Dr. VAGELOs. I have heard from other schools that there is a problem of communication, and that's very real. In fact, there is a program of teaching students scientific reading, however, we haven't entered that area. I would say, in fact, that none of our students has had any difficulty in comprehension.

Just to jump ahead, you asked what are we doing about it. I think the two things we can do to improve our recruitment are to add black physicians to the admissions committee, and this is in the works now. In addition, the school plans to add a person, a black recruiter, who will work throughout the health schools; that is, recruiting in all facets of health and medical education. Those are the two things that we are doing for the future, and we certainly hope to be more successful.

The second thing I'd like to touch on briefly, in response to some of the earlier statements that have been made, concerns the amount of science in medical school. Why is science taught in medical schools? Why is there research at medical schools? Why can't we just wipe out the amount of space that's used for laboratories for the teaching of scientific thought and utilize much of this space for clinical teaching? I think, in effect, we could do that and get back to the era of preFlexner.

Senator EAGLETON. We don't want to go back that far; do we?

Dr. VAGELOS. That would be disastrous for the teaching of the practice of medicine. Let me say that teaching science at a medical school has three or four bases. One, it teaches the basis of disease as it is presently understood.

Secondly, it gives the only rational understanding for the mechanism of action of drugs, and new drugs are being developed all the time. Just to give you an example, 90 percent of the prescriptions written this year were unknown in 1950. It is said that medical knowledge doubles every 10 years and, therefore, one of the chief purposes of a science department at the medical school is teaching students the way of scientific thought. Not because they are going to be scientists, but because they are going to be looking at patients and learning from examinations of the patients and laboratory results certain information. They are going to draw conclusions and determine procedures to be done based upon this information. This is a scientific way of thinking, and this is one reason for teaching science. Finally, research. How much research should be done at a particular medical school has been batted about, and it is a tremendous problem because there is a terrific maldistribution in the potential for doing research, as Dr. Danforth and you have discussed. To achieve better health care delivery we don't have to add research teams or large research universities because, as it happens, the researchers tend to congregate in places where there is already very active, large scale, complex research going on, and this research is extraordinarily expensive.

Senator EAGLETON. I agree with you and Dr. Danforth, you don't have to add more research teams, but if we don't change the current system of Federal funding, it leaves the University of Connecticut, which I recall being the low guy on the medical totem pole with its piddling $20,000 from Uncle Sam. They say, well, the way the ballgame is played now, unless we get a lot of research guys, we are left out, so the whole Federal scheme, as I view it, is basic parameters. As I said to Bill Danforth, it is almost research or perish.

I agree with you that we don't need to have every school in the country be a research mecca, but if we don't change the Federal structure of funding, I don't know where the University of Connecticut Medical School is going to go.

Dr. VAGELOS. As Dr. Danforth said, a per capita payment to the school for the teaching of students. I would emphasize that the cost of producing-educating a student per year varies from $10,000 to $20,000, depending on the institution. This depends upon the student to faculty ratio and this varies dramatically depending on the bioscience that's done at that particular institution.

Two other things I might mention. One is that research has to be done in all university medical schools. In other words, even though we are saying that there are some meccas and some smaller places, even the smaller places must have the means to do enough research so their professionals remain viable. There is no such thing as a professor of anything who is not involved in some active research. Thus he is driven to know the latest thing that is happening in his field so he can pass that on.

Senator EAGLETON. Is that really research, or is that just good, continuing education? That is, couldn't a fellow be an outstanding anatomy professor by keeping himself posted on the latest periodicals and latest seminars and latest medical techniques? Assuming the medical school is located anywhere reasonably near a metropolitan area, and 90 percent are in these metropolises, is it necessary that he have $50,000 from Uncle Sam to inject rats? Can he not be a terrific teacher of anatomy without having a research grant?

Dr. VAGELOS. I would say not. I think the problem with that is that although he would know the anatomy as it was taught when he learned it, as he started teaching it, that the advances in every area of biomedical research or subjects is advancing so rapidly, the technology is so complex, that unless a man is involved at the level of doing things, he will be passed by. It is incredibly difficult to remain on top of things secondhanded, as an observer, and be able to pass it on.

Senator EAGLETON. These research grants, some of them are very specific on a very isolated type of research, a very rarified situation. Why does he have to be worrying about the halitosis of a rat, if that be his research grant, how is that going to make him a better teacher of anatomy or whatever?

Mr. VAGELOS. The reason for that is that is knowing about the halitosis of a rat, in order to be able to do good research, and that is the idea of research grant applications, he really has to know the whole field, let us say, of pulmonary physiology, and in that way he adds to his teaching of pulmonary physiology. It is quite true, every explicit grant is extremely narrow because the man is going to do a finite series of experiments. In fact, a research grant that claims to study pulmonary physiology in general is probably rejected because the man does not have any good ideas. What the granting agencies want to know is does he have a specific idea for a critical experiment that can be done which, although in a narrow experimental design, might have broad implications. A good scientist is supposed to do that kind of experiment.

The final point, so far as differences in medical schools are concerned, and I know Bill and I agree on this point, is that within a given

region all medical schools need not be the same. But there should exist in some medical schools an educational process for producing the biomedical scientist of the future. In this regard, there are certain programs that 11 percent of the present medical schools have. They are called medical scientist training programs, and they are designed to produce people who know science in great depth. Washington University has one of these programs; it requires 6 rather than 4 years, and it teaches people science at the level that it is done at the very best science centers, so that science will remain within medical schools. We believe this is a good investment for the long-term health of the country.

Senator EAGLETON. What is the interrelationship between the science department of the Washington University School of Medicine and other science departments affiliated with Washington University on the other campus out west?

Dr. VAGELOS. There is a great relationship. We have formal relationships in having training grants that span both the main campus on the hill and the medical school. We have courses that are given jointly. We have undergraduate students coming to the medical school for courses. We have projects that are carried on jointly between campuses. Seminars are exchanged completely.

Senator EAGLETON. Do you feel you are achieving maximum optimum utilization of these very expensive facilities or, to put it conversely, do you find a large duplication that is not fiscally prudent? Dr. VAGELOS. I don't know of any duplicated type of facility that we could do without.

Senator EAGLETON. Dr. Perkoff referred to you, suggested that you answer the question of the multipurpose lab.

Dr. VAGELOS. Yes. The school has just this year moved into new multipurpose laboratories, and that is just as was described, I believe, by Dr. Felix earlier. That is a laboratory in which the student remains while various departmental subjects are brought into the same space, so that laboratory is never empty. We have just moved into such facilities.

Another question that was raised was the size that we could expand to. The school has gone from 86 students several years ago to 110 at the present moment, and ultimately we can accommodate, within those multipurpose laboratories, 140 students. We have no plans to enlarge to that number at this time.

Senator EAGLETON. Fine, doctor, thank you.
Dr. Bensinger, you have been very patient.

TESTIMONY OF DAVID A. BENSINGER, D.D.S., ASSISTANT DEAN, WASHINGTON UNIVERSITY SCHOOL OF DENTISTRY

Dr. BENSINGER. Senator, all of the comments that I shall make will pertain to professional dentistry as a member of the health professions team. I have interpreted all of your questions to refer, for the purpose of my testimony, to dentistry. In some instances, it will be difficult to transfer complete meaning as I understand it in the context of your letter to the profession of dentistry, but I shall strive to accomplish that purpose.

Pertinent to methods of increasing the number of health professions personnel who are actually involved in dental services, it is possible to

interpret this statement in one of two different ways. I shall make an attempt to address comments to both possible interpretations. On the first hand, I see the question referring to the methods of increasing the numbers of those health professions personnel who are currently eligible to be involved in the delivery of health services. That is those who are currently legally allowed to deliver service. On the other hand, I see the possible interpretation that the question refers to perhaps increasing the categories of health professions personnel who then could be potentially legally eligible to deliver service. To comment upon the first interpretation, that is, increasing the numbers of those persons already legally capable of rendering service, perhaps one must speak most directly of simply the process of graduating more dentists. The only other legally qualified category person involved in the delivery of dental care is a dental hygienist. Dental assistants, while receiving training, and formal educational requirements have been established in those training programs, are not legally licensed as health professions personnel. Their duties in the State of Missouri, as in many other States, are defined and restricted by determinations of the Missouri Board of Dental Examiners, Missouri Dental Association, and the attorney general of the State of Missouri.

Referring the possibility of graduating more dentists from schools of dentistry in the United States, the following observations can be made. There are presently 53 schools of dentistry operating in the United States and six new dental education programs in varying stages of development. It must be noted that two universities, St. Louis University and Loyola University of New Orleans, have or are in the process of phasing out their undergraduate dental education programs. Louisiana State University will eventually replace Loyola University in its dental education program, but no replacement school has been established for St. Louis University School which graduated its last class of students in June of 1970.

In 1969, the number of first year dental students was 4,355 which represented a 3.6 percent increase over the first year students enrolled in 1968. Since many schools are in the process of expanding their enrollment, and as new dental education programs are established with the opening of additional schools, the number of first year students will continue to increase. The total enrollment of undergraduate students was 16,008 in 1969. This represented a 3.9 percent increase over 1968 enrollment. To place these numbers into a more meaningful perspective, it should be noted that in 1953 the number of undergraduate students in dentistry was approximately 12,500. From that 1953 enrollment figure, numbers increase gradually until 1965. From 1965 until the present, 57 percent of the increase has occurred.

The number of dental school graduates in 1969 was 3,433, and on the basis of current fourth year enrollment, the number of graduates in 1970 will be significantly larger, approximately 3,650.

It should be recognized that all available spaces in the existing schools of dentistry are occupied by students. In other words, there is essentially capacity enrollment in all schools of dentistry. Increased enrollment in any given school without expansion of facilities is essentially impossible. Expansion of facilities becomes a very difficult task in light of the fact that present estimates indicate the approximate cost of $200,000 per student to develop new facilities. The major

proportion of the increased number of students enrolled in the study of dentistry related rather directly to the availability of Federal funds for initiating, expanding, and improving dental education.

From these figures it can readily be seen that at today's construction cost levels, to create a new school of dentistry capable of accepting 100 students in its entering class would require a minimum of $20 million. If the process of planning for such a school were to start today, it would be a period of at least 7 years and probably 8 or 9 before the first 100 students would graduate from that school.

As complex as the matter of creating new educational facilities to educate dentists is the matter of finding staff and faculty to teach these students in the new schools. The availability of willing, capable, adequately trained educators is not increasing. Levels of remuneration from institutions are not usually on a competitive basis with remuneration from private practice endeavors. The additional years of training to qualify for desirable teaching positions is further reason for the absence of adequate numbers of faculty people.

There are some other possibilities to resolve the problem of increasing the numbers of dentists. It should be possible but will require considerably more intensive study to utilize to greater extent the existing facilities in the educational institutions. It seems unrealistic to use expensive educational facilities 9 months out of the year. Various schools are giving consideration to a 12-month year, but once again, some problems exist in such programs. Increased staff is required when programs are increased by 25 percent. Lecture, laboratory, clinical schedules become significantly harassing on such a basis so that a great increase in staff is practically a mandate, and once again, where does the staff come from. A not insignificant problem further exists when a 12-month educational program is considered. Most students use the summer months to accumulate some dollar reserve to see them through the next school year. With tuition levels at the $2,000-plus level, cost of living not decreasing, and other expenses of considerable note that are encountered by the student, it must be recognized that the summer months respond to a financial urgency.

Financial aid to students through Government loans, through bank loans, institutional funding, et cetera, has through the years proved to be insufficient to meet the stated need. Washington University was funded at a very small percentage of its request for Federal funds to support financial aid to students.

The problem to this point is obviously discouraging. However, at present a number of universities are researching in great depth the possibilities of shortening curriculum and training periods in schools of dentistry. While there may be many valid reasons for considering this as a partial solution to the problem of manpower, I would not express great hopes simply on the basis that the incremental increase arising from such shortened curriculum periods would not be a meaningful increase in the capacity of service delivery.

The dental hygienist, a very essential part of the mechanism of service delivery in conservation of manpower hours, is a highly skilled person of academic background. In 1960, there were 992 dental hygiene graduates. In 1969, there were 2,269 graduates, an increase of approximately 129 percent. Considering there is a relative transiency to the career of a dental hygienist because of such interferences as