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The CHAIRMAN. Any further questions, gentlemen? I believe that will be all. Dr. Duckett Jones, did you have something to add?

Dr. JONES. I would like to say that early this summer I was invited to Canada to speak to a group of the heart association people who are interested in the beginning of plans where they will have both Government and private funds for cardiovascular research. They apparently are going to go ahead and hope it is very effective in the near future. Dr. WRIGHT. Mr. Chairman, since time is marching on if I may

I should like to ask the 3 men representing 3 major areas within a period of about 3 minutes each to mention briefly what they consider to be the main weaknesses in their particular areas in terms of their information at this time; and if they can, to suggest some direction of approach. Then we will summarize by our

recommendations. The CHAIRMAN. Before we proceed with that, did you have a question you wished to ask, Mr. Heselton?

Mr. HESELTON. No. I wanted to ask the previous question to see if anybody thought there were any weaknesses.

Dr. WRIGHT. If I may I will ask Dr. Wilkins first to outline very briefly what he considers to be the 2 or 3 real loopholes and major weaknesses in the problem of dealing with hypertension. STATEMENT OF DR. ROBERT W. WILKINS, VICE PRESIDENT OF

THE AMERICAN HEART ASSOCIATION, MASSACHUSETTS MEMORIAL HOSPITAL, BOSTON, MASS.-Resumed

Dr. WILKINS. I am not sure these weaknesses deal only with the field of hypertension, but for what they are worth I would see them as follows: It seems to me we are prone to have the impression, largely from the oft-repeated references here to the atomic-bomb project, that results come from the urgency of the need for the results on the one hand and the amount of money that is put into it on the other. Whether that is true in the atomic-energy field or not I am not qualified to speak to, but I am absolutely certain that is not true in the medical field. Á problem may be terribly urgent; you may pour great amounts of money into it; but that does not equal the answer.

Secondly, one of the points that I think ought to be emphasized in an introductory way is that we speak continuously of basic research and yet, being practicing medical men, we have to deal with the practical aspects of doing the best for the patients at the time that we can with what we have available. This has two effects so far as research is concerned. It makes us emphasize the practical or treatment aspects of the disease. That is particularly pertinent to hypertension, when we do not know its cause and we are really groping in the dark as to the proper methods of treatment.

I would say that that feeling has dominated the research that has been done in the hypertension field in the last several years. I, myself, have been active in it and guilty of it; namely, that we felt that treatment was so urgently needed that we have devoted a great deal of time to treatment and as a consequence we have perhaps left undone some of the basic research that could be done and needs to be done as to cause or mechanisms, if you will.

So I would put No. 1 on the list, so far as hypertension is concerned, the need for more research people to dodge, if they can, the intimate and practical necessity of treating patients with drugs or what have you in order to have time to try to get behind what causes the disease.

Now, as the corollary to that weakness it seems to me you have implied there the need for training of people in the basic sciences in this connection, and then you come hard up against the possibility of where are you going to get the people and where can you train them? This hits into the hard fact, so far as I am concerned, of the needs of medical education.

I do not want to deviate from my subject except to insert for the record, Mr. Chairman, that medical education today, in my opinion, is in a crisis situation and that something has got to be done or the recruits from which we in the research field hope to draw new material in terms of young, bright minds equipped by training to do the work that needs to be done will not be available to us in the proper quantities.

Dr. WRIGHT. Dr. Wilkins, I am sorry to interrupt; but please illuminate the committee on why you consider medical education to be in a critical state at this moment.

Dr. WILKINS. Well, I consider it to be in a critical state because of the medical schools, all private medical schools—that is, those not supported by State governments—being financially badly in the red and having been so for a number of years. They are losing propositions.

In my own university the medical school spends far and away more money than any other department of the university and does not even pretend to meet from its tuition income the costs of medical education; and the university has told us frankly that this can go on for a few years, but it certainly cannot go on indefinitely. That is just one medical school, but I know it is not unique. It is countrywide.

Where you have State or Government support of some kind that situation is not as critical.

Now, speaking for my own school, we would like very much to expand our school for the public good, to educate more doctors, to educate more research workers, and to get more people to draw on. We cannot do this under the financial situation in which we now exist.

There is another and very complicated problem, Dr. Wright, but it is intimately tied up with what I consider to be the great weakness in my field. Now, that is men. Assume that you have the men. And we do have more men now who would like to go into research than we could accommodate. Why is that? This is the second weakness.

There is not the money to build the laboratories and equip them for these men who are available to work in them. Well, you say, “That means you can pick off the cream. Yes, but you are not always certain you are picking the cream of the young men who come along. Every day I interview youngsters who seem to be bright and up and coming and have their hearts in this. I have to say: "I am sorry; there is only one position available next year. Obviously it is on a competitive basis and we will pick the best man."

For that reason I think the even more crying need at the very moment is for more space to put the men to work in that we could get today if we had the space to put them in.

Now, there is one other thing that comes back to the point about medical schools that I am not sure everyone appreciates in this connection and that is this: Assume that we build an institute in the medical school to do research. You have to do more than build the institute and support the local research in order to make it not a losing proposition for the medical school to allow it to go on, because the facts of the matter are that the administrative costs of bearing this adjunct, if you look at a medical school, are quite out of proportion with the 8 percent which I believe is the usual overhead figure that is given in research grants awards; so that the medical schools have gotten themselves into the bad situation of not being able to live without research money, and they are going into the red more heavily the more research money they take.

I do not know what the solution to this is, but if medical research is going to continue as it has in the past to be centered largely-I am not saying totally or that it should be totally-around medical schools, schools of medical education, then I believe our most crying need is to do something to relieve the medical schools and to get them on a sound economic and businesslike operating budget and something that will pay its way

at least as it goes. I do not think anyone proposes to make money out of medical education.

I would say those are the great needs.

Dr. WRIGHT. I think Dr. Wilkins has really expressed what has been in the minds of all of us. Perhaps he has picked the great needs with reference to the other specialties, too, so I will ask the other two speakers not to repeat these statements, since I am sure they are in agreement. If they disagree they may state so. But if they wish to add to them, taking up some other aspect of the particular fields, I should like to be able to call on them if I may, sir.

Dr. Jones?

STATEMENT OF DR. T. DUCKET JONES, MEDICAL DIRECTOR, HELEN

HAY WHITNEY FOUNDATION, NEW YORK CITY-Resumed Dr. JONES. I would like to clarify one of Dr. Wilkins' remarks.

I am sure it is absolutely true that the amount of money and the direct relationship to returns in relation to knowledge is not possible, but I hope you did not mean by that that more funds

were not needed. Dr. WILKINS. No. I am sure you do not get knowledge without funds.

Dr. Jones. I would agree with the remarks he has made with that change and emphasis; and I would like to add 1 or 2 more things.

I think that we have done up to now a really inadequate job. I am not criticizing anyone. I mean this is what has developed in the last few years. It is inadequate in the way in which we give continuity and stability to those workers who have shown themselves worthy, by the repetitive nature of the short-term grants, which are very disastrous to any operating research group; and I think we have not yet developed a satisfactory program whereby we can be certain that we are getting the very best potential personnel for research and utilizing them well. I think that is the key for future expansion, and that something could be done.

There is one other feature that I think Dr. Wilkins intended to stress very heavily, and that is that this is a question, as far as rheumatic fever is concerned, of the point of weakness in the present direction of attack. It makes me think of the fact that I certainly do not know the answer to rehumatic fever. I serve on a good many boards. I would hate to think that in serving on any research fund committing group that I did so with the thought that I voted “yes” on a given grant because it was going to give the answer to the rheumatic-fever problem. All I can do is express faith and confidence in the very able workers who have or possibly can contribute to knowledge.

Hence I think that there is very grave danger in limiting the number of fund-granting agencies for medical research to any very limited group of human beings or agencies. In other words, the freedom of scientific inquiry is greatly heightened when the authoritative control of the acquisition of knowledge is put in multiple agency or group hands rather than concentrated in a single authority, because no one is divinely ordained in this respect, and unless he were he could not predivine what was coming from any given grant.

I think it has been obvious from this discussion today that there are a number of agencies which are vitally interested in getting increased funds from the private individuals of this country; in getting, if possible, an increased volume of high-quality research; and in insuring that they are and will be spending funds well.

There are also multiple sources within the Government agencies. I am sure not only the Public Health Service, which has been concentrated upon today, but others have some interest in this field. I hope that there will be no grouping of everything under one single pattern of administrative control because when we do that then we obliterate the opportunity for the little-known person, and he may be the man who is going to bring us possible knowledge of great importance for the future.

Dr. WRIGHT. Thank you, Dr. Jones. Dr. Andrus?

STATEMENT OF DR. E. COWLES ANDRUS, JOHNS HOPKINS UNI

VERSITY, AND PRESIDENT-ELECT OF THE AMERICAN HEART ASSOCIATION–Resumed

Dr. ANDRUS. Well, speaking of the field of arteriosclerosis I think there are two great needs at present. First is a means of diagnosing the disease before the accident, such as a heart attack, which is a consequence of the disease cripples the individual. To put it another way, some means of characterizing those individuals who have atherosclerosis and are liable to these accidents.

In the second place, there is the need to gain some means of affecting the progress of the disease, to slow it down or to stop it.

Now, that problem shares with all the other problems that have been mentioned today in the need for new knowledge, and that means research. If we sound insatiable in our desires for more funds, there is a limit, of course, to what can be fruitfully employed, but there is a real need to collect the brains that can do this job, to create a favorable climate of opportunity for the younger, more imaginative investigators in the field. When a man demonstrates that he can do this work and that he can be productive, do not make him peddle

his idea from year to year in order to get a grant that he has to work to renew a year from now, but give him stability and continuity of resources so that he can forget that phase of the problem long enough to get on with his job. That, I think, is an essential.

Thank you.

Dr. WRIGHT. I think that we have largely concluded what we had in mind in terms of our outline. The recommendations have been made as we went along. We would be glad to try to answer any questions of the committee, sir.

The CHAIRMAN. With reference to this last phase of the testimony, Dr. Wilkins emphasizes the inadequacy of support for medical education, the thought that was expressed by Dr. Jones was as to the necessity of having some assistance diversified, and there was the point you have just made, Dr. Andrus, about emphasizing stability and continuity of service or help; and those questions are not new to this committee. In our study of the inadequacy of physicians, from the standpoint of numbers—I am not speaking otherwise the committee has been made aware of some startling information in that respect. I remember a statement made before us in one of our hearings not too long ago that there were not appreciably any more men being graduated in medicine today than at the commencement of this century. That struck me as a rather unusual situation. There was some explanation that was made of it, however, by saying that in the early part of this century the tests and the types of college were not the same as they are at the present time; that at that ime there were colleges in existence which were issuing licenses very quickly and not with the consideration which now prevails; and that that had something to do with the large number who entered the practice of medicine at that time as compared to the present.

Now, with respect to a lack of hospitals, this committee gave consideration to that subject. This committee originated the Hospital Construction Act which, so far as money has been appropriated to it, has done a pretty good job, particularly in its benefit to communities which were not able to build hospitals. We have left that very largely to the States to determine, as to where the money which comes from Federal sources should be expended.

I mentioned what has been referred to by Dr. Wilkins and Dr. Jones and Dr. Andrus as a matter that this committee has given consideration to and will continue to give consideration to. It is a very serious matter.

When you come down to the inadequacy or insufficiency of physicians, you run across the fact that after a physician has gone through several years of preparatory study, including college as well as the medical school, that it has brought him along pretty well in life and has cost him a great deal of money, and the tendency is to practice where there will be a return commensurate with the time preparing and the expense incident to it, with the result that we find doctors very largely gravitating toward urban centers rather than to rural areas. Therefore, we have figures with respect to the number of doctors in New York or Philadelphia or places of that size and even less that are astounding when you compare them to the number of physicians in some localities in different parts of the United States, and particularly the rural districts.

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