to be there, but educational advantages dealing with peers are necessary. We need the concept of development of clinics in rural areas, that would draw from a large area (that is, 20 doctors in one clinic, rather than two doctors in each of 10 small towns that may not make it.)

Senator EAGLETON. I think that is the inevitable trend. In the bootheel of Missouri, Sikeston will be the medical capital of the bootheel with ambulances and all the other rapid forms of transportation, automobile, the other cities will be serviced medically out of Sikeston. I think it is inescapable for the reasons you mentioned.

We went on a binge, of course, under Hill-Burton, where every hamlet was to have a hospital. There is something psychologically pleasant to one who lives in a small community to have a hospital in his midst and the doctor there, it is comforting. So we built hospitals all over the country. We have many Hill-Burton hospitals now with no physician throughout the country. So you learn through trial and error, and the Government certainly made some errors.

Dr. MCKEE. I urge people not to feel too emotional when they see the men standing by the sign "We'd like to see a doctor in this town." Senator EAGLETON. The psychological factor is tough to overcome. Dr. Maple.

Dr. MAPLE. Senator Eagleton, let me say two or three points, and I will just give an overview of the material that you have at hand.

One is that particularly the American Society and Missouri Society of Internal Medicine have been working toward providing the stimulus to gain better comprehensive health insurance benefits for the working group of people.

As a national level, we have pushed both management and labor to try to develop comprehensiveness in their insurance policies, and we have been, we think, very successful in this area, particularly trying to mirror the way medicine is practiced, rather than trying to practice the way the insurance is actually written. This, as you know, has been a very big problem of forcing people to the horizontal care versus the vertical care, which is well understood.

The other thing I would like to say is that I would agree as an internist, where half of my practice is family practice and half of it is perhaps consultative practice, that it isn't just enough to say that we need to turn out more M.D.'s, we have to have the kind of a graduate that is going to come out who is going to be meeting the needs of the community.