we would not have to wait until 6 months before those funds would have to be spent. These suggestions, Mr. Chairman, are respectfully submitted by the Senator HILL. You would make your determination in the beginning? Dr. RODGER. That is right. The one-third is purely suggested. Senator HILL. In other words, you wouldn't lose that 18 months' time? Dr. RODGER. No. That one-third may be changed. Perhaps a quarter would be better. We just put it in as a suggested amount. These suggestions, Mr. Chairman, are respectfully submitted by the Michigan State Medical Society in the hope that they may help this bill more adequately to achieve its purpose. Senator PURTELL. Off the record. (Off the record.) Senator PURTELL. I must leave now for another commitment. So, I am turning the chair over to Senator Goldwater, who will preside in my absence. Senator GOLDWATER (presiding). Do you have any questions, Senator? Senator COOPER. I would like to say I have particularly enjoyed the testimony of this witness and his description of the problems of a rural area. I live in such an area. I have seen the development of the hospital in my own town and know how it serves a rather large area in a radius of 50 to 60 miles. Do I gather from your testimony that you see a need in rural areas for the construction of diagnostic and other facilities in rural areas, even though they are removed from a general hospital, such as can now be constructed under the Hill-Burton Act? Dr. RODGER. Senator, I think that would have to be thought of in terms of whether we mean a laboratory, X-ray facility all by itself, serving an area, where it would meet the problem of personnel to man it, or whether the suggestion I have made here of where the clinic is owned by the community and leased to the physician-criticism might be made of that, that we are helping doctors. I would like to point out the physician who goes into a community and rents such a clinic from a community will be paying no more and no less than it would cost him to eventually build the facility himself, say, for 5 or 6 years after he is out in practice. The difficulty lies in these more isolated areas, in the kind of community Dr. Ferrell mentioned yesterday, and the kind which we have, too, and the kind which, I am sure, you have in Kentucky. Many times the young physician going out there is faced with no facility whatever, is heavily in debt, has no opportunity to build the facility, and isn't even sure he wants to stay there. If the community will build the facility and lease it to him, which would be at a cost no greater than his rent would be in the city, because the expense would be the same, then the community is always sure of getting a physician. That is our experience in Michigan. Senator CoOPER. Yes. Dr. RODGER. The doctors may come and go, but there is always a doctor there. Senator COOPER. Leaving out, for the moment, the question of how the facility would be manned, do you make this statement-that taking into consideration the situation where you had a general hospital, say, in one town, in a large rural area, and that general hospital serves several counties, that this bill would be valuable in that it would provide the means of constructing facilities, say, in the counties which surround that general hospital? Dr. RODGER. Yes, sir; it would be an integrated system. Senator COOPER. Then you do see value in the proposals made by this bill? Dr. RODGER. Yes, sir; very definitely. Senator COOPER. The position you suggest is related to getting those facilities properly manned? Dr. RODGER. That is right. As we see it, from an examination of this bill, it can't do what the President outlined in his health message unless there is a change. This is just one suggested change; but as it is worded now it cannot do what the President hoped it would do, and it cannot do what Dr. Ferrell talked about yesterday. Senator COOPER. What reaction do you think such a provision would have upon the medical profession in a community? I suppose in nearly every county there is a medical association. Would your arrangement be made with specific doctors, directly with specific doctors, or would you consider you would deal with a medical association in the community? Dr. RODGER. With a medical association; but all of us who are members of county medical societies, knowing a community in our area needs a doctor, working hard to get a doctor there—my suggestion here is for the community which has no doctor and needs 1 or 2, and which isn't getting any because there isn't any facility there to attract the man to come and practice as good medicine as he is trained to practice, and which he can practice if he goes to a larger community, and yet that community needs him just as much as a larger community, and needs him much worse. We are getting the men who are anxious to go into communities like that provided they can practice the medicine they have been taught to practice, the caliber, in medical schools. Senator COOPER. One problem it seems we are always talking about, not only here in the Congress but at home and every place else, is this problem of getting doctors to go into isolated communities, isolated areas. Your point is that by placing these facilities and by making arrangements with doctors for their operation you could help solve the problem? Dr. RODGER. Very definitely. That is the big point of this bill, as far as the rural area is concerned. Senator COOPER. One thing you mentioned in your statement, which interested me, was as follows: These days there is a marked increase in the number of young physicians willing and anxious to practice in smaller communities. Dr. RODGER. That has been our experience in Michigan. Senator, in our medical schools, whereas a number of years ago it was rare to find anyone who did not want to be a specialist. Now we find possibly an even division between the men who when in medical school are giving very serious consideration to general practice. Senator COOPER. That is a hopeful change. To what do you at tribute the change in attitude? Dr. RODGER. I think they are beginning to see in the family physician a real job. We are beginning to get the feeling now to be a family physician, a good caliber family physician, is ever important as being a specialist, and we can perform a service along with the specialist. It is all of us working together, not any group alone. Senator COOPER. I think your statement is very interesting. Senator GOLDWATER. Senator Hill. Senator HILL. The purpose of your amendment would be to carry forward what is already being done under the existing law in many places? Dr. RODGER. Yes, except under the existing law we have beds tied up with these health centers. Senator HILL. But you would carry forward the existing law, with the idea or the provision of leasing offices to Dr. RODGER. Yes; exactly that. That is being done now. Dr. RODGER. That is right. Senator HILL. And then, as I understand, your other main amendment goes to the proposition that you would not freeze these funds too tight? Dr. RODGER. Yes. Senator HILL. You heard the testimony this morning of Dr. Rusk, which, of course, was most challenging. Dr. RODGER. Yes. Senator HILL. He made it very definite and very clear that it is going to take some time to get the facilities and, more particularly, to get the personnel, which you must have if the facilities are worth anything so far as your rehabilitation work is concerned. Dr. RODGER. That is right. Senator HILL. In other words, you wouldn't tie down so tight, say, your funds for Michigan for rehabilitation which you know wouldn't be used and couldn't be used in the immediate future because, in line with what he said, of a lack of personnel to do the job, and you would permit those funds to be used for, say, the very thing you are talking about now, diagnostic centers or maybe general hospitals or other things; is that right? Dr. RODGER. That is right. Senator HILL. In that connection, I don't know what your situation is about tuberculosis, but I was interested this morning to see in the Washington Post and Times Herald a story captioned "Seckinger Calls TB Worse Disease Here"-Dr. Daniel L. Seckinger is the public health officer for the District of Columbia-in which it is stated: Dr. Seckinger observed that with improved techniques of treatment the average hospital stay for tuberculosis has increased from 390 days in 1947 to 439 days in 1952. We have heard quite a bit here lately about improved techniques of treatment in tuberculosis. The article goes on to say: "Longer stays in the hospital mean additional beds and increased cost of hospitalization," he said referring to Dr. Seckinger. "It means, therefore, that before there can be a decrease in annual appropriations for tuberculosis we will need, especially in the District of Columbia, to provide additional beds for hospitalizing the patients who need treatment now. Until those patients in the infectious stage are isolated in hospitals the dangers to the public health remain." Mr. Chairman, I ask to put that in the record at the end of the testimony. Senator GOLDWATER. Without objection, it may be so included in the record. Senator HILL. When he speaks about that infectious danger, he means everybody in this room, everybody in the District of Columbia is subject to a danger from the infection; isn't that right, Doctor? Dr. RODGER. That's right. Senator GOLDWATER. Senator, may I ask Senator HILL. Yes. Senator GOLDWATER. That is a little bit confusing. He states with the improved techniques in handling tuberculosis the patient is required to stay in the hospital longer. Senator HILL. Longer; that is right. I imagine he means by that-the doctor should answer the question, not me; I am only a layman-that if you want recovery, if you want to get rid of this disease today, using your improved techniques, you stay in the hospital longer, but you have a better chance, I suppose, of what you might call recovery and getting rid of the disease. Is that right, Doctor? Dr. RODGER. I think it is. I am no authority on tuberculosis. Dr. RODGER. But the terminal cases last longer, too. Senator HILL. Of course, I recall, and I am sure Senator Goldwater does, in the old days when we had to send these patients to Arizona and similar places, and that meant when they went most of them had to stay there. In fact, if they didn't stay, they were taking a pretty big, calculated risk. Isn't that true? Senator GOLDWATER. It was a little confusing. That is the reason I asked, because he states with the improved techniques the patient is required to stay in the hospital longer. Senator HILL. I am not a doctor, but I would certainly make that deduction. Dr. RODGER. That is right. Senator HILL. The idea being if you are going to get rid of tuberculosis, if you are going to take advantage of these new techniques to get well, you have to stay in bed and, as far as staying in a hospital is concerned, you have to stay longer today than you did in 1947; is that right, doctor? Dr. RODGER. That is right. Senator HILL. I think we might put that article in the record, not in the record with the doctor's remarks, but at the end of the testimony. Senator GOLDWATER. Would you mind, Senator, if we asked Dr. Cronin if he could explain that statement? It is still confusing to me. Senator HILL. No; go ahead. Senator GOLDWATER. Doctor, do you have anything to say that might shed a little light on that statement? Dr. CRONIN. I don't know. I read Dr. Seckinger's statement, Senator Goldwater, and in the statement it is noted that the total number of beds they need for tuberculosis is 1,175. The District of Columbia currently has a total of 1,065 beds for tuberculosis, of which 940 are acceptable. They have 125 beds which are not acceptable under the Hill-Burton Act, which usually means the institution is non-fire-resistant, and so on, or other reasons. The District of Columbia needs, on the basis of the formula in the Hill-Burton Act, which is the 212 beds per average annual death over a sample 5-year period, 1939 to 1944, and the subsequent 5 years, 235 more beds for tuberculosis. Senator HILL. You mean today? Dr. CRONIN. Today. Senator HILL. They need 235 additional beds for tuberculosis patients alone? Dr. CRONIN. That's right, to adequately care for the anticipated number of TB cases ahead. Now, as far as Dr. Rodger's statement that the terminal cases stay longer, that is because of the advances of modern medicine antibiotics, and so on. They get peneumonia and the antibiotics help the pneumonia to be defeated, so to speak, and we can keep people alive longer, even with tuberculosis. The newer drugs in tuberculosis, of course, haven't been in existence long enough to have a final say on them. Many people do well in getting newer drugs and are permitted to be treated outside the hospital. In some instances there are certain resistances built by the tuberculoses bacilli to these drugs, and in those instances those patients frequently come back to the hospital for care. Although I am not an authority on tuberculosis, as a physician in public health work, I don't think the whole story is here yet on these newer drugs or on the total care of tuberculosis. It is a picture which is changing from time to time, and it may change geographically. There are certain areas of the country that lend themselves to tuberculosis sometimes more than others. Senator HILL. Doctor, may I ask you a question? Dr. CRONIN. Yes. Senator HILL. Is the whole story here on any field of medicine? Dr. CRONIN. There is no whole story. We are in a state of flux, Senator. Senator GOLDWATER. Have you any other questions, Senator Hill? Senator HILL. When we got off on the subject of tuberculosis, I was talking about your amendment here, and you answered a question to the effect you didn't want these things frozen so tight, that you wanted an interchange as between the funds; isn't that right, Doctor? Dr. RODGER. That's right; between the four categories of this bill. Senator HILL. Yes. Dr. RODGER. We weren't suggesting going outside of that. Senator HILL. I understand. You want them more left at the State |