There is the objective of education which Dr. Cherkasky referred to. Education cannot take place without patient care, but if education is the end, then the patient care is the means, and what we need to do is to lift these individual hospitals out of the bounds of their complex history and the traditions that developed them and help them understand that they must relate more directly than they do now to the problems of the community, as a community, and not simply to the problems that happen to come to them for a variety of reasons, including the scientific interests of the individuals who are working there.

It is in this area that the areawide planning efforts of our cities have made only the most modest beginning. One of the reasons for this is, I believe, that their boards are generally dominated by the people who represent the hospital who would be affected by the determinations that are made.

I think the approach described by Cherkasky will not only contribute to making sure that we get value for our money, but it would hasten the confrontation that I mentioned in the organization of care in terms of the community as a community.

Senator SMATHERS. All right.

Dr. Thompson, you may make your statement, and then we have some other questions we want to ask.

Dr. THOMPSON. All right. I think, Senator Smathers and Senator Kennedy, that much of what has gone before really points up what I wish to talk about today; namely, the need for research, to study the problems that we have talked about this morning.

It is estimated that $50 billion is spent each year in the United States for health services. Despite the large expenditure of funds there are serious deficiencies in the delivery of health services which have been widely publicized. New programs such as medicare, medicaid, heart, stroke, and cancer have been superimposed on a system that has many inadequacies. These programs have focused attention on the need to develop a more efficient, effective, and economical approach to the delivery of health services and to some extent have accentuated preexisting deficiencies.

It is apparent that the many problems require thorough study and a large-scale research effort is needed if we are to develop new and better ways of meeting the health needs of our entire population.

As has been mentioned, there are critical shortages of personnel. Studies indicate that there are not enough physicians, nurses, and allied health personnel to meet today's needs. The research effort in biomedical sciences has resulted in better treatment, but at the same. time has made the practice of medicine more complex and accentuated the need for more health personnel.

PHYSICIANS' ASSISTANTS BEING TRAINED

Programs have been initiated to train new members of the healthcare team. One such program is in progress at Duke, where physicians' assistants are being trained. There is a great need to explore other training possibilities in order to add additional people to the health care professions and to relieve physicians and nurses of some of their traditional duties.

Many hospitals and other in-patient facilities such as nursing homes are obsolete. A study by the Hospital Review and Planning Council of Southern New York conducted in 1965 pointed up the needs of New York City hospitals. It is estimated today that $1.5 billion is needed for hospital construction in New York City.

At my own hospital, the New York Hospital, we have plans for renovation totaling $28 million. There is a serious question as to whether this investment is advisable in a 35-year-old plant. Indeed, architects have advised us that it would be more economical in the long run if a new in-patient facility were constructed. The source of such funds, which may total $100 million, is not apparent today, though legislation is pending in Congress which may provide a means for funding such large construction projects.

However, no major construction program for replacement of obsolete hospitals should move ahead without experimentation with new and better ways to care for sick people. There are research programs supported by a variety of local, State, and Federal agencies, but the efforts are not coordinated sufficiently nor are there adequate funds to mount a full-scale research endeavor.

The importance of coordination may be brought about by considering the individual patient. In his lifetime he is likely to need preventive measures; he will probably need ambulatory care for illness either at a doctor's office or ambulatory clinic; he will most likely need acute general hospital facilities and following this he may need convalescent care and home care. His needs require a continuity of effort in which many different health-care agencies and facilities are involved.

There has been a tendency to look at one or another aspect of this continuum without sufficient emphasis being placed on long-term needs of the patient. In designing new hospitals, for example, due consideration should be given to the progression of the patient's needs from the acute hospital to convalescent facilities and back into the home. It is wasteful of the resources of the acute hospital to provide care which can be given in a nursing or convalescent facility or in the home.

Changes in hospital structure and function will not come about unless well-designed experiments are carried out and the worthwhile new approaches are copied by others. I do not think there is adequate organization or funding of such research programs.

NEW APPROACHES TO PATIENT CARE

More important than the facilities themselves is the development of new approaches to patient care. We need to approach the problem of ambulatory care in our clinics with new perspectives. The traditional outpatient clinic should be replaced by one which provides more gracious and graceful patient care. I am convinced that this can and should be continued in large teaching hospitals such as the New York Hospital, but it will require revamping of current procedures. We should develop research projects and pilot programs to try out new ways of delivering ambulatory care.

Carefully designed and well-executed studies will be costly, but I know of no other way to assure improvement in patient care. The home care project which Dr. Reader has described, a 10-year study

carried out at the New York Hospital, is an example of the type of project for which research funds are needed.

The role of the nursing home should be studied more extensively. The traditional view of a nursing home as a long-term, terminal-care facility is outmoded. It should be looked upon as a way station between the hospital and the home. Continuity of care requires that a patient's course is planned through each step of the way to the hospital and back into the home.

Some patients may not require the elaborate resources of the acute hospital but could be admitted directly to an intermediate-care facility such as a nursing home. We do not have adequate studies of how nursing homes can mesh with other facilities to provide optimal patient care. I am confident that such studies would result in a new role for the nursing home, a more effective relationship between it, the hospitals, and home-care agencies.

It would also, I believe, be more economical if intermediate and extended care facilities took over some of the activities of the acute hospital.

In this regard, the problem of admissions to acute general hospitals has been a subject of such discussion. Long waiting lists are common, resulting in admission primarily of emergency problems. At the New York Hospital, for example, delays up to 4 weeks are common for less than emergency cases. One of the obvious solutions to the shortage of beds is a rapid turnover of patients. Better intermediate-care and home-care programs integrated closely with the general hospitals should help to correct the shortage.

I have proposed that a large-scale research effort be organized at a Federal level. I have compared this proposed undertaking to that of the National Institutes of Health, which have played a prominent role in the growth of biomedical research in this country. I believe a similar effort is needed in the field of health-care research.

In his statement to another committee, Under Secretary Wilbur Cohen outlined the needs for research and development in six major areas. He pointed out that currently only one-tenths of 1 percent of governmentwide investment in health services is invested in health services research. He stresses the need for a more vigorous effort and emphasizes the need to establish a National Health Center for Health Services Research and Development.

I agree with Mr. Cohen's analysis of the needs and with his proposal that this be organized on a national basis. Such an organization should be able to muster the topflight talent from the entire country to review and pass upon research proposals. It should also be able to coordinate research activities which are fragmented and inadequate to meet today's needs.

I have been quoted as stating that a billion dollars a year is needed for health-care research. This estimate is based on the conviction that funding comparable to that provided for biomedical research will be required to mount a vigorous, comprehensive research effort. It is unlikely that $1 billion could be spent wisely today. However, with the development of a national center or agency for health-care research, I would anticipate that a well-coordinated research program would grow rapidly.

I am pleased to have had the opportunity, Senator Smathers and Senator Kennedy, to address this committee and hope it will lend its support to the development of a large-scale research effort in health

care.

Senator SMATHERS. All right, sir. Thank you very much, Dr. Thompson.

Senator Kennedy, do you have any questions?

Senator KENNEDY. No, I don't. Thank you.

Senator SMATHERS. I have one brief question. I am keenly interested in this question so you will excuse me if I take just 3 minutes.

In the service in World War II, I became accustomed to going down in the morning when we were overseas and here in the United States to a health call. There would be lined up there 25 or 35 or 40 marines in the outfit that I was in and they had anything from broken knees at that moment, skinned knees, head colds, a lot of other things.

We never got to see the doctor. We saw the corpsman but after a little while we became accustomed to seeing that fellow. When you went in to see the corpsman-he was a fairly well educated young man in medical ways; he did not have a medical degree but he had enough sense to know if a man came in there with a fever or something serious he would then set him aside and have him see the doctor.

But what happened was that these other 40 people did not have to see a doctor. We developed confidence in the corpsman. I have wondered why it would not be possible for the medical profession to develop some subassistants, have them meet these many, many people so that they would be smart enough to isolate the very serious cases and then the doctors would not have to spend their time on so many unimportant cases. Is it practical to assume that we could develop such a system, or should we develop a system like that in the medical profession?

Dr. THOMPSON. Indeed it is, Senator Smathers, and this is one of the points that I wanted to make; namely, that in addition to the fact that we need more personnel in their traditional roles physicians and nurses-we do need to develop other health professionals.

This program I described at Duke is really a followup on the corpsman idea. The assistants are largely coming from the corpsman group. It is apparent in our hospitals today that nurses are taking on some of the traditional duties of physicians and then somebody will come along and take some of their traditional duties.

It is not only a matter of more personnel in their role but new personnel being fed into the health professions. I think you are quite correct that we have to develop new types of health personnel without question.

Senator SMATHERS. Thank you, Doctor.
Dr. SHEPS. I have something.

Senator SMATHERS. Yes.

Dr. SHEPS. I would like to add something to this. I think that the development of different types of personnel, which I believe is very sorely needed, will be inadequate if it takes place by itself and in a vacuum. This, it seems to me, sir, needs to be thought out in terms of the confrontation of different patterns of care.

The only way in which these new types of personnel can do the best job is if they are part of an organized program. In your Marine station the medical officer was indeed there, he was available and he was

supervising what these men were doing. This changes the whole structure of care and it also has implications for financing methods. It is an interesting thing to contemplate. You graduate these assistants to the physician from Duke University. Who is going to pay them? The doctor will be paying them. He will then be having hired help who are part of his cost of operation. He will receive a fee for what? For what this assistant does or for what he does by way of supervision? This raises a lot of very interesting questions that go to the heart of how we provide and pay for medical care in this country. Senator SMATHERS. All right, sir. Thank you very much.

(The chairman addressed the following questions to Dr. Thompson in a letter written after the hearings:)

1. Your case for an extensive research program is-as you pointed out-very similar to arguments raised in support of the National Health Center for Health Services Research now under study by the Department of Health, Education, and Welfare.

Do you envision the Center's being coordinated with action programs so that research can be put to immediate practical use. For example, if new techniques for ambulatory care of the elderly are developed in a promising demonstration program, could the Center in some way act to inform medical administrators throughout the nation as to the lessons learned from experimentation.

2. Have you any suggestions for research needed in health screening and preventive medicine in general?

(The following reply was received:)

Answer 1. You stress an important aspect of a research program in Patient Care; namely, the introduction of new ways of delivering health services to everyone. This will require that the promising results of research programs which have wide application be made known to appropriate groups who are in a position to implement them. This points up the importance of coordination of health care activities. The development of coordinating groups as a result of the Heart, Stroke and Cancer and Comprehensive Health Planning legislation should facilitate bringing the fruits of research more rapidly to the bedside.

You have asked whether a National Health Center for Health Services Research should act to inform medical administrators of new approaches generated by research. I think its most important function is the funding of promising new ventures. It could also help to designate the experimental results in a number of ways. These might include:

1. Publication of all ongoing research projects at regular intervals.

2. Publication of a bibliography including all published results stemming from research in health services.

3. Organization of symposia on research efforts which are receiving widespread attention.

4. Establishment of close liaison with governmental and voluntary agencies involved in health care research and delivery of health services.

Answer 2. These two areas are greatly in need of expanded research efforts. As you know, much has been written on these subjects; therefore, I shall only comment briefly.

Shortage of medical manpower has forced us to think of alternative methods of delivering health care. At the same time there is great demand for comprehensive care which includes a general examination at regular intervals. I think the goal is desirable, but its achievement should not accentuate shortage of health personnel in other health areas. It seems essential, therefore, to develop new methods of examination of patients requiring less time on the part of physicians and nurses. Screening procedures including history taking, laboratory examinations and certain aspects of physical examination can be carried out with a minimum number of professionals. Although the concept seems sound, there is need to examine the approach critically through well defined, well organized research projects. The role of the computer in history taking, the use of automated equipment for mass production of laboratory data, the development of health personnel to carry out most of these screening procedures should be studied carefully. Ultimately, I believe, the results of such studies will show that screening procedures will be beneficial to patients, will save time for doctors and nurses and will be more efficient and economical than the present system.