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We can multiply their efficiency, we can do far more than by simply working over a long period of time to turn out more doctors. It takes about 12 years from the time you start to plan a medical school until you have the product, the physician who can work with patients. We would like to do something more quickly than that.


Senator SMATHERS. I don't want to delay this hearing but we have a lot of witnesses and a lot of ground to cover and I am talking too much. I am going to stop in a minute.

You said to develop a physician assistant.

Dr. SILVER. Yes.

Senator SMATHERS. What do you mean by that?

Dr. SILVER. Well, I have in mind a person who would be specially trained to work with the physician to do many of the things that require professional training that a physician is not required to perform. I have in mind, for example, the kind of study that was made among pediatricians in the State of Washington where it was shown that 50 percent of what the doctor was doing in his office need not be performed by someone with that much training. The business of taking the history and keeping records and handling telephone conversations in pediatrics, for example, rearranging the formula, consulting with the mother about guidance with respect to the growth and development of the child, many of these things would be carried on by people who don't need the advance training of 8 or 10 years of professional training that a physician has.

Senator SMATHERS. You know I happen to agree with you very strongly.

Dr. SILVER. Good.

Senator SMATHERS. I know the doctors don't like it but I was in the U.S. Marines for 4 years and I so well remember overseas where we had a sick call in the morning and you would see the fellows lined up to receive treatment for poison ivy, cuts, diarrhea, things of a minor nature, whatever it was. Then we had a couple of corpsmen there. The corpsmen had enough training and enough sense to know if a fellow came in there with a fever that he would set him aside and say "You have to see the head man; you have to see the doctor." The doctors didn't mind this. Mind you, these were not Regular Navy doctors, this was World War II when these were private practitioners who, like everybody else, were going into service. It was a pretty good idea.

I have seen some of them since and say "Why don't you still have this same idea?" But they reply, "Oh, no, now we have to see everybody ourselves."

Well, anyway, this whole program, it seemed to me, took care of cuts, minor things of that nature, with fairly well-trained corpsmen who had some training, and was perfectly agreeable as far as the armed services were concerned. Four million people in service and nobody objected to it and it worked very well. You saved the doctors to do the very important and necessary things which they had to do and which only a doctor should do.

I never have understood why we cannot develop a system similar to that. I never heard it called a physician assistant before, but I like the idea. I don't know why we don't have a 2-year medical school for medical assistants.

Dr. SILVER. Dr. Wagner, himself, is involved in a program to develop specially trained assistants to work with purser's mates in the merchant marine.

Senator SMATHERS. We do this in all the services and it works well. I never have understood.

I understand there is a representative of the American Medical Association sitting out here this morning. I like doctors. I am for them. I think they render an enormous service and they should be respected. I know of no economic or political group in our society, next to the preachers, which gives more charity and gets more abuse for it. In this area I don't understand why they are not willing to go forward with a program of this particular nature, physician's assistants.

Dr. SILVER. The climate has changed, Senator. The doctors are not opposing. As a matter of fact, we have had expressions of cooperation from all kinds of physician groups to help us develop this. We now have on the agenda, for example, through the Health Services Research Center that we hope to establish in the Public Health Service and with which Dr. Wagner will be very intimately associated, to do some of the exploration and from the partnership for health bill hearings now in the Interstate and Foreign Commerce Committee. We need support for the programs that will help us accomplish this thing.

We know that it is necessary. We want to do it. We have the program ready to go and if we get the necessary appropriations and support from the Congress we will do it.

Mr. MILLER. I know from my own personal knowledge that the Michigan State Medical Society was promoting this idea at least 20 years ago. I am sure other medical societies have done so too. However, is not a basic factor in this the attitude of the patient himself? Isn't this an area that would require considerable educational effort to get a ready acceptance from the patient?

Senator SMATHERS. I think you are right. That is what some of the doctors have told me, that the patient's attitude is the critical factor. I think the reason is that the patient at that point has never talked with one of these qualified assistants. As patients see it, everybody's ailment is the worst. It does not matter what it is. They want the best. But once you get adjusted to talking to the physician's assistant, in some respects you might get a better, at least a longer treatment or a more thorough treatment from that physician's assistant.

I think it is a matter of educating the patients and public as well as the doctors. Every time I read of a doctor shortage I think, why don't we do this?

You call a doctor today, and I have an illustration right in my own office where we were trying to get a young lady in to see a certain specialist. She has to wait 3 weeks. She needs a doctor now. Now we can take her out and act like she is runover or something, maybe get some emergency treatment for her, but otherwise she has to wait 3 weeks.

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This does not make sense. She needs help now, not in 3 weeks. She needs prompt medical attention, but she does not necessarily need a graduate of the University of Florida Medical School, if I can give that a plug. She does not have to have someone who was an intern for 5 years and then went into some New York City college hospital and studied under a specialist, and so on, and so on, and so on. That guy ought to charge a fee; he is entitled to it. But he should not be seeing routine cases.

Dr. SILVER. You may be pleased to know that I have just returned from Gainesville, the University of Florida, where they are trying to develop a program, and hopefully will have a program in operation soon, for physician assistants, particularly in the area of pediatrics. I think that most of the kinds of objections that you are talking about are beginning to disappear.

For example, at Duke where Dr. Eugene Stead has been developing a program of physician assistants, he has only had four students in training this last year, but he has 600 applicants for next year's program. Senator SMATHERS. Great. That is good news.

All right. I will stop testifying so much and let you fellows testify


Go ahead.

Dr. WAGNER. I would like to emphasize again, Senator, that the very crucial element in the use of the assistant, whether it is the physician assistant or the nursing assistant, it is the clear-cut definition of the functions, responsibilities, and authorities of these people and the maintenance of supervision by the professional because it is only by managing the health needs of the patient through the allied health worker, whether he is a physician assistant or a nursing assistant or some other assistant, that the professional can actually function.

This is why it is so important, when we look at this, that we not generalize. We must look at the individual physician and the individual situation and then apply to the maximum the state of the art so that he can care for as many patients as possible while maintaining quality of care.

All of the efforts of the Public Health Service in the development of personnel are under this general policy.


In addition to the nursing and nursing assistants which I spoke about, we are also making progress in the training of home health aides with more than 1,300 now enrolled in 16 projects. These projects are funded by the Office of Economic Opportunity and the program not only develops an important occupational group within the health field but is directed at older, low-income workers for whom the training is a significant economic asset.

We have been very pleased at the leadership provided by many States in this program. In addition to the projects federally funded, several States have begun training home health aides through the States' own employment and education resources.

Every patient, Mr. Chairman, is entitled to receive the treatment and care appropriate to his needs. Determining the appropriate type of care is of a special importance for older patients because their medical

needs may be obscured by the social problems brought on by increasing


The utilization review process required by medicare brings physicians together with other service personnel to review the records of selected aged patients. Through this process, placement problems of patients can be detected and better choices made for him if indicated.

One result of this process has been to bring hospitals into closer association with extended care facilities so that transfer agreements can be worked out for the smooth transition of the patients from one facility to the other as his needs change.

We presently have five demonstration projects underway to test ways in which combinations of facilities and services can be arrayed so that dental care can be provided, for example, to patients in a facility that has no dental staff or equipment, or social services can be offered to patients by agencies that typically do not serve inpatient groups.


Earlier this year, the President announced his plans to establish a National Center for Health Service Research and Development. One of the major purposes of this Center will be to seek new ways of delivering services to the aged and more efficient methods of using existing medical specialties.

Meanwhile, we are testing ways to bring services to the elderly for whom the lack of transportation is often a serious handicap. For example, at the Dexter Manor public housing project in Providence, R.I., 283 elderly with an average age of 72 were provided health services ranging from nutritional counseling to direct and preventive services such as X-rays, immunization, diabetes detection, and so on. An important element in this demonstration was the assurance to each resident that he could call upon a competent, concerned person who knew what to do when a crisis arose.

This particular project was so successful that the community is now supporting it although Federal funds, which were supporting it, have been withdrawn.

Closely related to the problem of obtaining appropriate care is the problem of belated diagnosis of disease conditions. We are testing methods of assisting physicians in their diagnostic workups by using computers. In four communities, New Orleans, Providence, Brooklyn, and Milwaukee, the use of automated diagnostic devices is being tested to determine how much time may be saved in a communitywide, multiphasic health testing program while improving the diagnostic procedure.


As earlier reports of your full committee have noted, we know too little about nursing homes, how they are used, the level of services provided, and their adequacy as a treatment setting.

The Public Health Service has designed a nursing home socioeconomic research program to develop a baseline on data on nursing home utilization and costs of services; patient needs and sufficiency of services; and methods of improving nursing home care.

The program began in July 1966, and the contract studies will be completed on December 31, 1968. We will have a report on baseline utilization and costs later this summer.

Until now, I have been talking about training, demonstration, and basic information gathering efforts of the Public Health Service to improve health services to the elderly.


The translation of this knowledge and experience into improved patient care will come about through implementation of one of the major achievements of the 89th Congress the partnership for health legislation, Public Law 89-749.

Through the Federal-State-local partnership created by this legislation-which, incidentally, is now before the Congress for renewalfunds are available for gathering information about the health needs of all the population, the resources that must be developed, and the means of their development.

The importance of this information gathering cannot be overemphasized, Mr. Chairman. The general information that we gather at the Federal level is very valuable in developing administrative policy, but it does not tell us how to cope with the individual in a particular neighborhood who is cut off from health care for economic or social or any other reasons.

Only the community can overcome these specific obstacles, and the community can overcome them only when the facts are gathered and plans are made and implemented. We can advise, guide, and assist communities by helping them collect the data, working with them and State planning agencies on their planning, and offering alternative solutions for their consideration.

But the local and State planning effort is the place where the action is going to be. The partnership for health legislation offers the flexibility and financial resources needed at the community level to get the job done.

We expect the programs that will develop under the partnership for health to contribute significantly to the growth of services to the aged. Thank you very much, Mr. Chairman.

Senator SMATHERS. Thank you, Doctor.

(Subsequent to the hearing Senator Smathers asked the following questions in a letter to Dr. Wagner:)

DEAR DR. Wagner:


JUNE 30, 1967.

1. You referred to "progress in the training of Home Health Aides with more than 1,300 now enrolled in 16 projects."

I would like additional information on this program with special reference on its usefulness to older Americans.

2. In his testimony before us, Dr. George James said that there are only 70 medically directed home-care programs in the nation and that they serve only 5,500 persons. Doesn't this indicate that there are serious deficiencies in the availability of such services? If so, what additional efforts are needed to develop home-care programs?

3. The Dexter Manor project is of great interest to this Subcommittee. We have the excellent pamphlet describing that project in detail, but I wonder if a more recent and more succinct report is available for inclusion in our hearing record. 4. May we have a progress report on the multiphasic screening projects described in your testimony. I would like specifically to know when operations

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