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STATEMENT OF DR. JOHN R. RODGER, REPRESENTING THE RURAL MEDICAL SERVICE COMMITTEE OF THE MICHIGAN STATE MEDICAL SOCIETY

Dr. RODGER. I am John R. Rodger, M. D., of Bellaire, Mich. I have been officially appointed by the executive committee of the council of the Michigan State Medical Society to represent our society at this hearing.

I have been a member of the advisory council to the Michigan Office of Hospital Survey and Construction since the beginning of the Hill-Burton program, and I have practiced for 18 years in a rural community of 1,000 population.

I am a member of the rural-health committees of the Michigan State Medical Society and of the American Academy of General Practice. For 10 years I have lectured to the medical students of the University of Michigan on the opportunities and the problems of rural practice, and I have written concerning these problems in the Journal of the Student American Medical Association.

I mention these facts only to qualify myself, in some degree, as one who is actually practicing medicine in a rural community, and who has had some experience with the problem in an area wider than his own.

We of the Michigan State Medical Society are in complete general agreement with the aims of S. 2758, and wish to commend the Senators introducing this bill for thus showing their strong and nonpartisan interest in the health problems of our country.

We note that this is a bill which attempts to meet some of the needs set forth by the President in his health message to the Congress. However, as we study the bill in the light of the President's message, we are led to respectfully urge an addition at one point, without which we feel that the bill will fall short in meeting one of the needs set forth in the President's message. We refer to the section on diagnostic or treatment centers.

The complete text of the President's comments for the need of such centers is found in one paragraph, which I quote:

Many illnesses, to be sure, can be cared for outside of any institution. For such illnesses a far less costly approach to good medical care than hospitalization would be to provide diagnostic and treatment facilities for the ambulatory patient. The provision of such facilities, particularly in rural areas and in small isolated communities, will attract physicians to the sparsely settled sections where they are urgently needed.

We have given careful study to S. 2758, and sincerely feel, from our experience in the practice of medicine in a rural area, that the bill as now written will be unable to meet this aim outlined by the President. From the sentences I have quoted, I think it can be seen that the President primarily had rural areas of the country in mind as far as this part of the bill is concerned.

This is in no way meant as a criticism of the sincere authors of the hill, for we are certain that it is an unintended oversight which has come about because they have lacked the opportunity of knowing at firsthand some of the problems of rural health.

None of us can hope to know all of the varied aspects of our country's health problems, and those of us living in rural America might

not do too well in trying to solve the health problems of our urban neighbors.

Let us first look at what is meant by a diagnostic or treatment center. We note with interest the change in definition as expressed in H. R. $149, where it is stated that if such a center is not publicly owned it must be operated by or be a part of "a corporation or association which owns and operates a nonprofit hospital."

We would urge that some such similar change also be made by your committee; but, from the standpoint of rural needs, even this change is not enough.

It is highly important to realize that at the present time we have diagnostic and treatment centers, only they aren't labeled just that. Wherever we have a modern hospital with laboratory and X-ray facilities open to out-patients as well as to bed-patients, we have a diagnostic and treatment center, for we have a center which, coupled with the leadership of trained medical personnel, is performing diagnostic and treatment services.

We have built hundreds of such centers over the last few years through the Hill-Burton program.

What, then, further might be built under the definition of "diagnostic or treatment center" in the bill under discussion?

A hospital might build a specialized diagnostic center for patients not already covered by its out-patient clinics, or a hospital might build and operate what would amount to an out-patient center in an area some distance from the hospital itself.

These same facilities could also be owned and operated by a State, political subdivision, or public agency.

What could happen in a rural area?

A community not large enough to support a hospital and needing laboratory and X-ray services not available at a nearby hospital might build a facility for such a purpose.

It is important to note here that to man such a facility professionally would not be easy, and that the actual present need for such facili ties has been greatly reduced by our hospital building program of recent years.

I can think of few communities in my State where there would now be such a need.

What else then can this program do, in the words of the President, to "attract physicians to the sparsely settled sections where they are urgently needed"?

In its present form very little, unfortunately, as we from the rural areas which are supposed to be under consideration see it.

Is it possible to make a change in the bill in order that the President's aim may be more adequately met?

Yes; definitely, but to understand the need for the change, it is necessary first to have a picture of what medical practice in a rural area is really like today.

A typical rural area is composed of a number of smaller towns grouped around what, in rural sociology, is termed a trading center, larger town, or small city. This trading center is also invariably the hospital center for the area and, because it is the hospital center, a number of specialists will also have set up practice in it. The smaller towns, which may be from 10 to 50 or more miles away, will

be serviced primarily by family physicians, who are also sometimes termed general practitioners.

Does this family physician, all by himself, serve the health needs of his community?

Very rarely is this true, for the great majority of us work cooperatively with the specialists in our trading and hospital center.

Good medical care or, in other words, adequate diagnostic and treatment services in a rural area are the result of a team game between family physician and specialist, and are not the result of either one trying to do the job alone.

In my section of rural Michigan we have approximately 75 doctors of medicine. Two-thirds of us are family physicians and onethird of us are specialists. Of the specialists, approximately one-half belong to groups and the rest are practicing individually.

It takes all of us to do the job. Let me illustrate by recent cases from my own files. Patient A comes in with the symptoms of diabetes. I give him a physical examination, take certain tests which can be run in my own office, establish the diagnosis, and proceed to treat the patient.

Patient A has had his needed diagnostic and treatment services performed by his family physician. If at any time his case should prove extremely complicated, there are internists 40 and 50 miles away who can help me.

Patient B comes in and, in the process of her examination for possible cancer, certain tissue is removed in the office and sent to the pathology department of the University of Michigan for diagnosis. The family physician and the pathologist 270 miles away have provided Patient B with her diagnostic service. If surgery is indicated, it will be done by one of several surgeons at one of the hospital centers, some of whom are members of groups and some who are not.

Patient C, in the course of his examination, needs a specialized X-ray study, which he gets from one or the other of two radiologists at hospitals 40 and 50 miles away. Patient C has secured his diagnostic service from his family physician and the radiologist.

We will never answer the need of medical personnel for America by training only specialists; we will never answer this need by training only geenral practitioners. We will solve it only as we train both. In the early detection of disease, whether it be cancer, tuberculosis, heart disease or what have you, the primary responsibility rests with the first physician who sees the patient. He and he alone is in a position to initiate studies of his own, or, with the help of a consultant, to rule serious disease in or out.

As far as our smaller communities are concerned, the ones the President was talking about in his health message, it is of tremendous importance that they get and keep young physicians who have just finished their training.

I think you will remember yesterday Dr. Ferrell from North Carolina mentioned that.

These days there is a marked increase in the number of young physicians willing and anxious to practice in smaller communities, but they want to be able to practice as good medicine there as they could in a larger center.

What is one of their big deterrents?

It is the lack of a modern office equipped to help a doctor give good medical care.

In the city, large or small, the beginning doctor can rent an adequate office. In the country, he too often finds no space at all, or large, poorly heated rooms reached by a long flight of stairs which his cardiac and hypertensive patients climb only with difficulty and danger. To me it is a wonder that so many men have gone to the country under these circumstances.

What have rural communities done about this?

Some, by themselves, have built and equipped up-to-date clinics to which they will always hold title, and which they will rent to a doctor or doctors. Others have done the same with the help of foundationsin our State, the Kellogg Foundation. In each case where this has been done the community has gotten its doctor.

Most rural communities are not able to do this job by themselves and require help in the same way that their neighboring small city needed Hill-Burton support to build its hospital.

To date such help has been limited to that from foundations, which have blazed a trail to show us how it can be done but which do not have the resources to carry the entire load.

If this bill with its matching formula can bring such help to scores of rural communities over the Nation, it will assist mightily in providing better diagnostic and treatment services to rural communities; but the Surgeon General of the Public Health Service tells me that as the bill is now worded this cannot be done.

Providing good medical care to our rural areas as well as to all of the country is a bit like building a suspension bridge with towers on both sides of the river. One tower of support is that of the specialist in American medicine. The other tower is that of the family physician in American medicine.

In our judgment, this portion of the bill under consideration has inadvertently forgotten one of these towers-and it takes two to hold up the bridge. Therefore, the Michigan State Medical Society offers the following suggested addition to the definitions in section 631 (g), page 10, of S. 2758:

Provided, however, That in the case of a publicly owned diagnostic or treatment center, nothing herein contained would prevent such project sponsor from leasing or otherwise relegating the operation of the facilities to one or more persons licensed to practice medicine in the State.

Such an addition to the bill would permit a community to raise matching funds for a clinic building and then, while maintaining permanent title to the property, to lease it to a doctor or doctors.

We already have a precedent for this in the present Hill-Burton program, for many of the health centers we have built do have, in addition to a few beds, laboratory, X-ray, and space for public health personnel, as well as office space which is rented to the doctors of the community. The difference is that such a facility's primary function is not that of a clinic office, and that is why the present bill would seem to require a change along the line suggested here to permit the leasing of a building which was primarily a clinic

office.

If such a clinic was furnished by the sponsor with X-ray, laboratory, et cetera, the fees in connection with their use would be pay

able to the public sponsor, with the physician being paid by the sponsor for his contribution in the form of work and supervision. For each $1 million so used on a 50 percent matching formula, approximately 75 such clinics could be constructed.

May I respectfully call your attention to another problem which we feel we see in this bill?

As far as Michigan is concerned, an overall look at the relative needs represented by the four categories contained in the bill leads us to a rather strong conviction that, of the four, the greatest need is for chronic disease facilities.

We already have a backlog of 9 counties hoping to build chronicdisease facilities within the next few years.

Even with the change we have suggested in the diagnostic- or treatment-center portion of the bill, the relative need for chronicdisease facilities still seems to us much the greatest.

We feel that our experience will be not unlike that of a large number of the other States, and, therefore, we would strongly suggest the following changes in the figures for authorized appropriations:

That the authorized amount of $20 million for the construction of diagnostic er treatment centers be reduced to $10 million; and that the authorized amount for the construction of chronic-disease facilities be increased from $20 million to $30 million.

We feel that such a change will more adequately permit the bill to meet the needs out in the field.

Before this committee makes its final report it might, if it so desires, request the Public Health Service to contact the other State HillBurton offices on this point to see whether or not their opinions are similar to ours in Michigan.

We would also offer the following suggestion to permit greater flexibility of the program on a State level:

That the State agency administering the act be permitted to reallocate up to one-third of the amounts allocated for any 1 or 2 of the 4 categories to any or all of the remaining categories.

In our opinion, this would still retain the purpose of the bill as incentive legislation, while providing for a greater degree of flexibility on the State level.

To illustrate, a State might have the following amounts allocated to the four categories of the bill: $300,000, $300,000, $600,000, $600,000. Under this change it would be possible to plan a building program with the category amounts which could be changed up to the following: $200,000, $200,000, $700,000, $700,000; or $500,000, $500,000, $400,000, $400,000; or $200,000, $400,000, $400,000, $800,000, and so forth. Such flexibility would give each State a better chance to meet its specific needs, and yet conserve the fundamental aims of having categorical grants.

If this change were made, it would not be necessary to change the present amounts for diagnostic or treatment centers and chronicdisease facilities.

You will remember, Mr. Chairman, that yesterday the American Hospital Association had a suggestion in which flexibility might be granted. It would only mean that here the flexibility could be ascertained at the beginning of the 2 years the funds would be spent, and

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