nursing home that could step in and fire him if he really tried to fulfill all of his responsibilities as a principal physician.

Senator Moss. Your report is, as I say, a very excellent document and is most helpful. Has this been submitted to the Governor and circulated widely in Maryland?

Father SELLINGER. Certainly, it was given to the Governor the day that we submitted it to the public.

Senator Moss. This date of submission on October 27 would be to the Governor and to the Department of Health?

Father SELLINGER. Yes; and to Dr. Solomon.

Senator Moss. And to the Federal units operating in Maryland?

Father SELLINGER. I am sure they did receive copies. It wasn't at our direction. But Dr. Tayback and Dr. Solomon's office handled the duplication of the report and were willing to, and most gracious in, fulfisling all the requests for copies of the report.

So, I am sure all of those who were interested have gotten a copy of it.

Senator Moss. Mr. Miller.

Mr. MILLER. Thank you, Mr. Chairman.

Monsignor Sellinger, you have made an observation that, in your opinion, the situation constitutes, in effect, an indictment of our entire society as it relates to the elderly.

The question arises, however, when you are discussing the matter of the preemption of the nursing home field by persons who are engaging in it as proprietors for a profit, does this not, in your judgment, connote a particularly strong indictment of those institutions that normally enter into the provision of care through voluntary nonprofit institutions?

Father SELLINGER. Meaning that there hasn't been enough interest on the part of those groups to take care of nursing homes the same way they did with hospitals?

Mr. MILLER. That is right.

Father SELLINGER. I think so. And I think as a result of conversations since the report, it has been our intention to try to interest groups such as have been interested in hospitals to get interested in homes for the aged.

Mr. MILLER. Mr. Chairman, you may recall at your hearing in New York several years ago, the current mayor of the city of New York suggested that a simple solution to the problem would be for each voluntary hospital in New York City to undertake the construction of 100 nursing home beds as a part of their facility.

Senator Moss. Thank you very much, Reverend Sellinger. We appreciate your coming to testify before us and for the services you rendered to Maryland in heading this investigation on this very sad event that occurred earlier this year.

We will now hear Dr. Frank Furstenberg, and Dr. Dora Nicholson. We will hear from one and then the other.

We appreciate your coming here, Dr. Furstenberg. You are associ ate director for program development for Sinai Hospital in Balti

more.

You may proceed.

STATEMENT OF FRANK F. FURSTENBERG, M.D., ASSOCIATE DIRECTOR FOR PROGRAM DEVELOPMENT, MOUNT SINAI HOSPITAL, BALTIMORE, MD.

Dr. FURSTENBERG. Mr. Chairman and members of the committee, I was called just the other day, I haven't prepared extensive testimony, but I have jotted down a few notes.

I am a private practitioner in Baltimore as well as associate director for program development at Sinai Hospital.

For a number of years, I was the medical director of the hospital out-patient department. In this role, I helped develop a number of community programs, including organized comprehensive health care for the aged emphasizing independent living in the community. In addition we began the first hospital-based home care program in Maryland. And more recently, I was acting medical director of our chronic disease facility which is both a chronic disease hospital and nursing home.

I have a special concern about the quality of long term care and the especially difficult problem of rendering good care in nursing homes. I agree with the testimony that is being developed here today, that an objective should be to keep patients out of nursing homes, they should not be admitted to nursing homes because society has failed to bring services to patients which would allow them to live independently in the community.

Maryland nursing home problems are certainly not unique. The commission's report complaisized this. Society has not done its job, it can't feel comfortable now that a million older Americans are receiving care in nursing homes.

Even though we now pay $3 billion for nursing home care, largely Federal funds, we must face squarely that money, necessary as it is for good care, will not alone result in high quality care given sensitivity to these unprotected chronically sick-often depressed aged persons.

We must also accept the responsibility for the present status of nursing home care. We have fostered the proprietary nursing home industry, which necessarily concerns itself with profits, in caring for patients. It is the responsibility of your committee and Congress to work through the States to have these public dollars result in good bedside care. At this time it would be especially meangingful that Congress encourage the voluntary nonprofit nursing homes so that we will have nursing homes that can serve as examples, in on-going care programs of first-class care with innovative services for those patients who must become patients in nursing homes. Most innovative services will necessarily be nonprofitable.

What about the monitoring of nursing homes and its effect on the care given patients? We must insist that the States in their control procedures not only do that which they are doing now, inspecting safety, sanitation, the physical environment; setting standards, for nursing personnel, pharmacy and physician services, but they have to go further.

They must develop controls for uniformly good nursing and physician services delivered at the patient's bedside. Inspection procedures

41-304-71-pt. 10- -4

have to be so sensitive that deviation from proper care becomes apparent promptly. The nursing home patient is often an abandoned, sick, and a depressed person and we cannot expect such a patient as a consumer of nursing home services to exercise marketplace controls on the care he or she receives.

The day must come, and I hope soon, when nursing home inspectors take on the role of patent ombudsmen, and not regress to paperpushing bureaucrats engaged in proforma inspections, filling out inspection forms.

We should, in addition, promote surveillance of nursing home care by involving the potential consumers of nursing home services among them the older Americans.

We all face the distinct possibility of entering a nursing home in our last years as a patient. There are now 1 million persons 65 and older in nursing homes, 5 percent of that population. The ratio of nursing home patients is much higher at age 80. It becomes mandatory then that we, as the "upright" citizens, participate in the inspection system in some way.

Nursing homes are simply too important to be left to the providers and to the public officials and expect consistently sensitive services for the patients. And I include in such providers the voluntary nonprofit nursing homes, as well.

The medical professions' role in nursing home care has left very much to be desired. Organized medicine has not followed the slogan of the President of the AMA, who recently said "it should be the shaper of the future." It has done very little to shape the future of care in the nursing home field.

Individual physicians who have given patients excellent care for years too often literally forget the patient when he reaches the nursing home.

I am completely understanding of this phenomena. It is very depressing to visit almost any nursing home. The private practicing physician is very busy and he knows he can't do much more than he has done for his nursing home patient. So, he places a very low priority on seeing the patient, a low priority, also, because it may require a time consuming visit.

The result is often no visit or a delayed visit until there is an emergency call for care.

Hasn't it been rather irresponsible of society and hasn't it been really irresponsible of organized medicine not to have changed the delivery of physicians' services in nursing homes up to now? We face a shortage of physicians' services and yet-do we really expect 44 doctors to be responsible for visiting 146 patients in the Gould nursing home when these services could have been given well by two or three interested and responsible physicians working together.

Maryland's move to change the functions of the principal physician in nursing homes, to medical directors, is a move in the right direction. But this move must be more than simply a change in title. These physicians must soon be given the primary responsibility for all the patients in the homes.

They should be competent and show an interest in the nursing home patients and be paid adequately. It is going to be tough to find 175 such physicians for the 175 nursing homes in Maryland.

But, when we do find a cadre of physicians, and we don't need 175, who will give excellent nursing home physician service, we give these physicians the status, the professional stimulation that they must have and we pay them adequately, we will have done much to improve the quality of medical care in Maryland's nursing homes.

Senator Moss. Thank you, Dr. Furstenberg.

What percentage of doctors are in geriatric medicine?

Dr. FURSTENBERG. I don't know, but relatively few as specialists. However, every general practitioner or intern practices geriatric medicine. He may not enjoy it, but many of his patient visits concern sick older persons. While older persons are 10 percent of the population, they comprise 25 or 30 percent of the visits to the doctor's office.

Senator Moss. But there are very few, I take it, that specialize, set out to specialize in geriatrics?

Dr. FURSTENBERG. Yes. This specialty or subspecialty of internal medicine has not been developed. There are some that would like to see it developed as pediatrics developed its specialty at the turn of the century.

Senator Moss. I was very much interested in your suggestion that we ought to have inspectors who had a particular sympathy of older people and understood their problems. It crossed my mind, would it be feasible, do you think, if we might utilize some of our elder citizens who are well and are able to get out and to get in this inspector sort of cadre?

What I am thinking of is, in order to give some of our older people a feeling of independence and worthwhileness and so on, we have had a program called the green thumb, where they are hired to do beautification work along highways, around public buildings, and so on; and this has been extremely popular, particularly in rural areas where people are retired and really don't have enough to do. These citizens suddenly have a job again. They just felt wonderful to go off to work and do something they liked to do.

Is it possible that we might employ this principle with our older people working to improve our nursing homes?

Dr. FURSTENBERG. Emphatically. It is important and older citizens should be involved in this area. We must expect a higher "cop-out" rate. Just as physicians "cop out" of taking care of nursing home patients because they can't stand them, so older people will want to deny what they see in nursing homes. There is so much to be done. I emphasize again that we cannot leave nursing-home care or the care of health services generally, simply to the providers, to the third party payers, or to a government-payment mechanism.

We must have consumer participation in the nursing-home field and the care of the aged in general. I would like to see older persons involved in the nursing-home inspection programs. It would be helpful if they only visited and talked to the patients while the sanitary inspectors were performing their roles.

There are already friendly visitor programs, but I prefer older Americans involved in an official capacity in monitoring nursinghome care, where they will be improving care for older persons.

Senator Moss. You heard the exchange, I guess, on the signing of the death certificates. Do you have any view as to whether a doctor

ought to be required to personally view the body before he certifies the cause of death?

Dr. FURSTENBERG. Yes. While it is advisable generally, it is much more important that there be evidence in the record, of physician examination and care ordered, for the last days of that patient's illness.

Review of care should include ample record in the chart documenting what was going on, the medical care being given. I emphasize that we should be more interested in the care of the patient while the patient is alive than concern ourselves about viewing the body before signing the death certificate.

The importance, though, in your exchange with Dr. Tayback is the fact that nursing homes, as other providers of medical care, do not document unfortunate incidents in the care of patients.

Are there many patients who suffer falls while in nursing homes? Such data should be available. If the incidence occurs frequently in one nursing home, what kind of care is being given? Monitoring such incidents would be part of the review of care rendered.

Senator Moss. Would there be quite a difference in the procedure of a doctor who signed a death certificate for a patient who expired in a hospital, say, and what he does for one who expires in a nursing home?

Dr. FURSTENBERG. In a hospital the physician will have seen his patient prior to death. At the time of death other personnel may verify death. The personal physician signs the death certificate, but he may not be present at the time a patient dies. It is important that the death certificates be signed accurately. Most important is the need for adequate notes in the clinical record prior to death.

Senator Moss. Thank you, Dr. Furstenberg.

We would like to now hear from Dr. Dora Nicholson, most recently senior staff assistant of the psychiatric hospital at Peirpoint, Md. We will be glad to hear from you, Dr. Nicholson.

STATEMENT OF DR. DORA NICHOLSON

Dr. NICHOLSON. Good morning, I am Dr. Dora Nicholson. I received my M.D. degree from the University of Athens in Greece, and I have been licensed to practice in the District of Columbia since 1966. In between I have worked in research, hospital administration, and as special adviser to the Greek Government on women's disability. I have had graduate training at the University of Pennsylvania in clinical neurology. I was a research fellow and assistant professor in the anatomy department of the George Washington University Medical School. I have been director of research for the Rosewood State Hospital, assistant professor in pathology at the University of Maryland, and senior staff member of the Veterans' Administration hospital in Peirpoint. Md. Today I am in private practice, and my specialties are neurology, psychiatry, child growth and development, congenital defects, and mental retardation.

The truth, it seems, comes from all sides. My colleague has just said exactly what I was intending to tell you. I am glad we "speak the same language" because our problems are similar across the country.