STATEMENT OF DR. LUTHER L. TERRY, SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE; ACCOMPANIED BY BOISEFEUILLET JONES, SPECIAL ASSISTANT TO THE SECRETARY FOR HEALTH AND MEDICAL AFFAIRS

Dr. TERRY. Thank you, Mr. Chairman. I trust that your prejudice is not such that it has prevented your being objective.

To members of the committee I apologize in certain respects with regard to my statement. The prepared statement will go over some of the material which we discussed at least in part this morning.

However, since my statement is brief, Mr. Chairman, I would like to present the statement to you as we had prepared it, in the hope that it would clarify some of the questions raised this morning.

Mr. ROBERTS. Proceed.

Dr. TERRY. In projecting needs for professional health personnel, attention has been focused primarily on the ratio of manpower to population. Thus, our legislative proposals have set as a minimum goal the maintenance of the present ratios for physicians and dentists. Even to reach this minimum goal, as the President noted in his state of the Union message, will require a 50 percent increase in the capacity of our medical schools over the next 10 years and a 100 percent increase in dental school enrollments.

There are several aspects of the supply picture, however, that tend to be obscured when we talk in terms of ratios alone. The need to increase our manpower supply is more urgent than the ratios suggest.

To get some perspective on this problem, let us go back to 1930 and look at 10 young men newly graduated from medical school. What did these young doctors do then? If they followed the usual pattern for that time, all of them entered hospitals for 1 year of internship. A few had further training.

At the end of 1 year, most of them were in practice. After 2 or 3 years, 8 of the 10 were in private practice 6 of them general practitioners, 1 a specialist in internal medicine, and 1 a surgeon. Of the other 2, 1 was serving in a hospital; the other was in public health or other public service.

In effect, 7 of the 10-the 6 general practitioners and the 1 specialist in internal medicine-were in practice as family physicians. Now let us look at 10 typical graduates today. All of them will serve a 1-year internship. Most of them will continue with residency training in a hospital for an average of 3 years. Many of them will serve for 2 years in one of the uniformed services. Not until about 5 years after graduation will most of them have completed training and obligated service.

At that time we will find 7 of them in private practice of whom 2 will be general practitioners, 2 will be in internal medicine or pediatrics, 1 or 2 in surgery, and 1 or 2 in other specialities. Two will be engaged in hospital service or training, one will be in teaching, research, or some other field.

Thus we find that two significant changes in the patterns of activity of new medical graduates have taken place. First, after the completion of medical school it now takes about 5 years, rather than 1 or 2, for most physicians to enter practice. Second, in 1930, 7 out of

10 physicians became family practitioners; today, the rate is about 4 out of 10.

The implications of these changes are many. In 1930 about 70 percent of all active physicians were family physicians; today the figure is only about 40 percent. In 1930, 10 percent of our physicians were full-time surgical specialists; now the proportion is 24 percent. In 1930 only 1 percent of our physicians were psychiatrists; today they account for 5 percent.

In 1930 teaching, research, and public health took the time of less than 2 percent of all physicians in the United States; now the proportion is more than doubled. In 1936, 6 percent of all physicians were in hospital service; now the proportion is almost tripled.

I want to emphasize that even though larger numbers of young physicians are going on for specialized training and thereby are being removed from the pool available to provide family health services, this should not be looked upon as a net loss to the health care picture. Quite the contrary, with the rapid pace of advance in medical science and the increasing need for highly specialized skills in medicine, the increasing numbers entering specialty practice and the growth of teaching and research staffs are contributing greatly to overall improvement in the quality of medical care.

În fact, the increases have been too small. There are today many examples of unmet need in fields other than family practice. Outstanding among them is the lack of an adequate number of psychiatrists in mental hospitals and mental health clinics. Vacancies in general hospital staffs are a threat to the health of the community generally.

As Surgeon General of the Public Health Service I am only too well aware of the difficulties of recruiting physicians for essential public health positions so great is the competition for specialized medical manpower.

At the same time, there is real cause for concern in the rapid decline in the supply of family physicians. Turned another way, the figures I have given you mean that whereas in 1930 each family physician-including general practitioners, internists, and pediatricianshad a potential patient load of 1,300, today that potential load has reached 1,900. By 1970 it will certainly be well over 2,000.

All this has occurred in the face of greatly increased consumer demands for physicians' services. Most of you are familiar with the increase in the proportion of old people and small children in the population-the very groups who require the most physicians' care.

Almost as well known is the fact that rising educational and economic levels are increasing demands for physicians' care. The growth of health insurance and other health benefits is removing more of the economic barriers to needed service. New ways of extending the lives of chronically ill patients also place more demand on the time of medical practitioners.

Over the past 10 years the output of our medical schools has lagged behind population growth. The physician-population ratio has stayed almost constant only because foreign-trained physicians have filled such a large part of the gap between population growth and increased medical school output. If it were not for the foreign-trained physicians, the ratio of physicians to population would have dropped almost 10 percent below its present level.

To expect physicians to provide increased amounts of service simply by treating more patients in a day-seeing each patient for a shorter time and delegating more tasks to less highly trained assistantswould be unrealistic. Every possibility for improving efficiency deserves to be explored.

However, the days of the leisurely examination and frequent home calls are already long past. Even now, the patient often gets services from the nurse or the technician rather than from the doctor. There is a limit beyond which the number of patients treated by an individual physician cannot be increased without impairing quality of

care.

What I have been saying up to now about physicians also applies in considerable degree to dentists and professional public health personnel. The dentist-to-population ratio in the United States has dropped over the past 20 or 30 years and will continue to fall over the next 10 years. But in addition, an increasing proportion of dentists are entering specialty practice, research, and other fields of activity besides general care of patients.

Demands for dental service are mounting with increasing appreciation of the value of these services and growing ability to pay for care. Professional public health personnel are needed in increasing numbers, relative to population, as communities develop new and strengthened service and research programs in this area of activity.

Looking ahead, we see no alternative to a very substantial increase in the output of professional health personnel in the United States. The longer this increase is delayed, the greater is the hazard to the Nation's health.

Mr. ROBERTS. Thank you, Dr. Terry. I appreciate your statement very much, and I think the comparison of the numbers who became general practitioners or family physicians back in 1930 with what it is today points out a very important fact.

We have had a lot of testimony that many communities, especially small rural communities, have a very hard job getting general practitioners out of those areas. Do you feel that the forgiveness section of this bill will be some incentive to bring doctors to these communities that I am speaking of?

Dr. TERRY. Frankly I feel it will help, sir.

Mr. ROBERTS. There is, I believe, a nursing section in this bill. We have had a commission working on that problem. Do you know or have a pretty good idea of when that report will come up before Congress?

Dr. TERRY. Mr. Chairman, the consultant group which was appointed almost a year and a half ago has gone into a very detailed study and has now presented the final study to me.

At the present time the report is being studied in the Public Health Service and in the Department in relation to what position we should take.

However, we are not prepared at this time to submit specific recommendations pertaining to the nursing profession that might be included in H.R. 12.

I think this should be brought out. This morning we tended to talk physicians, sometimes talking about dentists, but I think that we might have been misunderstood by not having mentioned nurses, for this is one of our areas of very great shortage.

Mr. ROBERTS. My thinking is it would be very helpful to the committee if the work of that Commission could be made available to us before we go into executive session on this bill, because as you know there is a lot of feeling in the country that we will need a nurses bill.

I think if you knew something about that report, it would be very helpful to us before we take action on this bill.

Mr. JONES. Mr. Chairman, it has been the purpose of the administration to present to you a special recommendation having to do with nursing. This the President made clear in his health message last year, and the consultant group appointed by the Surgeon General was to develop the data on which a legislative program could be based and recommended to you.

It would be our hope that you could proceed with this legislation and give the administration opportunity to develop a legislative program for nursing, and make that the subject of special consideration by your committee at a later date.

Mr. ROBERTS. Do you mean to imply by that that we should not put any stress on grants for nurses in this particular bill?

Mr. JONES. No, sir. We think that the provision which your committee made last year, which is now in H.R. 12, to include construction grants for collegiate schools of nursing, would be quite in keeping with what would be recommended later.

What I am saying is that I would leave this as it is, if you wish the recommendation, and then subsequently we would bring other recommendations beyond construction grants for teaching facilities. Mr. ROBERTS. Those other recommendations would have to do with scholarships perhaps?

Mr. JONES. Yes, sir, and whatever the needs that would develop by virtue of this study.

We think nursing is a shortage area with a complete range of training activities that require special consideration over and beyond this particular bill as a vehicle, and we would much prefer to give you recommendations in a package for nursing, independent of this bill except for what you have properly added, construction grant authorization for collegiate schools of nursing.

Mr. ROBERTS. Thank you very much.

Dr. TERRY. On the other hand, Mr. Chairman, I think we can very well anticipate that the consultant group's report will probably, almost certainly, be available to you before final action is taken in the committee on this bill.

Mr. ROBERTS. Thank you very much. Mr. Chairman.

The CHAIRMAN. Doctor, you contemplate having that report out right away, don't you?

Dr. TERRY. Yes, sir. Certainly before the end of the month.

The CHAIRMAN. It would be very interesting to have it, if it includes the matters which are here before us. Insofar as the report concerns other programs pertaining to nursing since these are entirely different subject matters it should be given consideration separate and apart from this program.

Dr. TERRY. That is the way we felt about it, sir.

The CHAIRMAN. I would like to ask for a little further clarification as to how the loan provision would work, as you understand it, in this

proposal. We provided last year in the bill reported by the committee for loans over a period of 5 years.

Dr. TERRY. Yes, sir.

The CHAIRMAN. We have a budget that was presented to us not necessarily on the loan program, but which we developed from what you recommended for scholarships, and arrived at the figures which were included in the report.

Do

you have any more recent estimates of the cost required to meet the needs, should the loan provision be agreed to, in view of the AMA program and the opportunities on the local level to meet the needs? Dr. TERRY. We do, Mr. Harris, have some estimates of the cost of the loan program by years.

The CHAIRMAN. Would you supply them for the record?

Dr. TERRY. Yes, sir. May I give it to you, sir?

The CHAIRMAN. Yes, if you can briefly.

Dr. TERRY. For instance, in 1964 we would expect it to be about $5,100,000.

The CHAIRMAN. How much?

Dr. TERRY. $5,100,000.

The CHAIRMAN. All right.

Dr. TERRY. In 1965 $10,200,000; 1966 $15,400,000; 1967 $20,600,000 ; 1968, $21 million.

The CHAIRMAN. Those figures are included in the bill. Did we get them from you or did you get them from us?

Dr. TERRY. I am not sure, but I think they are reliable figures, sir.

The CHAIRMAN. I think you can be safe in that statement either

way.

Now would the provisions for loans in 1966, for example, include the amount that would be made available for the student who entered with a loan for the first year of 1964?

Dr. TERRY. Each year the school would make a determination of the individual student's needs, and would base the loan to that student on the amount of funds they had available and the relative need of the student.

Particular priority will be given, as brought out in the committee's report, to first year students in terms of trying to attract more promising youngsters into medicine, but at the same time the loans would be available as I understand it, sir, to any level of school during that particular year.

The CHAIRMAN. Maybe you don't understand what I am talking about or at least trying to get at. I would assume that any student with ambition to go to medical school, who did not have the funds to meet the high cost that goes with it to start with, would be in the same position after the second, the third, and even the fourth year as he was in he first year. By that I mean there would be very few who would strike it rich during the time they go to school.

Now the point I am trying to make is that if a student enters in 1964 and you make a loan out of the $5 million which is authorized for the first year, in order for him to get the loan in the second year you have to have authority in the second year.

Dr. TERRY. Yes, sir.

The CHAIRMAN. And if he were to follow all the way through in meeting the need requirements, in order for him to get the loan in