Mr. AYERS. Do you not think it is more important to take care of the nonservice-connected psycho case than it is the nonservice-connected case where a fellow goes out on the turnpike and bangs up his car and gets butchered up and goes to the VA hospital? Do you not think the psycho case is more deserving of attention than these of that type that are now being handled? Dr. TOMPKINS. That would draw a distinction between an individual with various illnesses. Mr. AYERS. I am looking at it from society's viewpoint. I know all of us have been contacted by parents in regard to boys who are psycho cases, nonservice-connected, and when they contact the VA hospital they get the same answer which you have given today. Your difficulty is that you do not have the personnel to take care of them, whereas, in the case of a man who gets in an accident, he can get into the hospital because you have the medical personnel to take care. of him. Dr. TOMPKINS. But, we are maintaining 96 percent of capacity as far as our psychiatric hospitals are concerned. Getting back to your question: If the community had the facilities for these psychiatric patients there would not be any distinction, but because the communities do not have facilities for a psychiatric patient, then we bear even a greater responsibility for the psychiatric patient. Mr. AYRES. How long do you think it will be before you will get this 1,300 or 1,400 personnel? How long do you think it will be before you have doubled your staff, which you stated previously you needed? How long a time lapse will you have before you have that number? Dr. TOMPKINS. I would hesitate to calculate it, because it is a question of how many students come out of medical schools and whether psychiatry is emphasized more than it is now in undergraduate training and whether after they graduate, individuals will be more interested in psychiatry than they are at the present time. For instance, I have some figures that indicate that perhaps there are 20,000 residencies in the country as a whole for all specialties and, perhaps, only a couple of thousand are in psychiatry. It is true that under the stimulus, particularly of the Public Health Service and the VA and the universities there is a greater interest being developed in mental health personnel and greater facilities. In doing so we have developed more psychiatrists now than there ever has been, but the attractiveness of private practice and the demands of the community are greater. The psychiatrists in private practice are increasing in number in the towns and in cities because of what they can offer and their opportunities for community service are continually spreading. These opportunities are outstripping the development or the production of psychiatrists. There are so many variables that I could not say when this need will be met. The only thing is that right now I am concerned with the patients we have in our hospitals. They are limited as far as quantity of care is concerned. I do not like to think that because of lack of funds-we are turning away, as we are, people whom we can recruit, whether they are psychiatrists, social workers, clinical workers, attendants, or nurses. I think that is a very important point, Mr. Congressman, to concentrate on. The patient requires considerable nursing and attendant care and with a reduced budget, it is increasingly difficult to meet these overall needs. Mr. GENTRY. Of the 21,000 on the waiting list of nonservice connected, did you make the statement that 13,500 were NP cases? Dr. TOMPKINS. Those are psychiatric cases and neurological cases and 10,000 of them are psychotic. Mr. GENTRY. Let me ask you in that character of case, on the average how much time do they spend in a hospital? Dr. TOMPKINS. Statistics on this are misleading. The statisticians tell me it is most difficult to determine. For instance, if you tried to determine it on the basis of discharges, you do not consider the individual that stays in the hospital and again if you try to determine it on the basis of individuals remaining in the hospital, then you pick up a case that has only been there 1 or 2 months who might continue on for an indefinite period. Our best approximation is about a year and a quarter. Mr. GENTRY. About a year and a quarter? Dr. TOMPKINS. Yes, sir, but if that was actually true, we would be discharging about 2,500 a month, and actually we are discharging from both our NP hospitals and general medical and surgical hospitals around a thousand-996 individuals that were treated for psychosis, per month. We turned back into the population about 11,500 former psychotics last year. Mr. GENTRY. That means that this 13,500 that are on the waiting list, it might be a year before a one of those would get in and it might be a year and a half. It might be anytime from now on up to another year and a half? Dr. TOMPKINS. If we are not required to admit any more nonservice-connected patients, except those now on the waiting list, and, of course, the service-connected patient, it would take us 5 years to bring those patients in our NP hospitals. Mr. GENTRY. All of them? Dr. TOMPKINS. All of them. Mr. GENTRY. But, you would be getting more all along. Mr. GENTRY. But it would actually take 5 years to get them all in. Dr. TOMPKINS. If we stopped right now and just admitted these non-service-connected men on our waiting list, it would. Mr. MATTHEWS. Does the Veterans' Administration have any plans for asking for new hospitals especially to take care of these psychiatric patients in the current year? I know all of us have particular hospitals in which we are interested and I was talking to the gentleman around here, our colleague from Philadelphia, and we were talking about the situation there and I know they realize, and all of us realize that each one of us has that same problem and especially in my State do we have the problem with the psychotic case. In the contemplated program of the Veterans' Administration, I know they will take into consideration the number of veterans. In other words, I would like to know something about on what basis they would proceed to go about, perhaps, to ask for more hospitals, if I could, Doctor? Dr. TOMPKINS. Well, our ratio of VA hospital beds contemplated would be on the basis of our present NP hospital population. I would like to state that at the end of our present building program half of the beds available in the VA would be for neuropsychiatric cases in 174 hospitals, that includes hospitals that are being constructed at the present time. Mr. SECREST. I am wondering about the detention of these patients. When I go home this weekend, I have an appointment with a man and his wife who had a son admitted to the hospital in Chillicothe, Ohio, who was a mental patient and apparently he just packed his suitcase and walked out and the next they heard from him, he was in the veterans' hospital in Florida as a mental patient and by the time they arrived there, he had walked out again. They do not know where he is or anything about him and they want me to try to locate him. Do they have the right to walk out of these hospitals, or do you have any power of detention? Dr. TOMPKINS. No, sir, we do not have power of retention unless they are committed to our care by the courts of the particular community. Mr. SECREST. They can just pack up and walk out whenever they please? Dr. TOMPKINS. No, sir. If the hospital feels that the individual is dangerous to himself or others, they get in touch immediately with our regional attorney and he attempts to coordinate with the family and civilian authorities to develop a commitment, if it is considered necessary. Mr. SECREST. If they get a commitment in time, they can hold him, but otherwise while you are trying to get the commitment, he can walk out. Dr. TOMPKINS. Yes, sir. Mr. AYERS. And he will come back to Ohio. Mr. GENTRY. And he will stay there. Before you leave, take one of your hospitals-say Philadelphia— and we will say in that area you have 600 NP patients, people that are trying to get in the hospital and you have 600 on the waiting list, do you take those patients in actually the order in which they were on the waiting list? Dr. TOMPKINS. Everything else being equal, yes. Mr. GENTRY. Yes; granted they are all NP patients. Dr. TOMPKINS. If you are dealing with a psychotic and he is an individual fourth in line and he should show all at once homicidal behavior, and while the individual who is third in line may not, they may skip the third man and take the fourth. Mr. GENTRY. You would say they generally, though, do take them in order? Dr. TOMPKINS. Yes, sir, that is right. As time goes on we take fewer and fewer non-service-connected patients because of lack of personnel. I would like to say this in closing, that we are attempting to utilize to a better extent our present hospitals and our present personnel. We are attempting to develop a day hospital, a night hospital, and an intermediate hospital. This has not been approved by the Veterans' Administration, and I just mention these things which we hope will develop a more effective utilization of our present facilities. A day hospital is a hospital for treatment of the individual during the day if he does not have to occupy a hospital bed at night. A night hospital would be for the individual who does work in the day, but who needs some amount of hospital treatment which he can get in the early evening hours and stays in the hospital at night. Mr. GENTRY. I want to ask you this question: Is it not almost an unbearable thing from the standpoint of the pressure and pulls that are put on your organization? Maybe this question should go to Admiral Boone instead of you. With your tremendous waiting list and people-an individual, a Congressman and probably Cabinet members-putting pressure on you for admissions, is that not a very difficult problem? Admiral BOONE. Mr. Congressman, I do not wish that many people would sit in my chair as Chief Medical Director, but if they did, they would find that telephone calls frequently do just that. Such calls come from all sources in Government and outside of Government, because illness and particularly the mental cases, naturally, are very distressing to any family, in fact can upset the whole community and I am asked to make exceptions innumerable times. Inquiries are not confined to neuropsychiatric cases. I am called upon many times a day, to get a patient into a hospital, and even beyond that, into a particular hospital. If I cannot, it brings down a flood of criticism. Mr. GENTRY. I do not see how you can do your work properly and be subject to all that pressure and pull all the time. Admiral BOONE. Mr. Congressman, I am appointed to a position to administer, as I said, the largest medical and hospital program in the world and yet a great deal of my time is consumed in answering questions and doing things that take me away from my more important duties. Mr. GENTRY. It is bad, and a Congressman has that same problem exactly. Admiral BOONE. I know it. Being a public servant is a tough job. Mr. HAGEN. I might say that I had a personal experience where I went into a restaurant and sat down and a man came in and sat next to me and talked to himself the whole time I was there. I do not know whether he was a veteran or not. What I want to ask you is this: The man that just testified mentioned the number of patients who otherwise would be eligible for care in a veterans' facility, if one were available, who are being cared for elsewhere. Now, that is not just the neuropsychiatric patient I assume, but also all categories of cases requiring medical treatment. Do you have any statistics on the exact number of those persons and what type of condition they are in? Admiral BOONE. No, we only have figures, Mr. Congressman, on veteran patients who are in contract hospitals, both Federal and nonFederal. We do not have the other. Mr. HAGEN. So, you have no idea how many neuropsychiatric veterans might be being treated at the expense of the State of California, or the county of San Francisco? Admiral BOONE. No, sir, unless they have filed application for VA hospitalization. This is a most intriguing subject and I wish we could have a day to go into it. There are a number of other things I really would like to have an opportunity to present, because in neuropsychiatry you can go on and on and on. It is a fascinating subject and one of the most important subjects we have in this Nation with which to deal. A subject that tears one's heartstrings. As I said earlier, I wish people could accompany me and see what I see in these hospitals. When I walked into the Memphis hospital a few months ago, I had never seen 60 quadriplegics in one hospital, and also some 200 paraplegics And, large numbers are at Long Beach and the Bronx and other VA hospitals. If I may even allude to it, it is a most difficult problem to care for 250 paraplegics in one hospital. The nursing care associated with this class of patients exceeds almost every other type of care. The detail of patient care is beyond ordinary comprehension. Again I say I wish more interest and attention would be given to the vital and large problem of veterans' medical care and not so much to the little things. The CHAIRMAN. And you have trouble sometimes in getting bills through for the quadriplegic, paraplegics, and amputees. Admiral BOONE. Clarifying one point, because it was raised several times yesterday, the Congress appropriates after presentations and hearings by the Bureau of the Budget. Our presentations start in the field. They clear through the Department of Medicine and Surgery and the top-level officials of the Veterans' Administration and on through the Bureau of the Budget and then the President acts on them and they come to Congress. Then, we have our hearings. Some new Members do not realize the transactions in getting this money. We do not get it immediately. It is allocated by the Bureau of the Budget quarterly and I believe by law, or regulation, the Bureau of the Budget can withhold as they see fit, or they foresee a change in our requirements for the next quarter, independent of VA's request for apportionment. But, I would like to emphasize when you are dealing with humanity, you cannot do it on a slide-rule basis. I approach my job as a family physician sitting at the bedside, I have carried that concept throughout my adult life and I apply it in my present official position. You are dealing with TB and NP patients, the paraplegics, the chronics, and others which require long period of treatment. The TB a year or so and the NP for 2 years, as a matter of fact until death. You just cannot run your program and have funds changed quarterly. We are getting terrible reverberations from medical colleges. Because of fund reductions. We had to cut the fees for consultants and attendings. The colleges make up their budgets for the fiscal year, and sometimes they take on additional staff predicated on the fact that the VA is going to give them part-time employment knowing that their salaries will be supplemented by the VA. Now, we turn around because of a budget cut and have to cut them. So, the faculties and university presidents are very much disturbed because their budgets are not prepared for this year to suffer those cuts we had to make. They think we are playing in bad faith, and have not carried out our commitments. These fluctuations in funds are very hard for them to understand. I have gone through this subject with the Association of American Medical Colleges and with other interested organizations throughout the country. They are holding firm now because I know they believe in us, but if we are not able to give them an assurance of what they can look forward to in the 30158-53--4 |