methods of diagnosis and treatment, and essential roles in the advancement of knowledge.

We strongly support the objectives of the Hospital and Medical Facilities Construction and Modernization Amendments of 1969 and similar legislation the committee is now considering.

Mr. Chairman, if it is agreeable to the committee, I will direct my comments to the importance of urban and teaching hospitals in the total pattern of providing health services, and Mr. Viguers will comment on the specific proposals under consideration and certain other important aspects of this legislation.

I am going to turn from the statement which you have before you, Mr. Chairman, just to make a few very brief points.

Mr. JARMAN. Your statement, Doctor, will be accepted for the record in toto, and then you can highlight what you would like to emphasize.

Dr. ROGERS. Thank you, Mr. Chairman.

First, I want to indicate I was impressed by the statement of Mr. Biemiller this morning. It was of interest to me to see how closely his statement parallels the views of the Association of American Medical Colleges. I found that a very eloquent and thoughtful statement.

The points I would make to this group are, first, that the majority of large urban hospitals are teaching hospitals. That has some important connotations to it.

Secondly, many of these hospitals were the predecessors of our most important teaching areas in medicine, our medical school, and I would use as an example the Johns Hopkins Hospital, which was in business some 10 years before the fact of the medical school with which I am now associated.

The third point I wanted to make, these large urban teaching hospitals are in my judgment critical to the survival, the growth, the improvement, and the changes that I think all of you feel necessary in the health care system.

First, they are responsible and increasingly responsible for total patient care, often even from very simple primary care to the most complex and technically sophisticated care that we have available in this country.

Secondly, they are responsible, or the staffs that are housed within them are responsible, for most of the advances in diagnostic procedures and therapeutic procedures that have changed so dramatically what we can now do for sick people.

Thirdly, and perhaps most important, in my judgment, they have critical responsibilities for training the majority of the health workers that this country now needs so desperately-the physicians, the nurses, the laboratory technicians, the whole spectrum of health professionals that are now needed.

Fourth, at present-and I think quite appropriately enormous demands are being put on the health-care industry for increasing the output of health programs for increased services, for increased work in how we can deliver medical care appropriately to all of our American citizens, and in my judgment, the leaders in this change must really be the medical schools and their close companions, the urban teaching hospitals.

I think it is the position of the AAMC that the Hill-Burton Act of the last two decades has been vital and critical in placing hospital

bed facilities where they were needed. I think the problem that we now face and you now face is that the centers of teaching, the ultimate centers for specialty care and for training of health professionals, the large urban hospital centers are in fairly serious state, and I think without the kind of assistance which is outlined in both of the pieces of legislation which you gentlemen are considering, they are quite incapable of financing the kind of modernization and construction that is vitally needed to fulfill their obligations to society.

I think it is easier for me to give one simple example here. This year, for example, the Johns Hopkins Hospital will have a deficit somewhat over $1.5 million, which makes the kind of capital improvements or modernization of facilities that are needed almost impossible. The reasons for this are very simple. One, that we have heavy responsibilities for teaching of not only physicians and nurses, but many postgraduate physicians and others, costs which cannot logically be offset to patient care. Secondly, and on this point, Mr. Rogers, I wanted to comment because of one of your earlier comments, sitting as we do in the center of an urban ghetto we have become the primary physicians really for the entire group of urban poor who surround us. One of the reasons for this-I am responding now to your comments about the suburban areas vis-a-vis the central city. I think these figures might be of interest to you.

We have become the physicians of really hundreds of thousands of underprivileged who live around us because the physicians in other hospitals have migrated to the suburban areas and we are left as primary physicians for these people.

Mr. ROGERS. The hospital schools?

Dr. ROGERS. That is correct, sir. For example, our emergency room which was designed to see 150 patients a day now tries to see 450 patients a day.

Our clinics, designed for a modest number, are now attempting to handle 450,000 patient visits per year.

So I wanted to make this point, that the large urban hospitals are indeed increasing the amounts of care which they give in part because of physicians and hospitals having migrated to suburban areas, to a significant extent.

Mr. ROGERS. May I just interject there. There is a program that we are considering now for modernization, which is geared to that problem.

Dr. ROGERS. Right.

Mr. ROGERS. This is what I am saying, and I am not sure we are giving much consideration to suburban areas that have built up rather rapidly where there are no hospital facilities, where no one has migrated.

Thank you.

Mr. CARTER. Mr. Chairman, sickness exists more in the ghettos and not in the suburban areas. That is where the pathology is, which the doctor no doubt realizes.

Dr. ROGERS. Very much so.

Mr. ROGERS. We are going to try to meet this with the guaranteed loan program, $400 million.

Dr. ROGERS. The other final comment that might be made, 2 days ago I know you heard testimony from the Under Secretary of Health and Welfare, in which he clearly stressed the need for out-of

hospital facilities-neighborhood health centers, nursing homes, and

so on.

I thought I might indicate that I think the AAMC thoroughly agrees with those concerns of the administration, but wanted to emphasize that in the judgment of us who are now responsible in urban areas, I do not believe that these can function without the flow of trained professional personnel, without the backup of resources, without the leadership of the staff, which is contained in the large teaching hospitals.

And I thought again that was quite eloquently summarized in Mr. Biemiller's statement to this committee this morning.

But clearly the needs at the moment are for the development of a system, a continuum of care which must move from the neighborhood health center through the entire continuum to the major teaching hospital.

I think if teaching hospitals were not supported and strengthened, the entire programs of outreach structures might well flounder.

I think the kind of legislation that is represented in the two bills that you are now considering is precisely the kind of thing which is required for these very precious national resources, the teaching hospitals, to fulfill their obligations.

Just one last comment, and that is I would like to reemphasize the association's feeling regarding the importance of the National Center for Health Services Research and Development. The AAMC has long been interested and when the Federal sector was searching for a chairman of this new organization, it selected Dr. Paul Sandzaro, a member of the AAMC staff. We are very soon again in conjunction with that new group conducting a conference on this problem of how we can develop systems for the delivery of health care, which in my judgment is the critical need at the moment.

Mr. Chairman, I thank you very much for the privilege of allowing me to make these comments. I might also interject the thanks of other medical people for all of the help this committee has given in enacting legislation for the health of American citizens, and I would like Mr. Viguers to comment on certain specific recommendations that the association would like to place before this committee.

(Dr. Rogers' prepared statement follows:)

STATEMENT OF DR. DAVID E. ROGERS IN BEHALF OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES

Mr. Chairman and Members of the Committee, I am David E. Rogers and I I am Dean of The Johns Hopkins University School of Medicine and Medical Director of The Johns Hopkins Hospital in Baltimore. With me today is Mr. Richard T. Viguers, Administrator of the New England Medical Center Hospitals, of Boston. On this occasion, we are spokesmen for the Associstion of American Medical Colleges, which consists of all the medical schools in the country, 29 distinguished academic societies which include most of the members of faculties of medical schools, and 340 of the leading teaching hospitals in this country. The Association has recently been reorganized so it can more effectively represent the institutions and organizations which play the principal role in the education of large numbers of health personnel for the future, vital roles in the improvement of methods of diagnosis and treatment, and essential roles in the advancement of knowledge.

We strongly support the objectives of the Hospital and Medical Facilities Construction and Modernization Amendments of 1969 and similar legislation the committee is now considering.

Mr. Chairman, if it is agreeable to the committee, I will direct my comments to the importance of urban and teaching hospitals in the total pattern of providing 28-236 0-6911

health services, and Mr. Viguers will comment on the specific proposals under consideration and certain other important aspects of this legislation.

We are confident that other spokesmen will present the needs of community hospitals for modernization and construction, and will focus our remarks on urban and teaching hospitals because it is their roles and needs with which we are the most familiar.

I would like first to make the point that the largest and most important urban hospitals are all teaching hospitals and many of them were the predecessors of the medical schools with which they are now intimately related. For example, The Johns Hopkins Hospital was a highly effective institution for nearly 10 years before The Johns Hopkins Medical School opened its doors. A great many urban hospitals less closely affiliated with medical schools have for years been the setting in which interns, residents, nurses, technicians, and therapists have been educated. In those very few instances in which teaching hospitals are located in small citiessuch as Gainesville, Florida; Madison, Wisconsin; and Iowa City, Iowa-their role is similar to that of urban hospitals in all but one major respect.

The primary role of every hospital is providing diagnosis and treatment for patients. Every urban hospital is of major importance in providing services for the patients in its immediate vicinity. Typically they are located in the "inner city", so they are a primary and vital resource for the people who live and work there. They are also of very great potential importance to everyone in their region, because they serve as "hospitals of last resort" to which some patients with complex and severe problems are referred for definitive care.

Many of the urban and all other teaching hospitals have long been the settings in which the problems of patients receive the closest and most detailed study and the places where knowledge gained in research laboratories is first applied to those problems. Most improvements in methods of diagnosis and treatment have first been developed in these institutions and then used in smaller community hospitals after they have been perfected and people trained in their use in large hospitals have become available. As hospitals and medical schools are developed in parallel, the bridge between the laboratory and the bedside has become very short indeed. This research function makes heavy special demands on the teaching hospital. The rendering of advanced medical care requires highly skilled health practitioners coupled with prodigious technical apparatus to aid in performing the many diagnostic, therapeutic, and rehabilitative functions so characteristic of the teaching hospital. These hospitals are now also becoming important centers for experimentation in different health delivery systems.

A third major role of these institutions is that of serving as an environment in which the education and training of physicians, nurses, technicians and therapists take place. For example, a medical student begins to learn how to study the problems of patients in the hospital setting before the end of his second year or earlier, and spends nearly all of his time in that setting during the third and fourth years. A typical young physician spends four years working very hard as an intern and then a resident before he moves on to some other role in the profession. The hospital is the setting for an even larger portion of the education and training of many other categories of health personnel.

At the most recent annual meeting of the AAMC, several far-reaching recommendations relating to an increased output of physicians were adopted. It is now the official position of the Association, in agreement with the wishes of Congress, that prompt and strenuous efforts be made to expand the enrollment of medical schools as a response to the demands and needs of society for more and better trained physicians and other health workers. To achieve this, new medical schools are being built and existing medical schools are expanding their classes. All of these training and educational advances require clinical facilities, and it is imperative that we increase our outpatient and inpatient facilities to provide the clinical basis for training the increased numbers of many categories of health personnel. The tremendous accomplishments of the Hospital Construction Program since it was enacted more than two decades ago and the responses to that program on the part of local and state governments are well known to the members of this committee. It is no exaggeration to say that if this farsighted program had not been initiated and been extended and improved by subsequent actions of the Congress, we would have already faced a shortage of facilities for meeting the health needs and demands of our society that would have been disastrous. The early emphasis of the program on the creation of hospitals and health facilities in small cities and towns was justified by the fact that at the time there were hardly any modern health facilities in those communities throughout our country. We believe that the emphasis of the program should now shift toward meeting the needs of urban and teaching hospitals. In the last two decades, there has been

an enormous movement of people from rural to metropolitan areas and society has placed increasing demands upon urban and teaching hospitals, but adequate ways to meet their needs for modernization and construction have not yet been developed. State, local and private sources have traditionally been the primary supporters for the construction and modernization of urban and teaching hospitals. Those sources cannot now provide the additional funds needed with the speed required. An imaginative program of Federal support, such as proposed in this legislation, is needed to insure that these institutions will be able to sustain their standards of excellence and respond to the needs and demands of society.

The urban and teaching hospitals are likely to be the loci of the confrontation when the forces of rising expectations and effective demands meet head-on with the hard facts of acute shortages of manpower and facilities. This nation and its teaching hospitals face a major crisis. We urge that the committee give favorable consideration to this legislation and that the Congress promptly enacts it.

I would like now to ask that Mr. Viguers comment on certain specific recommendations that the Association of American Medical Colleges has with regard to this legislation, after which we will be most pleased to answer any questions the members of the committee may have.

STATEMENT OF RICHARD T. VIGUERS

Mr. VIGUERS. I am Richard T. Viguers, administrator of the New England Medical Center Hospitals in Boston. I am chairman of the Committee on Modernization and Construction Funds for Teaching Hospitals of the Council of Teaching Hospitals, Association of American Medical Colleges. I appear today on behalf of the teaching hospitals and the AAMČ.

I would also like to express my appreciation for being heard by this committee, and your considered and thoughtful attention to our points.

I would just add that the hospitals of which I am the administrator are part of a medical center. The balance of the medical center is Tufts University School of Medicine and Dental Medicine. The reason I mention this, I was delighted to hear Mr. Biemiller say some amount of praise for Tufts' facilities at Columbia Point, and point out that Dr. Jack Geiger had said the Columbia Point project is health care on a comprehensive basis to some 6,000 low-income people, and it cuts the need for hospitalization by 80 percent, which is quite true. Both Drs. Jack Geiger and Count Gibson have done a grand job. But I would point out the hospital I am administering is picking up that 20 percent. Those people either before got no medical care, or got abominable care in various conditions which were practically inhuman, so they are now coming to the New England Medical Center Hospitals. So the very success of the program, which he is talking about, has increased our need for beds and other facilities.

Also, for example, the Columbia Point project, because of limited funds, largely, closes at 8 o'clock at night. Now, we run a shuttle service back and forth which takes only about 10 minutes. There is no public transportation, but anyone needing emergency service or thinking they need it after 8 o'clock at night, is shuttled back to the

emergency room.

Not only because of that, but because of that and other things, I now need a quarter of a million dollars to build new emergency room facilities. So I was particularly interested, as I said, to see examples of things which do cut our total health bill and are looked upon with favor by a great proportion of our people. But sometimes that adds something to what the teaching hospital is doing.