The ambulatory patient. Next is the fallacy of the ambulatory patient. Ninety percent of today's care is given to vertical patients. Yet in a great many institutions the finest physicians perform only on horizontal patients, and they are relieved of the responsibility of participating in ambulatory care.

The emergency patient. The third fallacy deals with the emergency room. This is the fastest growing source of medical care in many areas of our country today. It meets a tremendous social need. Yet the emergency room, while it is capable of treating patients with cut fingers and broken arms, is incapable of taking care of persons with chronic heart disease, chronic diabetes, nephritis, stroke, and so on. However, 30 to 40 percent or less of the patients coming to emergency rooms are true medical emergencies. Most of them require long-term continuous comprehensive fourth-stage medical care.

The undiagnosed patient. Another fallacy is the undiagnosed patient. In episode after episode, a patient goes to a clinic which specializes in one organ and he develops major pathology in some other organ. The clinic which has been responsible for this patient has been so interested in one disease, one organ, that it has not fulfilled its responsibility for the total patient. Our hospitals are filled with undiagnosed patients, undiagnosed in terms of other stages of other diseases. Precursors of disease. Lack of treatment of the precursors of disease is another fallacy. If a patient in the medical care system is a heavy smoker, this is a far more serious disease than most of the conditions that might have brought that patient to the hospital in the first place. To what degree do we accept this responsibility? To what degree do we even follow up in this regard?

Hospital competition. The sixth fallacy is a familiar one-the extra staffing of institutions, the competition between hospitals. One person in New York City made the astute observation that there are three places in Lower Manhattan where the medically indigent patient can have open heart surgery, but there is no place where he can have his teeth fixed. We are approaching the time when there will be almost as many cardiac surgeons in New York City as there are patients needing cardiac surgery. There are, of course, definite values to this situation. Maybe it will be the answer to coronary heart disease some day, and I would not in any way cut back on the training of an adequate number of cardiac surgeons.

But there is an equal responsibility to look at total medical needs in the community. If the needs include dental care, then this care should be provided. If each institution duplicates and develops extra staffs, this interferes with its ability to devote its attention and resources to meeting other needs.

Fragmentation. We have fragmentation where integration is needed. One man, aged 76, was told to go to 10 hospital clinics. This old man was far to sick to go to 10 hospital clinics, so he became an uncooperative patient. However, if he hadn't been an uncooperative patient, he would have died, because it was quite beyond his physical capacity to go to a hospital miles away, sit in a waiting room for long periods of time, spend hours in line at the pharmacy for drugs, and go from clinic to clinic. What happens to such patients? They end up in nursing homes.

The nursing home. A nursing home is in itself an enormous fallacy on our medical care system. Here we find patients with diseases so complex and so difficult to solve, that instead of giving them top priority for our best research and medical brains, instead of bringing them into teaching hospitals in large numbers, getting our best scientists to study them and work with them, we do the exact oppositerefuse them admission, get rid of them as quickly as we can, and put them in a nursing home where they get some of the worst medical care of which we are capable.

Concentration on acute cases. The concentration of medical care institutions on the acute and clinical illnesses, again the third stage of medicine, is fine. But, the unmet need in our country today is the chronic illnesses which are not acute and often not clinical.

Denial of staff privileges. A curious fallacy is that of the individual physician who is most interested in comprehensive family medical care. He is the general practitioner. We have so arranged our society of medicine that he is the one person kept at the longest arm's length from our best medical care facilities. In my city, for example, few general practitioners are admitted to the best hospitals. I am not for one instant suggesting that we lower the standards. I am merely pointing out a fallacy of our present arrangements for medical care.

The one person who is interested in integration, who is trying to tackle the first, second, and fourth stages of medicine, is the one kept farthest from the best health facilities in the community.

Dr. Robert Haggerty, professor of pediatrics at the University of Rochester School of Medicine, last summer looked into the practice of general practitioners and found them undertaking an amazing amount of the first, second, and fourth stages of medicine. I don't know whether this is true throughout the nation, but if it is, then perhaps the general practitioner may not lack a future, because he is meeting a problem which may not be met in any other way. And one of the major questions in the future is how to bring this interest of the general practitioner into the best medical facilities we have. I am not saying that the existing general practitioner is the best one to do it, but I am saying he is serving some purpose, which is not integrated with the rest of medicine.

The community hospital. We definitely have a lack of responsibility for community problems. One of my stories in this regard is that when I asked the staff of a local hospital in New York "How would you like to move more toward being a community hospital?" the director of internal medicine gave me a fishy stare. The director said, "What do you mean by a community hospital?"

I said, "Well, there is no time to give you a long, prepared talk. I will tell you in just two sentences: There are diabetics in New York City in the area around your hospital. We in the health department will find the diabetics through a detection program and when we find them we will turn them over to you for treatment."

Whereupon he became completely horrified and said, “Well, I have enough diabetics."

I said, "Well this is what I mean by a community hospital. Let me go one step further. Suppose we say there is a 50,000 population in your hospital area, and, with normal detection yields, suppose we find 1,000 diabetics that need a workup. Maybe we can do this workup on an outpatient basis with doctors who are related to your staff, but who would work in clinics in our own district health center. Then we would find among the 1,000 diabetics 50 with flame hemorrhages of the retina, with neurological disease, and some who do not respond to insulin." “Oh," he said, his eyes getting big. “I am writing a paper on that. That is just what I want." Well, how does he expect to get these patients unless we can develop some major community programs in his area?

So, it is possible to develop a partnership and let the profession of internal medicine have what it wants, and then use a little bit of its prestige or influence to help the health department or cooperating agency develop its part, and together we have a community program.

We certainly have lack of feedback from the community. I have seen hospitals developing highly specialized programs when communities around them were crying piteously for a totally different kind of program. One hospital, the Gouverneur Hospital in New York, did a small study on the needs of its community and found an enormous need for dental care. Together, we moved in with extra services and developed a dental care program, which has become the most popular program in that institution. Not that popularity is the final answer. However, there was a need, and lack of feedback through the years had allowed this institution to undertake other programs without any concern for dental care. This hospital was ready to build a new cardiac surgical wing and had never before been interested in the real needs of this area.

The teaching hospital. Another fallacy is provided by the teaching program of the teaching hospital. What is the teaching hospital teaching? In Boston, Dr. Kerr L. White demonstrated that 700 of 1,000 adults became ill within 1 month. Of the 700, only 1 was admitted to a teaching hospital. Therefore, medical students were primarily being taught by observation of only 1 of 700 sick persons out of a population of 1,000. This is hardly medical education in terms of what illnesses people have and the current major health problems and needs.

The proprietary hospital also poses a problem in many areas where some of the most highly qualified physicians are weaned away from the teaching hospitals to proprietary institutions, which generally have lower standards for education and training.

Control of hospital admissions. The last fallacy on my list, which could have been much longer, is that of the control of hospital admissions by residents. Few professors will battle the resident on this point. Of course, the resident should have the teaching material he needs, but the present admission policy of teaching hospitals is a fallacy in terms of the health needs of the community.

The Goal

What can we do to reach the goal of universal access to high-quality, comprehensive health and medical care? Ten years from now, perhaps I could say only universal access to medical care, because by then perhaps all of the other adjectives would be understood. But they aren't yet.

This goal is not controversial. Everybody wants everybody to have all the care he needs and wants it to be comprehensive care. How we reach that goal is what causes all of the bitter arguments.

One step is to improve access by removing barriers. The major barrier, removed partly by Federal Government, is the financial barrier. Medicare is largely a minimal program. It does provide services at minimal cost for a group of people who found it difficult to get this care before.

But there are many more barriers other than economic. There are geographic barriers. There are educational barriers. We have found, for example, when a clinic is open from 9 a.m. to 4 p.m. that is is very difficult to get working people to go to it. That is why they go to emergency rooms at 3 a.m. If you expect mama to come, you must realize that she can't until she gets somebody to watch her children. If you can arrange a family clinic and invite the entire family to such a clinic at 7 p.m., then perhaps they would be more likely to come. Some of the demonstration programs now underway indicate that this is true. When services are arranged to accommodate the patients, the response is much greater.

In the past we have provided services and then tried to educate people to use them. This is good, but then the unmet need must be studied. If persons are not using the service because their motivation with respect to this pattern of care is not sufficient then we try more education. We have a girl known as a social worker. Once I defined a social worker, at a meeting of about 2,000 of them, as a girl who tries to fit a square patient into a round program, because what the social worker does is try to guide the patient through the maze of existing facilities.

But why don't we try another approach? Why don't were arrange some of the programs to fit the existing motivations of some patients?

New York City's cervical cancer program illustrates this point. We opened a clinic in one area and mostly Jewish women attended. Very few had cancer of the cervix. We then moved the clinic to the Harlem area. However, most of our patients were still Jewish women-they simply stayed on the subway a little longer to get to the clinic.

Let's face it, in Harlem there is a struggle for existence, and here the need to have a Papanicolaou smear receives very low priority. Eventually, we opened a routine detection service for hospital admissions. All the women in this area, when ill, were admitted to two hospitals. We saved more than 300 lives through this little program alone in just a few years by arranging the service to fit the existing motivations of the patient.

In attempting to reach the long-range goal, we have to go through certain intermediate steps. What intermediate steps should we use? Let's admit first of all that the goal as I have presented it is a good one, that the facilities, the hospitals, are good ones, and that they are operated by sensitive, flexible people who would like to reach that goal some day.

How do we go about effecting improvements? How do we get hospitals to adapt? The hospitals will not ordinarily adapt themselves-they have to be pushed or they have to be pulled. They can be pushed by some rules and regulations, and that has to be done gently, but firmly.

For example, in New York City, we have said to hospitals, "If you wish to be paid by the government for care of medically indignet patients, you will have to do certain things which provide high-quality medical care. Otherwise, we are very sorry but we can't give you the $36 or $40 per day." Few hospitals in New York would care to lose this source of income. What we need in this country, in my humble opinion, are more programs which offer bonuses to those institutions willing to develop new and progressive demonstration-type programs which will feed back into the institutions and reshape them to meet health problems, present and future, along the lines I have mentioned.

We have used a particular technique in New York City-we have our own little National Institutes of Health. Eight million dollars per year are awarded for research, and a group of scientists organized like the NIH study sections and councils recommend how it should be allocated.

We gave a large amount of money to a study group at Cornell University which conducted a medical care project for a welfare population. As soon as families

were admitted to public assistance, they were called in and given a complete medical workup. They were seen in the outpatient department. They were followed on the wards. They were seen in nursing homes, and they were part of the regular home-care continuation program. In other words, they were given comprehensive, professionally competent fourth-stage medicine. We couldn't force them to come in, but between one-half and two-thirds did. Why the others did nt come in is another problem for later attention.

During the operation of the project, Cornell, for the first time, had to have signs printed in Spanish placed in the waiting room. This was a new population entering the institution and presenting new kinds of needs. Physicians at Cornell were now able to study health needs that existed in their area. Also, from the data on use, the people in this area rarely use home care services. They prefer to go to the clinic with their families to see the physician who is following them on a continuation basis. A study is also being made of the costs of the project.

A similar, but less costly, program was undertaken at St. Vincent's Hospital in New York City. This institution was given a small grant, and its staff approached the feedback and adaptation mechanism a little differently from Cornell's. They started with selected patients in the outpatient department. For some persons they had records, for some they did not. But they put the pieces together from the hospital records and manufactured a family record. Then they invited other family members to come for a medical examination, and thus they created a special family clinic. The program has had an enormous effect on outpatient care at St. Vincent's, and the staff has seen the value of such a program.

One institution is studying emergency room admissions to see to what degree these patients can be placed in a medical care system, doing more with them than merely pushing them through the revolving door and getting them out. This institution is also working with the health department on a number of joint clinics.

Another institution has investigated the prevalence of neuromuscular disorders in an area of New York City to determine what could be done to rehabilitate persons with these disorders. It is also studying whether rehabilitation services for stroke patients early in the course of the disease can prevent the disease from getting worse in terms of the rehabilitation potential.

One hospital opened a small branch clinic in a housing project having 1,500 elderly, medically indigent residents. Two internists who staff this clinic are able to prevent the need for 90 percent of the patients to attend the hospital clinic 4 miles away. This plan offers an enormously greater opportunity to reach aged patients, and it is bringing service to the patient in a most effective way. A voluntary hospital in New York City is teaming up in a comprehensive program with a city hospital and the departments of health, mental health, and welfare. The director of the hospital is responsible for all of the health, hospital care, welfare medical care, and mental health care for more than 150,000 persons in Lower Manhattan. The attending staff of private physicians are caring for the patients who can afford private care, and the clinics are treating patients who are medically indigent. One of the first things the director found necessary was a number of satellite clinics. Although the number of outpatients tripled within 12 years, the project still is not reaching enough of the 150,000 people, and the director plans to open branch clinics.

One of the interesting byproducts of the projects in New York City is the development of positions in hospitals for experts in community care, and a large number of hospitals are now doing this. This is of particular interest because in this way the hospitals can recognize their responsibility for the unmet health needs of the community.

Finally, a word about categorical versus general approaches. In the past we have taken the viewpoint of an agency, a facility, or a profession. What we have to do is look from the patient's standpoint. The person who can teach an 11-year-old not to smoke is much more effective in the control of lung cancer than the chest surgeon. I think we are going to live with categorical specialists and categorical approaches for a long time. I think this is good and it is necessary, because we certainly want to know more and more. But on the other hand, at the point where the service reaches the patient, let us learn how to develop the ingenuity to integrate and coordinate our efforts around him.

APPENDIX 2

LETTERS AND STATEMENTS FROM INDIVIDUALS AND ORGANIZATIONS

WORCESTER, MASS., June 18, 1967.

DEAR SENATOR SMATHERS: Thank you for inviting me to share my experience in the study of “the organization of health services today, and to determine whether our methods of delivering such services are raising costs to the elderly, or depriving them of even the opportunity to receive such services."

Primarily my statement is the result of personal experiences in the private practice of medicine. My observations are also derived as a member of a community hospital with teaching services for house officers, residency programs and a nursing school. At a community level I have also been Chairman of the Committee on Aging, Community Services of Greater Worcester, Inc., which participated in the seven (7) cities Ford Foundation Project on Aging.

I am the Founding President of the Age Center of Worcester Area, Inc. This is a central non-profit agency devoted to development, implementing, and giving services to the Older American in the areas of information and referral, craft shop outlet for people to sell their creations, and a senior service volunteer corps. For the past three years the Age Center has carried on a Nursing Home project with the aid of a U.S. Public Health grant. As Project Director of this project, we have attempted to study the effect of special consultative services in nursing homes.

I am also a member of the Subcommittee On Aging of the Massachusetts Medical Society.

The Worcester area has over 30,000 men and women 65 years old and over. This is over 10% of the total local population in the Worcester area.

I must again emphasize that my statement is entirely personal and specifically that derived from the local situation.

It is nearly a year since Medicare was launched, but the anticipated rush of patients never occurred. As the President of the American Medical Association has recently stated in effect, that doctors in hospitals are finding it less difficult to live with Medicare than they expected.

The question of our "rising medical costs causing special difficulties for the elderly" as far as I can determine, they are not. The only area that costs may cause difficulty are in the matter of drugs. For the most part, though individual drugs may be high and require purchase by the Medicare patient, this is not a severe obstacle. A Medicare patient requiring drugs which he is unable to pay for can receive them as the result of special plans developed by Roche & Co. a pharmaceutical manufacturer, as well as others, or with the help of the Medical Assistance Plan which is still in effect.

Medicare does not cover glasses for reading.

There may be difficulties in Medicare in the areas which it does not cover such as dentistry, hearing aids, cost of a wheel chair, or protheses. Medicare does pay for drugs that have to be injected.

Thus far I have noted very few Medicare patients who have been unable to afford the system of the "deductibles". This might possibly cause a special difficulty for the elderly, but in the Commonwealth of Massachusetts with its organization of MAA, Blue Cross-Blue Shield Medex I-II-III, assignment of fees by the physician to the State Street Trust Co. as a result of a plan of the Massachusetts Medical Society, as well as private carriers, this difficulty has been fairly overcome.

The second question, "Do many of the elderly face insuperable obstacles in obtaining needed health services?" There are no insuperable obstacles in obtaining needed health services if the community is sensitive to the elderly in their midst, and has attempted to organize its social and medical agencies so that attention can be given to locating and getting the elderly to the sites of the health services. In the Worcester area the Age Center has focused its work on this through its referral center. The Social Security office, Blue Cross-Blue Shield office, those

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