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Research aimed at prevention is, of course, of vast importance. This consideration is related to the screening procedures since these should help in prevention of illness and early detection of medical problems. In addition, we are still woefully ignorant of causes and means of prevention of killer diseases and other less dramatic, but nonetheless serious illnesses. Certain known important factors in producing illness, e.g., cigarette smoking, air pollution, should be brought home more forcefully to the public. Experimentation is needed to develop more effective means of controlling known factors in disease.

In summary, it seems to me that the enormous sums of money spent on health care could be utilized more effectively. To develop better methods of health care we must invest in research. I know of no other way to develop new approaches which I am convinced are essential, if the delivery of health services to our people is to improve substantially.

Senator SMATHERS. I will insert into the record an article describing a recent Government action related to my comments about medical corpsmen, as well as later correspondence on the subject.

[From Today's Health magazine, November 1967]

GROUPS COOPERATE TO STEER VETS INTO HEALTH CAREERS

A program to attract into the health field some of the 65,000 to 70,000 medically trained veterans discharged annually from the armed forces was to begin in midOctober. So announced Edwin F. Rosinski, Ph.D., deputy assistant secretary for health manpower in the Department of Health, Education, and Welfare.

"We wish to tap this tremendous pool of trained personnel and encourage as many as possible to enter the allied health fields," said Doctor Rosinski.

The program will be conducted on a voluntary basis with several agencies cooperating at the local, state, and national level, and at no added tax cost, according to Doctor Rosinski.

The program has a two-fold purpose:

1. To steer those who are adequately trained into the health field immediately. 2. To encourage those who desire a higher occupational level to continue their education.

At the time of separation from the service, before discharge, veterans will be asked to fill out a questionnaire indicating the nature of their service-connected training. Within two to three days after returning home, the dischargee will again be sent a letter outlining this Health Manpower program. This will be followed up with a personal contact from the state employment office asking if the veteran would be interested in further counseling on opportunities in the health field.

The health-counseling officer in the state employment office will be provided with information from hospitals in the vicinity indicating the positions available and salary range and training required as well as training being offered in the hospital. The chief educational administration officer in the state will make available a list of educational institutions in the state offering further education in health sciences including vocational schools, community colleges, colleges, and postgraduate institutions.

For those veterans who are missed through the separation and state-employment channels, the Veterans Administration also will provide similar information.

Also cooperating in the voluntary effort are the American Hospital Association, which is alerting hospitals; the Department of Labor, which is making available the personnel of the state employment offices, and the Office of Education, which is working with the chief educational administrative officers in each state.

NOVEMBER 2, 1967.

Dr. EDWIN F. ROSINSKI, Deputy Assistant Secretary for Health Manpower, Department of Health, Education, and Welfare, Washington, D.C.

DEAR DR. ROSINSKI: I was interested in the article on p. 15 of the November, 1967 issue of TODAY'S HEALTH concerning your program to attract into the health field some of the 65,000 to 70,000 medically trained veterans discharged annually from the armed forces. The Subcommittee on Health of the Elderly,

of which I am chairman, has been concerned over the shortages of trained health personnel which threaten to deny many elderly individuals—as well as individuals of all ages-medical services needed to maintain a high level of health. Your project impresses me as a sensible approach which gives great promise for improving health services in the United States at little or no public expense. Congratulations upon your imaginative work!

Our subcommittee is presently conducting a series of hearings on the subject, "Cost and Delivery of Health Services to Older Americans". Transmitted to you herewith is a copy of our first hearing in this series, to give you an idea of the scope of the hearings.

It would be a valuable addition to the record of these hearings to receive a statement from you describing your program, with particular reference to its anticipated effect upon cost and delivery of health services to the elderly. One aspect of this subject in which I am particularly interested is the development in civilian medical practice of subprofessionals of the type sometimes called "doctors' assistants" patterned after Navy medical corpsmen.

While serving as a Marine officer in the Pacific during World War II, I observed the efficient and effective use which was made of these personnel to perform many tasks which, while requiring a minimum of training, did not require the services of a Medical Doctor. Since returning to civilian life, I have been impressed with the need for a specialty of this type to help keep costs of medical treatment to a minimum and to relieve scarce physicians of tasks which could be performed by less highly trained personnel. Accordingly, I would be especially grateful for any advice you might be able to give us concerning the possibility that these former servicemen might continue in civilian life to carry out functions as "doctors' assistants" similar to those previously carried out as medical corpsmen.

You might also comment on the possibility that use of these trained, experienced former service personnel in this way might give impetus to the practice of using "doctors' assistants" in civilian life. Thanking you, and with kind regards, I am Sincerely yours,

GEORGE A. SMATHERS,

Chairman, Subcommittee on Health of the Elderly.

[From the New York Times, Oct. 17, 1967]

U.S. AIDS EX-MEDICS TO GET HEALTH JOBS

WASHINGTON, Oct. 16.-President Johnson announced today a plan called Project Remed to encourage discharged military medics to remain in the health field in civilian life.

The plan is part of a broader effort first announced last August to help smooth the transition of veterans to civilian life.

The new program will offer veterans either a job in the health field or training and education to improve the medical abilities obtained in the service.

The White House said about 60,000 men and women trained in the medical field were discharged from military service each year.

It said that about 300,000 more health workers were needed to give the nation the best possible medical care and that the rise in population alone would accentuate the shortage unless adequate steps were taken.

Officials said that no discharged medics could be employed as practical nurses, psychiatric aides and medical technicians, for example.

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, Washington, D.C., November 15, 1967. DEAR SENATOR SMATHERS: I should like to express my sincere appreciation for your most kind remarks about Project REMED in your letter of November 2, 1967.

The program was initiated for three major reasons: (1) To provide employment and educational opportunities for returning veterans; (2) To capitalize on the investment the Government made in training these men in the health occupations; and (3) To provide quality health care for all sectors of our society. Since the program has just begun, it is too early to predict, or to anticipate, what effect the program will have on the cost of delivery of health services to

the elderly. The Department of Labor is evaluating the program for us, and I shall provide you with data as soon as they are available.

I share your concern for the need to develop a new level of health personnel such as a "physician assistant." The enclosed article, which I wrote while still a professor of medical education at the Medical College of Virginia, might be of interest to you. While at the time I wrote the article I was still weighing the appropriateness of a "physician assistant" for this country, I am now convinced that such a medical auxiliary is indeed necessary if the health needs of our society are to be met. You might find the article of particular interest for it describes the efforts of the British and Australians in training and using "physician assistants" in the Fiji Island and Papua-New Guinea.

The Department of Health, Education, and Welfare strongly endorses the development and use of auxiliaries such as "physician assistants." A few significant starts have been made in this country. The University of North Carolina under Dr. Eugene Stead has such a program. Dr. Henry Silver at the University of Colorado is training "pediatric assistants." At Presbyterian Hospital Center in San Francisco, "orthopedic assistants" are being trained. As a matter of fact, one of the most imaginative proposals I have seen and discussed on this subject was prepared by the Department of Pediatrics at the University of Florida. They have a plan to develop an auxiliary that would be a physician assistant in the area of maternal and child health care.

As you can see, small inroads have been made. However, far more needs to be done. We need to develop and test a wide range of these "physician assistants" who can serve as an auxiliary to the physician. By using such auxiliaries, the physician's time could be put to more specialized use and health services could be extended.

We are deeply interested in the subject of physician assistant. I would welcome the opportunity to discuss it further with you.

Sincerely yours,

EDWIN F. ROSINSKI, Ed.D.,

Deputy Assistant Secretary for Health Manpower.

Senator SMATHERS. May I say let's give all these doctors, the four of them, a fine hand, because indeed they deserve it. [Applause.] We will stand in recess until 2 o'clock.

(Whereupon, at 12:20 p.m. the subcommittee recessed, to reconvene at 2 p.m., the same day.)

AFTERNOON SESSION

(The subcommittee reconvened at 2:30 p.m., Senator Smathers presiding.)

Senator SMATHERS. The meeting will come to order.

First we would like to apologize for the fact we were late. We went out to the Montefiore Bathgate Health Center supported by the Office of Economic Opportunity to observe what they are doing. It is a remarkable and heartening sight to study the contributions they are making, although the neighborhood leaves a lot to be desired.

We left there and went to the Bronx State Hospital which is primarily a mental hospital, with Dr. Zwerling who was connected with Albert Einstein University, as their chief psychiatrist. He took us through these wards to look at some of the elderly in these wards who regrettably are well, as he expressed it-they are stable emotionally but they really just don't have anywhere to go, they don't have any home to go to so they just stay on. It was a sad and yet warm experi

ence.9

We left there and went viewing some of the other areas so I regret

Statement by Dr. Zwerling appears on p. 582.

to say we are running late. We are here now and our first witness this afternoon is going to be the very able doctor who was with us all through the field trip, Dr. Wise. Harold B. Wise is the Project Director here.

I might further add so that there will be no disappointment and so that you will not wait and then be disappointed, Senator Kennedy was here this morning and with us during the lunch hour as we visited these various places but had some very important matters that he had to attend to this afternoon and doubts whether or not he will be able to get back before the hearing recesses at 5 o'clock. He regrets that he is not able to be here with you.

Dr. Wise, you may proceed any way you like.

STATEMENT OF HAROLD B. WISE, M.D., PROJECT DIRECTOR, MONTEFIORE HOSPITAL NEIGHBORHOOD MEDICAL CARE DEMONSTRATION, BRONX, NEW YORK; ACCOMPANIED BY MRS. DAVIS AND MRS. LOPEZ

Dr. WISE. Thank you, Senator.

I would like to introduce you to Mrs. Davis who is on my left and Mrs. Lopez will be up here momentarily. I have asked them to advise me if I get into difficulties.

Senator SMATHERS. All right, Doctor, you may proceed.

Dr. WISE. Senator, I would like to spend my time describing the problems from the viewpoint of a physician working in the community and rather leave the broad problems of medical care to the experts that spoke so ably this morning.

I would like to describe a patient who is under the care of a team consisting of a doctor and nurse and a family health worker. I included this in the testimony and I will summarize it. The only difference in the testimony is since Monday when we typed it up we have had to admit the patient into the hospital. Her problems I think represent many of the problems of an elderly person who is trying to maintain herself without going into the hospital or into a nursing home.

Mrs. O, and I am not giving you her full name for her protection, is a 72-year-old widow who lives alone on the fourth floor walk-up of a building not far from where we are now. She was born in the Carolinas and came to New York in 1950. She and her husband and three children were leading a productive life. He was manager of an apartment building and they belonged to a union health plan and things were not too bad, they were able to get their medical care from the union health service while he was alive.

About ten years ago things began to change and really from that point on Mrs. O's life has become a matter of just coping. Her husband was her entree to medical care. She had a couple of problems which were managed by her private family physicians at the union health plan. After that she had to get her medical care from a clinic in a city hospital, a free clinic, three-quarters of an hour here by public transportation. She went there for her heart disease and treatment of her diabetes and she went to another clinic in Manhattan because she had some tingling in her fingers and toes-a neurological problem. This was an hour and a half away by public transportation and your letter this morning really described a problem she had getting around.

S3-481-68-pt. 2- -5

She was unsteady on her feet and when she walked too quickly she got a pain in her chest, yet much of her time was spent going to clinics in various parts of the city and waiting many hours and often seeing a different doctor each time and trying to cope with her medical care. During an episode of unsteadiness she tripped. She fell and she broke her hip and was hospitalized and was in the hospital for many months because they could not find adequate housing for her on the outside.

Several years ago she had been living with her single daughter in her apartment. Her daughter got married and moved to Brooklyn so she lives alone now. Since that time her whole kind of robustness and happy attitude to life changed. She became lonely, she was afraid to go out. For shopping, she had to depend on a neighbor. She became gradually more and more reclusive. She didn't go to the doctors in the various clinics as they were hard to get to.

Her taking of medications was not reliable. This lady has gradually deteriorated so that her apartment which was very tidy and spic and span has gradually become run down. She has lost a lot of weight, she is not taking her insulin correctly. You have a person really who is both physically and psychologically run down because she has not really received comprehensive medical care and all the other things that go along with it that keep people healthy.

CONSEQUENCES OF ISOLATION

Now if this lady were left alone one of three things would happen. Her condition would become so bad that she might become forgetful and become unreasonable and she would be taken to a State mental hospital like the one we visited this morning.

She would slip and fall and break her hip again and be admitted into a general hospital where 10 percent of the patients in the general hospital units are just looking for homes on the outside to go and stay there as boarders in the kind of "hotel ward" very similar to the wards you have seen today.

Or the third and the most unfortunate failure of our system, she would not see anyone, her neighbors would not see her and one morning she would be found dead.

I see you are nodding. This is not an exaggerated story and I wanted to present one that was not too severe to focus on the kinds of problems we have in providing medical care for the elderly.

A major problem that has been discussed is the lack of medical manpower in this area. In these 55 blocks that we are in, there used to be 25 doctors practicing, now there are four. There used to be only 25,000 people living here and now there are close to 50,000. So in the Bronx where you have one doctor for 700 people, in this part of the Bronx you have one doctor for 10,000 people.

The doctors are working very hard, some of them seeing very many patients a day and making home visits trying to provide care. The only open avenue of care has been the emergency ward at the clinics which are run down and which in no way offer the kind of personal health services that people are looking for and are used to and have as their right to expect.

I want to deal a little bit with some other problems that I have to cope with as a physician that are really out of my control. You talk

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