HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE WEDNESDAY, FEBRUARY 6, 1963 HOUSE OF REPRESENTATIVES, The committee met, pursuant to recess, at 10 a.m., in room 1334, New House Office Building, Hon. Oren Harris (chairman) presiding. The CHAIRMAN. The commitee will come to order. As we continue hearings this morning on H.R. 12 and related bills, our first witness will be Dr. Russell Nelson, Johns Hopkins University Medical School, Baltimore, who will be representing the American Hospital Association. Dr. Nelson, we are very glad to have you. Dr. NELSON. Thank you, Mr. Chairman. The CHAIRMAN. I believe you have with you an associate whom you might identify for the record, Doctor. STATEMENT OF DR. RUSSELL A. NELSON, PRESIDENT, JOHNS HOPKINS HOSPITAL, BALTIMORE, ON BEHALF OF THE AMERICAN HOSPITAL ASSOCIATION ACCOMPANIED BY KENNETH WILLIAMSON ASSOCIATE DIRECTOR OF THE ASSOCIATION Dr. NELSON. Mr. Chairman, I am Dr. Russell A. Nelson, president of the Johns Hopkins Hospital, Baltimore. I appear here today in behalf of the American Hospital Association. Accompanying me is Mr. Kenneth Williamson, associate director of the Association. You are familiar with the association, as representatives have appeared before the commitee through the years, and I will not dwell on any further identification of the association. I am happy to endorse H.R. 12. I will not read the prepared testimony which is before you, but I would like to comment on some features of it briefly. We think there is urgent need for assistance in construction of teaching facilities, both in schools and in hospitals, and we commend to you as early and favorable consideration of the construction portion of this bill, particularly. We know that it will take many years to fill the pipeline of added facilities to produce the increased number of graduates which we know are needed for the health care of Americans. I would like to confine my remarks chiefly to the shortage of physicians, and point out one area that affects us in our hospitals daily, and that has to do with the shortage of interns and residents, the young graduate physicians who are in for further training in hospitals and are so essential to the care of patients in hospitals. You know the numbers involved. There are severe shortages which are only partially made up by the appointment of graduates of foreign medical schools. The United States, with all its vast educational resources, is an importer of medical manpower. This shortage of interns and residents does two very serious things to our hospital care: It diminishes the quality of the care in some situations, and this is a serious mater of considerable concern to the profession. Secondly, it seriously decreases the efficiency of the doctor in his work in the hospital and, to some degree, limits the capacity that he has to take care of all the patient demands that come to doctors and hospitals. In my own State of Maryland, which we think is a State with good educational resources and perhaps better than average medical resources, we face this shortage, too. There are 19 of our 40 hospitals in the State of Maryland approved for intership and residency training. Those hospitals last year had places for 315 interns and about three times that many residents. Last year for the 315 positions we got 125 American graduates. There are probably 50 to 75 foreign medical graduates obtained to fill in the vacancies, but, as you can see, there were one hundred or two hundred positions never filled. Now, this reflects itself in the hospitals, particularly in the urban area of Baltimore, by inadequate doctor coverage of our emergency departments where patients seriously ill or injured may be forced to wait unnecessarily long times in order to get needed care. We are, also, constantly, I think, short of practicing physicians particularly in the rural and isolated areas in our State. In our hospital in Baltimore we, monthly, I would say, get requests from communities to refer physicians there because they either have none or the physician that is there is old and soon to retire or cannot keep up the pace of his younger years. We also know that in our urban areas our doctors are so busy that emergency care at night and over weekends is difficult to get for the families in their homes and the patients and the people are coming to our hospital emergency departments where we, in turn, have our difficulties because of inadequate numbers of interns and residents. Another point I would emphasize to you is in the area of public health officers. Again, in our State of Maryland we feel that we were leaders in establishing sound public health organization, and we have provision for a qualified physicial public health officer in each of our 23 counties and have had for a number of years those provisions. As of today five positions are vacant, even though funds from local and State sources are available to pay the salaries. There are 15 other important physician positions in our State health department that cannot be filled. This is at a time when we see the responsibility of a State health department for not only public health, but growing public medical care programs increasingly. We do have in our teaching institutions sources of Federal funds. for research facility construction. We do have sources of funds through the Hill-Burton program for the creation of bed facilities, outpatient facilities, and we do get some relief to teaching facility needs through these two programs, but some of us are concerned that this is leading to imbalance in the programs within our institutions, with a greater tendency to emphasize research and clinical care and not enough emphasis upon the teaching of students. Our students have trouble, and the provisions of this bill for loans would, I think, be helpful. I am sure you know how costly it is to go to medical school. There is no doubt that costs do keep some students from enrolling in medical schools. It costs $3,000 or $4,000 a year for a student in some of our private medical schools to attend. Tuitions are over $1,000, approaching $1,500, in some of our private schools. You know what living costs are. They are high. And I remind you that in medical schools there is a tendency to have 12-month operations or 11-month operations, not the academic year of 9 months. We do need loans to provide additional financial assistance to students. There is a special need here, too, for interns and residents who are, in fact, graduate students in medicine. I remind you that these men and women are spending at least 4 years in graduate education. They are surviving on very low stipends, $2,000 to $3,000 per year, with two-thirds of them being married. I hope that some assistance can be given to this group of students. I would like to close with a comment on a provision of the bill which does give us concern, and that is the provision to provide construction assistance for schools of nursing. We know that schools of nursing do need this assistance. Our nursing situation is serious, and I know that you and other groups in Congress will be studying this in detail later. But the bill before you provides construction assistance only to collegiate schools of nursing. These account for approximately 15 percent of the schools of nursing and 15 percent of the production of nurses. Eighty-five percent of our production of nurses comes from the hospital-sponsored school of nursing. These schools are approved by educational authorities in our States, can be identified as sound and proper educational groups, and we believe that the hospital schools should be included in the provisions of this act. We know that Hill-Burton funds are available to hospitals in each of the States, but they are not adequate to meet the teaching facility needs of a school of nursing. First, any financial assistance provided for such teaching facility have been incidental to the needs to expand or create hospital beds and other diagnostic and treatment facilities, and often suffer because of their incidental nature. And, furthermore, in a practical sense, the priorities directing the use of Hill-Burton funds in all of our States provide that the funds go for the provision of beds rather than teaching facilities. And, finally, Hill-Burton does not provide a 50 percent matching, on the average, for hospital construction. For these and many other reasons, gentlemen, on behalf of our association, I urge that you favorably report H.R. 12. Thank you, sir. (The complete prepared statement of Dr. Russell A. Nelson follows :) STATEMENT OF THE AMERICAN HOSPITAL ASSOCIATION TO THE HOUSE INTERSTATE AND FOREIGN COMMERCE COMMITTEE ON THE HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE ACT OF 1963 (H.R. 12) Mr. Chairman, I am Dr. Russell A. Nelson. I am president of the Johns Hopkins Hospital, Baltimore. I appear here today in behalf of the American Hospital Association. Accompanying me is Mr. Kenneth Williamson, associate director of the association. You are familiar with the association, as representatives have appeared before the committee through the years, and I will not dwell on any further identification of the association. I am happy to endorse H.R. 12. I will address my remarks to the national need for an adequate number of physicians. Hospitals are deeply concerned with both the quantity and quality of medical education. There is a growing need for more and better physicians. To provide adequate numbers of good doctors, we must insure the availability of high quality medical education. The primary problem therefore is to modernize or replace many of the existing medical schools and also to provide new schools. have not changed since representatives of this committees of the Congress in the past except, intensified. The problems and the needs association appeared before perhaps, as they have been I cannot emphasize too strongly that it will be at least 5 years after the start of a construction program before the first students graduate. I do hope that the Congress will not delay any longer in initiating the construction phase in particular. The following is the situation as we in the hospital field see it : 1. The population is increasing and the proportion of physicians in relation to the population is decreasing. 2. The total number of approved internships and residencies has increased from 13,000 in 1940 to more than 30.000 this year. Hospitals are unable to fill a substantial percentage of available internships and residencies. We estimate one-fourth of these positions remain vacant. Last year, 7,138 students graduated from medical schools. 3. Shortages of interns and residents result in practicing physicians being able to treat fewer patients as an increased amount of their time must be spent in hospitals. 4. Desirable higher standards for acceptance of foreign medical graduates as residents reduces the number available from this source and aggravates the problem. 5. Increased financing of health services through voluntary health insurance and by Government results in increased demands by the public for medical care. 6. Medical research and medical education are brought together in the teaching hospital. It is in the hospital that much of our medical research is translated into patient care. Our future progress in health affairs must be closely related to research. Increasing numbers of well-trained physicians are essential if we are to take advantage of the opportunities which medical research offers. 7. Two examples of population groups which in particular require large and increasing amounts of medical care are the mentally ill and the aged. Great improvement is needed in the whole field of mental health care. There is now a substantial shortage in the number of psychiatrists. The needs of the mentally ill are not likely to be met without more doctors. Older persons require two to three times more care than younger age groups. The number of available doctors must increase just as the aged segment of our population has increased, if their health needs are to be met. 8. The need for increased numbers of doctors at all levels of Government has grown. Their services are needed in institutions operated by Government and in the whole field of public health. The provision of health services to our Armed Forces necessitates a constant drain on available physician manpower. 9. World health has an important bearing upon international relations. Our ability to assist people in other parts of the world to meet their health needs is dependent upon the availability of adequate numbers of physicians. We are particularly pleased that H.R. 12 recognizes the essentiality of teaching hospitals to the training of physicians so that the hospitals owned and operated by the 49 schools of medicine, as well as the 283 hospitals affiliated with medical schools, are given consideration in the program. The concerns of hospitals for medical education go beyond the medical student, since internships and residencies provided in hospitals are an integral part of the education of a physician. This concludes my written statement. Thank you Mr. Chairman. The CHAIRMAN. Doctor, thank you very much. Mr. Williamson, did you have any further comment? Mr. WILLIAMSON. No, thank you, Mr. Chairman. I would like to thank Dr. Nelson for a very frank and forthright I would like to ask this: statement. The situation that you have given for Maryland, do you think that prevails across the Nation? Is this a typical State? I know you have a great deal of teaching facilities in your State, but perhaps, if it is bad there, it would be the same in other States, or worse. Dr. NELSON. I do think we are better off, Mr. Staggers, than the average State, and the conditions that I describe might very well be worse in other States. Mr. STAGGERS. Now, I want to ask you this: Talking about foreign interns coming in and serving, do American students go to foreign medical schools, to any great degree, to get their medical training and then come back here? Dr. NELSON. To some degree. I think there are, let us say, about 7,000 graduates of American medical schools, most of whom are American citizens. I believe each year there would be 300 or 400 Americans that graduate from foreign medical schools. Mr. STAGGERS. I might ask you this: Is the trend for them to come back to America to practice. or to practice abroad? Dr. NELSON. No, to come back to America to practice, I think, sir. Mr. STAGGERS. I know some in my area that have gone to other medical schools for reasons and circumstances that they had to, and I assume they are coming back to this land to practice. Dr. NELSON. I think most of them do; yes, sir. Mr. STAGGERS. In your statement there about the lack of interns, spaces for 315 and you had only 125, and you talk about the resident doctors, I did not get the amount of resident doctors whom you said were available to fill these spaces. Dr. NELSON. I do not have that immediately available. I could get it for you, but I made an estimate that for each intern there would be three residents, on the average, and I would assume that the vacancy rate in the residents would be about the same as it is with the interns. I think that is about right. Mr. STAGGERS. Thank you very kindly. The CHAIRMAN. Mr. Springer? Mr. SPRINGER. Dr. Nelson, I know that you are faced with the same thing that we are in many of the other States in rural areas as you are in Maryland. With reference to the lack of doctors in the rural areas, do you have any suggestions as to how you can improve this situation? Dr. NELSON. Well, first, I think it is a difficult decision for a young man to make. He must be a very dedicated individual to give up the many advantages of an urban practice for the numerous disadvantages of rural practice, both to himself and his family, And, as long as we are short of physicians, as we are, in the cities, the tendency, I believe, is going to be for new doctors to stay in the cities. So I would say let us have more doctors. Mr. SPRINGER. I think you are right. |