In medical schools and teaching hospitals these changes were recognized in part. Curricula had been made more rigorous; clinical teaching was conducted in hospitals equipped with the best physical facilities, their general and special services conducted by integrated staffs of competent experts. The fact that teaching hospitals were forced to adopt this pattern is an indication of its supe riority. This is further attested by the outstanding reputation for service that these hospitals and others that have imitated their organizaion have achieved. Internships in them are especially prized. Through their systems of residentships, fellowships, assistantships, and minor faculty positions they have become the chief sources of specialists. From them has emanated clinical investigation. Within their walls the developing physicians have been brought into contact with investigate work, taught to evaluate its products and imbued with the scientific spirit. This seldom came to full fruition, however, because the organization of these institutions did not provide for the continuous development of physicians; but discharged all but the merest handful, at various states of their development into competitive practice, where most of them were forced to get along as well as they could with few of the perquisites they had learned were desirable; close contact with a hospital service, diagnostic and therapeutic facilities, close association with specialists, contact with new thoughts and methods and their inventors. As evidence that these deficiencies were not altogether unappreciated, however, physicians congregated more and more in urban and thickly populated communities where they might at least aspire to better opportunities, thus creating a serious problem of maldistribution. With the war these deficiencies have been greatly exaggerated. Premedical and medical courses have been accelerated; internships have been curtailed; the number of residentships has been sharply reduced and the terms shortened. Opportunities for more advanced studies have been almost abolished. The faculties and staffs of medical schools have been so depleted that the quality of clinical teaching has inevitably deteriorated. Clinical investigation has been contracted and largely diverted to military projects. The majority of the younger physicians after entering military service have little opportunity to supplement their education; many are almost completely divorced from medical activities. Not only has the supply of physicians with superior training been cut off, but the quality of all physicians who have been developed under this program has been lowered. If the standards of medical practice are not to be degraded these deficiencies must be corrected. For this purpose the provisions of the GI bill of rights are quite inadequate. Because of the protracted educational course, by the end of an internship the physician has reached maturity. After a term of service in the military forces is added he cannot be treated like a schoolboy or college undergraduate. He does not require formalized classroom exercises. Refresher courses are inadequate. What he needs is experience under competent guidance. He can no longer afford, however, to spend a period of years in internships and residentships without remuneration or on mere subsistence wages. If he could, there are not enough positions of this kind which really offer educational opportunities to absorb even the continuing output from the medical schools. Under the existing system of medical care the great majority of medical officers upon discharge will have no alternative but to enter competitive private practice. Under these circumstances their chances for self-improvement are exceedingly small. From polls that have been taken the great majority of physicians in service hope to settle in urban communities. This will only exaggerate the present maldistribution of physicians. One of the reasons for this maldistribution is the lack of adequate facilities for the practice of high-quality medicine in rural and thinly populated areas. Another is the inability of such areas to support the physicians they require. The Hill-Burton bill is intended to provide the needed facilities by the construction of hospitals and medical centers planned in accordance with the needs of the Nation. This will make practice in rural communities more attractive, but it will not insure its quality unless provisions are included in the bill for the organization and remuneration of the staffs of these hospitals, along the lines suggested in statement 13 about the Hill-Burton bill. A national system of hospitals organized in this manner would permanently increase the number of internships and residentships with educational value and would provide for the continuous development of physicians beyond the internship and residentship. If these hospitals are integrated on a State, regional, or national basis, careers would not be limited by geographical boundaries. Were such a system available the reeducation and relocation of returning medical officers would be a less insoluble problem. (See Statement No. 14.) These hospitals and medical centers should have out-patient diagnostic ! therapeutic clinics as well as in-patient services. If this were the case and the clinics were organized along the same lines suggested for the hospitals abert educational opportunities would be further multiplied. Moreover, this weld tend toward the coordination of in-patient and out-patient services, a feature too often lacking in hospitals today. Without such coordination there is ofte so little continuity and consistency in therapy that sojourn in the hospita a little benefit to many patients, who return to an out-patient clinic that feu wa altogether different therapeutic principles. EFFECTS ON MEDICAL EDUCATIONAL INSTITUTIONS The lay public, practitioners and educators have not sufficiently appreciate! the educational implications of proposals for State or national programs f.r medical care. The most indispensable feature of clinical teaching is exemp medical services. Students will not develop meticulous habits of thought an action if they are exposed on the wards to demonstrations of inferior practica A medical school must, therefore, have available both hospital and dispenser services with all the equipment, facilities and personnel required for diagn and therapy. Sufficient material in the form of patients must be available for teaching and study, with enough physicians, not only to direct and admiñs'-* care, but also to instruct students, interns and residents. These physica must have the time not only to perform their medical and educational dates, but also to see that these are correlated with clinical and investigative acti ties of their associates. They must have both the training to comprehend scientific advances in their fields and the technical skill to utilize them. The clinical teachers should themselves be constant contributors to medical scien It is becoming more and more evident that this is impossible if, for the ... jority of these physicians, clinical teaching and the care of ward patients only avocations. For this reason full-time salaried staffs have been gradua↑ established and enlarged. Support of a complete full-time system, however. desirable as it might be, places an intolerable burden on education. The clini departments of a medical school must assume, in addition to their teaching fa tions, responsibility for the support and care of patients. A variable part f the cost of maintaining these patients is met by public or philanthropic furds but physicians' services are traditionally gratuitous. Nevertheless, both these items contribute to the benefit of the community. Under these circumsta" extension of the full-time system has been extremely slow. It is confined aim entirely to a few administrative heads of departments and to the lowest grades in the educational scale. The system would break down entirely were it :: still possible to delegate a large part of the teaching and care to interns 1! residents who receive no remuneration or only token wages. It follows th careers in clinical teaching are quite rare and that the material available f~ professional positions is small and not selected in the best manner, because I large proportion of the superior men are forced into competitive practice eary in their careers. Since the care of patients in these hospitals is a public service, its est should be assumed by the public. If this were done, either through insura** or by tax funds or both, it would be possible to establish complete full faculties in medical school and teaching hospitals, or to remunerate mende of the staff for the time spent in the care of patients in these hospitals would allow these members to devote their energies earnestly to these cy 1 responsibilities. At the same time it would relieve the medical schools of " burden of supporting purely clinical activities. The funds now used to port these purposes would thereby be made available for activities more dire: relevant to education. Compulsory insurance bills have been presented to the Congress of the U:"" States and numerous State legislatures. The popular demand for legis of this nature is steadily increasing. Whether these measures are favers or unfavorably regarded by medical schools, their enactment cannot fall * affect the systems of medical practice and medical education. They would vide the costs of maintenance and medical care for a large proportion of patients that now enter the wards of teaching hospitals and thereby might seler for clinical departments of medical schools the financial problem described abr They might enable these institutions to extend the full-time system of clinica teaching. If provision were also made to include the medically needy by as plementary tax-supported system, the costs of all ward patients would be zur n this case, indeed, unless the teaching hospitals participated in these systems hey would have no climical material. If they did participate they would be bliged to accept insurance or tax funds, and to use these funds for the purposes or which they were intended, to pay physicians for the maintenance and care -f patients. * ** * * If these health programs are to benefit educational institutions, however, they must be directed to this purpose. The great majority have placed more emphasis pon free choice of an individual physician than on specifications of quality. Payment by fee-for-service is also included in most of these plans. A typical lause, found in the Wagner-Murray-Dingell bill (S. 1161) has been adopted in many State legislative proposals: Payments to general medical practitioners may e made "(a) on the basis of fee-for-services rendered to individuals * * * according to a fee schedule approved by the Surgeon general; (b) on a per capita asis * according to the number of individuals on the practiioner's list; (c) on a salary basis, whole time or part time; or (d) on a combination or modification of these bases, as the Surgeon General may approve, accordng in each area as the majority of the general medical practitioners to be paid for such services shall elect, subject to such necessary rules and regulations as may be prescribed." Since the American Medical Association is uncompromising in its insistence upon fee-for-service payment, this system would indoubtedly be elected by "the majority of the general medical practitioners." In this case the very existence of teaching hospitals would be jeopardized. If hey did not qualify for participation in the program they would have no clinical naterial; if they did participate they would be forced to become open hospitals which would destroy the present organization of clinical faculties and the possibility of controlling the quality of medical care. This is one of the most rogent reasons for insisting upon organized salaried staffs in hospitals. Medical schools cannot afford to ignore this possibility. It has been recognized in two health programs thus far proposed; the bill presented to the California Legislature n behalf of the Congress of Industrial Organizations and the preliminary prospectus of Mayor Fiorello H. LaGuardia's plan for New York city. Both of these measures have special provisions for the protection of educational institutions. Committee of Physicians for the Improvement of Medical Care, Inc.: Channing Frothingham (chairman), Milton C. Winternitz (vice chairman), Carl Binger (vice chairman), Russell L. Cecil (honorary chairman), John P. Peters (secretary and treasurer), Alf S. Alving, Bertram Bernheim, Ernst P. Boas, Samuel Bradbury, Allan M. Butler, Alexander M. Burgess, Hugh Cabot, Louis Casamajor, Thomas B. Cooley, Robert L. DeNormandie, Nathaniel Faxon, Charles A. Flood,' Maurice Fremont-Smith, Harry Goldblatt, F. T. H'Doubler, William J. Kerr, H. Clifford Loos, F. D. W. Lukens, George M. Mackenzie, Harry S. Mackler, Irvine McQuarrie, J. H. Means, T. Grier Miller, George R. Minot, Fred D. Mott, Robert B. Osgood, Walter L. Palmer, H. B. Richardson, G. Canby Robinson, David Seegal, Clement A. Smith, Richard M. Smith, Joseph Stokes, Jr., Borden S. Veeder, Allen O. Whipple, James L. Wilson, W. Barry Wood, Jr., Edward L. Young, John P. Peters, M. D., Secretary, 789 Howard Avenue, New Haven 11, Conn. COMMITTEE OF PHYSICIANS, FOR THE IMPROVEMENT OF MEDICAL CARE, INC., STATEMENT No. 16 À SUMMARY AND CRITICAL ANALYSIS OF THE MEDICAL FEATURES OF THE WAGNERMURRAY-DINGELL BILL (S. 1050), INTRODUCED MAY 24, 1945 GRANTS TO STATES FOR PUBLIC HEALTH SERVICES The programs of the Public Health Service for the prevention and elimination of venereal diseases and tuberculosis have more than justified themselves. There s hope that by their expansion, especially if they are coordinated with a general 1U. S. Army. medical care program, these diseases may be reduced to a minimum, or even eliminated. In statement 14, commenting on the report of the Pepper subcommittee, the need for Federal aid in improving the Public Health Services of the States was 25 serted. The present bill could be used to remedy gradually the defects mentioned in that statement and in the Pepper report. Like the other provisions of the bill the ultimate authority to allot grants resides with the Federal Security Administrator to whom the recommendations of the Surgeon General must be submitted for approval. GRANTS TO STATES FOR MATERNAL AND CHILD HEALTH AND WELFARE SERVICES In statement 6 (August 15, 1939) dealing with the first Wagner bill, the ext mittee of physicians made the following statements: "Divided control in the planning and execution of the program is incompatible with any sound program for national health. There should be a unified Federa health authority." "Although special measures ** * may be expedient, the objective should be to provide in every community a unified program of health service and health care. "There must be a unified Federal authority responsible for the institution and execution of all parts of the health program. "The authority for a general health program is properly the United State Public Health Service. It is impossible to separate for administrative purposes measures for the prevention from measures for the treatment of disease. Fear has been expressed that the able personnel and efficient work of the Chil dren's Bureau of the Department of Labor or of the Public Health Service or bot may suffer if the identity of either organization is lost by merger. Some formu a must be devised by which the Federal agencies dealing with various aspects of the same problem may be coordinated and consolidated without impairing the efficiency. Reorganization must recognize the varied professions and agencies involved in a comprehensive program and provide that the interests of each safeguarded in order that full advantage may be taken of the expert services of all who may contribute to the success of the program. "Under the supervision of the general health council provisions should be made to continue present Federal health activities, to expand specific activities of proved merit, and to coordinate and merge all such activities into a future gereral program of health service and medical care. Titles V and VI provide for expansion of maternal and child health programs under the Children's Barva: of the Department of Labor and for the development of medical-care programs for these groups. Since machinery exists for the continuation of the activities f the Children's Bureau and the Public Health Service and they have proved the utility, their reasonable expansion is warranted. The personnel and facilit involved should, however, be incorporated in the reconstituted Federal He Agency and their activities subjected to review by the general health counci Public health and medical care should not be separated and the care of childre and expectant mothers should be integrated with that of the rest of the pope's tion." The committee of physicians is fully aware and appreciative of the excellen pioneer work of the Children's Bureau and believes that it should be maintain in its present position and authority so long as there is no unified national bea program. If there is established a comprehensive national medical-care program in which a large proportion of the hospitals and physicians participate in car for the illnesses and disabilities of the majority of the population, pres children and mothers will have to receive their care through this machine Surely it would be unfortunate if entirely separate machinery had to be provvle" In addition the principle of coordinated medical services, proclaimed in eth sections of the bill, would be violated by segregating obstetrical and pediatri services from the rest of the system. A unified system, however, with dual entrul would not conduce to efficiency and economy, but to invidious rivalry and discret The committee is well disposed to the extension of the programs for materns and child health and care for crippled children, provided these are integrat with the medical-care program and machinery of the contemplated national i insurance system. The child-welfare services, provided in section 521 of the title, are no less desirable, but have no direct relation to a health and medi care program. They may suitably be consigned to some other authority than the Public Health Service. There is no reason other than a historical one why the should ultimately be the Department of Labor. If the development of Federal welfare services becomes accelerated, as other provisions of this bill indicate, it may be more suitable for the welfare of the children to be merged with that of their elders. Thus far these services have accumulated within the control of the Social Security Board. Up to the present time this has been almost entirely a fiscal and administrative agency. Its character will need some change if it is to assume the functions of a service agency. Intention COMPREHENSIVE PUBLIC ASSISTANCE PROGRAM This is an essential supplement to the national social insurance system. Unless provision is made for noninsurable needy persons the best interests of preventative medicine cannot be effectively served. Rehabilitation depends upon the proper care of such persons. The most comprehensive insurance system cannot prevent victims of serious and prolonged illness from falling into this category. In times or regions of economic depression it may grow to include large proportions of the people. If a compulsory insurance system is elected as a means of providing for the majority of the population, separate provision must be made for tax-supported care for the needy. As the Committee of Physicians suggested in its statement on the Wagner bill of 1939 (statement 6) and reiterated in its statement on the previous WagnerMurray-Dingell bill (S. 1161) (statement 12), it is the opinion of the committee that, when the major part of the population is to be covered and dependents become entitled to benefits, a tax-supported system may be both more equitable and more economical. The committee, nevertheless, recognizes that political expediency and the temper of the public may compel acceptance of the insurance system, despite these inequities and disadvantages. Even if it is necessary to establish two methods of finance, two systems of medical care would be intolerable, especially if this meant care of two grades of quality, which would be likely. Provision that the needy may enjoy the privileges of the medical machinery established for insured persons is sound. The bill should offer every incentive to the States to provide medical care through the machinery of the national social insurance system. It would probably be preferable to prescribe this as the exclusive procedure for securing such medical care. Financial Acceptance of the principle that appropriations be flexible and proportioned to need, when this need is as variable as it has proved to be, is intelligent. The high Federal percentage proposed is equally wise because it will furnish a desirable incentive to the States to qualify for grants for the medical care of the needy. Qualifications The general formula used is quite satisfactory. Benefits The medical benefits which may be made available under contracts between the States and the Federal authority through the national social insurance system will be discussed under the comments on this title. Cash benefits are essential supplements to any provisions for medical services. Authority The Social Security Board is the appropriate authority for the program as a whole. Properly, contracts between States and the Federal authority for medical care come under the control of the Surgeon General, subject to the approval of the Federal Security Administrator. Intentions NATIONAL SOCIAL INSURANCE SYSTEM The attention given to the committee's criticisms of the previous bill is a proof of the receptive attitude of the proponents of this bill to constructive suggestions and their solicitude for the quality of medical services, the chief interest of the Committee of Physicians. The following comments and criticisms are advanced with confidence that they will be received in the same sympathetic spirit. Coverage That a program for medical care should ultimately comprehend the whole population has been the opinion of the committee since its inception. The diffi |