STATEMENT OF JOSEPH C. EDWARDS, M.D., PRESIDENT, Dr. EDWARDS. Senator Eagleton, and gentlemen. For several years now, the physicians in this area have held the same view as that indicated in the second paragraph of your letter to me of August 24, 1970, that there is an immediate need for more doctors, dentists, nurses, and allied health personnel, and the need will be even greater in the future. You raised interesting points for discussion. Your No. 1 question, methods for increasing the number of health professionals who are actually delivering service, in answering that, I would say Father Drummond of St. Louis University and William H. Danforth of Washington University School of Medicine, called a conference on November 24 and 25, 1969, for the purpose of studying the problem of the allied health professions. The conference discussed whether there is a need for more allied health personnel and, if so, what method will be used in filling that need. Dr. Leonard Feniger, Associate Director for Health Manpower, National Institutes of Health, attended the conference, as did all the other representatives in these various institutions, the various people in the schools in this area, and the junior colleges. From this conference and discussions with the various groups, everyone felt there was more need for trained allied health personnel in these various fields, and not just on the research laboratories and centers, but to help deliver medical care not only to the poor but to everyone actually. Doctors are just not able to deliver all the care that the people want nowadays, and perhaps through better education and knowledge of the benefits of prevention, as well as treatment, and the better availability of insurance, funds, and moneys through which they can seek this care. It is not enough, however, just to increase the number of doctors by enlarging present medical school facilities and taking in more medical students. University medical centers and the physicians, through local societies and State medical associations, and the American Medical Association and their committees on health manpower and education, should cooperate to see that certain standards are set up for training of medical assistants, allowing for some latitude in curriculum to satisfy certain local needs in one area or another. The medical schools and a committee of practicing physicians from the medical society in the area should formulate this training policy in cooperation with the junior colleges and educators from other areas, to avoid purely didactic training for potential medical assistants. By drawing men from private practice and educators from the medical centers into the educational process for these people, we can give them access to clinical training and hospital experience. Just as some of the other speakers alluded to, they should be working in conjunction with the doctors who are going to use them, or employ them or help them and aid them in their practice in the clinics and hospitals, seeing patients with them, so that they will both know how to relate to each other as well as to the patient. Senator EAGLETON. I take it, then, Doctor, you subscribe to the theory that a medical school will have to teach more than just future M.D.'s and also have as part of their curriculum the subprofessional, the assistant physician and/or whatever his title may be, at least in part, perhaps in cooperation with the junior college? We don't want to tie ourselves down to a precise formula, but there will have to be some identification educationally with the subprofessional? Dr. EDWARDS. They are going to have to expand this area in order to take care of the huge increase in demand for health services. Many routine duties, such as-we will not enumerate all of themblood pressure determinations, physicals, and history taking to some extent can be done by the assistants, just as medical technicians now draw blood samples, do tests in laboratories. We all know of the paramedical personnel. I will not go into the routine. This will all enable the doctor to see more patients, yet not lose the physician-patient relationship nor neglect the patient because it is only the doctor who is trained that can really make the diagnosis and know just what method is best to use for treating this patient, each one patient with the same disease, the diagnosis may take a different approach. The average health assistant might not be able to do that, but they can help the doctor so he can then devote more time to these critical areas and yet serve more people. The physician's assistant should serve as a supplement to rather than a competitor of the nurse. Nurses can be trained to master the necessary skills, but we need nurses so badly in other areas, and the nursing schools are reluctant to start losing their graduates to training programs of this sort. However, with an increase in trained nurses, some could be trained in this manner on a voluntary basis, just as nurses now volunteer for training in coronary and intensive care units They are trained to meet emergencies until the doctor arrives on the scene, and many times the measures they take may be lifesaving. Some of the other speakers alluded to the fact that if we give them more interesting areas to expand in, then nurses might not drop out, or if they become married, or their children are older, they might come back into it if they have some real challenge. Dean Robert Howard, M.D., director of the physicians assistants program at Duke University Medical Center, Durham, N.C., really where the more intensive study of this, I guess, started, stated: The physician's assistant has been designed to complement the available health services. The nurse continuing to be the physician's right hand, and the physician's assistant making the physician ambidextrous by providing him with a left hand as well. We have already heard about their approved training program for registered nurses as pediatrician's assistants and how they help. The University of Colorado program was mentioned earlier and Children's Hospital in St. Louis has a program now where a few of these are in training. Several other schools in the country are doing this, but rather than the formal 2-year training program after highschool or a program based on 2 years of college, in some instances programs have been devised around medical corpsmen from the various armed services. In many cases, these men have not only done a lot of first aid work, they have also assisted in operations and even performed actual operations because of the absence of doctors in the front lines, or the fact that there were not enough doctors at the right time. Some of these men received postgraduate training at Government expense in various fields of public health and medicine which will be lost if they are not put in some kind of program in which their knowledge can be utilized. If they become salesmen, merchants, or go back to farming, for instance, then we would lose the they would have lost their know-how in a few years. Some methods should be worked out where we can approach these men and get the Armed Forces to perhaps give us a list of these men as they are separated from the service so they could be approached and circularized and interviwed. Senator EAGLETON. I might point out there, doctor, our problem in this field with utilization of veterans does not lie entirely with the medical profession or with the medical schools. Part of it lies with the military itself. There is a very minuscule post military placement program at the present time. We have this repository of well-trained medical corps personnel, and when their enlistments are up, or their tour of duty expires, there is very little in the military setup now that helps place them or makes any attempt to see that they go into the civilian health professions. So I think the blame cannot be placed solely on the medical profession or the teaching hospitals. Part of the blame is on the Government itself that runs the military or pretends to. Go ahead. Dr. EDWARDS. There are, of course, other people like high school graduates who might be interested in this field if they were acquainted with it. Perhaps we don't do enough recruiting in that area. In North Carolina, where the Duke University program is in effect, a ruling by the attorney general on current medical legislation provides a legal status for the physician's assistant, so he is now well recognized and a customary member of the health team there. The faculty, having been exposed to physicians' assistants in training, are quite eager to make use of their services, but some have gone to other areas, but not all over the country yet. They have not graduated but, perhaps, 27 or 30 so far. They have gotten some grant assistance and funds for these men. The Duke program demonstrates that independent operators at the intermediate level on the health care team, while tolerable in small numbers, wind up competing with, rather than complementing the health services, that is, if they work as an independent man. The development of the independent associate would be professionally undesirable, and it would increase the legal problems that are already attending the concept of the physician's assistant. Therefore, it is thought best that the physician's assistant develop along the lines of a dependent professional, who participates in various medical functions, and time has demonstrated the wisdom of this choice in the Duke area. The attorney general of North Carolina ruled that an assistant could, within the confines of the law, carry out virtually every task assigned by a physician. The only limitations on the assigned functions concern diagnosis and the prescription of care, two functions already ruled out by the assistant's dependent role. Beyond these functional limitations, all activity is under the direction of the physicianemployer. Because the wise or unwise use of dependent personnel is more likely to be a function of the physician than of the assistant, some have sug gested that the physician-user should be licensed rather than the assistant. A physician-user is licensed to practice medicine, but I mean some special form of license to employ an assistant. At Duke, a permanent committee has been formed with representatives of medicine, nursing, hospital administration, and the general public reporting to the State board of medical examiners. This committee is responsible for considering all new health manpower training programs in the State. The director of a planned new training program applies for approval, submits a summary of the program's objectives, its faculty, its facilities, the source and selection of candidates, and so on, as part of the application. If his program is approved, he then submits twiceyearly reports on the program, including names, addresses, and employers of all trainees and graduates. Everyone using these submits a statement regarding the performance of the assistant. After 3 years of such observation, the program then receives final approval, although it must be renewed every 5 years. Innovation is, therefore, totally visible to the professionals on the committee, and unproductive or unreliable elements are eliminated. This setup permits flexibility for change in the program before its outline is fixed by law, as alluded to by Dr. Perkoff, and that is we should not try to actually delineate, by law, in every State now, just what the confines of these people will be until we know a little more about what they should and should not do. Changes in the State laws might be necessary, and the design of model legislation applicable to any State is part of the Duke plan. The physician who is licensed is responsive to his own colleagues through his own medical society's committees; grievance, ethics, utilization reviews for duration of hospitalization, etc. He is further regulated by the State board of healing arts. He is then covered on the physician's insurance policy, the assistant is covered, with, so far, no increase in premiums. Contrary to what some doctors think who have stated that perhaps it would increase the doctor's malpractice insurance annual premium by about 50 percent, the experience with the Duke program is that so far they have not had to pay any increase in premiums because the doctors are hiring graduates in the program as assistants. The main obstacle to implementing such a program in this community, and I presume in any community, would be the availability of funds. The organization which was created with bi-State regional medical program at the conference of Father Drummond and Dr. Danforth which I attended last year, could be put into operation if they had the funding. Now, as far as training health personnel, it is set up in cooperation with the various junior colleges, the medical schools, and is already attained by this organization. The hospitals and colleges cannot be expected to assume all this burden themselves at the present time for they are strained to support the students they now have with the taxes levied on the people for the support of colleges and the private income available to the medical schools. We have already heard enough about the funding of medical schools, and I will not go into that so much, but I inserted in my written remarks here just a page from our medical society bulletin just to show that we are taking up these things from time to time, and some of these editorials at various times discuss training of paramedical personnel, of the costs of medical care, and the use of home care programs to decrease the amount of time a person has to spend in the hospital, decreasing, therefore, the hospital costs. We have discussed hospital insurance companies, and so on, and we hope someday to get people, insurance companies, to underwrite some outpatient programs so that doctors could get paid from the third party for taking care of the patient in the office and doing the tests in the office as an outpatient rather than have to put him in the hospital or the patient insisting on going to the hospital. Of course, there are certain restrictions we recognize, because they would not know what to charge for a premium that would include everything, but they could include a certain number of x dollars per vear for checkup or for tests and so on. I don't think we would be trading dollar for dollar as some insurance people have told me. Nowadays, so many of the patients receive partial help from employer insurance programs, and, if they had an annual physical, for example, they would not just be paying money out of the insurance company, but they would ordinarily be paying out of their pocket or into their insurance program. Some would not use up their maximum allowance; funds would thus accumulate. If it were restricted to, say, one examination a year, a full examination or something of that nature, or so many visits, I think it still would be desirable and would help keep a lot of these people out of the hospital who actually would not need to be occupying a bed just because they need a certain test. Question No. 2, the role of the medical center, which I define as a medical school and associated institutions, in the community and its value to the community. The role of the medical center we have already heard from two of our medical schools, excellent schools. The men have done a wonderful job, I think, in presenting their side of the picture and how they serve as centers for specialized medical training and knowledge on a postgraduate level, as well as undergraduate, and for specialized care of patients, and how the research centers make contributions to our knowledge, and so on. Not the least of their functions is stimulation of the physicians in the area, not only those who participate in the teaching program, many on a voluntary basis without pay, but the entire physician population, and the people in the area who are better informed about public health and medical matters because of the leadership of the kind of men the medical centers attract. They also attract many capable physicans in practice who stay and work in the medical societies and various other community groups and neighborhood health centers, either on a voluntary basis or a part-pay basis, and they are a great benefit to the community. They allow for the exchange of knowledge through one part of the country or from one country to another, and newer medical knowledge is diffused into the medical community very rapidly as a result, perhaps 1 or 2 years before it is even printed in the medical journals. A medical center, in cooperation with the practicing physicians in the area and their leaders, can be very valuable in advancing medicine and in giving the people the best kind of medicine to which they are en |