THIS CONTRACT, made between the Subscriber named in the application and MICHIGAN MEDICAL SERVICE, a non-profit corporation.

ENTITLES the Subscriber, in consideration of payments at the subscription rates indicated in the application, to have Michigan Medical Service pay for surgical and other services, as hereinafter defined, rendered to the Subscriber and, if listed on the application, the spouse and unmarried dependent children until the end of the calendar year in which they attain nineteen (19) years of age, for a period of one month next following the date of execution, upon and subject to the terms and limitations hereinafter set forth.

In WITNESS WHEREOF, Michigan Medical Service by its agent duly authorized in the premises has executed this Certificate.

MICHIGAN MEDICAL SERVICE,
JAY C. KETCHUM,

Executive Vice President.

SURGICAL BENEFIT CERTIFICATE

MATERNITY SERVICES ARE NOT A BENEFIT UNDER THIS CERTIFICATE

The CHAIRMAN. Thank you.

Dr. SENSENICH. May I introduce Dr. Victor Johnson, secretary of the Council on Medical Education and Hospitals of the American Medical Association and professorial lecturer in physiology of the University of Chicago.

STATEMENT OF VICTOR JOHNSON, PH. D., M. D., SECRETARY. COUNCIL ON MEDICAL EDUCATION AND HOSPITALS OF THE AMERICAN MEDICAL ASSOCIATION

Dr. JOHNSON. Unlike my two predecessors I do not practice medicine. My professional career has been in teaching, in medical education and in research.

THE COUNCIL ON MEDICAL EDUCATION AND HOSPITALS

My official position in the American Medical Association is that of executive officer, or secretary, of the Council on Medical Education and Hospitals. This council consists of seven national leaders in medical education and hospital matters, under the distinguished chairmanship of Dr. Ray Lyman Wilbur of California.

The work of the Council (and earlier, the committee) on Medical Education and Hospitals in the past century is generally conceded to be a major factor in the high standards of medical and hospital care now obtaining in this country, since the quality of a physician's serv ices can be no better than the quality of his education as an undergraduate in medical school and after graduation in a hospital internship or residency. After the turn of the century there were increase efforts to improve medical education in this country. Some of the medical schools were still operated primarily for the financial profit of the faculty and provided exceedingly inferior instruction. At the instigation of the council, the Carnegie Foundation conducted survey of medical schools under the direction of Abraham Flexne and with the collaboration of council representatives. The finding in this survey, constituting the classic publication generally know

as the Flexner Report, resulted in the closing of a number of the medical schools of the country; these were schools scarcely deserving the name, producing graduates entirely unqualified to treat the sick. This effect of the Flexner Report is astonishing, since the report carried no legal or governmental authority, but produced results entirely through its influence on public opinion.

Through the ensuing years to the present time, the recommendations of the Council on Medical Education and Hospitals still derive their effectiveness, not from legal authority, but from public opinion, lay and professional, which recognizes the objectivity of the conclusions of the council in its efforts to improve medical education and, as a consequence, the quality of medical care. In carrying out this work, the council, with the approval of the house of delegates of the American Medical Association, has established standards of education for medical schools and for hospitals offering internship and residency training to medical school graduates, as well as standards for schools in technical fields related to medicine, such as physical therapy, medical record libraries, X-ray, occupational therapy, and clinical laboratory work.

Annually, the council publishes three special numbers of the Journal of the American Medical Association dealing with statistics, problems, and information on medical education, hospital care, and medical licensure, as well as revised lists of medical schools, hospitals, and other institutions adhering to the high educational standards which have been established. These publications are for the guidance of prospective individual students, physicians, hospitals, various Government agencies, and the public.

In my prepared statement I describe a number of publications by the council which are employed by prospective medical students, Government agencies, and the public, and if the committee wishes I can leave for any possible reference they wish to make to this material these publications for the files of the committee.

The CHAIRMAN. You may submit them for the committee records. This work of the council has been a major factor in warranting the following recently expressed judgments by experts that medical education in this country is unexcelled anywhere in the world and that the low death rate of our armed forces from disease and wounds was due primarily, not to plasma, penicillin, or sulfa drugs, but to the high quality of the medical education of our medical officers.

The legislative measure under consideration deals only briefly in a direct way with medical education and medical research

The CHAIRMAN. I would like to ask you there, Doctor, if it is true. that the general practitioner of medicine in the United States is a graduate of a recognized college and medical school.

Dr. JOHNSON. The vast majority of them are.

The CHAIRMAN. Very few men are allowed to practice medicine in the United States nowadays who are not really qualified to practice. Dr. JOHNSON. In two States of the Union, Illinois and Massachusetts, graduates of so-called unapproved medical schools have eligibility for license. It has recently been changed in Massachusetts. The CHAIRMAN. But it still exists in Illinois?

Dr. JOHNSON. Illinois, yes. The school does not adhere to the standards, and the graduates are eligible.

The CHAIRMAN. Was that due to a shortage of physicians?

Dr. JOHNSON. That school has been in existence for a number of years, certainly since long before the war, so that the war shortage had nothing to do with it.

The CHAIRMAN. But the reason for permitting them to be licensed was the fact that the shortage of physicians made it necessary to undertake to get more doctors licensed to carry on medical practice?

Dr. JOHNSON. I cannot say with certainty what the exact origin of that medical school was, but I do not believe it was a matter of any acute deficiency.

The CHAIRMAN. But generally the doctors that are practicing medicine in the United States are qualified?

Dr. JOHNSON. Yes, generally they are graduates of approved medical schools.

The CHAIRMAN. Very well.

A NATIONAL SCIENCE FOUNDATION PREFERABLE TO S. 1606

Dr. JOHNSON. The legislative measure under consideration deals only briefly in a direct way with medical education and medica! research directly, which are inseparable in any sound program. Section 213 provides for "Grants-in-aid for Medical Education (and Research * * *." The desirability of such aid has been recog nized by the house of delegates and by the Council on Medical Education and Hospitals of the American Medical Association. Thes bodies have endorsed such Federal support provided it is organize and administered soundly, as is the case in certain of the proposa!now before Congress. There are several bills calling for the estat lishment of a national science foundation to administer funds an programs for research and scholarships in the sciences, including medicine. The administrative arrangements provided by certain of these bills (the Magnuson bill, S. 1285, and the Kilgore-Magnusor bill, S. 1850) are sounder by far than that of S. 1606, and promi greater success in achieving the desired ends than is the case with the measure under consideration. The Kilgore-Magnuson bill wise! limits the authority of the director, appointed by the President, a places considerable authority in the hands of the members of th foundation, who are to be scientists of repute, functioning not simply as advisors to the administrator, but possessing the authority to in tiate positive action in some instances, and to veto the decisions of the administrator in other cases. In contrast to this arrangement. under S. 1606 the Surgeon General of the Public Health Service is required to seek only the advice of the National Advisory Medica Policy Council, which advice he is free to follow or not, as he choose

Safeguards for the preservation of independence of research workers and institutions are provided in the Kilgore-Magnuson bill in a manner which promises effectiveness. Such safeguards, which are indispensable for productive research, are almost entirely lacking in the reasearch section of S. 1606.

In the Kilgore-Magnuson bill the scholarship program is carefully worked out in considerable detail. In the bill under consideratio virtually no organized program is set forth in the scholarship field.

DISTRIBUTION OF HOSPITALS

In any program for the extension and improvement of medical care, hospitals occupy a key position, because modern medicine cannot be practiced except with the diagnostic, therapeutic and other facilities which hospitals provide for the use of physicians. The Council on Medical Education and Hospitals has long been interested in the numper, distribution, and quality of hospitals in general. Besides the assistance it renders, upon request, to hospitals operating educational programs for medical-school graduates at the internship and residency evels, the council also serves hospitals in general, in efforts to improve he quality of hospital services. This it does by establishing standards of hospital care (as set forth in one of the documents I will submit for your records), providing free consultation services to such hospitals is request them in their efforts to achieve these standards, and mainaining a list of "registered hospitals," revised annually, which meet hese standards.

I then quote certain figures which we need not go into unless you wish to know them concerning the number of hospitals, admissions to them, and the bed capacity in the United States.

At present about 78 percent of the bed capacity of this country is in hospitals operated by some Government unit, Federal, State, county, or municipal. However, these hospitals, about half of which are for nervous and mental cases, account for only 40.8 percent of the total ospital admissions. Nongovernmental hospitals provide only 22 percent of the hospital beds of the country but they account for nearly 60 percent of the patient admissions..

Over the years, the increase in hospital beds in this country has been phenomenal, independent of the great wartime increase in the Federal hospital bed capacity of the armed forces and the Veterans' Adminstration. Hospital beds have multiplied far more rapidly than has he population. Hospital beds have tripled in number from 1909 to 1940. The population did not double during those years. During that time hospital beds were provided more than one and one-half times is rapidly as the population has grown.

The percentage occupancy of hospital beds in the various States lisplays a phenomenon difficult to interpret. If the States are aranged in the order of increasing number of hospital beds per 1,000 population, we find that this order is also approximately that of inreasing percent of beds occupied in general hospitals. That is, the States with the fewest beds per 1,000 of the population use those beds east; those with most beds use them most. For example, 3 States aving less than 2 beds per 1,000 people (in 1940) had an average bed Occupancy of 62 percent; 16 States having 3 to 4 beds per 1,000 people ccupied over 70 percent of them; while in the District of Columbia, vith 10 beds per 1,000 people, the occupancy was still higher.

Several factors may be involved. Perhaps the people in States nable to provide adequate hospital facilities are financially unable o take full advantage of these facilities. Perhaps the quality of hese hospitals and the means of transportation to them are inferior to hose in States with more hospitals. However, there is probably also he factor of lack of education of the public to the use of such health

facilities as do exist. This factor must be considered in any progra.. for the improvement of the people's health. To be successful, such program must educate the people to know the health facilities an. stimulate their use.

There has been much discussion of inadequate distribution of hos pital beds, especially in rural or economically ill-favored areas or States. Frequently this inadequacy is expressed in terms of the larg number of counties in this country possessing no hospital. Such fig ures present an entirely erroneous picture, since the natural unit not the county but the trade area, and distance of people's homes fro a hospital is more important than artificial boundary lines. In 19 an extensive study by the Council on Medical Education and H.! pitals of the American Medical Association revealed that over 98 pe cent of the population of the United States lived within 30 miles of a hospital, a distance of rapidly shrinking significance, with moder roads and transportation. The accompanying map on the next page shows in white all areas within 30 miles of a hospital, and in bla all areas not within 30 miles of a hospital. In determining the shaded areas such special institutions as mental, maternal, tuber losis, and other restricted hospitals were not considered and hospitali under construction were excluded. The shaded areas are almost entirely limited to sparsely settled areas.

This distribution picture would be somewhat improved by the hpital construction since that time and considerably improved in: years immediately ahead, since vast programs of hospital construct are contemplated. It has been estimated that existing registered h pitals will spend about a billion dollars for expansion, improveme * and replacement. The volume of construction of entirely new no. governmental hospitals is not known, but will probably be tremendo

It is recognized that the mere existence of a general hospital wit! 30 miles does not indicate that hospital facilities are adequate in th.. area. The bed capacity may be inadequate for the population of t area and the hospital plant and equipment may be inferior a obsolete. Recognizing this, the American Medical Association be lent strong support to the Hill-Burton Hospital Survey and Constru tion Act in actions by its board of trustees and house of delegates ar in testimony before two committees of the Congress.

In drafting and revising the Hill-Burton bill expert profession advice was sought from a number of qualified organizations. An? portant provision of this measure, which has passed the Senate. that surveys of existing hospital facilities shall be conducted by States, and comprehensive plans developed relieving deficiencie areas needing hospitals and able to maintain them, before Federal a to States for hospital construction will be provided. This is an a proach to the problem of extending and improving medical care accordance with the scientific method, which should be employed only in solving medical problems of the cause and control of disea but also in our efforts to evolve programs for providing a high qual of medical and hospital care to all people of this country who ne and desire it.

The CHAIRMAN. Thank you, Doctor. Do you care to ask s questions, Senator?

Senator DONNELL. I do not think so, Mr. Chairman.