Miss MOORE. The entitlement that the schools got this year was 65 percent of what the law had authorized.

The new programs are not being funded. There are only 17 professions that are approved for funding under the law at present. If you expand this even more, the money would get thinner.

There is not an awfully lot you can do with $9,000 which is what my allocation is this year. We are grateful for the funds we have received. We hope the formula grant will be maintained. It is the best boost in morale and help that our schools have had for a long time. You have five in your own state.

The project grant authority would be helpful in initiating new programs, but I would agree with the statement that Senator Dominick made previously that after a certain point of time in initiating new programs, the states and medical schools should assume responsibility for carrying on these.

There should be obligation for at least part of the funding from the institutions.

As far as students are concerned, we are asking for equal treatment for the allied health professions. Our students are at a disadvantage as compared to specialized education and nursing.

The opportunities should be equal. We lose students who have better opportunities for funding under other laws.

The greatest road block is the funding, and you have very little to do with that, I know.

Construction is important. Space is the greatest hindrance to increasing the enrollment. I wish it were not true, but I believe out of the 3 previous years in only one has there been construction money appropriated.

This hurts. This is the biggest road block to increasing manpower. The lack of administrative costs on the scholarship programs is a hardship on schools, and I am sure that schools would take them whether they had any administrative funding or not. We want to help students as much as we can, but the burden is pretty heavy these days.

The CHAIRMAN. I know it. We have that in many programs where we have allocated a certain percentage of the grant for administration.

Miss MOORE. It is under the work study program, but not under the other two.

The CHAIRMAN. It is under the NDEA.

Miss MOORE. But the student has to repay that money. There is no cancellation clause in the allied health program, and this is what I mean by equal treatment.

I am concerned about the feeder schools. We have been on record about that before. But we think basically your proposals are most worthy. We hope they are passed. We hope that they have adequate funding later on and we are grateful for the support we have had and are delighted to see some of these things included in there that we have been talking about for several years.

The CHAIRMAN. Thank you for your very cogent statement. It is boiled down, and specifically on the point. We appreciate these rep

resentations and as we go to mark up this bill in the Health Subcommittee, we will consider all of these recommendations.

Miss MOORE. I don't want to be ugly, but do you know your own State is the only one that does not have a licensing law in physical therapy?

The CHAIRMAN. No, I did not know that.

Mr. NOLAND. I am pleased to note that it appears that will soon be corrected.

Miss MOORE. I think the Medical Society has bucked it before.

The CHAIRMAN. I am surprised, because we have 11 million people, and when you have a large, populous State it is easier to pass a licensure law. I was surprised we had not done it.

It was pointed out in a study in North Dakota that the highest lack of training was in the hospital. In a hospital, a person would think they had protection.

Miss MOORE. That is why a lot of us in education are concerned about the desire to expand the health professions without quality control. I am afraid we are going to realize we have let this get out of hand with a lot of people in fragmented service.

The CHAIRMAN. In the North Dakota experience 49 percent of the persons operating the machines are not registered with the association, and many of them were employed by hospitals.

Miss MOORE. And when you are on the table, you don't know whether the guy is qualified behind the machine or not

The CHAIRMAN. They recommended in North Dakota that the survey go to other States, and of the nonregistered technicians, 74 percent indicated that aspects of X-ray protection were not included in their training.

They had had no training at all in protecting people.

Miss MOORE. In physical therapy, programs in the community colleges have expanded greatly. Out of 12 schools, half of those are in States where new licensing laws have been put on the books.

The CHAIRMAN. You have a very active organization in Texas, do you not?

Mr. NOLAND. Yes.

Miss MOORE. I think the one in Houston is the medical technology group.

The CHAIRMAN. Thank you very much.

I regret that I am forced to leave. I would like to ask you some questions, and may submit them in writing for your replies.

This knowledge and use of physical therapy is spreading rapidly in this country, largely, I think as a result of so many nerve and bone injuries in World War II, in Korea, and the war in Vietnam.

The necessity for the therapy there has spread to where the people are learning something about it. That and automobile injuries have contributed to that. We have in this country also many millions of people injured each year, 7 million in industrial accidents alone, and that is only about one-eighth of the total accidents in the country.

We have 400,000 people permanently disabled from accidents every year, and 115,000 killed and many millions of people are disabled for some period of time.

Many millions are disabled, many of whom can be restored through physical therapy. I think the growth in the recognition of physical therapists and what they can do has been phenomenal.

45-552 0-70-15

At this point I order printed all prepared statements of those unable to attend the hearings and all other material pertinent to the record. (The material referred to follows:)

PREPARED STATEMENT OF MICHAEL M. DACso, M.D., DEAN, INSTITUTE OF HEALTH SCIENCES, HUNTER COLLEGE OF THE CITY UNIVERSITY OF NEW YORK

The problem of the increasingly critical health manpower shortage has been often discussed in this and many other committees of both the Senate and the House. Many have testified, experts and lay people alike, some of whom pleaded, others warned of the dire consequences that will result, if this shortage is not treated seriously. The results of these representations have been far from satisfactory. The precarious balance of manpower supply has always been easily upset by unanticipated events, such as wars, natural disasters, and the fortunately rare outbreaks of epidemics. World War II and the Korean conflict were such eye-openers. Those who had persistently denied the existence of a physicians' shortage, were forced after these periods, to alter their opinion enough to begin making optimistic forecasts and assurances of a more than adequate supply of physicians by the mid-sixties. The rest is only too well known. There is not only an inadequate number of physicians in the country, but their uneven geographic distribution is a far more serious problem.

It is a sad fact that, at the present rate of production of medical doctors, there will never be a sufficient number to meet the rapidly growing demand. According to a recent statement in the Journal of Medical Education there is, at present, a shortage of 50,000 physicians. To correct this by the mid-seventies, a 50% increase in the freshman admissions to medical colleges will be needed. As things stand today, with the war in Vietnam and the drastic cutbacks in financial assistance to medical schools and medical research, obviously we cannot anticipate improvement in this situation. As a matter of fact, I fear things will get much worse before they begin to improve.

In the past few years it has become increasingly obvious that new and imaginative solutions must be found to meet the present and anticipated health needs of the nation. The present methods of the health delivery system must be reviewed and restructured. The present heavily hospital-focused patient care must yield to new types of ambulatory care and use of community health resources. To support this trend, the production of allied health professionals must be accelerated. In addition to the specialist allied health personnel, such as the laboratory technician, x-ray technician, physical and occupational therapists, etc., a new category of health professional must be trained whose broad knowledge and experience will enable him to support the physician through his entire spectrum of activities. As a generalist, he will share the physician's administrative, clinical and preventive responsibilities, and thereby release the physician for the performance of those functions requiring the kind of judgment and decision that only a medical doctor can make.

In the course of the development of the various health professions, the nurse became the closest collaborator with the physician and thereby established the nucleous of the now rapidly expanding health team. This being a fact, the logical question then arises, why should the nurse not fill the need that we propose to assign to a physician's assistant? The answer to this question is not a simple one. The nurse, as a result of her education and in response to an existing demand, has reached the level in the structure of health professions where she acts in the capacity of a quasi-independent health practitioner. Based upon this and other professional, social, and economic considerations the nurses were not willing to serve as a physician's assistant. More recent developments, however, seem to indicate that the official representatives of the nursing profession are now prepared to reconsider their current somewhat rigid stand and are increasingly talking about the nurse's role as a physician's assistant, or whatever name they will chose for identification. While logical considerations would support such development, one cannot help but be deeply concerned about the possibility that the prevailing critical shortage of nurses might be further aggravated, if many nurses decide to make such change and continue their professional activities as a physician's assistant.

In addition to the few already operational physician's assistant programs, some colleges and medical schools are actively considering the establishment of such programs. With this upsurge of interest, it behooves us to make every effort to coordinate these new educational activities. In the absence of such coordination, we are running the risk of producing new health professionals with diverse degrees of education, clinical experience and competence. On the other hand, we must recognize that the increasing health manpower shortage creates a vacuum which in the absence of appropriate precautionary measures will allow persons with inadequate basic and professional education to enter the field of health services. The most important element in settling this problem is time-any procrastination may very well lead to the creation of poorly trained and unlicensed health practitioners. It would seem far more prudent to take effective steps now to prevent this development, rather than find ourselves faced with the knotty problem of uncovering and prosecuting unqualified practitioners in the future.

Being a new concept, the education of the physician's assistant is a complex issue. While it is true that some people with long military or civilian experience in health profressions could be retrained within two years, I would suggest rather that this new health professional, who will be expected to bear major responsibilities, should be given a full four years of college education; the first two years should be devoted to a solid foundation in liberal arts, humanities, social sciences and the basic courses in natural sciences; the second part of the college course should be devoted to clinical sciences on the theoretical, clinical and practical level. It is conceivable that a useful assistant type of health personnel could be trained in two years in community colleges. However, it must be realized that the education of these people will be limited and, consequently, the responsibilities and tasks assigned to them should also be carefully restricted. A man or woman with a full college education would be prepared to assume a much wider range of responsibilities and would also be in a better position to exercise independent judgment. Those with master's degrees, could be entrusted with commensurately broader range of responsibilities. In some instances, there is no reason why exceptionally well qualified persons could not continue their studies toward a doctor of medicine degree. This is a brief description of a career spectrum which would hopefully open the road to a wide range of health professions for qualified students. It should be emphatically stated that the training of the physician's assistant must become the responsibility of medical education. Important as the basic college course is, his function as a health practitioner will still depend on his clinical and practical experience which he can learn only within the framework of a medical school. Continuing this train of thought, it is entirely possible, if not highly desirable, that the education of all health professionals, ranging from the more modest level to the level of medical doctor, should take place within the confines of one educational establishment. This new concept would gradually expand the scope of medical schools until they become health science universities, dedicated to the education of health professionals on all levels.

In conclusion, a word of warning about the role of the physician's assistant in the health delivery system. It must be accepted as an unalterable principle that the physician's assistant, regardless of his level of training and experience, can act only as the name indicates, as an assistant to the medicl doctor and work under his close supervision. At no time, except in grave emergencies, should he be allowed to act independently or serve as a substitute for a physician. Also, it must be borne in mind that, since the most critical shortages in physicians and other health professionals exist in the ghettos and remote rural areas, this situation may create the almost irresistible temptation to train people for services in these areas, exclusively. Such a practice would create a system of "poor man's medicine" with all its discriminatory and undesirable consequences. Such development must be anticipated, and effective steps must be taken to prevent such an undesirable and inequitable distribution. If the physician's assistant is needed, he must be used throughout the entire medical care system without regard to the socio-economic status or geographic location of the recipient.

PREPARED STATEMENT OF FRANCES E. FISCHER, PRESIDENT, THE AMERICAN DIETETIC ASSOCIATION

I am Frances E. Fischer, an assistant professor in the Department of Nutrition of Case Western Reserve University. I also serve as the president of the American Dietetic Association and it is on behalf of the Association that I am presenting this testimony.

Since this is the first time the American Dietetic Association has appeared before this distinguished Committee, I might mention that the Association is the professional organization of 20,000 dietitians and nutritionists who are responsible for the application of the scientific principles of nutrition. Our members work in hospitals, in health departments and agencies, in colleges and universities, and also in school food programs, industrial plants and commercial eating establishments.

The American Dietetic Association urges the approval of S. 3586, the proposed Health Training Improvement Act of 1970, that provides for a five-year extension of the Allied Health Professions Personnel Training Act. If universities are to attract the faculty and resources that are required to expand our capacity for the training of allied health manpower it is essential that there be some assurance of continuity of support on the part of the Federal government. This is one of the reasons for our endorsement of S. 3586.

CONSTRUCTION

The increase in appropriation authorizations for construction under S. 3586 is very encouraging. We are concerned, however, because no funds have been requested under this authority in 1970 or 1971 by the Department of Health, Education, and Welfare. Only $3 million of the $35.5 million that is authorized has been appropriated over the four years 1967–70.

IMPROVEMENT GRANTS

Our Association also endorses the provisions of S. 3586 that continue the eligibility criteria with respect to formula grants. As we understand the provisions of S. 3586, it would be possible to support more dietetic intern training programs through project grants. We hope that in the project grants that are authorized for "training and retraining," that "retraining" will be interpreted to include continuing education.

TRAINEESHIPS

The increasing authorizations for appropriations for traineeships under S. 3586 are essential if we are to increase our faculty resources for the training of allied health manpower. We would suggest, however, that authority for institutional support be added to strengthen and expand graduate training. The very successful training grants program of the National Institutes of Health provides for institutional support as well as stipends. This same authority should be available under the Allied Health Professions Personnel Training Act.

DEVELOPMENT OF NEW METHODS

The authority for project grants to develop new methods for the training of health manpower under S. 3586 should prove most valuable in increasing the supply of allied health personnel. Here, too, we hope that the actual appropriations will at least approximate the authorizations. We also strongly support the grants and contracts that are authorized to encourage full utilization of educational talent for the allied health professions.

RECRUITMENT STUDENT ASSISTANCE

Both S. 3586 and S. 2753 authorize appropriations for recruitment, student loans and scholarships. These authorities are needed and we hope that they will be a part of the legislation approved by the Congress. Similar authorities are provided for in the case of the Nurse Training Act. They are no less essential to an expansion of allied health manpower through the Allied Health Professions Personnel Training Act.